KEN 109 THE ANNUAL REPORT on THE HEALTH, SANITARY CONDITION, &c., &c., of the parish of St. Mary Abbotts, KENSINGTON FOR THE YEAR 1882, T. ORME DUDFIELD, M.D. Medical Officer of Health. KENSINGTON : †. WAKEHAM & SON, PRINTERS, 4, BEDFORD TERRACE, SILVER STREET 1883. TABLE OF CONTENTS. page Prefatory Remarks on Death-rate—Parochial, Metropolitan, and National, in 1882 5 Registration District, "Kensington What it includes 7 ,, Sub-Districts, "Kensington Town" and "Brompton" 7 Wards, Division of Parish into 8 Kensington, Population and Rateable Value of, 1801-82 9 Vital Statistics, 1882; Summary of 9 Zymotic Diseases, General Remarks on the "Seven Principal" 15 „ „ Number of Deaths from the „ „ 17 „ „ Death-rate from: in Kensington, in London, and other large Towns, and in England and Wales 17 ,, „ Monthly Return of Deaths from, in Kensington 18 Measles 18 Whooping-Cough 19 Scarlet Fever, Histories of Cases of 21 Diphtheria 23 Fever: Typhus, Enteric, Simple-Continued 24 „ Enteric, Local Prevalence of, at Notting Hill 24 „ „ Is it "Infectious?" 25 Diarrhœa 36 Small-Pox 26 Hospitals Commission (Infectious Diseases) 28 „ „ Subjects of Commissioners' Report 29 „ „ Practical Recommendations of the 29 ,, „ Many of the Recommendations of the; anticipated in "Propositions," submitted by the Vestry to a Conference of Sanitary Authorities, held July, 1878 30 2 PAGE Infectious Diseases, Provision of Hospital Accommodation for Recommendation with respect to, by Conference of Sanitary Authorities, held July, 1878 35 ,, „ Notification of: Compulsory Removal of Sick to Hospital: Free Hospital ment: Recommendations with respect to, by the Kensington Conference of Sanitary Authorities, March, 1881 35 „ „ Deputation to Local Government Board with respect to (April, 1881) 36 „ „ Establishment of Country Hospitals for, recommended (April, 1881) 36 Hospitals Commission: Multiplication of Hospitals objected to by 37 ,, ,, Endorse the principle of Free Hospital treatment 37 ,, „ Recommend transfer of Superintendence of Vaccination to Managers of Asylums Board ("Hospital Authority") 38 „ , Recommend increased powers of sory Removal in suitable cases 38 „ „ The Views of the Medical Officer on the Subjects dealt with by the 38 „ ,, On Hospital Accommodation for the infectious sick 39 Hospital Accommodation River Hospitals recommended by Hospitals Commission 40 „ ,, Ship Castalia purchased by Managers to increase 41 „ „ Land at Darenth and at Long Reach purchased by Managers to increase 41 Hospital Authority: The (Infectious Diseases) 42 „ „ Views of the Local Government Board and of the Hospitals Commission, with respect to the 43 Diseases Prevention (Metropolis) Bill 44 Hospitals for Infectious Diseases, The use and influence of: Notes on Dr. Thorne Thome's Report on 47 „ „ „ Mr. W. H. Power's Report on Fulham Hospital, chiefly with reference to the question whether "personal communication" or "aerial dissemination " is the true explanation of the spread of Small Pox in the vicinity of Small Pox Hospitals 48 3 PAGE Hospitals for Infectious Diseases, What the Commissioners say, with respect to the above question 57 „ „ The "notable outburst" of Small Pox around Fulham Hospital, January, 1881 58 „ ,, Another notable outburst, April, 1878 63 Notification or Infectious Diseases: 66 ,, ,, Deputation to Local Government Board 66 , „ The action of the Vestry with respect to 69 „ ,, Letter to the Postmaster General 72 „ ,, The views of the Postmaster General 74 ,, „ Letter to the Chief Commissioner of Police 75 „ „ The action of the Chief Commissioner of Police with respect to 75 „ „ Correspondence with the Secretary, and Medical Officer, of the Gas Light and Coke Company with respect to 76 Voluntary Notification : The existing sources of information 78 „ ,, The benefits that have resulted from 80 Ambulance Service 83 Increased Facilities for removal of the infectious sick 84 Interruption of Education at Elementary Schools, resulting from prevalence of Infectious Diseases 86 Population: Number of Inhabited Houses, &c 87 „ Relative Numbers of Males and Females in the 87 „ Of Sub-Districts 87 „ Rateable value, &c: Increase in 25 years and in 11 years 88 Marriages, and Marriage-Rate 89 Births, and Birth-Rate 90 Deaths, and Death-Rate, in whole Parish and in Sub-Districts,&c., at ages; periods of the year; in sexes; among illegitimate children under five years, &c 91 Infantile Mortality 92 Death Rate, Monthly: Monthly mean Temperature, &c. 93 Death, Summary of causes of (Table) 94 Death, Assigned causes of 94 „ Zymotic Diseases 95 ,, Constitutional Diseases 97 „ „ (Tubercular) 98 „ Local Diseases 100 „ Violent Deaths 104 4 PAGE Public Institutions, Deaths in 104 „ Pariah Infirmary and Workhouse 105 „ Brompton Consumption Hospital 107 „ St. Joseph's House 107 „ Marylebone Infirmary 107 Deaths "Not Certified" 108 Inquests 109 „ Violent Deaths 109 „ Why bo many become necessary ? 110 Meteorology 111 Vaccination in 1882 111 „ Officer's Report 112 „ Evidence furnished by Medical Officer to Local Government Board, as to the Protection afforded by 112 „ Animal; Calf Lymph 115 Sanitary Work of the Year 115 ,, Legal Proceedings in connexion with 116 Water Supply, Domestic, Power of Company to "cut off " 117 „ „ The law with respect to 118 ,, „ Waterworks Clauses Act, 1847 118 ,, „ Metropolis Water Act, 1852 120 1871 120 „ „ The Water Regulations (1872) 123 ,, „ The views of the Vestry with respect to 125 Slaughter Houses, The Licensed 126 „ ,, Report on, by the Sanitary Committee 127 ,, „ Metropolitan, Number of 127 Cowsheds, The Licensed 128 Dairies, Cowsheds, and Milkshops Order of 1879 128 Public Health (Dairies, &c.) Bill 130 Bakehouses : Factory and Workshop Act, 1878 133 ,, The Regulation of: Report on for 1880-81, by Factory Inspector 135 ,, „ Action byVestries,Ac.,with respect to 137 „ „ Metropolitan Board of Works propose to take in hand 138 ,, „ The action of the Vestry with respect to 138 ,, ,, The views of the Medical Officer of Health with respect to 140 ,, „ The action of the Society of Medical Officers of Health with respect to 141 4A PAGE Bakehouses, The Regulation of: The views of the Operative Bakers Union with respect to 143 „ „ Notes on Report for 1881-82, by Factory Inspector with respect to 144 „ ,, Basis suggested by Chief Factory Inspector for fresh legislation with respect to 146 ,, „ Factory and Workshop Bill (1883) introduced by Government, to make Vestries, Ac., the Local Authorities with respect to 147 House Refuse, Removal of 148 Stable Refuse, Difficulties in respect of periodical removal of 149 Refuse, Report on removal of, by Society of Medical Officers of Health 150 Public Urinals 151 Baths and Wash-houses, Public 152 Mortuary, History of: and law relating to 152 ,, Regulations 155 ,, Conditions on which bodies can be compulsorily removed to the 156 „ Post-mortem examinations: Regulations for the Place provided for making 156 ,, Keeper, Duties of 157 Coroner's Court (Proposed) 158 Disinfection 159 Water Supply (Metropolitan), Notes on Report by Professor Frankland 159 ,, „ Messrs. Crooke3, Odling and Tidy 163 ,, „ Colonel Bolton 164 „ Deterioration of, in dirty cisterns, &c. 167 Gas, Results of Examinations for ascertaining the illuminating Power and Purity of the 169 „ Supply of, for street lighting 170 Conclusion 170 [appendix.] 4b APPENDIX. STATISTICAL AND OTHER TABLES. page Table 1. Estimated Population in 1882 and ten previous years, 1872-81; Number of Inhabited Houses; Gross numbers of Marriages, Births, and Deaths 175 ,, 2. Birth Bate and Death Rate; Death Bates of Children, Deaths in Public Institutions, 1882, and 1872-81 176 ,, 3. Deaths Registered from all Causes in 1882 177 ,, 4. Deaths from Seven Principal Zymotic Diseases; Pulmonary Diseases; Tubercular Diseases; Wasting Diseases of Infants; Convulsive Diseases of Infants: Gross numbers; and Proportion of to 1,000 deaths and to 1,000 population 178 „ 5. Deaths in 1882 and in 1872-81 from the Seven Principal Zymotic Diseases: in the Parish, the Metropolis, and in England and Wales 179 „ 6 & 6a. Sanitary Work, Summaries of 180-1 „ 7 & 8. Comparative Analysis of Mortality in London and Kensington from certain Classes of diseases; Death rates and percentages of deaths, at ages; from Violence ; and in Public Institutions, &c., &c.182-3 „ 9. List of street* where fatal cases of the more important of the Zymotic Diseases occurred in 1882 184 ,, 10. Vaccination Officer's Annual Return 185 „ 11. Slaughterhouses, Licensed, and Names of Licensees 186 12. Cowshed* „ „ „ 187 TWENTY-SEVENTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, BEING FOR THE YEAR 1882. To the Vestry of the Parish of St. Mary Abbotts, Kensington. Gentlemen, I propose to place before you, in this my annual report, the vital statistics for the registration year 1882, which terminated December 30. The ordinary sanitary statistics have been compiled, as usual, for the parochial year—viz., to March 25, 1883. Other matters calling for notice will be dealt with as occasion may require. The vital statistics are calculated on an estimated population at the middle of the year, of 165,450, a number arrived at mainly on data furnished by the census taken in April, 1881. The year 1882 was a healthy one; the death-rate being the lowest on record. The total deaths, 2,691, were 372 below the corrected decennial average. This total, it should be mentioned, includes 13 deaths of parishioners in the hospitals of the Metropolitan Asylums District, and 80 of non-parishioners at the Brompton Consumption Hospital, as well as a not inconsiderable number of strangers at St. Joseph's House, Notting Hill, at the 6 Workhouse, and at other public or quasi-public institutions, that have been retained in the vital statistics by way of compensation for deaths of parishioners, at public institutions and elsewhere, outside the parish; but it does not include deaths of nonparishioners at the Marylebone Infirmary, Notting Hill, to which some reference will be made in another part of the report. The 2,691 deaths were equal to a rate of 16.2 per 1,000 persons living, this being 2.2 per 1,000 below the decennial rate, and 5.2 per 1,000 below the Metropolitan rate (21.4), which, moreover, was 1.3 per 1,000 below the mean rate in the previous ten years. The rate in all England 19.6 per 1,000, was 1.4 per 1,000 below the decennial average, being the lowest rate recorded in any year, 1881 only excepted, since civil registration was established in 1837. The subjoined table shows the annual death-rate per 1,000 persons living in Kensington in each of the last eleven years, and, for sake of comparison, the rate in the Metropolis and its several districts, and the rate in all England:– Death Rate. 1882. 1881. 1880. 1879. 1878. 1877. 1876. 1875. 1874. 1873. 1872 Kensington 16.2 16.6 17.8 18.8 20.2 17.3 19.5 19.2 19.4 18.3 17.6 London 21.4 21.2 21.7 22.6 23.1 21.5 21.9 23.5 22.4 22.4 21.4 W. Districts 19.9 19.6 19.8 20.9 21.6 19.2 20.9 22.2 20.9 20.5 19.6 North „ 19.7 20.6 20.8 21.5 22.0 21.5 22.1 22.1 21.7 21.1 21.1 Central,, 23.9 23.2 23.4 26.0 25.1 24.2 24.1 26.2 25.6 25.1 23.6 East „ 25.3 24.2 24.3 25.5 25.0 24.5 23.9 25.7 25.5 25.2 23.6 South „ 20.7 20.5 21.3 21.8 23.0 20.5 21.2 23.3 21.0 21.7 20.6 England and Wales 19.6 18.9 20.5 20.7 21.6 20.3 20.9 22.7 22.2 21.0 21.3 The Registrar-General in his Annual Summary, referring to the mortality in all London states that "The rate in the immediately preceding year was 21.2, and the rate in 1850 was only 21.0, but with these exceptions the rate in 1882 (21.4) was the lowest on record, having however been exactly equalled in 1872. Had the deaths in 1882 equalled the annual average of the preceding decade, allowance being made for increase of population, 3,099 persons would have died in the course of the year, who, as it was, were alive at its close." The rate in the "Outer Ring" of London was 17.4. The rate in the 27 extra 7 metropolitan great towns of England, with an aggregate population of 5½ millions, was 22.3 per 1,000, ranging from 18.7 in Derby, to 27.6 in Preston. In 50 other considerable urban districts with a population of 2,640,000, the rate for the aggregate was 20.4, ranging from 15.3 in Burton-on-Trent (population 42,000), to 25.5 in St. Helens (population 58,000). Only two of these towns (Dover and Burton) had a rate lower than that of Kensington. The death rate in the rest of the country, mainly rural, population 14¼ millions, was 18.0 per 1,000. Having premised so much by way of introduction it will be desirable, before proceeding further, to say a few words with respect to the Registration District and Sub-Districts, in which we are locally interested. "Kensington" is the title of a Superintendent Registrar's District—No. 1 in the Registrar General's London list, which comprises the parishes of Kensington and Paddington. The subjoined table shows the relative areas of the two parishes, and other particulars relating to the census years 1871 and 1881. Area in Staute Acres. Inhabited houses. Increase in 10 years. Population. Increase in 10 years. 1871 1881 1871. 1881 Kensington 2,190 15,735 20,103* 4,368 120,299 163,151 42,852 Paddington 1,251 11,847 13,187 1,340 96,813 107,098 10,285 Registration Sub-Districts. For registration purposes Kensington parish is unequally divided into two "sub-districts," viz., "Kensington Town"—hereinafter for brevity designated "Town"—and "Brompton." The Town sub-district, according to the Registrar-General, has an area of 1,497 acres, and Brompton, 693 acres,—total, whole parish, 2,190 acres: in your Vestry's Annual Report, the total acreage is given as 2,245. The population of the Town sub-district at the middle of 1882 was about 122,423, and of Brompton. 43,027—total, whole parish, 165,450. The Town sub-district still includes some open spaces, e.g., Holland Park, Kensal Green Cemetery, and fields at * The number 20,103 is taken from the Census return. The rate books show 20,705 occupied and rated premises, many of which presumably do not afford living or sleeping accommodation, and therefore would not be enumerated at the Census, 8 Notting Barn Farm, which however are being covered slowly with houses. The Brompton sub-district, in which the builder has been active of late years, many of the new houses being of a palatial character, includes within its boundaries the West London or Brompton Cemetery. The sub-districts present considerable differences which have to be borne in mind in any comparison of their vital statistics. In Brompton the rich and well-to-do form a large proportion of the population, whilst in the Town sub-district there is a large and increasing percentage of persons of the poorer classes. The poor in Kensington, however, possess one advantage over the poor in some other parts of the Metropolis, in that for the most part they live in well-built houses obviously intended for occupation by a superior class of people, miles of streets of such houses being now inhabited by a class of persons who, in the older parts of the Metropolis, find shelter in dwellings that by comparison might be described as squalid. But rents are high, and high rents, where the poor dwell, mean overcrowding, which is certain, in the long run, to increase the death-rate, wherever it exists. It has already, I fear, led to a wider range in the rate of mortality, in different localities, than should rightly prevail: the ultimate effect of the overcrowding, should it continue and increase, may well be to cause the death-rate of Kensington to approximate more and more closely to the Metropolitan rate. The Parish of Kensington is for some local purposes divided into "Wards:" the subjoined table shows the acreage of the wards, their population, and the number of inhabited houses, etc., in 1871 and 1881. Name of Ward Area in Statute Acres. Inhabited Louses. Increase in 10 years. Population Increase 10 years.* 1871 1881 1871 1881 St. Mary Abbotts 846 4,781 6,573 1,792 35,696 48,604 12,908 Holy Trinity, Brompton. 439 3,224 3,936 712 22,128 26,746 4,618 St. John,Notting hill, & St. James Norland. 905 7,730 9,594 1,864 62,475 87,574 25,099 * The increase in the table totals up 42,625, and was ascertained upon the unrevised figures of the census, showing a parish population of 162,921: the actual increase was 42,852, the revised figures showing a population of 163,151; but details are not yet available. 9 The rateable annual value of property in the wards in 1871, was St. Mary Abbotts, £323,992; Holy Trinity, £246,716; and St. John and St. James, £365,012. Total, whole parish, £935,720. In 1881 the returns for the first and second wards, which cannot now be given separately, show a rateable value of £1,078,512 (increase, £507,804); for St. John and St. James, of £501,704 (increase £136,692). Total, whole parish, £1,580,216. The subjoined figures are interesting as evidence of the development of the parish in population and wealth, since the beginning of the century. The Year. Population. Rateable value of Property. The Year. 1801 8,556 £75,916 1823 1821 14,428 93,397 1833 1841 26,834 142,772 1843 1851 44,053 257,103 1853 1861 70,108 590,711 1865 1871 120,299 817,326 1870 1882 (July) 165,450 1,665,983 (April) 1882 SUMMARY OF VITAL STATISTICS, 1882. The first thing to be remarked is the fact, already mentioned, that in 1882 the death-rate in Kensington was lower than in any other year of which we possess the vital statistics. And this lower death-rate was due, not to exceptional causes operating at particular periods, but to a good average condition of the public health from the beginning to the end of the year; for in eleven out of thirteen monthly reports, each covering a period of four weeks, I had the satisfaction of recording a rate below the decennial average, while in the remaining two reports relating to the 5th—8th and 41st—44th weeks respectively, the rate recorded was only 1.0 and 0.7 per 1,000 in excess of the decennial average. The mortality from the principal diseases of the zymotic class, as a whole, was below the average ; but the deaths from measles, scarlet fever, and diphtheria were slightly, and the deaths from whooping cough considerably, above the average. On the other hand, and for the first time since 1875, we had not one death from small-pox. The deaths from "fever" 10 were below the average, and those from diarrhoea considerably less than half the average, corrected for increase of population. It may be mentioned, that more than a moiety of the deaths from diarrhoea occurred between the 29th and 40th weeks (July 16th to October 7th), the incidence of this disease having been delayed as a result of the unseasonable coolness of the summer. Whooping cough was most fatally prevalent in the first half of the year. On the decline of whooping cough, measles for a few months took the leading place among zymotic diseases. Scarlet fever and enteric fever were most fatal towards the end of the year, about one half of the deaths from these causes having been registered in the last quarter. The death-rate in Kensington during the first four weeks of the year (19.9 per 1,000) approximated somewhat closely to the decennial average (20.9), owing to the fatal prevalence of whooping cough (31 deaths), and for the first time in several months the deaths from the principal diseases of the zymotic class were considerably above the average. In the second period of four weeks, January 29 to February 25, the death-rate (21.9), highest in 1882, was 1.0 per 1,000 above the average, the rate in the Metropolis as a whole (29.4) being 4.0 per 1,000 above the average, and 7.5 above the Kensington rate. The highest death-rate in the Metropolis in 1882 (35.3 per 1,000) was reached in the week ended February 11th, when London stood at the bottom of the RegistrarGeneral's list, which shows the annual rate of mortality in the 28 largest English towns. This unusual rate was due to the prevalence of fogs of unusual density, offensiveness, and duration, which were the cause of an excessive fatality from diseases of the respiratory organs. In the four weeks the deaths in the whole Metropolis from this class of diseases exceeded the corrected weekly average by 43, 430, 237 and 46 respectively. In the parish there were 91 deaths from bronchitis and pneumonia, as against 61 in the previous four weeks. Happily the fogs were not associated with any intensity of cold (the temperature, 41°.1, was 1°.6 above the decennial average), 11 otherwise the ill results would have been greater, and the deaths of very aged and very young persons far more numerous. The deaths from the principal diseases of the zymotic class, which in the previous month had been 14 above the corrected decennial average, fell to 5 below the average, the most fatal of these diseases being whooping cough; the deaths from this cause, however, were 16, as against 31 in January. In the third period, 9th-12th weeks, ended March 25, the deathrate, under the influence of fine spring weather, and notwithstanding the temperature, 41°.0, was slightly below the average, fell to 17.7, or 2.6 per 1,000 below the decennial average, and 6.1 per 1,000 below the Metropolitan rate. This reduced rate was accounted for by a falling off in the number of deaths from diseases of the respiratory organs. The deaths from these diseases, which had been excessive throughout the Metropolis for many weeks, fell to a number 66 below the corrected average in the 12th week of the year. The deaths from whooping cough in Kensington, which in the two previous periods had been 31 and 16 respectively, rose again to 21. Scarlet fever was the cause of eight deaths, the largest total in any month save October, when the deaths, as we shall see, were twice as numerous. In the fourth period (13th-16th weeks, ended April 22), the deaths from whooping cough fell to 14, and the death-rate underwent a further decline to 17.5, or 2.5 per 1,000 below the average. The Metropolitan rate (21.9) was 4.4 per 1,000 higher than the Kensington rate, but 2.3 per 1,000 below the decennial average. In the fifth period (17th-20th weeks, ended May 20th), the deaths from whooping cough further fell to 10; the death-rate (15.3 per 1,000, the lowest to date) being 2.4 per 1,000 below the average, and 4.3 per 1,000 below the Metropolitan rate, which, moreover, was 1.9 per 1,000 below the decennial average. In the sixth period (21st-24th weeks, ended June 17th), there was again a reduction in the rate of mortality—viz., to 14 per 1,000, or 2.7 per 1,000 below the average, and 4.2 per 1,000 below the Metropolitan rate: this, moreover, being 1.4 per 1,000 below the average. The deaths from whooping cough declined to 8 12 During these four weeks however there were 13 deaths from measles, as against 1, 3, 5, 5 and 6 in the five preceding periods. In the following (seventh) period, comprising the 25th-28th weeks, the deaths from measles further rose to 16, while the deaths from whooping cough fell to 3. In this period the death-rate fell to the lowest point for the year, viz., 12.5 per 1,000, being 4.4 per 1,000 below the decennial rate, and 5.4 per 1,000 below the Metropolitan rate (19.8), which was 1.9 per 1,000 below the decennial average. The mean temperature in this period (from June 18 to July 15) was 59°.2, or 2°.5 below the decennial average; and there was much rain. To these causes, cool and rainy weather, we were indebted for the comparative absence of diarrhœa; there were but two deaths from this cause during the four weeks, the corrected decennial average being 16. In the next, eighth, period (29th-32nd weeks, July 16 to August 12), the deaths from diarrhœa rose to 12, the mean temperature being 61°.2: the death-rate, moreover, rose to 13.6 per 1,000, being, however, 4.7 per 1,000 below the decennial rate, and 4.9 per 1,000 below the Metropolitan rate, which again was 4.8 per 1,000 below the decennial average. The deaths from the principal diseases of the zymotic class, which in the previous month had been 11 below the corrected decennial average, were during the period under notice, no fewer than 30 below the average, still owing to the comparative abeyance of infantile diarrhoea, the deaths from this disease being 32 below the decennial average corrected for increase of population. The deaths from measles, which in the previous month had risen to 16, fell to 8. In the following, ninth, period (33rd-36th weeks, August 13 to September 9), there were 8 deaths from measles and only two deaths from whooping cough: the deaths from diarrhoea (12) were 18 below the average. Scarlet fever, which now began to be prevalent, caused six deaths. The death-rate, nevertheless, fell again to 12.6 per 1,000, or 3.2 per 1,000 below 13 the decennial average, and 6.6 per 1,000 below the Metropolitan rate (19.2), which, however, approximated closely to the decennial average, 20.1. The weather at this time was still ' cool, the mean temperature in the four weeks being 58°.2 or 2°.9 below the average: hence the comparatively small number of deaths from diarrhoea, to which the low death-rate was largely due. In the tenth period (37th-40th weeks, September 10 to October 7), the rate of mortality (12.9 per 1,000) approximated more nearly to the decennial rate (14.2) than in many previous months, but it was 5.8 per 1,000 below the Metropolitan rate (18.7), this, however, being within 0.2 per 1,000 of the decennial average. For the third time the deaths from diarrhoea, in the four weeks, were 12, and the deaths from the principal diseases of the zymotic class were but one below the corrected decennial average. The deaths from scarlet fever were only 3, but the recorded cases were 31 as against 15 21 and 28, in the three previous periods. Scarlet fever was very prevalent in the Metropolis generally at this time. The London Fever Hospital was full of it, and the Asylum Board's Hospitals contained 500 cases. The eleventh period, comprising the 41st-44th weeks (October 8th to November 4th) was marked by the greatest prevalence and fatality of scarlet fever, 52 cases having been recorded, and the registered deaths being no fewer than 16. Hampstead and Fulham Hospitals were now specially reopened for the reception of fever cases: the injunctions only restrained the managers from admitting cases of small-pox. Enteric fever had also become prevalent; 5 deaths from this cause were registered during the four weeks. The deaths from the principal diseases of the zymotic class were 7 above the corrected decennial average. And now, for the second time in 1882, the parochial death-rate (17.0 per 1,000) exceeded the decennial average, but only to the extent of 0.7 per 1,000. It was still below the Metropolitan death-rate to the extent of 3.0 per 1,000; this (20.0 per 1,000) being l.l per 1,000 below the 14 average. The mean temperature, 49.8 was 2°.2 above the decennial average. In the twelfth period (45th-48th weeks, November 5 to December 2), the death-rate, 17.1 per 1,000, was 2.2 per 1,000 below the decennial average, 4.3 per 1,000 below the Metropolitan rate, this moreover being 2.l per 1,000 below the decennial average. The deaths from the principal diseases of the zymotic class were 7 below the average. The mean temperature (41°.3) was 1°.4 below the average. The nearer approach to the end of the year was signalised, as usual, by an increasing mortality from chest diseases: the total deaths from these affections were 58 (including bronchitis 36), as compared with 20, 28, and 48 in the three previous periods respectively. The deaths from the principal diseases of the zymotic class fell from 31 in the eleventh period to 19, and the deaths from scarlet fever from 16 to 4; the cases from 52 to 37. Enteric fever was the cause of 4 deaths. In the thirteenth period (49th-52nd weeks, December 3.30) the rate of mortality (18.1 per 1,000) was 2 per 1,000 below the average, and 6.7 per 1,000 below the Metropolitan rate (24.8), which, however, was 1.3 per 1,000 below the decennial rate (25.l). In this period measles and whooping cough were accountable, each, for 5 deaths, scarlet fever for 7 (including 2 in hospital), and enteric fever for 3; whilst the deaths from chest diseases further rose to 61, the mean temperature (40°.4) having further declined, but only to the extent of 0O.9, and being 20.l above the decennial average. The year 1882 was a singu'arly healthy one, as gauged by the death-rate, in the country generally. The RegistrarGeneral in his fourth quarterly return states that "The deathrate showed an increase of 0.7 upon the unprecedentedly low rate in 1881, but was with that single exception lower than the rate in any year since civil registration was established in 1837." The death-rate in the Metropolis (21.4 per 1,000) was 0.2 above the rate in 1881, in respect of which the Registrar-General in 15 his annual summary for 1881 remarked that "only once since civil registration began had a lower death-rate than this been recorded in the Metropolis—namely, in 1850, when the rate was 21.0." THE ZYMOTIC DISEASES. Before entering into details with respect to population, births, deaths, &c., I propose to consider specially the sickness and mortality from the principal diseases of the Zymotic class, and subjects naturally arising out of this topic. The "Class" of diseases called Zymotic, comprises in the Registrar-General's recently re-arranged classification of the "causes of death" six "orders." The first and second orders ("Miasmatic" and "Diarrhœal") include the diseases which the Registrar-General calls "the seven principal diseases of the zymotic class," still grouping under the generic term "Fever" the three distinct fevers, "Typhus," "Enteric," and "Simple continued." These diseases have a high interest for sanitarians, arising out of their more or less preventible character: it being customary, moreover, to regard the absence or the prevalence of them, as the case may be, as a test of the sanitary condition of a district. But, without under-rating the importance of this test, there are limitations to its applicability which must be borne in mind if we would draw sound conclusions. What I mean may be best explained by an illustration or two founded on our own local experiences within the last few years. Thus Measles was very fatal in 1874 and 1876; the deaths were far above the average: it was, so to speak, the zymotic disease that gave a special character to these years. In 1875 and 1877, on the other hand, the deaths from Measles were below the average; but the reduced mortality—evidence of the diminished prevalence of the disease -was, as it were, the corollary of the excessive prevalence and fatality of the malady in the preceding Years. In saying this, I do not, of course, ignore the fact that one epidemic of a zymotic disease may be more severe than 16 another ; still less am I forgetful of the fact that the fatality of an epidemic is largely influenced by the means taken, or the neglect to take means, to limit the spread of infection. Again, the rate of mortality in the Metropolis from whooping cough in 1881, was the lowest on record; it is not surprising to find therefore that in 1882 the disease was excessively fatal. Diarrhœa may be cited as an illustration of quite another kind. The mortality from this disease amongst infants was excessive in 1878; the mortality in 1879 was far below the average: but the diminished mortality in the second year had on relation to the excessive mortality in the first; the conditions were altogether different. The summer season in 1879 was cold and wet, and in a cold and wet summer the mortality from infantile diarrhoea is always low, just as it is always high when the summer is hot and dry, as it was in 1878. Per contra, it may be observed that the conditions that were so favourable to infantile life in respect of diarrhoea, in 1879, were very unfavourable to life, both in the young and in the aged, in respect of another class of diseases—viz., the pulmonary, the mortality from which throughout the year was excessive, as it always is in cold and wet seasons. Again, the significance of a high rate of prevalence of enteric fever may vary widely in different circumstances: the disease may be constantly present in one district owing to drainage defects, or a bad water supply; in another its introduction may be due to an accidental pollution of water, or to a contaminated milk supply—and the same observation in respect of milk, applies equally in the case of scarlet fever also. These and like circumstances must be kept steadily in view if we would draw sound conclusions from a high or a low rate of prevalence of this or that disease, or class of diseases, especially in relation to the sanitary condition of a district. Subject to corrections for climatic conditions, and for high rates in previous years, the concurrence of a low zymotic rate with a low general death-rate, furnishes just ground for 17 faction; and as the general rate and the zymotic rate were both below the average in 1882, to that satisfaction we are fairly entitled. It need hardly be said, on the other hand, that a persistently high rate of mortality from zymotic diseases is always a subject for serious consideration; but, as we shall see in due course, Kensington has hitherto been in the happy position of having a death-rate from these diseases much below that of the Metropolis generally. The subjoined table* sets out necessary particulars of the mortality from the principal zymotic diseases in 1882, together with the decennial average, &c.:— Diseases. Sub-Districts. In Hospitals. Decennial Average. Town. Brompton. Town. Brompton Totals. (uncorrected) (corrected) totals in 1881 Small Pox .. .. .. .. .. 55 27.5 30.7 Measles 70 7 .. .. 77 67 66.2 73.9 Scarlet Fever 38 13 11 .. 62 38 51.3 57.3 Diphtheria 16 9 .. .. 25 8 17.7 19.7 Whooping Cough 97 22 .. .. 119 85 88.9 99.3 Typhus Fever 1 .. .. .. 1 32 2 29 34.7 38.7 Enteric Fever 20 3 2 .. 25 22 Simple Con. Fever 5 1 .. .. 6 6 Diarrhœa 54 7 .. .. 61 101 118.0 131.8 301 62 13 .. 376 383 404.3 451.4 From the above table we learn that the deaths from the seven principal zymotic diseases, were 7 fewer than in 1881, and 75 below the corrected decennial average. As usual, the deaths in the Brompton sub-district were relatively fewer in proportion to population than in the Town sub-district. The deaths from zymotic diseases were equal to 139 and 163 per • 1,000 deaths from all causes in Kensington and the Metropolitis respectively, and to a rate of 2.2 and 3.5 per 1,000 persons living, the decennial average being 2.7 in Kensington, and 3.6 in London. By way of comparison it may be mentioned that * The figures in the table do not tally with the figures in the RegistrarGeneral's Annual Summary, because (1) deaths of non-parishioners at Marylebone Infirmary are excluded; (2) deaths at the Asylum board's Hospitals are added; (3) corrections are made of known errors in medical diagnosis; and (4) I do not always accept the Registrar-General's selection when two or more diseases arc1 entered in the medical certificate of the cause of death. 18 in all England the deaths from these zymotic diseases were only 134 in each thousand deaths; and the rate was 2.6 per 1,000 persons living, in 1882, the decennial average being 3.2 per 1,000. In the 27 large Towns grouped by the Registrar-General with the Metropolis, the rate was 3.6 per 1,000, ranging from 1.6 in Halifax to 5.7 in Sunderland. The zymotic death rate in the 50 large Towns coming next in order of importance, after the 28, averaged 2.9 per 1,000; the highest rate (7.30 per 1,000) being recorded at St. Helens. The following table shows the distribution of deaths from zymotic diseases registered in Kensington in 13 periods of four weeks, corresponding to my monthly reports:— PERIOD. DISEASES. Four weeks ended Small Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Typhus Fever. Enteric Fever. Simple Continued Fever. Diarrhoea. Total. Jan. 28, 1882 ... 1 5 2 31 1 4 1 1 46 Feb. 25 „ ... 3 3 2 16 ... 1 ... ... 25 Mar. 25 „ ... 6 8 1 21 ... 1 ... ... 36 April 22 „ ... 5 ... 1 14 ... ... ... 3 23 May 20 „ ... 6 3 1 10 ... 2 1 2 25 June 17 „ ... 13 3 4 8 ... 1 1 3 33 July 15 „ ... 16 3 1 3 ... 1 ... 2 26 Aug. 12 „ ... 8 1 5 4 ... 2 1 12 33 Sept. 9 „ ... 8 6 ... 2 ... ... 1 12 29 Oct. 7 „ ... 4 3 1 3 ... ... ... 12 23 Nov. 4 „ ... 1 16 2 2 ... 5 1 4 81 Dec. 2 „ ... 2 4 2 ... ... 5 ... 6 19 Dec. 30 „ ... 5 7 3 5 ... 3 ... 4 27 77 62 25 119 1 25 6 61 376 I now proceed to make a few observations on each of the diseases, and first with respect to Measles, which, as already mentioned, was prevalent, especially in the second and third quarters. The deaths 77 (70 in the Town sub-district and 7 in Brompton) were 3 above the decennial average, corrected for increase of population. In the majority 19 of the fatal cases, intercurrent diseases, e.g., pneumonia, bronchitis, etc., complicating the original malady, were the immediate causes of death. Little care is taken by the poor to prevent the spread of measles in their families; they consider it as inevitable as teething, and reason that it is less trouble in the end if all the children have the disease at one time. It must, however, be admitted that there is much difficulty in preventing measles from spreading, for it is highly infectious from an early stage, if not from the very beginning of the attack. ' The circumstances, moreover, in which the poor live in London —several families occupying one house and using a common staircase, almost preclude the possibility of isolation. More care perhaps, might be taken to protect the sufferers against the complicating affections which, as already stated, are generally the immediate causes of death. Whooping Cough (the most fatal disease in the zymotic class in 1882) was the cause of 119 deaths—97 in the town subdistrict and 22 in Brompton—or 20 above the corrected decennial average. One hundred of the deaths were registered in the 24 weeks ended June 17, and 68 of these in the first 12 weeks of the year. The London death-rate from whoopingcough in 1881 was the lowest on record, only 1,961 deaths having been assigned to this cause, whereas there would have been 3,144 had the mortality been at the average rate of the preceding ten years: but towards the end of the year an epidemic commenced, and the deaths in 1882 were 4,647, or 1,526 above the average of the previous ten years, and equal to 1.20 per 1,000 inhabitants. If so great a mortality had occurred from small-pox, what an outcry there would have been ! The destruction of infantile life is, but too commonly, somewhat lightly regarded. But as I have had occasion to remark in former reports, the danger of this always distressing malady is scarcely appreciated by the general public, and least of all by parents in the poorer classes, who, in the engrossing struggle for existence, have little time to devote to the care of their 20 children, in respect of an ailment which they have come to regard as at once inevitable and not very serious. Often enough the fatal event takes them by surprise, as when it is immediately due to some complication, e.g., convulsions — the secondary cause of death in many cases. Pulmonary complications are the most frequent. Not very many deaths are returned as due to whooping cough alone ; and even in such cases it is open to question whether there may not have been complications which the certifying practitioners thought it unnecessary to mention, upon the ground that the said complications were secondary to the specific disease, and but for it would not have existed at all. This observation raises the question whether the complications referred to are avoidable or otherwise? Now, whilst I have no doubt that, in some instances, complications, e.g., chest diseases, are unavoidable, I am, nevertheless, of opinion that the secondary diseases are frequently due to want of care in the home treatment of the sufferers— though I by no means would imply that such want of care proceeds from indifference, still less from unkindness. The little ones are not, perhaps cannot be, confined to a single room, kept at an even temperature : they catch cold ; the " cold " and the " cough " are not differentiated. Medical treatment is not sought until the child is obviously very ill, and when it is obtained, the child is beyond the reach of help. The deaths recorded within the year from whooping eougli, were, as stated, 119; but it is to be feared that the deaths really due to this disease exceeded even this large total, for whilst on the one hand it is probable, as before stated, that whooping cough is sometimes returned as the sole cause of death, notwithstanding the existence of complications; on the other hand, there is ground for believing that sometimes the primary disease is not mentioned in the medical certificate of the cause of death, the immediate cause of death alone being stated, e.g., bronchitis or pneumonia. A locality which suffered considerably from this whooping cough epidemic is that at the back of Kensington Square —not 3 very good one in respect of the construction and sanitary 21 arrangements of many of the houses; and this leads me to remark that overcrowding and insanitary conditions generally, which alone may produce disease,e.g., pneumonia—to quote but one illustration—will naturally tend to aggravate any and every disease, and may easily turn the scale against a patient who, in more favourable circumstances, would have had a good chance of recovery. Whooping cough had been prevalent in the locality for a considerable time prior to the first death. Under a system of "Notification of infectious diseases," the existence of the epidemic would have been revealed at a much earlier date. Scarlet fever was the cause of 62 deaths, or five above the corrected decennial average; in the two preceding years the deaths were 105 and 38 respectively. Of the 62 deaths 49 belong to the Town Sub-district, including 11 that took place in Hospital, and 13 to Brompton. Three hundred and nineteen cases were recorded, viz., 217 in the district north of Uxbridge Road, and 102 in the remainder of parish south of that road. Considerably less than half of the known cases were removed to hospital; many cases were concealed; and frequently when the existence of the disease became known at an early period, it was found impossible to persuade parents to consent to the removal of their children. In many instances, when it was too late, the refusal came to be lamented. Some patients, of course, were well isolated at home, and removal was unnecessary, but there were not wanting proofs that, even when the patients had "proper lodging and accommodation," either due care was not taken to prevent the spread of disease, or that no amount of care suffices, in some cases, to prevent its spread. In not a few instances where removal was absolutely necessary, the greatest difficulty was experienced in obtaining the parents' consent, and in a few cases it became necessary to have recourse to the compulsory powers of removal, such as they are, which the Sanitary Act of 1866 confers. It need hardly be said that a great majority of the cases were 22 of children, usually of school age, and in fact about 130 of the sufferers had been attending school up to the time of the attack. Every effort was made by co-operation with school-teachers and visitors, &c., to prevent the disease from spreading, and no child was allowed to go to school from an infected house. The existence of the disease was often revealed by the registration of a death, and it is the fact that the spread of disease was usually the result of keeping patients at home under circumstances that rendered nugatory any possible attempts at isolation. The subjoined histories are deserving of record in illustration of the necessity of removal when the patients cannot be safely isolated at home; the trouble in the first group of cases however arose from an error in diagnosis:— At a house in Elgin Mews, a hoy aged four years, fell ill towards the end of September, and a girl aged two, a few days later; they were medically treated for measles. Their mother falling ill shortly afterwards, another doctor was called in, who recognised all three cases to be scarlet fever. A third child fell ill on October 14. The mother recovered; the three children died on the 15th, 18th, and 29th October respectively. Had the first case been correctly diagnosed and removed to hospital, probably the trouble would have ended with its little life, supposing that life could not have been saved: as it was, the parents had to mourn the loss of their entire family. The father stated that if he had known the nature of the illness in the first cases, he would have had the children removed to hospital. A young woman came home at the end of August, to Portobello Road, from Kentish Town, with a sore throat, having been unwell for some days previously; with an unrecognised ailment, which no doubt was scarlet fever, for about twelve days afterwards, her sister, a married woman, fell ill with this disease. This woman's son, aged 3, was attacked on the following day, and her husband also a fortnight later. The child died. Recognition and isolation of the first case would have saved a life and prevented the illness of a married couple. At South Street, St. Mark's, there were four cases in one house. One of them, a fatal case (second in order of occurrence), was supposed to be measles, as by one doctor the first case also was. The occurrence of the third and fourth cases left no room for doubt as to the nature of the illness. Removal of the first case would have prevented the other three cases, and by consequence would have saved the life of one child. At Ifield Road, scarlet fever appeared in the family of an auxiliary postman in September. The first and second cases did well, and then three cases in 23 succession, in two families, proved rapidly fatal late in October. The removal of the first and second cases would have saved three lives. A child fell ill at a house at Stamford Cottages, St. Mark's, and died after an illness so brief that removal could not have been effected had the parents consented. .The other three children successively fell ill, the parents still refusing consent to removal. Two of them died, and the only remaining child had a narrow escape. Diphtheria, which was unusually prevalent in London in 1882, was the registered cause of 25 deaths in Kensington, or 5 above the corrected decennial average: 16 in the Town subdistrict and 9 in Brompton. Not all the deaths certified, and therefore classified to diphtheria, are really due to this cause. Cases of scarlatina anginosa, for instance, are sometimes erroneously certified as diphtheria ; and we had illustrations of the fact in 1882. On the other hand, it sometimes happens that true diphtheria is not recognised in the primary stage. In one such case the nature of the disease was not known until paralysis supervened. After seeming recovery the child had been sent out of town, and it was not until his return home that the insidious form of paralysis, which is so often the immediate cause of death in diphtheria, revealed the true nature of the previous illness. An inexplicable, but happily very limited outbreak of diphtheria, occurred in the vicinity of Holland Sreet in May. There were 4 cases, 2 in Holland Street and 1 each in Holland Place and Gregory Place. One of the sufferers, a boy aged 4 years, was removed to St. George's Hospital, and another boy, aged 2 years, to the Parish Infirmary ; both died after tracheotomy (opening the windpipe to prevent imminent suffocation). Two other cases, a boy of 4 years, and a youth of 17, recovered at home. In the four weeks ended August 12, the unusually large number of 5 deaths were registered, all of children, aged respectively 6 months, 15 months, 18 months, and 4 years (2). One of the cases was beyond question scarlet fever, and not diphtheria at all, for the skin was actively peeling at the time of death, and other 2 cases of scarlet fever in the same family were at once removed to the hospital The disease 24 in the other houses did not spread beyond the first case, and it is quite possible that some of the children had really suffered from membranous croup. Fever. The deaths from the 3 diseases grouped as " fever," were 32, viz., 28 in the Town sub-district and 4 in Brompton ; the decennial average, corrected for increase of population, being 38.7. Typhus. One death from typhus occurred at Princes Place, Notting Hill. The patient, a fishmonger's assistant, was too ill to be removed when first seen by the district medical officer, and the disease, which ran a rapid course, terminated fatally in five days. The room was disinfected, and there was not a second case. Enteric Fever was the registered cause of 25 deaths—viz., 22 in the Town sub-district and 3 in Brompton. Two of the deaths allocated to the Town sub-district occurred in hospital. This disease was, as usual, very prevalent in the Metropolis in autumn ; we had our share, but mainly confined to the northwestern part of the parish. Of the 25 deaths, 4 were recorded in my first monthly report, dated January 28, and 13 in the last three reports—November 4 (5 deaths), December 2 (5 deaths), and December 30 (3 deaths). There were not wanting illustrations of that want of accuracy in diagnosis in relation to this disease, to which I have adverted in former reports. Sometimes the existence of the disease was overlooked, and sometimes other diseases were certified as enteric fever. I have added to the tale of deaths one in which a jury returned a verdict of " perforation of the intestines " as the cause of death. The subject was a female, who refused to have medical attendance. Post-mortem examination revealed ulceration, characteristic of enteric fever, and as the cause of the perforation. One of the fatal cases was imported from the Isle of Wight. In my eleventh report, dated November 8,1 stated that 18 cases of enteric fever had been recorded since the end of September ; 25 13 of these were in the north district, including 8 in the practice of one medical firm. I have little doubt that there were a good many cases of which we never heard at all. The disease existed at Lockton Street, Bramley Road, Manchester Street, Silchester Terrace, Walmer Road, and Talbot Grove. The case at Talbot Grove was the daughter of a laundress : we endeavoured to get her removed to hospital, or alternatively to have the business temporarily suspended, or carried on at other premises, but without success. At one house in Lockton Street there were 6 cases in the family of a greengrocer, between Sept. 26 and Dec. 1. This outbreak, of which we did not hear till October 20, may have originated in sanitary defects, which the occupier, who was also the owner of the house, had promised to rectify. He was the first to be attacked, and he died after a lingering illness in December. The subsequent cases were probably due to infection, no special precautions having been taken to prevent the disease from spreading. It was unfortunate, in any case, that we could not get any of the patients removed to hospital: the family occupied the whole of a seven roomed house, and removal was considered unnecessary by the medical attendant. Not until many weeks after this outbreak was at an end, did I hear of another local outbreak, which appeared to be intimately connected with it. It occurred in a family residing in Manchester Street. There were five cases, and two of the sufferers, brothers, aged 17 and 11 respectively, had been in the employment of the greengrocer in Lockton-street. These youths fell ill some time in November ; a younger brother and a sister fell ill at the end of the month, and their father about the middle of December. The father and the eldest son died in hospitals outside the parish, and as none of the cases had been reported, we were in ignorance of the matter, until February, in the present, year, when I received from the Medical Officer of Health for Paddington, information of the son's death at St. Mary's Hospital. A question has been raised whether enteric fever is infectious ? I have already stated that there was ground for the suspicion, that the first case in the family, at Lockton-street, 26 originated from sanitary defects in the house (although there were several other cases in the locality at the time), but no such defects existed to account for the outbreak in the family at Manchester Street. It is probable rather, that one or both the youths, the first cases in this family, contracted the illness at the house in Lockton Street, where they were engaged as porters, and thus became the source of infection to the other cases. Not all medical men believe in the infectiousness of enteric fever, of which I, personally, entertain no doubt. Sometimes large numbers of cases occur simultaneously, and then the outbreak may usually be traced to specifically contaminated water, taken alone or in milk ; but the cases in the above group—eleven in two houses—fell ill successively, and in such a way as to suggest in the strongest manner that the later cases were due to infection. It was a lamentable affair, ending as it did in three deaths, including those of two fathers, each leaving a large family. Diarrhcea.—The deaths from diarrhoea, 61 in number, were so many as 70 below the decennial average, corrected for increase of population ; 54 of them took place in the Town SubDistrict, and 7 in Brompton. As usual, the deaths were mainly those of young children, viz., 56 under 5 years of age, including 45 under 1 year. Such a low rate of mortality from diarrhoea has not been recorded for many years: it was the result of the generally low temperature that prevailed in the summer months. The immediate causation of this. infantile scourge has never been clearly made out: probably the enquiry delegated by the Local Government Board to their Inspector, Dr. Ballard, will ultimately throw light on the subject. Small-pox.—Not one death from small-pox was registered in Kensington in 1882, and only 16 cases were recorded, viz., 7 (including three doubtful and concealed cases) in that portion of the parish which lies north of Uxbridge Road, and 9 in the remainder of the parish. Twelve of the cases were removed to hospital. 27 THE METROPOLITAN ASYLUM BOARD'S HOSPITALS. A suggestion having been made to the Managers that the Hospitals under their control should be distinguished " by the points of the compass, or by the postal districts," rather than by the names of the parish or union in which they are locally situated, the Managers have resolved, with the approval of the Local Government Board, that the several Infectious Hospitals shall henceforth be designated as follows:— Homerton Hospitals as the " Eastern District Hospitals," Hampstead Hospital as the " North-Western District Hospital," Fulham Hospital as the " Western District Hospital," Stockwell Hospitals as the "South-Western District Hospitals," Deptford Hospital as the " South-Eastern District Hospital." WESTERN DISTRICT (LATE FULHAM) HOSPITAL. No case of small-pox was admitted into this hospital in 1882; two patients admitted in January were found to be suffering from other diseases. The hospital was shortly afterwards closed. On 6th October the hospital was re-opened for the reception of scarlet fever cases, and on 25th November, for the reception of enteric (typhoid) fever cases, the parishes and unions of Kensington, Fulham, Chelsea, Wandsworth, and Clapham being allocated to it. At the end of the year there had been 165 admissions, of which 149 were scarlet fever, 13 enteric fever, and .3 "other diseases." Of the scarlet fever admissions, 139 were acute cases, and 10 convalescents from Stockwell Fever Hospital. Kensington contributed the largest number of cases, 31 per cent, of the whole, Chelsea standing next. Thirty-two per cent. of the admissions were " overflow" cases from outside the district allocated to the hospital. Nearly three-fourths of the admissions from scarlet fever were of children under 10, and no case proved fatal above that age ; nearly half the cases were of children between 5 and 10. Twice as many males as females were admitted. The mortality was at the rate of about 10½ per 28 cent. The average duration of stay of completed cases, was 58 days. None of the cases of enteric fever had heen completed when the year closed. Eleven of the employes suffered from scarlet fever, 8 being first attacks, but happily none of them died. Measles broke out in the hospital ; 2 children were admitted with the disease, and 11 children convalescing from scarlet fever were attacked: two of the cases proved fatal. I am indebted to the report of Mr. Sweeting, reappointed medical superintendent, for the above particulars. HOSPITALS COMMISSION. In my last annual report (at page 48) I alluded to the appointment in November, 1881, of the Commissioners to inquire respecting Small-pox and Fever Hospitals in the metropolis, and stated in full the subjects, under six headings, referred to their consideration. The Royal Commission consisted of the following gentlemen : Lord Blatchford (Chairman), Sir James Paget, Sir Rutherford Alcock, Mr. A. W. Peel, M.P., Mr. E. L. Pemberton, M.P., Dr. Burdon Sanderson, Dr. Alfred Carpenter, Dr. Broadbent, and Mr. Jonathan Hutchinson. The Commissioners held 37 meetings, at 32 of which they examined 48 witnesses, " comprising physicians of the highest eminence, the Secretary and several medical inspectors of the Local Government Board, managers and officers of the Metropolitan Asylums Board, Metropolitan Health Officers, District Medical Officers, &c." The results of their enquiry are set out in a blue book, published in the autumn, and containing an able and interesting report, dated July 21, minutes of evidence and several appendices, with maps, plans, &c. The Commissioners state that the questions on which they are called upon to report " relate to the prevention and control of epidemic infectious diseases in London and its neighbourhood, and concern mainly the operations of the Metropolitan Asylums Board, constituted under the fifth clause of the Metropolitan Poor Act, 1867." 29 The Report, which extends to some thirty pages, deals with the subject under sixteen heads, as follows :— 1. History of Asylums Hospitals. 2. Objects of Inquiry. 3. Behaviour of Small-pox in England. 4. Notification and Isolation of Disease. 5. Distinction of Pauperism to be abolished ; paying and non-paying patients. 6. Hospital Authorities. 7. Amount of Hospital accommodation required for pox. 8. Location of Hospitals. 9. Hospitals whether Centres of Infection. 10. Hospitals whether Centres of Infection by their Incidents. 11. Hospitals whether Centres of Infection per se. J.2. Distribution of Small-pox Patients. 13. River Hospitals. 14. Fevers. 15. Practical Recommendations. 16. Compulsory Purchase. Having in Sections 1 to 14 dealt with the subject generally the Commissioners continue as follows :— 15. Practical Recommendations. And now it will be convenient to preface our further recommendations by a recapitulation of those which we have already made. (1). " We are of opinion that the provision of hospital accommodation for persons suffering from infectious disease in the metropolitan districts should be entirely disconnected from the administration of the poor law, and treated as part of the sanitary arrangements of the metropolis. (2). " We think that the conduct of the hospitals cannot be better placed than under the management of the Metropolitan Asylums Board, with such changes in their mode of election as shall give the sanitary authorities of London—that is to say, the vestries, district boards, and commissioners of sewers—at least an equal influence with the guardians of tha poor in the choice of the elective members of the board. 30 (3). " We think that every person suffering from an infectious disease, or those in charge of him, or, if these neglect their duty, the occupier of the house in which the sick person is residing, or if he is a pauper, his medical attendant, should be required by law to notify the nature of the disease to the medical officer, of health so soon as they or any of them are aware of it; and that, in the case of non-paupers, the medical attendant should, if it is inexpedient to impose any further obligation on him, be similarly required by law to furnish the sick person, or those in charge of him, with a certificate of the nature of the disease, in the form which we have already suggested, to be by them communicated to the medical officer of health. On every certificate so communicated a small fee should be paid to the medical man who signed it. (4). " If the medical officer after receiving such a certificate is satisfied that the patient can and will be properly isolated, and requisite means of disinfection adopted, the matter will proceed no further. (5). " If he is not so satisfied, and if the sick person is not too ill to be removed, he will notify the case to the Metropolitan Asylums Board ; who will thereupon be at once and entirely charged with the patient till his complete recovery, and, in particular, will be empowered to remove him at once to one of their hospitals. So far no distinction should be made between paupers and nonpaupers who cannot be isolated. But within the hospital those who are desirous of being placed in separate wards should be allowed such accommodation on paying for it. In case of ordinary accommodation, it appears to us a question whether payment should be claimed even from those who can make payment without difficulty. (6). " If the sick person cannot be removed or isolated by those about him, the medical officer will be bound to take all necessary steps for his isolation, and generally for the protection of the neighbourhood, with power to clear the house of its inmates. In all cases he will be bound to disinfect the house, and in the case of houses invaded by small-pox, should be empowered to require the revaccination of all occupants who are not otherwise protected. (7). " We are led by the concurrent evidence of several experienced witnesses to hope that the immediate and complete isolation which ought to be secured by these means will greatly diminish the amount of small-pox, scarlet fever, and typhus in London. With regard to these, and also to typhoid, still further diminution may be anticipated if the attention of the proper authorities is directed to the removal of all local causes of disease, and to the constant employment of means of disinfection. And we feel bound to repeat our conviction that small-pox would be still further reduced if vaccination could be made more effectual and re-vaccination more frequent. But in what follows we take little or no account of these reductions. How far our recommendations will, from this cause, be in excess of what is eventually found necessary is a mere matter of conjecture. We hope they may prove considerably so. Meantime this uncertainty is a reason for proceeding somewhat tentatively. 31 (8). " Subject, therefore, to what may be expected from the above or other preventive measures, we think it would be advisable that there should be sites and buildings which could without difficulty be made capable of receiving 3,000 fever patients, and 2,100—or by special exertion 2,700—small-pox patients. (9). " Of the 3,000 fever cases, those in the earlier stage —probably about half—should be provided for in the near neighbourhood of London ; the other half—the convalescents—in two or three country hospitals. (10). " The existing hospitals of the Metropolitan Asylums Board which, in our judgment, can no longer be used to anything like their present extent for cases of small-pox, should, we think, become in the main fever hospitals. And we think it probable that with the aid of another hospital, which appears to be indispensable for the east of London, they would fully accommodate all the cases requiring London treatment. By these arrangements cases of fever would be adequately provided for. (11). " Of the 2,100 small-pox cases the mild and with them the convalescent cases, being probably more than three quarters of the whole, should be provided for in two or three more country hospitals. (12). " The remainder, being the severe cases, during their acute stage, must be provided for in or within easy reach of London. (13). " For these 400 or 500 persons who, being too ill to take a long land journey to the country hospitals, but at the same time not too ill to be removed from their immediate neighbourhood, cannot or will not be properly isolated by those in charge of them, we think, in the first place, that administrative blocks with a few small wards attached to them might be maintained within the precincts of the fever hospitals, sufficient, in each hospital, for 30 or 40 smallpox patients ; that the hospital authorities should divide the metropolis into hospital districts, assigning one to each hospital; and that no hospital should receive small-pox patients except from the district in which it is situated. " This qualification is required not only because the patients will always be such as must be sent to the nearest hospital, but also to obviate, as far as the nature of the case admits of it, the great and natural complaint of those who are in the neighbourhood of large small-pox hospitals, that the infection of the rest of London is poured in upon them. (14). " It is evidently of paramount importance that the areas of the smallpox wards as well as their administration should be rigorously separated from those of the fever hospitals, and further, that their construction should be such as to reduce within the smallest limits the chance of spreading infection. We fully believe that contrivances for this purpose might be devised, and we again call special attention to the evidence on this head which has been furnished to us by Dr. Burdon Sanderson. 32 (15). "This will provide for those cases which cannot be sent down the Thames. But we concur with Sir. W. Jenner and Sir E. Currie in thinking that others—and in years of severe epidemic a larger number—might be sent down the river to hospitals in isolated situations on its banks, or if this is found impracticable, to floating hospitals on the river itself. For this opinion we have already given our reasons. (16). " It is plain that under these circumstances small-pox or fever hospitals supported by parishes or unions, like those at Finchley and Plaistow, will become superfluous, and they will probably be disused unless either of them should prove available as hospitals of the Asylums Board. Concerning hospitals supported wholly or in part by charity it was not within our duty to inquire, except in so far as facts observed in them might help to elucidate the questions put before us. It seems only right to record that we received evidence of excellent management both in the Small-pox Hospital at Highgate and in the London Fever Hospital at Islington. We do not doubt that both these institutions have done excellent service to the public by their care of the sick, and in diminishing the risks of infection, by taking many from houses in which they could not be duly isolated. But we think it very doubtful whether the establishment of other hospitals of the same kind, either as charitable institutions or as places of reception for those who can pay, should be allowed unless they are to be subject to the general but effective supervision of the sanitary authority. (17). " The foregoing suggestions are calculated to meet in some degree the intermittent character of small pox visitations. If the hospital authorities had only to do with small-pox, they would have to collect a staff on occasion of each epidemic, and, if they did not wish to retain it in idleness, to break it up when the epidemic was past, just as it had effectually learnt its work. The experienced officers being thus in a great measure lost, a fresh, and, from the nature of the case, a less perfect machinery would have to be created when the next emergency occurred. The comparatively permanent fever establishments, however, will supply something in the nature of a cadre, which it will be comparatively easy to expand by the temporary engagement of fresh officers when the smallpox visitation arrives, and to reduce when it is past. (18). " With regard to matters of detail we have already recommended that the hospital authorities should have the entire control of the ambulances, by which all other modes of conveyance should be as far as possible superseded ; that the regulations intended to prevent the communication of infection by visitors should be strictly enforced; that the entrance appropriated to the sick should be entirely separate from that of the tradesmen, contractors, and others; that letters should be carefully disinfected ; that the nurses and attendants should not be permitted to leave the hospital except at longer intervals, and for proportionately longer periods; that great care should be taken respecting the exposure of infected clothes or bedding ; and that the greatest attention should be paid to the state of the drains in and around the hospital. To all these 33 tions, mainly for the protection of the neighbourhood, we attach the highest importance, and in the general interest we express a hope that means may be taken to secure that the unprecedented mass of information which has already accumulated, and is constantly increasing in the hands of the asylums' authorities, may be so studied and methodized as to become available for the advancement of medical science." It is hardly necessary to remind senior members of your vestry that many of the subjects dealt with in the above recommendation, had from time to time been under the consideration of your Yestry, which had in no uncertain tones expressed views which have now received the high sanction of this important Commission, having previously commended themselves to the approval of the Sanitary Authorities in the Metropolis. As an illustration, and for the information of members recently elected, I may refer to the subjoined " Propositions," which were drawn up for the use of your Vestry's delegates at a Conference of Metropolitan Sanitary Authorities appointed to consider the question of hospital accommodation for " non-pauper" cases. Having been " approved as fairly representing the views of the Vestry, as expressed at various times on the subject of the provision of hospital accommodation for persons suffering from infectious disease," the Propositions were communicated to the members of the Conference (in July, 1878), together with a reprint of that portion of my Annual Report for 1876, dealing with the Hospital question, under the heading, " Hospital Accommodation for the Non-Pauper Infectious Sick."* THE PROPOSITIONS were as follow, the figures in brackets referring to the Paragraphs in the " Practical Recommendations" of the Commissioners, treating of the same subjects :— * This Report, with the •'Propositions,'' was exte, sively circulated, having been forwarded to the Members of the Asylums Boards and the Metropolitan Board of Works, the Vestries and District Boards of Works, the Medical Officers of Health, the Boards of Guardians, the Medical and General Newspaper Press, &c., &c. The Report embodied views set out in my fifteenth Report for 1876, and in my letter to the Asylums Board (March, 1877), dealing with the same questions. "1 That the provision of hospital accommodation for the large class of persons whose isolation in hospitals is necessary for preventing the spread of infectious diseases can be best made in a comprehensive and systematic manner by one Central Authority acting for the whole Metropolis (2). "2 f\ That the Metropolitan Asylums District Board should be such Central Authority, the Managers already having, in the several hospitals erected under their auspices, nearly sufficient accommodation to meet the requirements of the sick of all classes, excepting those who may be able and willing to pay for hospital treatment, and for whom provision is already made, or could be made, at the London Fever Hospital, and the London Small-pox Hospital (2) (5). "3 That steps should be taken to obtain an Act of Parliament to alter the constitution of the Metropolitan Asylums District Board, by severing its connection with pauperism in so far as relates to the treatment of infectious diseases; and by providing for the election of a certain proportion of the ' Managers' by the several Vestries and District Boards of Works, the Sanitary Authorities within the Metropolis (1). " 4. That pending such legislative action, and seeing that the hospitals of the Managers have been established at the public cost and for the common good, no compulsory payment should be exacted from any persons whom the Sanitary Authorities may deem it necessary or expedient to remove to the hospitals for the sake of isolation; and all expenses incident to the maintenance of such persons in the hospitals should be defrayed out of the general rate (5). Note.—Under the proposed altered constitution of the Board, the hospitals should be supported out of a Metropolitan rate; or power might be given to the Managers to issue precepts on the several Sanitary Authorities for their quota of the expenses. "5. That the admission into the hospitals of persons suffering from infectious diseases should not involve the loss of any political or other rights by the said persons (5). Note.—It is proposed to place the treatment of infectious diseases on the same footing as Public Vaccination : in other words, admission into the hospitals should not be deemed to be Parish or poor relief. It has been ascertained that on the 15th February, 1877, the proportion of patients in the several asylums who acknowledged to having previously received parochial relief, was under ten per cent. The principles embodied in Propositions 1,2, and 3, so far as respects a " Central Authority," are expressed in terms of a Report to the Asylums Board by their Committee for General Purposes, dated Feb. 22, 1877 ; but the Yestry had previously adopted the principle of one Central Hospital Authority. 35 " 6. That in order to facilitate the stamping-out of infectious diseases, rovision should be made for the disclosure to the Sanitary Authority of all cases of such diseases in such manner as to the wisdom of Parliament may appear most expedient" (3). The influence of the above communication on the Conference qua provision of hospitals was decisive, the following resolution having been unanimously adopted, viz.:— "That in the opinion of this Conference many almost insurmountable obstacles present themselves to the carrying out by the Vestries and District Boards of the Metropolis of the powers conferred upon them by the 37th Section of the Sanitary Act, 1866; and it is further of opinion that it is desirable that provision should be made by Act of Parliament for one Authority acting for the whole Metropolis, to provide hospital accommodation for non-pauper persons suffering from infectious diseases, and that such Authority should be as far as possible representative." The above resolution, the Propositions, the report on " Hospital Accommodation" (1876), and additional information, viz., " Abstract of Evidence, "were by me submitted to the Royal Commission, together with the following resolutions, drawn up for, and unanimously adopted by, the Kensington Conference of Metropolitan Sanitary Authorities (1881), called to consider the questions of Notification of infectious disease, Compulsory removal to hospital, Gratuitous hospital treatment, &c., viz. : " 1. That in the interests of public health, and to enable Nuisance Authorrities to discharge the duty of checking and preventing the spread of infectious diseases, such as small-pox, scarlet fever, &c., provision should be made by legislative enactment to secure the compulsory disclosure to the said Authorities of all cases of such diseases immediately after their occurrence (3). " 2. That the provisions of the 26th Section of the Sanitary Act, 1866, (Section 124, Public Health Act, 1875), are insufficient for the protection of the public health, and should be so amended as to empower any justice to direct the removal to a hospital within the district of the Nuisance Authority, of any person suffering from any dangerous infectious disorder and being without proper lodging or accommodation which would enable him to be properly isolated, so as to prevent the spread of disease to other inmates of the same house, and to be properly treated (5). 36 " 3. That the admission into hospitals for the purpose of isolation of persons suffering from infectious diseases, and being without proper lodging or accommodation, is eminently desirable in the interests of the public and should be encouraged : that payment for the assistance given in hospital to such persons, removed thereto for isolation by the Nuisance or Poor Law Authority, should not be enforced; that the giving of such assistance should not entail on the recipients the loss of any social or political status; and that the cost of hospital treatment of such infective sick persons should be made a charge on the Metropolitan Common Poor Fund." The foregoing resolutions, I may mention, had been submitted to the President of the Local Government Board (April 23rd, 1881) by a deputation, at which, in addition to the Sanitary Authorities of the Metropolis, the British Medical Association, the Society of Medical Officers of Health, the Social Science Association (Public Health Section), and the National Health Society, were represented. To a certain extent the Deputation, so for as immediate results were concerned, seemed to have had little effect, for as respects the recommendations specifically dealt with in the resolutions, the President merely promised his " consideration." But Mr. Dodson was so deeply impressed at the time with the gravity of the " Hospital question " which, as he said, underlay the entire subject of " Compulsory Notification" and its corollary " Compulsory Removal," that he did not entertain any other, and having asked for definite information thereupon, I, having been invited by the deputation to supply such information, availed myself of the opportunity to state the views I had sometime previously submitted to the Asylums Board, on the necessity for making provision for the reception and treatment of mild and convalescent cases of small-pox in hospitals outside London, and gave it as my opinion that " the difficulty in which the managers found themselves placed " would vanish if such provision were made, the difficulty being that the hospitals were full, and hundreds of cases, consequently, were being treated at home, to the great danger of the public health. What follows is matter of history. The Local Government Board 37 cated with the managers of the Asylums Board, who gave effect to the excellent suggestion by Sir E. H. Currie, to utilise the Darenth site for a convalescent hospital. The hospital was opened on the 11th May ; as many as 600 patients were provided for in it at one time, and some 2,400 cases in all; the result being that the " hospital difficulty " was at an end, so far as the sufficiency of accommodation at the disposal of the managers was concerned. The experiment was so successful, indeed, that it is no matter for surprise that the ('ommissioners should have made the establishment of country hospitals for mild and convalescent cases of small-pox (and of fever also), the central feature in their " recommendations," justly recognising it as the practical solution of the difficulty. But to resume:—Your Yestry having steadfastly opposed every proposition to establish numerous local or district hospitals for infectious diseases, it is satisfactory to observe that the Commissioners (par. 16) are equally opposed to the multiplication of such establishments for reasons which closely correspond with your Vestry's objections, as set out in my fifteenth report for the year 1876, and repeated in my report on " Hospital Accommodation." The principle of "free hospital treatment" is strongly recommended—(" It is desirable in the public interest to attract to these hospitals, even by the bribe of gratuitous treatment, all who will go thither." Report, page xii.)—and provision of separate wards at the several Hospitals for those who are able and willing to pay for special accommodation, as was proposed in my report above mentioned. The Commissioners would greatly reduce the number of smallpox cases to be treated at any one centre in London, but they have recommended provision of a limited number of beds (30 or 40) for small-pox at each of the Fever Hospitals, a plan to which I made favourable reference in my " Abstract of Evidence." ( Vide Annual Report for 1881, page 52.) But I thought, and am still of opinion, that more beds for acute cases of small-pox might safely be set apart at each 38 hospital, provided that effectual steps were taken (such as the Commissioners recommend in pars. 14 and 18) for the proper isolation of the wards. Restrictions on the movements of nurses, &c., will, I am satisfied, be found imperatively necessary to success. ( Vide Abstract of Evidence, in Annual Report for 1881, page 52.) The Commissioners, at page xiii. of their report, draw attention to the question " whether the general superintendence of vaccination should not be transferred, with that of the hospitals, from the Poor Law to the Sanitary Authority ?" and state that their opinion is " distinctly in favour of such a transfer," a conclusion with which I entirely concur, having in a letter to the Asylums Board (March, 1877), " on grounds of public policy," proposed to " transfer the execution of the Vaccination Acts in the Metropolis " to a proposed new Hospital Authority, which was to be a purely Sanitary Authority. It is satisfactory to note that the Commissioners speak with no uncertain sound on the subject of "compulsory removal," which I have always insisted on as the corollary or complement to "compulsory notification." They say that, "in default of isolation (at home), the Hospital Authority should be bound and empowered to remove to the hospital any patient capable of removal without risk to life or serious aggravation of the disease and again—" without the power of removal the compulsory notification of disease would be of little avail." (Report, Page xi.) Speaking for myself, it is with no slight satisfaction that I find in this weighty Report the justification for nearly every principle in dealing with infectious diseases that I have advocated, chiefly in reports to your Vestry, at one time or another, during the last ten years, including, inter alia :— Compulsory Notification in all cases. Compulsory Removal in suitable cases. 30 Unity in Hospital administration, and representation of Sanitary Authorities on the Hospital Board. Separation of Hospital treatment from all connexion with poor relief ; or in other words — Abolition of distinction of pauper and non-pauper in respect of the treatment of infectious diseases. Free Hospital treatment of infectious diseases. Paying Wards for those who desire special or separate accommodation. Provision of additional Hospitals in London, with " skeleton staff of doctors, nurses, and other officers," capable of extension so as to cope with all emergencies. Provision of Hospitals in the Country for removable cases of small-pox, and for reception of all convalescent hospital-treated cases of infectious diseases. Transference of vaccination to the Hospital, i.e., Sanitary Authority. As respects the greater number of the above recommendations, Parliamentary sanction has yet to be obtained to give them effect : the principle of the main recommendation, however, that which may be said to be at the root of nearly all the others, viz., compulsory notification, has already, in numerous instances, found expression in Local Acts, and it has recently been approved in a Report by a Select Committee of the House of Commons, (Vide Annual Report for 1881, page 42), which Report, like the Report of the Commissioners, will assuredly form the basis of important sanitary legislation at no distant time. HOSPITAL ACCOMMODATION FOR THE INFECTIOUS SICK. The Royal Commissioners, in their " practical recommendations " (supra, page 32), express their concurrence with the view of Sir William Jenner and others, that in years of severe epidemic, when the urban hospitals are inadequate for the 40 ments of the metropolis, the sick might be sent down the river to hospitals in isolated situations on its banks ; or, if this be found impracticable, to floating hospitals on the river itself. This proposal appears to have commended itself to the Local Government Board, which, under the vigorous initiative of its new President, Sir Charles Dilke, recently addressed a communication to the managers, recommending the provision of " one or more floating hospitals, in addition to the Atlas," on the Thames, some 15 miles or more below London Bridge, " where the less acute cases of small-pox might be received." " Probably," they say, " land at no great distance from the hospital ships could be secured for the erection of buildings to which convalescent patients could be transferred." A steamer, with adequate appliances for the immediate treatment of the sick, would have to be provided for the conveyance of patients down the river, and " suitable places on the banks for the transfer of the patients from the ambulances to the steamers must be found." If the managers should be unable to secure such embarking places by voluntary arrangement, and if compulsory powers of purchase should be required, the Board would be prepared to consider the question of proposing legislation for conferring such powers on the Managers. No specific reference is made to the subject of additional accommodation for fever cases, the Board probably considering that when the existing hospitals (minus the beds to be reserved for small-pox), can be wholly devoted to this class of cases, the accommodation will prove sufficient for acute cases, at any rate ; the question of convalescent homes standing over. The Board conclude by assurances of their " desire to assist the Managers as far as practicable in meeting the difficulties with which they have to contend, and in securing the additional hospital accommodation which appears to the Board to be essential to the satisfactory discharge of the responsible duties with which the Managers are entrusted." The Managers lost no time in acting on the recommendation with regard to the ambulance, a design of a vessel having been prepared, and approved by the Local Govern- 41 nient Board, which, to judge from the engineer's description, should be very well suited for the purpose. But the managers would appear to be of opinion that the provision of shiphospitals, and their appurtenances on land, as proposed by the Board, will not suffice to enable them to carry out the recommendations of the Hospitals Commission: but that it will be necessary " to supplement these floating hospitals, &c., by the establishment of convalescent or other hospitals on land within a reasonable distance of the Metropolis," a step which the great success that attended the Darenth experiment would amply justify. Moreover they have urged upon the Board the " importance of asking Parliament to confer upon the Managers compulsory powers, not only for the purchase of wharves, &c., but also for the acquirement of additional hospital sites;"meanwhile having empowered their General Purposes Committee " to institute inquiries, with the view of ascertaining where such wharves and sites can be obtained." [After the above section was in type I had' the satisfaction of reporting to your Vestry, that the Managers, in taking active steps to carry out the recommendations, had made preliminary arrangements* for securing by purchase, with the approval of the Local Government Board— 1. The "twin-ship" Castalia, as an additional floating hospital capable of being fitted for the treatment of a large number of small-pox patients, for the sum of .£5,500. 2. Land to the extent of 8¼ acres at Long Reach, where the hospital ships are moored, for the sum of £1,000, and 3 The Gore Estate, consisting of 134 acres of land adjoining the Managers' property at Darenth, for the sum of £13,175. It is proposed, should the vessel be purchased, to moor her endon to the bows of the Endymion, which would then serve as an administrative ship for both the Atlas and the Castalia. It is also proposed to establish a Hospital for Convalescent * These arrangements were subsequently carried into effect. 42 Small-pox patients on the above-mentioned Gore Estate, which is within easy distance of the river and the hospital ships at Long Reach. The land at Long Reach is immediately abreast of the hospital-ships, and as there is here but little foreshore, the water rapidly deepening, at comparatively little cost a suitable pier could be constructed (with a dummy rising and falling with the tides), from which convalescent patients from the ships could be disembarked at any time and be conveyed by road to the hospital at Darenth. The land will also be suitable for the erection of buildings, if any are hereafter required in connection with the administration of the hospital ships. The contemplated arrangements thus indicated will suffice for the provision of hospital accommodation for a very large proportion of the small-pox cases occurring in the Metropolis, even in time of tolerably severe epidemics, should the estimate of the Hospitals Commissioners prove correct, viz., that provision will be required for " 2,100, or by special exertions 2,700 patients," seeing that it is intended to provide beds at each of the existing hospitals for a certain number of patients " too ill to take a long land journey." It is estimated that from 400 to 500 such cases would have to be provided for in a severe epidemic; the remaining cases, " being probably more than three quarters of the whole number" (i.e. 2,100, or 2,700) to be " provided for in two or three more country hospitals." The main difficulty hindering the collection of all cases capable of removal out of town, in the ships and at Darenth, is the distance that separates a large portion of the Metropolis from the river. For the cases occurring in the northern districts, probably an additional hospital, at some distance from the Metropolis, will have to be provided. Patients that can be conveyed to the river will doubtless be provided for in the ships, and at Darenth.] THE HOSPITAL AUTHORITY. In the communication to the Metropolitan Asylums Board alluded to in the previous section, the Local Government 4?. Board in advising the Managers to give effect to the views of the Royal Commissioners for providing additional small-pox hospital accommodation to meet all probable fixture requirements, expressed the opinion that the proposed Municipality Bill (subsequently abandoned for the current Session) should not be made a cause of delay, inasmuch as there was not any intention by that Bill to alter the constitution of the Board of Managers. The only question, the Board say, will be " Whether the care and management of the patients of the non-pauper class should not be clearly shown to devolve on the Sanitary Authority rather than upon the Asylums Board ? " It would thus appear that the Local Government Board do not agree with the Commissioners in their recommendations that (1). " The provision of hospital accommodation for persons suffering from infectious disease in the Metropolitan Districts should he entirely disconnected from the administration of the poor law, and treated as part of the sanitary arrangements of the Metropolis," and that (2). " The conduct of the hospitals cannot be better placed than under the management of the Asylums Board reconstituted so as to give the Sanitary Authorities at least equal influence with the Guardians in the choice of elective members." (" Practical recommendations," supra, page 29.) Probably it was as the result of an oversight that the Board recommended the Managers, as a poor law authority, to increase the already excessive accommodation at their disposal, regarding the hospitals as poor law establishments, in the same communication which suggested the creation of a separate authority for providing hospital accommodation for non-paupers. Be this as it may, I desire once more to reiterate my conviction that it would be a misfortune, and the reverse of economical, to have two hospital authorities, and that the proper course would be to abolish the distinction between pauper and non-pauper, placing the treatment of infectious disease on the same footing as public vaccination.* * "It is hereby declared that the Vaccination, or the Surgical or Medical assistance incident to the Vaccination, of any person in a Union or Parish heretofore or hereafter performed or rendered by a public vaccinator shall not be considered to be parochial relief, alms, or charitable allowance to such person or his parent, and no such person or his parent shall by reason thereof be deprived of any right or privilege, or be subject to any disability or disqualification." Section 26 : The Vaccination Act of 1867. 44 DISEASES PREVENTION (METROPOLIS) BILL. On the 2nd August, 1883, long after the previous section was in type, a Bill with the above title was introduced in the House of Commons by the President of the Local Government Board with the object of making " better provision as regards the Metropolis for the isolation and treatment of persons suffering from Cholera and other infectious diseases." Should the Bill pass, it cannot fail to have very considerable influence on the future of the Metropolis, regarded from a public health point of view, dealing, as it does, with questions of the first importance. For instance, Section 2 makes the Managers of the Asylum District a " Local Authority " under the Diseases Prevention Act, 1855,* thus constituting them a Sanitary Authority for certain purposes of Diseases Prevention, with powers to utilise their buildings, ambulances, staff, &c., for the execution of powers and duties conferred, or imposed, on them under the said Act, or this Act. By section 6, compulsory powers of purchase are given to the Managers, enabling them to obtain land, with approaches. &c., for three wharves or landing places, within the Metropolis, and one beyond the Metropolis (i.e., at Long Reach, where the hospital ships are moored), to facilitate the conveyance cf the Rick to hospital ships or hospitals on or near the Thames—this being the first occasion of such powers having been conferred. The Local Authority (i.e., Vestry or District Board of Works) will be empowered to borrow money for provision of hospital accommodation under the Sanitary Act, 1866 (Sec. 37), and a part of the money expended in this way, together with two-thirds of the salaries or remuneration of officers and servants employed in hospitals so provided, will be repayable out of the Common Poor Fund. • The Local Authority for executing" the Diseases Prevention Act is "the Local Authority acting in execution of any general Act in force for the time being for the removal of nuisances." 45 There are other provisions, but the Section which interests me most is 7, which depauperises the relief given in Metropolitan infectious disease hospitals. It is so important I quote it in extenso:— " The admission of a person suffering from any infectious disease into any hospital or hospital ship provided by the Managers, or the maintenance of any such person therein, shall not be considered to be parochial relief, alms, or charitable allowance to any person, or to the parent of any person, and no such person or his parent, shall by reason thereof be deprived of any right or privilege, or be subject to any disability or disqualification." At last, therefore, we have come within view of the concession by Parliament of a most important principle, for which I have been contending many years, but more especially since 1876, viz., that maintenance and treatment in hospitals of persons suffering from infectious diseases, and removed thereto for isolation for the protection of the general public, shall not pauperise such persons—in other words, admission into hospital shall not be deemed to be parochial relief, " so as to deprive the person, or his parent, of any right or privilege, or subject him to any social or political disqualification." Probably I should not be far out if I said we are indebted to the initiative of the President of the Local Government Board for this promised boon, Sir Charles Dilke having, with Mr. Rathbone and other Members of Parliament endeavoured, so early as the Session of 1878, to deal with the question in what was known as the " Disqualification by Medical Relief" Bill,* which ran as follows :— " From and after the passing of this Act. no person shall bo deemed to be disqualified to be registered as a voter or to vote at any election of a member or members to serve in Parliament for any county or borough, by reason only that he, or any member of his family, or any person whom he is liable to maintain, has before or after the passing of this Act, received medical treatment or relief for any infectious or contagious disease, as an in-patient or out patient of any hospital, infirmary, or dispensary, established or maintained by any Sanitary Authority or Poor Law Authority, or at which he has been so treated or relieved by the order, or with the sanction, of any such authority or the Medical Officer thereof.'' *In my annual reports for 1878 and 1879, I entered fully into the reasons for the introduction of this measure. Time and space forbid further reference to the subject now. 46 This Bill passed the House of Commons in 1879 : your Yestry petitioned in its favor, and urged other Vestries and District Boards to do likewise; but having been mutilated in the Lords, and so rendered practically useless, it was withdrawn. In my 14th report for 1878 (December 11th, page 95), I ventured to express the opinion that the object sought could be attained by a Bill, or clause, drawn in some such terms as follow, viz :— " It is hereby declared that the surgical or medical assistance incident to the treatment of any person in a union or pnrish hereafter removed to a hospital provided for the isolation and treatment of persons suffering from any infectious disease shall not be considered to be parochial relief or charitable allowance to such person, or his parent, and no such person or his parent shall by reason thereof be deprived of any right or privilege, or be subject to any disability or disqualification." Your Vestry having been the first in the Metropolis, and probably the first Sanitary Authority in England, to contend that admission of a person into an infectious disease hospital should not entail any disqualification, may fairly be congratulated on the concession of the principle by Parliament.* Your Vestry moreover, and for a long time alone, advocated the principle of "free hospital treatment" of such cases. That this principle will be conceded by law ere long, being already established in practice, I do not doubt. "Notification" with increased powers of " compulsory removal" must follow. No sanitarian now questions the necessity of these things in order to success in the contest with infectious diseases. The great Conference of Sanitary Authorities, held at this Town Hall in March. 1881, by an unanimous vote passed resolutions in favour of them, and last, not least, they obtained the equally unanimous support of the Hospitals Commission. With such a consensus of scientific, official, and popular opinion, legislation to give them effect can be but a question of time. * It is assumed that the Bill will pass. Introduced on the 2nd August, the third reading was taken on the 6th, there having been no opposition, and the measure, apparently, having undergone no alteration. 47 THE USE AND INFLUENCE OF HOSPITALS FOR INFECTIOUS DISEASES. Under the above title, Dr. Thorne Thorne, now the Assistant Medical Officer to the Local Government Board, has prepared a report containing the results of an inquiry made by him in 1880-1, at the instance of the Board. The report contains a great amount of information that will prove of value to sanitary authorities, and is the fruit of inspection of some seventy hospitals, in use by urban, by rural, and by port sanitary authorities, of every variety of locality, size, and construction," including some that were " ill-placed, or on an altogether insufficient scale, or badly planned, doing duty in default of better, though of flimsy material and hurried construction." Dr. Thorne endeavoured to learn what influences for evil, as regards the neighbourhoods surrounding the hospitals, had resulted from their use for the isolation of cases of infectious diseases, and it is satisfactory to know that he has " nothing to record of fevers, scarlet, typhus, enteric, or other infectious diseases, spread from the hospital, as such, to its neighbourhood." In respect of small-pox, however, he has " recorded two instances where infection had appeared to spread from a hospital in a row of houses, in a way that suggested conveyance of infectious matter through the atmosphere rather than by means of persons and things."* In many other instances Dr. Thorne heard of no extension of infection to neighbouring streets and houses, in spite of the best inquiries that he and officers of health before him could make. " When Dr. Thorne's inquiry was planned, it was not intended that it should extend to the Metropolis. This limitation was made partly for the reason that the circumstances of London were expected to be so intricate that the influence of hospitals on the population would be specially difficult to recognise .... representations, however, were received * " The hospitals in question were buildings which ought never to have been used by a Sanitary Authority for the isolation of cases of infections diseases, forming part, as each one did, of a row of dwelling houses." 48 by the Board, at the end of 1880, that cases of small-pox were occurring in an exceptional fashion round certain of the Metropolitan Asylums Board Hospitals, and it was felt that Dr. Thorne's experience on this subject, derived from hospitals in the provinces, ought not, without further inquiry, to be accepted as representing the whole truth for hospitals in London." The inquiry relating to the Fulham Hospital, made in the early part of 1881, by Mr. W. H. Power, one of the Board's medical inspectors, was the outcome of this view. Mr. Power sums up the results of his inquiry in certain conclusions, nine in number, concerning which Dr. Buchanan, the Medical Officer to the Local Government Board (from whose report the preceding quotations are taken), states he has "no choice " but to accept them, and to believe that the hospital, " with all its advantages of site and construction, and with the many excellences of its administration, has, by dissemination of small-pox material through the atmosphere, given rise to an exceptional prevalence of small-pox in its neighbourhood." "It is to be distinctly noted," however, that Mr. Power's report " relates to Fulham hospital only; and it is possible that the circumstances of that hospital are in some way exceptional, and that its experiences cannot be taken as true for other London small-pox hospitals." It should be added that several eminent medical authorities have, like Dr. Buchanan, accepted Mr. Power's conclusions, which, in a word, attribute the prevalence of disease in the district around the hospital—especially at " the commencement of an epidemic when acute cases are beginning to come in, in considerable numbers," and under favouring atmospheric conditions—to " dissemination of small-pox material,'' from the hospital. The Hospitals Commission, on the other hand, are of opinion that "personal communication" would equally well account for the observed facts. The question to be determined, therefore, is, whether the first cases of small-pox in the vicinity of a hospital, asuming them to be due to the hospital, are to 49 be attributed to dissemination or to personal communication, alone or conjointly? This question is so vital to the public-health interests of the Metropolis, that one naturally desires to contribute, in however slight a degree, to its solution. And first I would remark that the amount of personal communication going on between the hospital and the outside, not merely at the period of Mr. Power's inquiry, but at all times, was very great. Every nurse and ward servant was allowed to go out once a day for two hours; the day nurses in the evening, the night nurses in the forenoon, and this privilege was largely used by them, the average number of women leaving the hospital daily being eighteen. I felt it my duty, in the early part of 1881. to call attention to this excessive leave, as involving a possible danger to the district; but the Chairman of the Hospital Committee informed me that if "the limited opportunity the nurses now enjoy of meeting their friends outside the hospital were restricted," they would not keep a single nurse : the regulations, he said provided for a change of clothing, and bathing was encouraged ; but I need hardly say how difficult it is to follow up a number of young women, to see that regulations are carried out; and as for bathing, if practised, I suspect it would not extend to ablution, followed by disinfection, of the hair, a part exceedingly likely to become the vehicle of infectious matter. I ventured to make the suggestion, which the Hospitals Commission subsequently repeated, that the nurses should be kept strictly within the walls for a definite period, and then be allowed a longer holiday, after all necessary precautions in the way of change of clothing, bathing, &c., had been practised, in such a manner as to preclude the possibility of infection clinging to the person. I also suggested the desirability of providing common sitting rooms, with games, books, &c., to amuse and occupy the nurses, &c., during their enforced seclusion, a plan which afterwards was successfully carried out at Darenth :but at Fulham, it was said, "nothing we 50 can provide for the nurses would compensate for the loss of liberty:" even the provision of a "recreation room" was objected to. So far I have referred to the nurses, wardswomen, &c., these being naturally most nearly in contact with the sources of infection, but there were abundant other means of personal communication between the hospital and the district, viz: by non-resident officers (5), by tradesmen, artizans (6), dustmen, visitors, and callers (very numerous from infected localities, and by ambulance divers; to all of which Mr. Power refers, but without attributing to them any share in the causation of an outburst of small-pox (Jan. 26-30, 1881), on which in considerable measure his theory of aerial infection is based.* It will naturally bo asked what evidence there is that small-pox was spread by means of this excessive personal communication? I can only reply that little such evidence was obtained : much mischief, however, may have been done, and no one the wiser. The following case was suspicious:—The fiancee of a male servant at the hospital contracted small-pox; she had never gone within the hospital gates. I strongly suspected she had received infection through the man, but of course it could not be proved. Moreover, as she lived not more than a quarter of a mile from the hospital, her case might equally, in Mr, Power's view, be cited as an instance of spread by dissemination, but that it occurred in July; and, as Dr. Burdon Sanderson put it to me (question 4818), "no one suggests that the spread of smallpox after an outbreak has commenced is dependent upon atmospheric influence." Again, what suspicions does not a case like the following suggest? A medical man, whose servant was admitted into the hospital in January, stated that she informed him, that her nurse, who went to evening parties, had made up bows for her dancing shoes, while sitting at her bedside, and that before going to bed on her return, she used to come into *Mr. Power speaks of "some 70 occasions day by day of communication between the hospital and the district," but deems only one in six or eight of such occasions " worth consideration." 51 the ward to say "Good Night," without change of clothes. I quote this statement, by permission, to show how difficult it is to get nurses to obey regulations. Mr. Power, as already stated, admits that at the critical period in his inquiry there was an excessive amount of personal communication, with the outside, and from the outside, going on —there is nothing to suggest that it was unusual or anything but every day custom—and this is what he says regarding the communicability of small-pox by personal communication. It can be "readily transmitted to others by persons who have been in close relation with the disease, though they themselves may not suffer from it:" it may be transmitted "in clothing, parcels, &o," and it is capable beyond other diseases of "infecting susceptible persons after the briefest exposure to its contagion" These by no means exaggerated statements going to show the necessity of absolute isolation of persons brought into contact with small-pox patients, can it be justly said that the facts cited by Mr. Power himself bear out the further statement that "the current doings of the hospital" were "regulated with the express purpose of avoiding all needless communication with the outside ?". To my mind they rather suggest the idea of an infected ship in quarantine, to which visitors are admitted, and from which officers and crew are allowed to go out at discretion. Under such circumstances would the spread of disease from ship to shore excite surprise, or would it be reasonable to set it to the score of aerial infection ? In my humble opinion the question whether small-pox can be spread without personal communication, say at a thousand feet distance, can never be satisfactorily settled until proof of spread without possibility of such communication has been given. The facts stated by Mr. Power do no more than raise a suspicion that infection may have been disseminated through the atmosphere: they do not exclude the probability of personal communication as the starting point in the spread of disease in the surrounding district. On the other hand, there are striking illustrations of the fact that if personal communication 52 be excluded, small-pox does not spread at even moderate distances, and to these the Hospitals Commission allude at page 26 in their report. The strongest case in point is that of the Infirmary of the City of London Union at Homerton, cited by Dr. Collie. The windows of this institution are within a hundred feet of the windows of the Homerton Small-pox Hospital, and yet small-pox has never spread from the hospital to the infirmary, there being no means of personal communication between the inmates of the two buildings. Small-pox has spread around Homerton Hospital in other directions, but under circumstances of which an essential feature was the opportunity afforded for personal communication or contact. Around this hospital, moreover, the originally open ground has been covered with buildings up to the walls. Fulham Hospital, on the other hand, is wonderfully well isolated, being surrounded on every side by large open spaces. The nearest houses in Kensington are at a distance of some 800 feet from the boundary fence of the hospital site, and separated from it by the width of Brompton Cemetery, which is full of trees. These nearest houses however, are in Ifield Road, and in this street there have been more cases of smallpox than in any other—a fact that has impressed the public imagination, being held almost to prove the dissemination of infection through the air from the hospital: in 1881 there were more cases than ever, but the disease disappeared months before the hospital ceased to receive "acute" cases. The instructive facts with regard to small-pox in this street, in 1881, were fully set out in my evidence before the Hospitals Commission: with what effect may be inferred from the statement in their report that they ''lay no stress" on "an outburst in Ifield Road, which has occasioned so much controversy in relation to Fulham Hospital." And yet probably there were more cases in this street (42) than in all the remaining streets within a quarter mile of the hospital. The next largest number of cases occurred in Finborough Road. This street is in part a continuation of Ifield Road, and 53 nowhere is it more than a few yards more distant from the hospital. It contains a larger number of houses and an equally large population, and yet there were but six cases. In the majority of streets invaded, the cases were solitary, that is. there was but one case in a street in the course of the year.* In some streets equally near the hospital there was not a case, and in streets in Fulham closest to the hospital—and on, or close to, the ambulance route, the disease was conspicuous by its absence. As respects Ifield Road, I may state that I was unable to trace the origin of the first two or three cases—and if untraced cases are to be set down to the account of dissemination, judgment against the hospital must go by default. But I was able to account for more than a moiety of the 42 cases; tracking the disease from person to person, from house to house, and, as I believe, in two instances, from hospital to house, through the agency of patients prematurely discharged at a time when the pressure on the very limited accommodation was considerable. The case against the hospital, qua aerial infection, appears none the less strong in Mr. Power's mode of stating the facts, viz., in percentages of houses invaded by disease (in a quartermile circle, and in three outer, quarter-mile, rings constituting the special area," a circle of a mile radius drawn around the hospital) without reference to the actual number of homes, or to the classes of persons resident in the several divisions. Great importance is attached to the "graduated intensity" of infection from centre to periphery. It is stated, for example, that between March, 1877, when the hospital was opened, and the end of March, 1881—a period covering the admission of 2,527 cases—small-pox invaded 6 37 per cent, of the houses within the special area ; the percentage of houses invaded in the quarter-mile circle being 17.35, whereas it was only 9.25 *Small-pox invaded 68 streets in Kensington within the "special area" in 1881. In 34 streets there was one case only; in 19 streets 2 cases; in 9 streets 3; in one street 4; in three streets 5; and in two streets (one being Cromwell Road) 6; while in more than 100 streets there was not a case. In many instances the origin of illness was easily traced, and in some streets the second and subsequent cases were clearly due to infection by primary case3. 54 in the first ring, and fell to 6.16 and 2.57 in the two outer quarter.mile rings. But in the inner quarter mile circle there are only 432 houses, occupied to a considerable extent by the poorer classes, while in the three rings, counting from within outwards, there are 3,488, 4,224 and 3,569 houses respectively, occupied for the most part, in Kensington at least, by well.to.do people, the outer ring moreover being to a considerable extent uncovered by buildings. In the inner circle,17 35 percent, of the houses were invaded, the actual number being 75; in the first ring, quarter to half mile, only 9.25 per cent, of the houses were invaded, but the actual number was 320. During the three months covered by Mr. Power's inquiry, small.pox appeared in 13 houses only, within the inner circle, but these count for 3 per cent., whereas in the first of the outer rings 54 houses, or four times as many, were invaded, but these only count for l.54 per cent., or just half the percentage in the inner circle. The following table from Mr. Power's Report will make these points clearer, but I have added to it the total number of houses, and the number of houses in which small.pox occurred, in the special area, and in each of its divisions. TABLE SHEWING admission of acute small.pox to Fulham Hospital, and incidence of small.pox upon houses in several divisions of the special area during five epidemic periods. Cases of acute smallpox admitted. In epidemic periods since opening of hospital. Incidence on every hundred houses within the special area and its divisions. On total special area. On small circle 0—¼ mile. On first ring ¼.½ mile. On second ring ½.¾ mile. On third ring ¾.1 mile. 327 March '77, end '77 1.10 3.47 1.37 1.27 .36 714 Jan. '78, Sept. '78 1.80 4.62 2.55 1.84 .67 679 Sept. '78, Oct. '79 1.68 4.40 2.63 1 .49 .64 292 Oct. '79, Dec. '80 .58 1.85 106 .30 .28 515 Dec. '80,2 Apr. '81 1.21 3.00 1.64 1.25 .61 2527 Five Periods 6.35 17.35 9.25 616 2.57 Number of Houses in Special Area 11713 432 3448 4224 3569 Number of Houses in which small-pox appeared (in four years) 748 75 320 261 92 65 It is said that the same evidence of "graduated intensity" has been observed in connection with the spread of small-pox around the other hospitals; but I think it will be found that in respect of some of them, if not all, the ground is covered with houses up to the walls, and that the incidence of disease diminishes rapidly from centre to periphery, being little, if at all, marked at a distance at which in the district of Fulham Hospital the incidence of infection begins to be felt, the intervening space being, for the most part, unoccupied ground. Thus at Stockwell we are told that "the sickness appears to have been intensified within 200 yards of the hospital, but not sensibly beyond that limit." Within that limit of Fulham Hospital there are no houses in Kensington, and there was little sickness in the houses in Fulham. Mr. Archer Farr, late Medical Officer of Health for Lambeth, however, a supporter of the aerial theory of infection, finds no difficulty in the spread of disease over far wider open spaces. He believes, moreover, that a high brick wall—level with the roof of a single storey hospital—would be a far more efficacious protection to a district than an open space. Dr. Bristowe, Medical Officer of Health for Camberwell, on the other hand, recognises the value of open isolating spaces around the hospitals, and thinks 100 yards interval adequate for the protection of the surrounding neighbourhood. Dr. Tripe, Medical Officer of Health for Hackney, to a certain extent supports the theory of concentration of poison, and aerial dissemination, having suspicion that infection has spread to a distance of 110 yards when more than 50 patients have been in Homerton Hospital at one time; but he has no ground for suspecting the aerial dissemination of infection at 200 yards however overcrowded the hospital may have been. Even Mr. Pearson Hill, so well known in connection with the Hainpstead Hospital case, appears to be of opinion that infection does not spread further than 300 yards from the hospital. By way of comment on Mr. Farr's views, I may state that at the London Small-pox Hospital at Highgate, patients are never put 56 on the ground floor, under cover, so to say, of the protecting boundary walls of the site.* It is the fact moreover, that the ridge of the roof of the Fulham Hospital is about on a level with the top of the wall separating Brompton Cemetery from the West London Railway, so that, standing with one's back to I field Road, on the raised terrace in the Cemetery, and looking westwards towards the hospital, distant some 800 or 900 feet, nothing can be seen over the trees besides, the ridge of the roof. The power of foliage in arresting the spread of malaria is well known. Ifield Road is protected by a perfect grove of trees, many evergreen, and by fences, yet it is alleged by some that small-pox infection—vaulting over all impediments, and carried by the wind, invades this street especially; another theory, however, making the disease-germs rise gently, under favoring conditions, when there is little air-movement, to become deposited in all directions uniformly, even to a distance of a mile, or a mile and a half, from the hospital. Mr. Power favours the latter view, considering a still atmosphere essential to the spread of small-pox infection ; but, as it is almost needless to say, the majority of those who are opposed to small-pox hospitals hold that wind is the chief factor in the spread of the disease. Assuming this to be so, this further difficulty meets us—and I proved the point before the Commissioners—that whereas a south-west wind, which would carry infection to the north-east, is four or five times as prevalent as a north-west wind, which would carry infection to the south-east, by far the larger amount of small-pox in I field Road, in 1881, occurred to the south-east of the hospital. Are we therefore to infer that small-pox travels against the wind? And, referring again to the alleged protection of fences (in which connexion Mr.Farr stated that small-pox had relatively ceased in a particular street near Stockwell Hospital, after the completion of another street interposed between it and the hospital), I may *Dr. Munk, Physician to the Hospital, says "There is one point of great importance: you should have no patients on the ground floor for the sake of the surrounding neighbourhood." (4598—9.) 57 mention that there were more cases of small' pox on the side of I field Road farthest away from the hospital, than on the nearer side, while there were none at all in Adrian Mews, which is about opposite, and still nearer, the hospital, lying to the west of Ifield Road, under the Cemetery wall. But to resume, and admitting small-pox to be more prevalent around hospitals than elsewhere,* does it follow that the disease is spread by dissemination of " particulate" small-pox matter from the hospital as alleged ? This is a question which the Commission carefully considered, and at page 25 in their report they have given "a resume of the case for atmospheric dissemination," on the evidence brought before them, whilst on the following page they state the grounds that may be urged against a belief in widely extending atmospheric dissemination, and which may be employed in support of a (more probable) theory of spread of infection by "personal communication." They refer also to an admission by Mr. Power that "the graduated distribution of disease around the hospitals is as explicable by personal communication as by atmospheric dissemination." "With such a hypothesis," says Mr. Power (meaning that of dissemination), "equally with a hypothesis of conveyance by human movements, the gradation of hospital influence from centre to periphery would be in complete accordance: "the italics are in the Commissioners' report. "The admission is so material that it ought to be developed. Let us," say the Commissioners, "replace the image of a wave, which is suggestive of one hypothesis, by an image equally appropriate, but adjusted to the other. Instead of an expanding wave, let us imagine a number of converging and diverging lines of infection. It is plain in the first place, that along these lines—the lines of hospital communication— the incoming and outgoing of persons and things would offer more occasion of disease wherever these persons or things were likely to pause in their route, aud by consequence more in the immediate neighbourhood of the hospital than farther off. But disregarding this "The Hospitals Commission, however, refer to the fact that evidence was given of districts remote from hospitals presenting a greater intensity of small-pox than in any of the hospital districts—an intensity attributed to overpopulation, neglect of sanitary precautions, &c. (vide Report, page 23). 58 effect of propinquity, and supposing that one quarter of a mile is as fruitful in occasions of contact with the carrier of infection as another, let us imagine that, on the different lines of communication which radiate to and from the hospital, infection is shed equably along the whole of their courses, and is represented on a diagram by black lines, varying in breadth according to the amount of infection which is dispersed, and in length according to the distance along which it is carried. It does not need the actual inspection of such a diagram to perceive that the effect of these lines in blackening each successive hospital ring will constantly increase as they close in on the centre; or, in other words, that the converging incomings and outgoings of the hospital would produce exactly that 'graduated intensity of infection,' from which, prior to reflection, we are tempted to infer an expanding wave. The argument is capable of arithmetical statement, and it would be easy, if it were worth while, so to exhibit it." Having thus reported "the chief grounds for accepting or rejecting the theory of distant atmospheric dissemination of small-pox," expressing no opinion of their own, the Commissioners conclude by saying—and who will not agree with them?—"that so long as it is not proved that 'personal communication' is adequate to the explanation of the whole spread of small-pox ; and so long as distant 'atmospheric dissemination' is not shown to be in the highest degree improbable, so long it is essential that in the construction and management of small-pox hospitals, both sources of danger should be with the utmost care guarded against." I might well leave the matter here, but my observations would be very incomplete without a reference, however brief, to a striking incident graphically described by Mr. Power, and which ultimately led him on to momentous conclusions. The hospital began again to receive patients (convalescent cases) in December, 1880, and before the end of the month a few acute cases, 16 in all, had been admitted. By the 22nd January, 11 cases had occurred in the three parishes of Kensington, Chelsea, and Fulham, 7 of them in the "spccial area," but at a distance of more than half a mile from the hospital. More than half of the seven, there was reason to believe, had 59 been in contact with small-pox, and it seemed probable that, if the facts could be ascertained, a similar explanation would have been forthcoming in respect of the remainder. In the next fortnight, ending February 5, there was a "notable outburst" of small-pox, the number of cases in the three parishes going at a bound, from 7 in the preceding fortnight, to 62. Of this number 47 occurred in the "special area." Forty-two persons were attacked in five days, January 26-30, including 32 in the special area. Evidence was got, or reasonable suspicion could be entertained, in nine cases out of the 32, that the sufferers had been in personal relation, direct or indirect, with small-pox: in respect of the remaining 23 persons, "there was scarcely a hint to be got to account for their illness." Mr. Power lays great stress on the atmospheric conditions, characterising the five days (January 13-17) on which these 32 persons must have become infected, to wit: "severe frost, still, sometimes foggy, weather, occasional light airs from nearly all points of the compass, and absenceof ozone in the atmosphere at Greenwich."* These conditions came to an end by a notable snow-fall on January 18, accompanied by a heavy gale from E.N.E. The effect of these conditions, Mr. Powers states, was to produce "opportunities of a remarkable kind, not for the removal of matters contained in the air, but for the quiet dissemination of matters contained in the air, and for the deposit, perhaps, of any that were particulate.'' The incidence of small-pox, he adds, was almost the same in all directions from the hospital as a centre, but the intensity (measured by the percentage of houses invaded) was proportioned to the nearness of the houses to the hospital. In these days, he adds, "an increasing number of acute cases of small-pox being received at the hospital, was charging the air of the hospital with abundance *Some years ago Dra. Tripe and Burge, the Medical Officers of Health for Hackney and Fulham respectively, male simultaneous observations with regard to ozone, and found that when ozone was present in the air at the east end of London it was absent at the west end, and vice versa. The presence of ozone at Fulham, therefore, is made more probable by the recorded absence of ozone at Greenwich. 60 of infection in an active state." We shall see presently how few the cases actually were. Of the 32 cases occurring in the special area, January 26—30, twelve were in Kensington, but at distances from the hospital ranging from 350 to 1,650 yards. The sufferers were:—a scavenger working in Chelsea, but living in North Street, St. Mark's; a child three years old, living in South Street, St. Mark's (a somewhat doubtful case, "eruption undeveloped," and death occurring on the third day); a daughter of a coachman, aged 18, living in I field Road; a florist's assistant, who slept in Ifield Road, but was away from the locality from six a.m. till nine p.m.; a lady living at Redcliffe Street, a schoolboy, aged six, living at Stamford Cottages, St. Mark's, and six domestic servants* residing respectively at South Street, St. Mark's, Redcliffe Gardens, Tregunter Road, Gledhow Gardens, Earl's Court Square, and Stanhope Gardens. Four of the 12 cases thus occurred in the confined area, a cul-de-sac, approached by St. Mark's Road, Fulham Road, and at a distance of about 1300 feet, as the crow flies, over an open space, from the hospital: the fatal case and the case of a servant occurred in adjoining houses in South Street: the Stamford Cottage case, and the case in North Street in the same district, were at a very few yards from these. The servant, I may add, was removed to hospital compujsorily, her mother persisting in going out charing day by day: the boy in Stamford Cottages went under threat of compulsion: the scavenger went voluntarily. The disease was thus "stamped out" in this district and no similar " outburst " occurred.† *Half the Kensington cases, it will be observed, were domestic servants. In no recent epidemic has the proportion of domestic servants attacked been less than 25 per cent, of total cases. In 1880 the proportion was 33 per cent. Generally there was no other case in a house than the servant. I state the facts quatUum valeant—merely adding that the suggestion that servants get small-pox through the sewers has no warrant in fact, in Kensington, at least. + Mr. Power stated (5,486), "There is a good deal of intercommunication" (in the St. Mark's district), "children playing together in the streets so that I am not able to say they do not get small-pox from communication with antecedent cases when the disease has become established there." Five cases occurred in the district, singly, in the remainder of 1881,—all of adults (Baker, Plasterer, Bricklayer, Porter, and single woman. All the cases went to hospital: two of the men walked in), 61 I did not hear of the majority of these 12 cases till after they were in hospital, and 1 am free to confess that I can throw little light on the origin of them. 1 pass on to observe therefore, that the last of the five infection days of the cases whose visible illness began between Jan. 26-30, was Jan. 17, (the usual period of incubation in small-pox being thirteen days) and that there had been admitted into Fulham Hospital, at that date, only 55 acute cases in all, viz.:—4, 5, 14, 14 and 18 in the five weeks ending Jan 17 ; five of the cases came from Kensington, Chelsea, and Fulham, including two from the "special area." Now, mild cases convalesce rapidly, and three-fourths of all the cases are mild: it follows that on the infection days, January 13-17, there were very few really " acute " cases in the hospital. Indeed, information supplied by Mr. Sweeting, the resident Medical Superintendent, goes to show that on January 15 there were only ten persons on the "low diet," given during the acute stage of illness, and this number had risen to 17 only on the 22nd. So small absolutely, was the "increasing number of acute cases" which, "charging the air of the hospital with abundance of infection in an active state," led to the "notable outburst." Convalescents were more numerous, 99 and 93 on the 15th and 22nd respectively; but convalescents, it is said, do no mischief. Admissions went on increasing day by day till a maximum of 300 was attained at the end of April: the number of acute cases (i.e., persons on low diet) was highest, averaging 80, in the month of June*: yet notwithstanding these large numbers, no similar " outburst " occurred.† *At the middle of this month there were upwards of 1,600 cases in the several hospitals of the Managers, including 600 at Darenth. The opening of the "Camp Hospital" gave great relief to Fulham, but as convalescents were removed as soon as possible, it followed that while the total numbers decreased, the relative proportion of acute cases increased, so that on July 30, when the number in hospital had fallen to 115, there were no fewer than 53 acute (or low diet) cases, there having been only 56 acute (low diet) cases April 30, when the number in hospital was about 300. Ten, or at any rate less than 20, acute cases in January led to the "notable outburst," but in August, with ail average of nearly 50 acute (low diet) cases daily, no mischief was wrought in Kensington, the weekly number of cases south of Kensington Road (population 80,000) averaging less than two, and not one case having occurred in Ifield Road, the street nearest the hospital. †It may be mentioned that the new cases in the three parishes fell in the fortnight ending February 19, from 62 in the preceding period, to 38, including 62 But it is said, and not by Mr. Power only, that the dissemination of small-pox matter through the atmosphere is always most marked "at the commencement of an epidemic,''* and therefore such outbursts were not to be looked for at later periods ; when, moreover, it came to be " seen that a considerable proportion of small-pox cases in the special area were in persons who had had more or less opportunity for getting small-pox in a commonplace way by communication with persons or things previously infected," So, then, it would appear that so few as ten to twenty acute cases in hospital will suffice to produce small-pox matter adequate to infect the "\special area," i.e., a circle two miles in diameter (=31/7 square miles), at the commencement of an epidemic, given a particular condition of the atmosphere favourable to its spread; aye, and at a bound will do more mischief than three times as many acute cases in hospital when the epidemic is at its height: when, moreover, the district is, so to speak, full of infection, and the small-pox kept at home is admittedly adequate to explain the spread of disease in "commonplace ways." It is hard to believe! Mr. Power's fifth proposition reads thus: "The appearance of excessive small-pox in houses around the hospital has never been delayed until the hospital has become full, or nearly full. It has been always most remarkable at the time when admissions to the hospital were beginning to increase rapidly. "In the succeeding months of active operations, though the use of the hospital may have gone on increasing, the excess of small-pox upon the neighbourhood has habitually become less marked." The statement in the sub-section, at any rate, is true enough ; whether it is consistent with the theory of aerial infection is another question. 29 in the special area, the houses newly invaded from 41 to 21; and in the three following fortnights (to April 2, when Mr. Power's enquiry ended) the new cases were 59, 59, and 41, of which 38, 28, and 26 were in the special area. *Dr. Bristowe observes with reference to Deptford Hospital that "the tendency of cases to aggregate round the hospital is usually at the close of an epidemic." (488.) 63 In the course of my examination, the facts of the above "notable outburst" were communicated to me, and I was asked whether there had been any similar outbursts around the hospital? I knew of only one, and that one still more severe, occurring in the month of April, 1878.* Thirty cases were admitted into Fulham Hospital from Kensington, mostly from the "special area," in six days (April 15-20), in addition to 27 admitted from Chelsea and Fulham, and irrespective of home treated cases. This outburst, however, occurred not at the ''commencement of the epidemic," but when the epidemic was at its height: the atmospheric conditions, moreover, on the infection days (approximately March 30—April 4) were very different to those of January 13—17, 1881. The mean temperature, (40°) it is true, was below the average, but, it was 18° higher than in January, 1881: the atmosphere was clear, not foggy, the air was not still, for the horizontal movement, on an average, was 90 miles per day in excess, the general direction of the wind being S.W.†: lastly, ozone was present in the air. Here then we have two "notable outbursts" occurring under conditions as opposite as can well be imagined, so that inferences drawn from facts in respect of the one, qua origin, are neutralized by inferences fairly deducible in respect of the other, There was, however, one feature common to the two periods, and a most important one, to which I alluded in my evidence, viz., a sudden rise in the quantity of small-pox in the metropolis generally. "There was a great increase in the number of cases, and a great increase in the mortality: a concurrence of great local prevalence and great general prevalence of the disease : the number of patients in Fulham Hospital and the number of patients in all the hospitals rose rapidly," and as regards the April, 1878, "outburst" the deaths *Vide Appendix to Report of Commission, pages 267 and 361. †The hospital records show only five oases infected, April 7—13, on which days the wind was continuously east, or easterly : on the "wind theory" many persons should have been infected in Kensington in this week, but four of the five cases were in Fulham, 64 in London from small-pox were more numerous than in any other week in the year. Mr. Power states that "periods resembling in their meteorology (especially in the small movement of air and the absence of ozone) may be found in front of each of the more notable epidemic extensions of small-pox in the neighbourhood round the hospital." I do not know to what particular periods he refers—I cannot find them—but the meteorological tables published with his report show that periods resembling in their meteorology the period January 13-17 (especially in the small movement of air and the absence of ozone) occurred before and after those days, without producing any ill effects on the district, e.g., January 2, 3, 4, and January 20, 21, 22, 23 and 24. On January 2, 3, 20, 22 and 24, the weather moreover was foggy, and on January 20 and 21 the mean daily value of the thermometer was below freezing point. Did time and space permit, I might extend these observations to far greater length, but I have said enough perhaps, for my purpose, which is to direct attention to the momentous issue involved in Mr. Power's conclusions. If personal communication—not from the hospitals merely, but in whatever way brought about—be the true explanation of the spread of small-pox around the hospitals, it should be possible by improved management, and by rigid isolation, to diminish, if not wholly to remove, the risks attendant on their presence; but if the theory of aerial infection be the true explanation of observed phenomena the attempt to stay the plague is all but hopeless, and the very cautious scheme of the Royal Commissioners, which contemplates the retention of some 30 or 40 acute cases in each of the town hospitals, will have to be abandoned. For consider how small a number of acute cases had been admitted up to the last of the infection days of the " outburst," which terminated 65 January 30, 1881 : only 55 in a period of five weeks. I drew the particular attention of the Commission to this point, because the numbers were so very small absolutely, and so small in comparison with the numbers later on, when, however, it was said that atmospheric influence played no part in the spread of disease; and because it seemed to me that if Mr. Power's conclusions were right, if the atmospheric theory, as I understand it, were true, this important deduction must be drawn from the facts, viz., that a hospital, however small, must be a public danger, even at 1,000 feet distance and upwards, and would be such a nuisance as ought not to be inflicted on any locality. Ardently and successfully as I have advocated the provision of country hospitals for cases able to be removed to a distance, I know that there must always be a considerable residuum of sick persons imperatively needing to be isolated, and yet too ill to be taken long distances. These will be the worst of the acute cases, and for them alone Town Hospitals are to be retained. But if the theory of concentration of poison, and its dissemination atmospherically, is true, a continuance of the evils hitherto experienced may be anticipated, and it would probably be found better to keep the sick at home, emptying the infected houses of their other inmates, at whatever cost, than to inflict dire injury on the surrounding districts by transferring them to the hospitals. At present I would fain hope—notwithstanding the weight properly attaching to the opinions of those eminent authorities who have endorsed the views set forth in Mr. Power's able, laborious, and conscientious report, that the attractive theory formulated in his propositions, accounting for the spread of small-pox in the vicinity of hospitals by aerial dissemination of infectious matter, will not be generally accepted without further investigation and more decisive evidence. 66 COMPULSORY NOTIFICATION OF INFECTIOUS DISEASES. In several of my Annual Reports I have referred to the need of legislation to secure immediate information to Sanitary Authorities of the occurrence of illness from some of the more dangerous infectious diseases; and in the Report for 1880 (page 44) I gave a full account of the steps that had been taken by means of legislation, in the shape of "Local Acts," to secure such notification in certain provincial towns and boroughs. The subject was continued in my Report for 1881 (page 40), and 1 stated that, as the desirability of the extension of such legislation in the shape of a Public Act was generally acknowledged, it only remained for the Government to introduce a measure for the purpose of securing notification. In the last Session of Parliament, several Private Bills, providing for Police or Sanitary Regulations, were introduced at the instance of Provincial Corporations, and referred to a Select Committee, of which Mr. Sclater-Booth, an exPresident of the Local Government Board, was the Chairman. In their Report on the "Sanitary Regulations "the Committee stated, with respect to "Notification," that they had "little difficulty in forming the opinion that the time had arrived when provisions of law on this subject may be sanctioned, at least in the more important Urban Sanitary Districts." Encouraged by this report Mr. Hastings, who was a member of the Committee, with Sir Trevor Lawrence, Dr. Farquharson and Mr. Brinton, have recently introduced a Bill "To provide for the better Notification of Infectious Diseases," drawn on the lines sketched by the Committee in a "Model Clause," which will be found at page 44 of my last Annual Report. Without entering into details, I may state that the Bill proposes to throw upon the householder, and upon the medical attendant, the duty of notifying cases to the Medical Officer of Health—the so called "dual system." The gentlemen named are active members of the Social Science Association, the Health Section of which body 67 has taken a prominent part in promoting legislation to secure Notification. It is not too much to say, perhaps, that the Bill is the Bill of the Association, and it was natural, therefore, that the Association should endeavour to promote its success by means of a Deputation to the Local Government Board. Such a deputation waited on the Board in March of the present year, and comprised, besides members of the Association, numerous medical and other persons known to take an interest in the question. The deputation was introduced by Sir Trevor Lawrence, and Sir Charles Dilke at once took the opportunity of stating that the speakers "need not trouble themselves by going into the general question of the notification of infectious diseases-, as to which there was no difference of opinion whatever at the Board," and he asked them to "keep to the question of the Bill now before the House, that is to say, of making the powers compulsory over the whole country." Sir Rutherford Alcock then addressed the President, and was followed by Mr. Powell, and Mr. Michael, Q.C. Having been requested to speak, I took the opportunity of recalling to the President's recollection the action of those Sanitary and Scientific Authorities who had waited on his predecessor, Mr. Dodson, in April, 1881, to " request that he would be pleased to bring under the notice of the Government the desirability of taking measures for giving effect by legislation " to certain resolutions adopted at the Conference of Vestries and District Boards of Works, held at this Town Hall in the previous month; the first of the said resolutions having reference to "Notification." The President, in his reply, said— "There is no difference of opinion amongst us here as to the advantageous nature of these powers, where they are possessed. We think the evidence before us from the various localities where they have been worked is ample on that head. We are not, however, quite ready to adopt this Bill or to support this Bill in its present form, for there is great fear, in going at all in advance of public opinion, of our producing reaction. I think that here we shall be disposed to agree to general legislation in some form, that is to say, legislation to facilitate the application of these provisions by local authorities. But the Bill goes beyond this, and it is not the opinion of the Board that the time 68 has yet come to give universally the compulsory powers proposed in this Bill by absolute, by out-and-out, legislation. We think that after a few years' experience of the working of these provisions in the districts where they have been applied, and in the other districts which may try them very shortly; then, after investigation, the matter may be extended still further. But we are disposed to give local authorities who want these powers the means of dealing with infectious diseases at once, without the necessity of applying for a local Act, either by means of a general Act, which they could bring into force themselves, or else by giving them power to make bye-laws for that purpose.* Therefore, as at present advised, and without having heard any debate which may take place in Parliament on the subject this year, it would be our opinion that the second reading of this Bill might be supported on behalf of the Government; but we can hardly consent to the third reading, supposing it to be in its present form. It would require modification in the way I have indicated ; that is our view." A question having been asked, Whether the Government would introduce a Bill? the President said he "feared the prospects of legislation this year were not encouraging on that head, and there would be little chance of a Bill, if introduced by the Government, passing into law : should the Bill now before Parliament obtain any chance of a proper discussion, he would be disposed to support the second reading, but not the third"; and having been asked, AVhether he would refer the Bill to a Select Committee ? he said he should be " prepared to support such a proposition.''† It may be mentioned that prior to the reception of the deputation, the President had received a deputation from the " Vigilance Association," which desired to enlist the President's influence in opposition to the Bill, on the *The Medical Officer of the Board in his Annual Report for 1881-2 writes on this subject as follows: "Seeing how greatly the usefulness of Sanitary Action in respect of infectious diseases must depend upou early knowledge of its presence, I have had no hesitation in advising that this power (i.e.), of obtaining immediate information of the existence of infectious disease in any house) might properly be possessed by any Sanitary Authority who wanted it, and who, having made adequate arrangements for securing isolation and disinfection for the district was prepaied to put to effectual use the knowledge which a system of disease notification would afford." It may be remembered that the Select Committee on " Sanitary Regulations " (House of Commons, Session 1882) recommended that " in any future amendment of the Public Health Act powers " (i.e., to secure " notification") " should be extended to all Urban Sanitary authorities, or at least that means should be devised for clothing them with such powers on application." †The Bill was strongly opposed on the motion for the second reading, and, the House having been counted out, may be considered as "dropped" for the current session. This is not altogether to be regretted, the subject being one that can be properly dealt with by the Government only. 69 ground of its interference with the " liberty of the subject," indifferent or oblivious to the fact, to which I subsequently called attention, that the most democratic communities are precisely those which are the most stringent in such interference with indi- vidual liberty when necessary for the general good. The President was subsequently invited to receive a third deputation, viz., the Parliamentary Bills Committee of the British Medical Association, for the purpose of urging upon him "That the local authorities should not have the power of imposing the duty of compulsory notification on medical practitioners." The Committee in taking this step, was acting upon a resolution carried, at the Jubilee Meeting of the Association, held at Worcester last year, as follows:— "That this meeting earnestly desires compulsory notification of infectious diseases, but it wishes to express its opinion that the compulsion to notify should be placed upon the householder, as his duty as a citizen, and not upon the doctor." The Action of the Vestry in Respect of Notification. —I have referred above to the action taken by the Sanitary Authorities of the Metropolis in 1881 to promote notification : it will not be deemed out of place here, I hope, briefly to recapitulate the part taken by your Vestry in the matter. In my Monthly Reports for November and December, 1880,1 had called attention to the necessity of legislation to secure " notification," among some other not less important sanitary reforms, and in January, 1881, the following resolution was adopted, viz.:— "That this Vestry approve the principle of compulsory intimation to the Public Health Authority of all cases of such diseases as small pox, scarlet fever, diphtheria, typhus, typhoid, and cholera." By another resolution the Vestries and District Boards were invited to send delegates to a conference, with a view to joint action to promote legislation; and a " Memorandum " on the subject, drawn up by me at the request of your Vestry, was forwarded, for information, to every member of a Vestry or District Board in the Metropolis. (Vide Annual Report, 1880, page 49.) The Conference met at the Town Hall, March 23rd, 1881, under the presidency of Major-General Boileau, R.E., F.R.S.; 70 24 Vestries, &c. (out of 38), being directly represented by delegates, and other six by their Medical Officers of Health. Twenty-three medical officers were present. The Conference adopted the following resolution, among others, unanimously, viz.:— "That in the interests of public health, and to enable nuisance authorities to discbarge the duty of checking and preventing the spread of infectious diseases, such as small-pox, scarlet fever, etc., provision should be made by legislative enactment to secure the compulsory disclosure to the said authorities of all cases of such diseases immediately after their occurrence." A copy of the resolutions was sent to the several Vestries and District Boards, to the Commissioners of Sewers for the City of London ; and to the Councils of the British Medical Association, the Society of Medical Officers of Health, and the Social Science Association : the Vestries, moreover, were asked to appoint delegates to go in deputation to the President of the Local Government Board to present the resolutions. This was done, and the deputation waited on the President (Mr. Dodson), April 23rd, 1881, having been introduced by Mr. Hastings, M.P., and Dr. Farquharson, M.P. The resolutions were spoken to by Major-General Boileau, for the Sanitary Authorities ; by Dr. Alfred Carpenter, J.P., for the Council of the British Medical Association ; by Dr. Bristowe, F.R.S., for the Society of Medical Officers of Health ; by Mr. Michael, Q.C., for the Social Science Association ; by Mr. Ernest Hart, for the National Health Society ; and by myself, at the invitation of the deputation, the President having requested information on the subject of "hospital accommodation" for the infectious sick (small-pox).* In his reply, the President promised to give the matter brought to his attention his best consideration. Not only did the Sanitary Authorities warmly, and with complete unanimity, take up and support the principle of notification, on this occasion, but the Guardians of the Poor, to whom the resolutions of the conference had been forwarded, may he said to have followed suit, for the attention of the " *Vide page 36 ante. 71 politan Poor-Law Guardians' Association "having been called to the subject, in a paper by Mr. Rutherglen, the Clerk to the Kensington Guardians, it was resolved, unanimously, to ask the Government " to include (in a proposed Bill) provision for the compulsory notification of infectious diseases." Commenting at the time on the remarkable unanimity which had characterised the proceedings of the several public bodies, &c., in dealing with this question, I said, and I can find no more suitable words now with which to complete my reference to the subject, that " It is difficult to imagine what further evidence can be wanted to satisfy the Local Government Board of the ripeness of the time, and of public opinion, for such legislation as is here contemplated." Referring, moreover, to the deputation—and the words are in degree, applicable to the proceedings of the recent deputation, I said:— "As an expression of opinion from the official, the professional, and the general public point of view respectively, nothing could well have been more impressive than this deputation, or more weighty than the statements and arguments brought under the President's notice." Whether we shall obtain a Notification Act this year depends largely perhaps, upon the chapter of accidents. We may be doomed to temporary disappointment; but at least we can feel that the movement has made progress, more especially as the Hospitals Commission in their report strongly advocate the principle of notification. (Practical Recommendations, par. 3, page 30 supra.) So far on the question of compulsory notification. I shall presently enumerate the sources from which, in this parish, voluntary notification in regard to the occurrence of infectious diseases is obtained, and I now propose to mention the steps taken in the past year, with the view to still further increasing the sources of such information. And first I may state that I availed myself of an opportunity afforded by an outbreak of scarlet fever in the family of a letter-carrier, to place myself in communication with the Postmaster General on the subject. 72 The letter I addressed to the right hon. gentleman, in October, was as follows:- "Sir,—The Post Office has a salutary rule that no employe is to be allowed on duty when infectious disease prevails in his family. "I beg respectfully to submit for your consideration that it would be for the public advantage that Medical Officers of Health should receive immediate information of the occurrence of infectious illness in the families of Post Office employes—for this reason, among others, that in many instances the Sanitary Authority would be able to remove the sick to hospital, and then, after disinfection of the house, etc., the employe would be able to return to duty at a much earlier period than is practicable when the illness is treated at home. "Notification of infectious disease would often operate to the advantage of the employe himself, and I think, Sir, you will agree with me, it would have done so in the following case:— "John D-. residing at No.—, I field Road, is an auxiliary letter carrier, who has been off duty since his daughter Agnes, aged 7, was attacked with scarlet fever, on, or about, Sept. 8th.* A second daughter, Laura, aged 5, fell ill September 12, a son, George, aged 3, fell ill October 19, and a third daughter, Harriet, aged 15 months, fell ill Oct. 21. The son George and the daughter Harriet died Oct. 23 and 28 respectively. I may mention that a daughter, aged 7, of a lodger in the house, also fell ill Oct. 21, and died Oct. 24. "Had the existence of infectious illness in this house been reported to me at any time during the month of September, the two children first attacked might, and probably would, have been removed to hospital, and three lives would have been saved. I will only add (1) that the first intimation I had of the presence of scarlet fever at No.—, I field Road, was on the registration of the first of the three deaths, last week, and (2) that if a death had not occurred, we might never have heard of the illness, and the house might have remained infective for an indefinite period. "I respectfully submit further, for your consideration, Sir, that pressure should be put on the employes to send their sick to hospital (it can be done free of charge), when, as in the above instance, there is not 'proper lodging or accommodation 'to enable them to be isolated and safely treated at home. *I was afterwards informed that the nature of the illness in this first case was not recognised, and that it was not until the second child fell ill that, a doctor having been called In the illness was pronounced to be scarlet fever, and the father reported the occurrence to his official superiors. The inaccuracy in my letter to the Postmaster General, however, does not aflfect the argument, for if the two first cases had been removed within the first ten days of October even, all would have been well. 73 “John D.s family, I may mention, consisting, till last week, of six persons, occupied two basement rooms (kitchens) only, and the spread of disease therefore was practically inevitable ; I have reason to believe that he would have consented to the removal of the children had he been placed en rapport with my Department." I am, Sir, &c. Formal acknowledgment was made of the letter, but nothing appeared to come of it. A similar letter was addressed to the Chief Commissioner of Police, making the same request, police regulations in respect of infectious diseases, requiring notification to the Departmental Authorities, being the same as in the Post Office. The letter was not acknowledged, but, as will appear, action was taken in the matter. In my last monthly report for 1882 (page 94), I had occasion to refer to other cases of scarlet fever connected with the Police and Postal Services, and the report, by direction of your Vestry, was sent to the Postmaster General and to the Chief Commissioner of Police. It was felt desirable that notification and, when necessary, removal of such cases as I have described, should be carried out, in the interests of the sick themselves, as well as for the public good from the sanitary and economic point of view equally, since the retention of them at home, without possibility of isolation, is dangerous to the public, who moreover are called on to pay wages to men who cannot render services, not being allowed, as a rule, to go on duty while infectious disease exists in their houses. In forwarding the report your Clerk under date January 23, wrote as follows:— “I avail myself of the present opportunity to remind you of the letter which the Medical Officer of Health addressed to the Postmaster General, on the subject of infectious diseases, on the 30th October last; and, as representing the Sanitary Authority, to endorse the Medical Officer.s application for the co.operation of the Post Office Authorities in measures to secure the isolation of cases of infectious illness occurring in the families of Post Office employes. Notification of disease, alone, would be of service, but, still more, the assistance of the Post Office Authorities to facilitate the removal of 74 the sick to Hospital, when they cannot be safely treated at home. I may mention that a similar communication was addressed by the Medical Officer of Health to the Chief Commissioner of Metropolitan Police, and that the Chief Commissioner has issued instructions to Divisional Surgeons, requiring them to notify the occurrence of infectious illness in the residence of a police officer, to the Medical Officer of Health." The above letter was formally acknowledged, without loss of time, and a further communication promised, which duly arrived July 21. In this letter "an anxious desire to meet as far as may be the wishes of the Vestry " was expressed, and it was stated that “the Department never loses an opportunity of inculcating upon its servants how important it is that in cases of infectious and contagious diseases in their families they should remove the sick to hospital." Copies of three notices, which “have been placed in the hands of every post office servant having infectious or contagious disease in his house," were enclosed, one of them having been issued “early in the present year to the numerous medical officers of the Department throughout the country, in which they have been instructed, that if in their district it be not already the rule to give notice of such disease to the Sanitary Authority, it would be well that such a rule should be introduced in the case of post office servants," and another, also issued this year, “indicating how, so far as the metropolitan district is concerned, admission to hospital can best be secured and the removal of the sick effected. As regards compulsion, however, which would seem to be suggested in.Dr. Orme Dudfield.s letter of the 30th October last, this . . the department is not prepared to employ." The letter having been considered by the Works, Sanitary and General Purposes Committee, they adopted my suggestion that your Vestry should be recommended to request the Postmaster General to issue an instruction to the numerous Medical Officers * of the Department, to give notice to the Sanitary Authority, of the existence of dangerous infectious disease in the persons or families of post office servants, no such notice having hitherto been given or received, and this was done accordingly. 75 To the Chief Commissioner of Police your Clerk wrote, at the same time, as follows:— “I understand that the Medical Officer of Health communicated to you, on the 30th October last, a copy of a letter he had addressed to the Postmaster General, with reference to infectious diseases. That Officer informs me that he did not receive any reply to his communication, but that he is in possession of the ‘Police Order. sent to Divisional Surgeons subsequent to his letter In the interests of public health, and as representing the Sanitary Authority, I beg to endorse the Medical Officer.s application for your co.operation in efforts to isolate cases of infectious illness occurring in the families of police.officers." A correspondence ensued, and action was taken by the issue of memoranda for the guidance of Divisional Surgeons of Police, to which I shall now refer. It appears that the subject had been dealt with to a certain extent by the issue of the subjoined memorandum in the early part of 1882:— “Sick: Infectious Diseases, March 7, 1882.—On the occurrence of infectious disease in the residence of a police.officer, the Divisional Surgeon is to visit the premises to verify the fact, and to see that the parish authorities receive due notice, so that the rooms and their contents be properly disinfected. A report from the Divisional Surgeon is also to be submited — Whether, in his opinion, the case ought to be removed to the Fever Hospital ? “The diseases to be recorded as infectious are small.pox, typhus, scarlet.fever, and diphtheria. In cases where the Divisional Surgeon thinks it necessary that a police.officer, in whose residence infectious disease has broken out, should be absent from duty, leave will be allowed by the Commissioners on the Divisional Surgeon.s certificate from week to week." As the result, apparently, of the communication I made to the Chief Commissioner in October, the following (second) memorandum was issued in November:— “Sick: Infectious diseases.—Referring to Police Orders, 7th March last, under this head.—On the occurrence of infectious disease being reported in the residence of a police.officer, the Divisional Surgeon is to see that the Medical Officer of Health receives due notioe, as well as all other Parish Authorities." 76 And finally a third memorandum was issued in January, 1883, shortly after the despatch of your Clerk.s letter, as follows:— “Sick: Infectious Diseases.—Referring to Police Orders, 7th of March last, under this head.—When the Divisional Surgeon reports in accordance with that order that he considers a member of a police. officer.s family ought to be removed to the Fever Hospital, the case is to be reported to the Parochial Authorities. Certificates of admission to the Fever Hospital are to be issued to police.officers only. The second memorandum required the occurrence of an infectious disease in the residence of a police.officer to be reported to the Medical Officer of Health, irrespective of the question whether the sick person was, or could be, properly isolated. By the third memorandum such report, in respect of a member of the family, appears to be required only when the Divisional Surgeon is of opinion that the sick person ought to be removed to hospital; the Divisional Surgeon apparently being relieved from the obligation to report cases when the sick (in his opinion) can be safely treated at home. Such cases, I fear, having regard to the circumstances of police.officers. families, would not be very numerous. Many or few, your Vestry will readily assume the responsibility of removing them when able : hitherto the cause for regret has been our ignorance of the occurrence of such cases, and it may be doubted whether under the January memorandum we are likely to be much better off. in respect of information. The occurrence of scarlet fever in the families of two men employed in the service of the Gas Light and Coke Company, at their Kensal Works, led to a correspondence with the Secretary, and afterwards with the Medical Officer, of the Company. To the Secretary I wrote as follows:— “Will you kindly inform me whether the Gas Light and Coke Company have laid down any rules in respect of their employes in relation to infectious diseases ? In the post office and police, no man is allowed to go to his work while any member of his family is ill of an 77 infectious disease in his home, the theory being that he is capable of conveying disease to his fellows. It is a salutary rule, and not unreasonable, inasmuch as persons in the above classes can so easily get their sick removed to special hospitals for isolation and treatment. I am writing to you on this subject because I know of two recent instances in which men employed by your Company have continued at their work while infectious disease (scarlet fever) existed in their families. The sick have been kept at home despite our efforts to have them removed to hospital, and the circumstances are such as to suggest a strong probability that the working men may easily spread disease by their infected clothing. If the Company take any interest in this matter we might aid them and they might aid us." The Secretary in reply stated that my letter “came most opportunely," as the Medical Officer to whom it had been forwarded, had been instructed to “procure general information on the administration of the Medical Department, which has now assumed large proportions." The Medical Officer subsequently informed me that he was “engaged in trying to organize more careful supervision over the health of the staff," promising to send me a copy of their “regulations and improvements with reference to infectious disease." Later on he said that he had been “unable to frame any definite regulations to prevent workmen going from infected houses to the works. The whole matter is hedged round with difficulties. It appears still more dangerous to prevent workmen going to the gas works than to allow them to continue their occupation in the disinfectant atmosphere of coal gas works." The Medical Officer concluded by asking my advice in this matter, and as to what, in my opinion, the Company ought to do ? Thereupon I wrote as follows (February 27th, 1883):— “I would beg to say that if you are unable to frame any definite regulations to prevent workmen going from infected houses to the works, it would be possible to insist (1) That the house should be made non.infective by removal of the sick and disinfection; or (2) that the workman should take lodgings away from the house while it is infective. At the least I would say (as you ask me what the Gas Light and Coke Company ought to do) the Company should insist on Notifi. 78 cation of Infectious Diseases to their Divisional Surgeons, who should be instructed to report all such cases to the Medical Officer of Health. This information would enable the Medical Officer in many cases to persuade the parents to allow the removal of the sick to hospital. Sometimes the Medical Officer would feel constrained to put compulsory powers of removal into operation, not often probably. I fully expect a ‘Compulsory Notification Bill,. ere long, with, probably, increased powers of compulsory removal when required for the patient.s benefit, or for the security of the public." The Medical Officer courteously acknowledged the receipt of the above communication, and promised to place the matter before the Company again : and there the matter rests. VOLUNTARY NOTIFICATION OF INFECTIOUS DISEASES AND ITS RESULTS. Prevention of the spread of infectious diseases being a chief duty appertaining to my office, constant efforts have been made, in the absence of compulsory legislation, to obtain by voluntary information knowledge of the occurrence of such diseases. Having in the preceding section stated the steps recently taken to increase the sources of such information, it will not be out of place here to mention the sources from which, in the past, information has been obtained. 1. By virtue of an arrangement entered into between your Vestry and the sub.district registrars, I receive notice of every death from the graver infectious diseases (small.pox, scarlet fever, diphtheria, typhus, enteric and simple continued fevers), within a few hours after registration. It may be observed that when a death from an infectious disease has occurred, there is always a probability of finding cases of illness in the same house or in the locality, and such discovery not unfrequently results from the Sanitary Inspector.s visit. Now and then the registration of a death has been unduly delayed—sometimes apparently with the object of temporary concealment of the cause of death. It would be well if registration within a limited period, say twenty.four hours, were made compulsory. 2. The Relieving Officers, by direction of the Board of Guardians, report all cases of the graver infectious diseases that come within their cognizance, and generally these are cases that have been, or are about to be, removed to the hospitals of the Asylums Board, admission to 79 which (practically denied to no person) can only be obtained on the order of a relieving officer, or the master of a workhouse. 3. Similar information is given by the Resident Medical Officer of the sington Dispensary, by request of the Committee of Management. We seldom hear of sickness through any similar institution ; and it is a matter of regret that many cases that ought to be removed to the hospitals are treated at home by medical men attached to so.called " provident dispensaries." 4. Medical men favour me occasionally with information of cases, especially when they desire assistance in order to get patients (e.g., domestic servants) removed to hospitals; or when they want the assistance of the disinfecting staff. 5. In my annual report for 1877 I referred to what I considered an portant step then lately effected through the action of the London School Board, which, at my request, had instructed the Superintendents of Divisions throughout the Metropolis to desire the “Visitors" to report to the Medical Officers of Health all cases of infectious disease that should come to their knowledge in the discharge of their official duties, which take them frequently into the homes of the poorer classes. To facilitate the transmission of this information by the Visitors your Vestry authorized me to prepare a form for their use. This was done; but I must say that hitherto the resolution of the Board has not been attended with all the hoped.for results. The Board moreover, at one time, showed a disposition to recede from the position they had taken up, for on my calling their attention to the omission on the part of the Visitors to report cases, the “divisional members," to whom my communication had been referred, simply agreed that the Visitors should report cases when they had reason to suppose that no duly qualified medical man was in attendance. “When a duly qualified medical man has charge of a case, they are not prepared to do more than take steps for seeing that proper precautions are taken at the Schools." This decision, if final and acted upon, would be regrettable, as I am sure the Visitors could render us essential assistance by giving effect to the original instructions of the Board. Some of the Visitors officiating in Kensington have supplied information of a not inconsiderable number of cases during the past year. 6. Clergymen, District Visitors, and School Teachers occasionally report cases of sickness. 7. The Resident Medical Officers of St. George.s and St. Mary.s Hospitals report the admission of cases, or the application of inadmissible cases, of infectious illness from houses in this parish. 8. Occasionally anonymous communications are the source of information, for I have not felt at liberty to disregard such communications, which have frequently proved accurate. 80 In one or other of these ways some hundreds of cases come to our knowledge in the course of every year. How many never get reported at all it is impossible to sav, but from the fact that most of the fatal cases are concealed until death has been registered, it may be inferred that unrecorded cases of recovery are numerous. This drawback, notwithstanding, much good has resulted from the success of our efforts to obtain voluntary notification, so that we are encouraged to persevere in endeavours to increase the sources of information, whilst we hopefully await the superior advantages of the compulsory system. With the view of informing myself upon this point I have recently investigated the statistics of mortality for twenty.four years in respect of the “principal diseases of the zymotic class;" comparing the total number of deaths in the first half period (1859.70), before I entered upon the duties of Medical Officer, with the number in the second half period (1871.82), during which, moreover, we have had the inestimable advantage of hospital accommodation. The results of the investigation are set out in the following tables, showing the deaths of Kensington people (at home and in hospitals) in two periods of twelve years respectively, and from the diseases in question. First period (1859.70); without notification and without hospitals :— Diseases. 1859 1860 1861 1862 1863 1864 1865 1866 1867 1868 1869 1870 Totals. Small Pox 11 18 2 0 49 5 18 10 29 4 6 8 160 Measles 42 29 53 30 83 100 52 40 19 84 27 70 629 Scarlet Fever 53 86 57 110 89 90 31 28 35 170 106 198 1053 Diphtheria ... ... ... ... ... ... ... ... ... ... 9 14 23 Whooping Cough 11 56 37 54 22 56 37 28 68 34 71 55 529 Fever 17 25 32 51 54 60 77 33 46 52 42 46 535 Diarrhœa 72 35 66 24 54 63 104 112 78 113 108 154 983 Total 206 249 247 269 351 374 319 251 275 457 369 545 3912 Yearly average 326 81 Second period (1871.82); with voluntary notification and with hospitals :— Diseases. 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 Totals. Small Pox 120 68 1 0 0 8 84 24 24 11 55 0 395 Measles 64 43 38 121 23 128 54 53 60 75 67 77 803 Scarlet Fever 95 29 10 32 83 59 31 77 51 105 36 62 670 Diphtheria 11 14 11 26 23 17 10 20 26 22 8 25 213 Whooping Cough 72 77 44 45 107 124 34 185 93 95 85 119 1080 Fever 48 42 41 52 29 36 27 33 23 33 31 32 427 Diarrhœa 129 110 145 112 107 126 99 181 71 128 101 61 1370 Totals 539 383 290 388 372 498 339 573 348 469 383 376 4958 Yearly average 413 Summary of preceding tables with corrections for increase of population:— Diseases. Deaths in 1st period 1859.70. Deaths in 2nd period 1871.82. Estimated No. of Deaths in 2nd l period. 1871.82. corrected for increase in population. Increase (corrected) in 2nd period, 1871.82. Decrease (corrected) in 2nd period, 1871.82. Nett decrea8o (corrected) representing ated saving of lives in 2nd period, 1871.82. Small Pox 160 395 261 134 ... ... Measles 629 803 1029 ... 226 ... Scarlet Fever & 1076 883 1761 ... 878 ... Diphtheria Whooping Cough 529 1080 865 115 ... ... “Fever" 535 427 875 ... 443 ... Diarrhœa 983 1370 1608 ... 238 ... 3912 4958 6399 249 1790 1441 The average population iu the first period of twelve years (1859.70) was 90,000, and in the second period (1871.82) 147,300. It will be noticed that after making correction for increase of population there was an increase in the number of deaths, in the second period, in respect of two diseases, small.pox and whooping cough. Of whooping cough I shall only say that it is one of the diseases of which we rarely hear until it has proved fatal and its occurrence is never notified. Small.pox, on the other hand, is more frequently notified than any other disease, and yet the deaths show an increase of 134. This disease, however, was severely epidemic in four years out of the twelve, whereas in the first period of twelve years only twice did the annual number of deaths exceed twenty. Measles exhibits a 82 decrease, although, like whooping cough, it is not notified; but I am not aware that we are entitled to claim any credit for the reduced mortality. The diminished diarrhœal mortality may be attributed in considerable measure to the coldness of recent summers, and may therefore be regarded almost as accidental. It is when we come to scarlet fever and “fever," that the real grounds for satisfaction appear, these being the diseases which admit, the latter of mitigation by improved sanitary arrangements, and the former of control by early isolation by removal to hospital. And what do we find ? That the deaths from fever in the second period were 108 less than the number in the first period, without correction for increase of population, and no fewer than 448 after such correction; and that the reduction in respect of scarlet fever, without correction, was 383, and with correction no fewer than 1053. But it will be observed that in the first ten years of the first period no deaths from diphtheria were recorded, although the table commences in 1859, the year in which diphtheria was first registered as a separate disease. I am unable to account for the omission, except upon the assumption that no deaths from diphtheria were registered in Kensington—a somewhat improbable assumption —there being no records extant. I have thought it fair, therefore, to bracket scarlet fever and diphtheria in the two periods respectively, for comparison; and thus adding the deaths from diphtheria to the deaths from scarlet fever, only 23 in the first period, and so many as 213 in the second period, we observe in the second period an absolute reduction in the number of deaths, amounting to 193, the reduction corrected for increase of population being 878. Taking the “seven" principal diseases of the zymotic class together, there appears a corrected reduction in the number of deaths in the second period of no fewer than 1441. In other words had the rate of mortality from these diseases been the same in the second period, 1871.82, as in the first period, 1859.70, there would have died 1441 persons in the twelve years more than did die; or 120per annum—the difference between the actual annual 83 average number (413), and the number corrected for increase of population (533). The zymotic death.rate, I may add, which in 1859.70 was 3.6 per 1,000 persons living, fell to 2.8 per 1,000 in 1871.82; the deaths from these diseases, moreover, which in 1859.70 were 18 per cent. of total deaths, were only 15.4 per cent. in 1871.82. Other causes doubtless, besides notification, contributed to bring about this satisfactory result, and we must not forget, as regards enteric fever, that this disease, under improved sanitary arrangements, has “continuously and notably declined in England during recent years.“Chief among these causes, and one, in my judgment, even superior in efficacy to notification, is the provision of hospital accommodation by the Asylums Board, under the Metropolitan Poor Act, 1867. So highly, in fact, do I value this provision, that were I offered a choice between hospitals and notification, I should unhesitatingly choose the hospitals, for this reason, among others, that I am certain provision of hospital accommodation leads, almost inevitably, to notification; whereas, judging from the experience of certain towns, compulsory notification has comparatively little value if hospital accommodation be not provided. Ambulance Service.—It will be remembered that power was conferred on the Asylums Board by Section 16 of the Poor Law Act, 1879, to provide ambulances for the conveyance of the infectious sick to their hospitals, and that the Managers exercised this power by establishing an ambulance station near London Fields. This establishment, however, they will shortly be compelled to abandon as a result of proceedings at law. The Hospitals Commission, in their “Practical Recommendations," strongly urged “that the hospital authorities should have the entire control of the ambulances, by which all other modes of conveyance should be as far as possible superseded and the Managers lost no time in taking measures to give effect to this recommendation, which is strictly accordant with the intentions of the Legislature, and, 1 may add, with the views of the Local Government Board. It 84 is proposed to establish an ambulance station at each of the hospitals, and a report by the Board.s Architect, with plans for a station at the “Western District" (late Fulham) Hospital, was submitted to the Managers by the Committee of that hospital at their meeting held 6th January last. The plans having been approved were forwarded to the Local Government Board and obtained their sanction. It is intended to provide stabling for 15 horses, coach.house for 12 ambulances, with all necessary accommodation for drivers, nurses, &c., on a site 220ft. by 76ft., and at an approximate cost of some £4,500. The scheme seems well adapted to meet the requirements of the case, but its execution will involve the loss of some thirty of the beds now available for the use of the sick. The Managers moreover I may mention, appointed a Special Committee to elaborate a scheme for the transmission of the sick from their homes to the hospitals, whose report, approved generally by the Managers, was subsequently transmitted to the Board for their information and consideration. I have perused this report, the recommendations of which appear well calculated, if strictly carried out, as doubtless they will be, to put the ambulance service in the Metropolis on a satisfactory footing. Whether the adoption of the plan will, in the long run, prove more costly than the present system, under which nearly all the Sanitary and the Poor Law Authorities have provided a more or less satisfactory service of ambulances, time alone can show. Increased Facilities for Removal of the Infectious Sick.—In my annual report for 1880 I referred to the action taken by the Board of Guardians in evidence of their desire to facilitate the removal of the sick: in an instructional letter addressed to the Relieving Officers, their Clerk, Mr. J. H. llutherglen, wrote as follows:— “The Guardians having recently had urged upon them by the Medical “Officer of Health the importance of facilitating in every way “possible, the immediate removal t© hospitals of cases of infectious “disease, have directed me to instruct the Relieving Officers to 85 “abstain generally from taking any steps for obtaining payment in “cases sent to the Metropolitan District Fever and Small.pox “Hospitals." The carrying out of these instructions has been attended with the best possible results, for since they were issued I have not heard of a single case prevented from going to hospital, on grounds of inability or unwillingness to pay for maintenance and treatment. Having always held that the removal to hospital of the non.isolated infectious sick, at whatever cost to the public, is justifiable on strictly economical grounds, it is a source of satisfaction to me to know that this view is shared by the Guardians, equally with your Vestry. Practically, moreover, very little is lost in money by the enlightened action of the Guardians, for, as the result of an enquiry made in view of the Conference of Sanitary Authorities held at the Town Hall in March, 1881, I ascertained that less than £60 had been received, by some twenty Boards of Guardians, in respect of 79 patients only, out of 3,100, removed by them to hospitals in a little less than one year. Objection had been raised to the principle of "free hospital treatment," on the ground that many patients contributed towards their maintenance a sum considerable in the aggregate, and that patients able to pay should be made to pay. Even had this been the case—and I have shown that it is not so—sanitarians, who know the terrible consequences that so often result from the home treatment of infectious diseases, when the sick cannot be isolated, would have been ready to justify a sacrifice in money rather than imperil life. It was more difficult to satisfy the representatives of the ratepayers—those who hold the strings of the public purse, of the good policy of such a course, but the facts and figures I submitted to the Conference brought conviction, and it was resolved unanimously “that payment for the assistance given in hospitals to persons removed thereto for isolation, by the Sanitary or the Poor Law Authority, should not be enforced," and “that the giving of such assistance should not entail on the recipient the loss of any social or political status." 86 Interruption of Education at Elementary Schools resulting from the prevalence of infectious diseases..It is customary at Board and other elementary schools, to refuse admission to children from houses where infectious disease exists even when the rejected children are not members of the family affected. The propriety of this practice is beyond question, and to its existence we may reasonably ascribe the fact that on no occasion has it been found necessary, in this parish, to close a school on account of the prevalence of infectious disease among the pupils. The “notification of infectious disease," when it shall have been secured by legislation, and the increased powers of removal to hospitals of non.isolated cases of infectious sickness, for which Sanitarians are asking as a correlative measure, will probably have the desired effect of limiting the occasions on which it will become necessary to close schools on account of epidemics, e.g., of scarlet fever. Sanitary authorities under the provisions of the new Education Code* have greater powers than they formerly possessed of closing schools—powers which it need hardly be said should be used with great care and discretoin. It has been my constant endeavour to work with, and obtain the assistance of, school teachers, and this plan has often been attended with excellent results. The regrettable fact connected with the existence of infectious diseases, in relation to education, is the length of time during which children, themselves in good health, but living in infected houses, are often kept away from school, to the curtailment of the short period devoted to education; and yet at the same time they may be meeting their school fellows at play, thus to a certain extent neutralizing the precautions taken at school. It is obvious that fresh and even stringent legislation is needed to enable us to cope with this difficulty, viz., for the compulsory removal of the sick when necessary to secure isolation. . “The Managers must comply with any notice of the Sanitary Authority of the district in which the school is situated, requiring them for a specified time, with a view to prevent the spread of disease, either to close the school, or to exclude any scholars from attendance, subject to an appeal to the Department, if the Managers consider the notice to be unreasonable." 87 POPULATION, INHABITED HOUSES, &c. The population of Kensington, estimated to the middle of the year, was 165,450: males 66,366, and females 99,084; excess of females, 32,718. The population of the Town sub.district was, approximately, 122,423, and of the Brompton sub.district 43,027. The natural increase during the year, represented by the excess of births over deaths registered, was 1,636: an estimated further increase of 274 represents the balance of immigration over emigration; total increase, 1,910. It is always more or less difficult to estimate with accuracy the number of persons living in a large and populous place like Kensington, still in the process of growth, and having a somewhat shifting population. The best available test is the number of inhabited houses: if these show an increase, an increase in the number of people may be inferred, and vice versa. In July, 1882, there were some 20,908 occupied and rated premises, an increase of 242, as compared with July, 1881. The number of persons to a house at the census in April, 1881—taking the return of houses from the rate.book—was 7.89, a number which multiplied by 242 gives 1,909 as the theoretical increase of population during the 12 months. In places having a stationary population, e.g., parishes which have no available building land, and which are not undergoing obvious depopulation, as by the pulling down of the houses of the poor to make room for mansions, warehouses, &c., the birth.rate may serve as a guide in estimating a population. But this test is of little practical use in a place like Kensington. We shall see, moreover, that with a constantly.increasing population, not merely our birthrate, but also the absolute number of births, has declined considerably of late years, fewer children being born now than in bygone years, when the population was less by tens of thousands. The most remarkable feature in connexion with the population of Kensington is the inordinate excess of females. It was thought something astonishing when the census of 1871 revealed an excess of 22,000 females, but that excess has now grown to upwards of 32,000. We shall be better able, when the 88 details of the census shall have been published, to offer an explanation of this excess, which, of course, helps to account for the decreasing birth.rate already referred to. But I may say at once that the excess is due in no slight degree to the fact that Kensington being a rich parish, a very large number of female domestic servants are employed. It is at once a salubrious and a fashionable parish, moreover, and these considerations may account for the presence among us of many ladies, single and widowed, who prefer to make it their place of abode. There are numerous boarding schools for girls, and they, probably, contribute in some degree to the excess. The superior longevity of women is a factor of no mean importance in determining the relative numbers of the sexes. It is almost needless to say that females are in excess in the general population: in London the excess is about 13 per cent., in Kensington nearly 50 per cent. Kensington is still in process of development by building, but to a very moderate extent compared with past years, 1861.70. For example, owing to the increased value of property, its rateable value rises higher and higher, and out of proportion to the actual increase in the number of house. The following table brought up to date will well bear repetition as illustrating the growth and wealth of our great parish since the passing of the Metropolis Local Management Act in 1855:— Estimated number of 1856. 1882. Gross Increase in 25 years. habited Houses (as per rate books) 7,600 20,908 13,308 Population 57,000 165,450 108,450 Rateable Value of Property £308,000 £1,665,983 £1,357,983 The increase in all respects, within the last eleven years, is not inconsiderable, as the subjoined figures will show:— 1871. 1882. Increase in 10 years. Estimated number of Inhabited Houses, July (as per rate books) 15,395 20,908 5,513 Population 121,300 165,450 42,240 Rateable Value £935,7.20 £1,665,983 £730,263 89 These figures, demonstrating a transcendent growth, speak for themselves; nevertheless, attention may he called to the tact that in a quarter.century the rateable value of property became more than quintupled, and that in the last decade the mere increase was double the total in 1856. The population and the number of inhabited houses increased nearly threefold in 25 years; the increase in the last decade alone attaining the proportions of a large city. In the nature of things the material growth of the parish must cease ere many years shall have passed, and there will be an arrest to the increase of population, for there will be no room for additional buildings; but property in some parts of the parish will probably continue to increase in value long after the population shall have become comparatively stationary: even now the rateable value has attained such proportions as to be exceeded by that of the cities of London, Liverpool, Manchester, and Bristol only. At present the population of Kensington to that of London is about 1 to23½ and the rateable value 1 to 16½. MARRIAGES AND MARRIAGE RATE. The number of marriages, which in 1880 were 1,483, fell in 1881 to 1,461*: last year the number rose to 1,474. Of these there were celebrated— By the Church (80.3 per cent. of total marriages) 1,184 At Roman Catholic places of worship . 115 At other Nonconformist places of worship 49 At the Superintendent Registrar.s Office 126 Total 1,474 The marriage rate, i.e., persons married per 1,000 of the population, was 17.8. The marriage rate in the country generally was 15.4 per 1,000, against 14.4, 14.9, and 15.1 in the three * In nay last annual report, the number of marriages in 1881 was stated to be 1,761, that number having been given me in error for 1,461. 90 preceding years: it was, however, 0.5 below the mean rate in the ten years 1873.82. The marriage rate declined steadily from 17.6 in 1873 to 14.4 in 1879, which was lower than any previous year on record: since 1879 the recovery has been slow, but continuous, the rate in 1882 being 15.4. The marriage rate in London, in 1882, was 18.2, which is very far below the average, although slightly higher than in any of the immediately preceeding years. BIRTHS AND BIRTH RATE. The births of 4,327 children were registered in 1882 ; males, 2,240; females, 2,087; 3,489 in the Town sub.district, and 838 in Brompton, the total being 73 below the number in 1881, and 655 below the decennial average corrected for increase of population. The birth rate was only 26.1 per 1,000 (28.4 in the Town sub.district, and 19.4 in Brompton), being 8.2 per 1,000 below that of the Metropolis generally (34.3), and 7.6 per 1,000 below that of all England and Wales. We have to go back to 1873 for so small a number of births as in 1882, when the population was some 33,000 larger than in 1873. There was one birth to every 38.2 persons living, and 107.3 male births to 100 of females. The illegitimate births were 208; males 116, females 92, and of these 186 took place in the Town sub.district, which includes the parish workhouse, at which institution, out of a total of 120 births—males 71, and females 49—99 were illegitimate. The illegitimate births in the parish formed 4.8 per cent. of total births. The subjoined table shows the quarterly numbers of births, of males and females, in each of the sub.districts:— Kensington Town Sub.district. Brompton Sub.district. Gran d Total Whole Parish. Males. Females. Total. Males. Females. Total. 478 444 922 105 96 201 1123 431 435 866 109 115 224 1090 436 397 833 122 93 215 1048 460 408 868 99 99 198 1066 1805 1684 3489 435 40.3 838 4327 91 Additional particulars respecting births and birth rates during the decennium 1872.81, are set out in Tables 1 and 2 (Appendix). DEATHS AND DEATH RATE. The deaths registered in 1882 were fewer by 35 then in 1881, and some 372 below the decennial average corrected for increase of population. The total was 2,(591, viz., 2,101 in the Town sub. district (including 13 at the infectious disease hospitals), and 590 in Brompton. The deaths of a large number of non. parishioners are included in the above total, having been retained in our vital statistics by way of compensation for an unknown number of deaths of parishioners in hospitals and elsewhere outside the parish. They include 80 at the Brompton Hospital, 27 at St. Joseph's House, Notting Hill, and a considerable number of strangers who died at the Parish Workhouse and Infirmary. The death rate, whole parish, was 16.2 per 1,000, the lowest on record, being 0.4 below the rate in 1881 (16*6), of which I had the same satisfactory observation to make in my last annual report. The death rate, I may add, was 2.2 per 1,000 below the decennial average rate (18.4), 3.4 per 1,000 below the rate in England and Wales (19.6), and 5.2 per 1,000 below the metropolitan rate (21.4), this being 0.7 per 1,000 below the decennial average (22.1). There was one death to every 60.4 persons living. After making the necessary distribution of the deaths at the parish infirmary in the Town sub.district, and at the Consumption Hospital in the Brompton district, the rate of mortality was 17 per 1,000 in the Town, and 14 per 1,000 in Brompton. The death rate in the male sex was 20.5 per 1,000, in the female sex 13.4 per 1,000. Only 1328. females died in a population of 99,084 (or one in 74.6), whereas there were 1,363 deaths among our 66,366 males (or one in 48.7). In 1881 the deaths of females exceeded those of males by 70: in 1882 the deaths of males were 35 in excess. 92 INFANTILE MORTALITY. The deaths of young children always bear a high ratio to total deaths, but in 1882 the ratio was lower than usual. The deaths under five years, 1,114—47 more than in 1881, but 115 fewer than in 1880—were equal to 41.3 per cent. on total deaths, and to 25.7 per cent. on births registered: the relative percentages in the metropolis generally, being 43.7 and 27.2. Under one year of age there were 635 deaths, or 9 less than in 1881, and 86 less than in 1880, equal to 23.6 per cent. on total deaths, and to 14.6 per cent. on births registered: the relative percentages in the Metropolis generally, being 24.2 and 15.1. The deaths of illegitimate children under five years of age were 114, equal to 54.8 per cent. on births registered as illegitimate: all but 11 of them occurred in the Town sub.district. Of the 114 only 33 outlived the first year, and of these 18 died in the second year. The causes of death as registered were, scrofulous and wasting diseases, 35 deaths; want of breast milk, debility, &c., 6; diseases of the digestive system 7; of the lungs 17; of the nervous system (convulsions) 7; zymotic diseases, 24; (viz., diarrhoea 10; whooping cough 8; measles 3; diphtheria 2; scarlet fever, 1); syphilis 7; violence 5; premature birth 5, and congenital malformation 1. A large proportion of illegitimate children are brought up by hand, and by strangers: the evidence of improper feeding, and absence of maternal care, is sufficiently apparent in the above list of diseases. At sixty years of age and upwards there were 619 deaths—7 more than in 1881 but 37 less than in 1880—equal to 22.4 per cent. on total deaths, the proportion in all London being 20.7 per cent. The deaths in the first and fourth, or colder, quarters of the year, exceeded the deaths in the second and third, or warmer, quarters by 355: in 1880 and 1881 respectively the difference was 240 and 120 in favour of the warmer quarters. 93 The subjoined table shows the quarterly numbers of deaths, of males and females, registered in each of the sub.districts, plus thirteen deaths that occurred at Infectious Disease Hospitals. KENSINGTON TOWN Sub.district. BROMPTON Sub.district. Total Whole Parish. Males. Females. Total. Males Females. Total. 324 308 632 83 95 178 810 242 238 480 76 73 149 629 212 224 436 55 48 103 539 298 260 558 73 82 155 713 1076 1030 2106 287 298 585 2691 The Births were, Males 2240 the Deaths, Males 1363 Females 2087 Females i 1328 4327 2691 2691 Deaths 1636 Excess Births over Deaths The subjoined table shows the death rate in each of 13 periods of four weeks, corresponding with my monthly reports; and the mean temperature of the air:— Mean Temperature of the Air. DATE OP REPORT. Death.rate per 1,000 living. Decennial Average. In 1882. Decennial Average. Above or below Average. For four weeks to Jan. 28, 1882 19.9 20.9 39.5 38.4 + 1.1 ,, ,, ,, ,, Feb. 25, ,, 21.9 20.9 41 1 39.5 + 1.6 ,, ,, ,, ,, Mar. 25, „ 17.7 20 3 41.1 41.7 — 0.6 ,, ,, ,, ,, April 22, ,, 17.5 200 47.9 45.4 + 2.5 ,, ,, ,, ,, May 20, „ 15.3 17.7 50.7 49.5 + 1.2 ,, ,, ,, ,, June 17, „ 140 16.7 56.3 55.7 + 0.6 ,, ,, ,, ,, July 15, ,, 12.5 16.9 59.2 61.7 — 2.5 ,, ,, ,, ,, Aug. 12, „ 13 6 18.3 61.0 62.6 — 1.4 ,, ,, ,, ,, Sept. 9, „ 12.6 15.8 58.2 61.1 — 2.9 ,, ,, ,, ,, Oct. 7, ,, 12.9 14.2 53.4 54.1 — 0.7 ,, ,, ,, ,, Nov. 4, „ 17.0 16.3 49.8 47.6 + 2.2 ,, ,, ,, ,, Dec. 2, ,, 17.1 19.3 41.3 42.7 — 1.4 „ „ „ „ Dec. 30, „ 18.1 20.1 40.4 38.5 + 1.9 Averages (whole year) 16..2 18.4 49.2 49.1 The subjoined table is a summary of table 3 (Appendix), showing the number of deaths registered in 1882, in each class and order, according to the Registrar-General's re-arranged classification, exclusive of 80 deaths of non-parishioners at Brompton Consumption Hospital:— 94 I. SPECIFIC FEBRILE OR ZYMOTIC DISEASES No. of Deaths 1. Miasmatic diseases 315 2. Diarrhœal ,, 61 3. Malarial „ ... 4. Zoogenous ,, ... 5. Venereal „ 21 6. Septic „ 32 429 II. PARASITIC DISEASES ... 8 III. DIETIC DISEASES ... 12 IV. CONSTITUTIONAL DISEASES ... 545 V. DEVELOPMENTAL DISEASES ... 146 VI. LOCAL DISEASES I. Diseases of Nervous system 260 2. Diseases of Organs of Special Sense 3. Diseases of Circulatory system 167 4. Diseases of Respiratory system 609 5. Diseases of Digestive system 157 6. Diseases of Lymphatic system 3 7. Diseases of Glandlike Organs of uncertain use ... 8. Diseases of Urinary system 74 9. Diseases of Reproductive system ... a. Diseases of Organs of Generation 8 b. Diseases of Parturition 9 10. Diseases of Locomotive system 5 1,292 VII. VIOLENCE. ... 1. Accident or Negligence 47 2. Battle. ... 3. Homicide. 2 4. Suicide. 11 5. Execution. ... 60 VIII. ILL-DEFINED AND NOT-SPECIFIED CAUSES ... 119 Total 2,611 ASSIGNED CAUSES OF DEATH. Having already (at page 15) treated of the deaths assigned to the principal diseases of the zymotic class, I now proceed to give some particulars in respect to the deaths assigned to the remaining diseases in this and other classes. But before doing so I desire to point out that the classification of registered causes of death in the weekly return of the Registrar-General was materially altered at the beginning of 1882. “The list of causes, in its new form, is an abbreviation of the much 95 more detailed list which lias been drawn up for use in the ‘Annual Reports of Births, Deaths, and Marriages in England,. and which has been compiled in general accordance with the classification of the Royal College of Physicians. The London deaths, though they are only classified by the abridged list in the Weekly Return, and in the Annual Summary, will be afterwards classified by the full list in the .Annual Report of Births, Deaths, and Marriages in England'" (Annual Summary, 1882). Table 3 in the Appendix, in my previous reports, was framed upon the lines of the less abridged list of the causes of death, contained in previous annual summaries, and it was the basis, to a greater or less extent, of other tables. As it was not possible to accept the more abridged list contained in the annual summary for 1882, but at the same time desirable to frame table 3 in the greatest possible accordance with the full list to be hereafter contained in the annual report, I placed myself in communication with the Registrar-General.s Department, and having been favoured with a copy of the proposed detailed list, I brought the subject under the notice of the Society of Medical Officers of Health, who, after devoting a large amount of attention to the subject, agreed to revise the tables which they had adopted, for the sake of uniformity, some ten years ago. The tables 1 to 6 in the Appendix, therefore, will be found to present some differences, as compared with similarly numbered tables in my previous annual reports, as I felt it my duty to accept and to use, without delay, the new forms settled by the Society. With these preliminary remarks, I pass on to deal with the remaining diseases included in the “Class" of Specific Febrile or Zymotic Diseases, which comprises six “Orders," the first and second “Miasmatic," and “Diarrhœal," including the diseases already dealt with. Order 3, “Malarial Diseases," includes Remittent Fever and Ague. Order 4, Zoogenous diseases, includes cowpox and effects of vaccination, and such diseases as hydrophobia, glanders, and splenic fever. Not one death, however, was registered from any of the diseases in these two orders, 96 Order 5, “Venereal Diseases," includes syphilis, gonorrhoea, and stricture of the urethra. Syphilis was the only fatal disease in 1882, the deaths registered being 21—viz., 18 in the Town sub-district, and 3 in Brompton: l6 of the deaths were of infants under one year of age. Probably if the whole truth were known, it would appear that this Protean malady was really accountable for a much larger number of deaths. Order 6, Septic Diseases. This order comprises Erysipelas, Pycemia, Septiœmia, and Puerperal Fever, the total deaths registered being 32. Erysipelas was the cause of 14 deaths, all save 2 in the Town sub-district, and 8 of them of children under one year of age. Pyœmia and septiœmia were the causes of 8 deaths, including 1 in the Brompton sub-district. Puerperal Fever was the registered cause of 10 deaths, all but 2 in the Town sub-district. Seven of the deaths were of women between 25 and 35 years of age; 1 and 2 deaths respectively, occurred in women between 15 and 25, and 35 and 45. In addition to these 10 deaths, nine other deaths (all but 1 in the Town sub-district) were registered as having occurred in childbirth. The distinction between the deaths in these two classes of cases is, that whilst puerperal fever is a specific and highly infectious or contagious disease, deaths registered in childbirth are generally accidental, a common cause being hemorrhage ("flooding"). The total deaths registered as having been occasioned by the diseases, and accidents associated with parturition (19, or 5 more than in 1881), were equal to 0.4 per cent. on the registered live births. Class 2.—Parasitic Diseases. This class includes, Thrush and other vegetable parasitic diseases; 8 deaths, in the Town district, 6 under 1 year of age, and 2 between 1 and 5; and “Worms, Hydatids, and other animal parasitic diseases," no deaths having been registered from these latter causes. 97 Class 3.—Dietic Diseases Were the causes of 12 deaths, all save two in the Town sub. district. Want of breast milk was the. cause of 3 deaths; and Starvation of one. To Scurvy no death was assigned. Chronic alcoholism and delirium tremens were the registered causes of 6 and 2 deaths respectively. Six of the deaths attributed to the abuse of alcohol occurred in the Town sub-district. It is hardly necessary, perhaps, to say that if all the deaths due, directly and indirectly, to the immoderate use of intoxicating liquors could be ascertained, “Alcoholism" would occupy a much more important position in the “Bills of Mortality but many deaths due to the abuse of alcohol get registered as having been caused by visceral and degenerative diseases, secondary in their character, which have been caused or aggravated by “drink." Man's ingenuity in the discovery of alcohol is accountable for a large share of the misery of his race. “Drink" is the fruitful parent of vice and crime, as well as being the cause of much bodily sickness, mental trouble, moral degradation, ruin, and many premature deaths : it fills our prisons and workhouses, our asylums, and hospitals, our cemeteries, and, though happily to a decreasing extent, our National Exchequer ! Class 4.—Constitutional Diseases. This important class of diseases comprises the causes of 545 deaths (=20.2 percent. of total deaths): including 123 of children under the age of 5 years, 437 in the Town sub-district, and 108 in Brompton. Rheumatic Fever and Rheumatism of the heart caused six deaths; Rheumatism, 8. In the previous year, 23 deaths were assigned to the cause, rheumatism. In my report for that year I stated that “In the majority of fatal cases of rheumatism the immediate cause of death is disease of the heart arising in the course of the malady, and many of the deaths from heart disease that occur in the later periods of life, might justly be ascribed to rheumatism as primary cause, 98 though the connexion may have been overlooked, and is not recognised in the medical certificate of the cause of death. In the new classification an attempt has been made to distinguish deaths due to rheumatic disease involving the heart, from ordinary rheumatism, without such complication. Gout was the cause of 6 deaths and Rickets of 1. Cancer (Malignant Unease) was accountable for 92 deaths; 66 in the Town sub-district, and 26 in Brompton. The deaths from cancer appear to be on the increase, the numbers in the previous 8 years having been (67, 74, 69, 88, 79, 95, 90, and 112. The deaths from this cause in Brompton are more numerous in proportion to population than in the relatively poorer Town sub-district. Cancer, in fact, is quite as common in well-to-do people, or even more common, than amongst the poorer classes. The parts of the body most commonly affected are the viscera or internal organs; in women, the uterus and the breast; the malady being most common in later life. Seventy. seven of the deaths took place at ages above 45. It may be well to mention that in Table 3 the deaths of persons who had cancer are classified to cancer irrespective of the question whether any other disease was named in the medical certificate, and of the question whether cancer was the immediate cause of death. Purpura, Hemorrhagic diathesis, caused two deaths. Anœmia, Chlorosis, and Leucocythemia 5 deaths; and Glycosuria, Diabetes mellitus, 8 deaths. The remaining diseases in this class belong to the group generically known as Tubercular, and they are amongst the most important with which sanitarians have to deal, the degree to which they prevail in a given district being regarded, in some sort, as a test of the healthiness or otherwise of the people. Generally hereditary, these diseases are nevertheless susceptible of considerable amelioration under improved hygienic arrangements. Scrofula is unknown in Hygieapolis ! Sunlight and pure air ; efficient drainage and its corollary, a dry sub-soil ; good food, warm clothing, and temperance in all 99 tilings, are powerful antidotes to the bane of tubercle, which is fostered by the opposites—by squalor and dirt, by cold and nakedness, by vice and intemperance, by the want of the proper necessaries of life, by over-crowding in ill-constructed, unventilated, and sewage-tainted houses, and, in a word, by whatever is inimical to the maintenance of a typical condition of health. The cases that occur in the well-to-do classes, it has been the custom to say, are usually traceable to the influence of heredity, but modern researches, which have thrown great light on the origin of tubercle, raise a presumption that tuberculosis may be really an infectious disease, a specific fever of slow progress with a veiled resemblance to other specific eruptive fevers ; and they encourage the hope that in time a remedy may be found for this great scourge of the human race. It is satisfactory to note a considerable reduction in the number of deaths from these diseases as compared with 1881, when they were 442, for in 1882 they were the registered causes of 417 deaths only, viz., 342 in the Town sub-district, and 75 in Brompton ; 120 of the deaths being of children under 5 years of age. The numbers in the four quarters of the year respectively were 109, 86, 97 and 125; 234 in the winter and 183 in the summer quarters. Not uncommonly " phthisis" is returned as the cause of death in the earliest infancy, a period of life at which tubercular disease usually manifests its presence in other parts of the body, e.g., brain and bowels, rather than in the lungs. Such deaths are here classified with those properly certified due to tuberculosis and other forms of scrofula, the total being 44, of which 29 occurred under 5 five years of age, including 9 registered in the Brompton sub-district. Tabes mesenterica, popularly known as "consumption of the bowels," was the cause of 46 deaths (44 under 5 years of age) : 8 of them in Brompton. Tubercular meningitis and Hydrocephalus (water on the brain), were the causes of 54 deaths—(13 in Brompton), 45 under 5 years of age. Phthisis, the form of disease popularly known as " decline," or "consumption," was the cause of 273 deaths, irrespective of the deaths of non-parishioners at the Consumption Hospital, which 100 will he referred to later on. Two of the deaths occurred under 5 years of age, 18 between 5 and 15 ; and 247 between 15 and 65, viz., 38, 59, 76, 51, and 23, in the five decades respectively : 6 deaths were registered at ages over 65. The quarterly numbers were 75, 54, 56, and 83; of the total, 228 belong to the Town sub-district, and 45 to Brompton. The deaths from tuberculous diseases generally were disproportionately more numerous in the Town sub-district, little more than a fifth having occurred in Brompton (which contains more than a fourth of the population), a fact which may be explained, in part, by the relatively small proportion of children, and of the poorest classes, in this sub-district. It is probable, however, that the deaths ascribed to tubercular diseases do not comprise all the deaths that might justly be attributed to diseases indicating the tubercular diathesis, and that many deaths of young children classified to such causes as premature birth, atrophy, debility, convulsions, &c., are primarily due to the scrofulous taint. In many instances other diseases, e.g., of the lungs, as bronchitis, pneumonia, &c., are associated with phthisis in medical certificates of the cause of death, but all such associated diseases are here disregarded: when phthisis is returned, the death is classified to that heading, it being assumed that the tubercular trouble was underlying the other disease or diseases, and was in fact, the primary cause of death. Class 5.—Developmental Diseases. In this class, Premature birth is the assigned cause of (52 deaths ; Atelectasis of 5, and Congenital malformation of 6. Old age was the registered cause of 73 deaths; all but one at ages over 65. Between 75 and 85 there were 38 deaths, and 23 at ages above 85. The total deaths in this class were 146, viz., in the Town 122, and 24 in Brompton. Class 6.—Local Diseases. The diseases in this great Class, containing 11 orders,named after the systems or organs to which the diseases relate, were 101 able for 1,292 deaths, or 48 per cent. of the total number of deaths from all causes: 1,022 of the deaths wore registered in the Town sub-district, and 270 in Brompton; 446 were of children under five years of age. 1. Nervous System.—Diseases of the nervous system were the registered causes of 260 deaths (as against 305 in 1881), viz., 210 in the Town sub-district, and 50 in Brompton: 92 under five years of age. The quarterly numbers were 63, 68, 62 and 67. Inflammation of the brain or membranes was the cause of 9 deaths; Insanity and General Paralysis of the insane of 4 ; Epilepsy of 12; Disease of spinal cord, paraplegia, and paralysis agitans of 11, and Other diseases of nervous system of 21. The principal diseases are apoplexy, softening of brain, hemiplegia, and brain paralysis, which account for 119 deaths (28 in Brompton), of which one only occurred under the age of five years : 106 of these deaths occurred at ages above 45. Convulsions was the cause of 77 deaths (all but one under five years of age, and 14 only in Brompton), irrespective of the twelve deaths already referred to epilepsy. Convulsions as a cause of death is frequently associated, in medical certificates, with definite diseases, and with " teething," the convulsions being a symptom only ; such deaths are classified to the primary diseases named, or to dentition, as the case may be. Laryngismus stridulus (spasm of the glottis), included in the new classification with diseases of the nervous system, was the registered cause of 7 deaths, all under five years of age ; but as the children were generally " found dead in bed," it is probable that the title has little more meaning than " want of breath," as a cause of death; and indeed want of breath is the cause of death when death results from spasm of the glottis. In the absence of other apparent cause of death, the pre-existence of spasm of the glottis may have been inferred, but it is quite possible, to say the least of it, that some of the children may have been " overlaid," i.e., suffocated—a remark that applies, equally, to deaths attributed to convulsions, when the children have been " found dead in bed." The cause of death in such cases—whether spasm of the glottis 102 or convulsions be returned, can be only guessed at when the child has not been seen to die, for examination after death would not disclose the pre-existence of spasm, during life, and there is no pathological condition which would enable one to say positively that a child had suffered, still less that it had died, from convulsions. 2. The second order comprises the Diseases of the Organs of Special Sense (e.g., of ear, eye, nose), but no deaths were assigned to these causes. 3. Circulatory System.—The deaths due to diseases of the organs of circulation, heart and blood vessels, were 167, as against 158 in 1881: 125 were registered in the Town sub-district, and 42 in Brompton; 8 were of children under five years of age. The quarterly numbers were 52, 31, 33 and 51. To specified diseases, 34 deaths were assigned, viz., Pericarditis 2: Acute endocarditis, 3; Valvular diseases of heart, 20; Aneurism, 4; Embolism, Thrombosis, 5. Other diseases of heart, nature not specified, account for no fewer than 131 of the deaths, and other diseases of blood vessels for 2. 4. Respiratory System.—The deaths from the diseases of the chest (phthisis being excluded) were 609 (91 more than in 1881), and 22.6 per cent. of total deaths. Of this number 494 were registered in the Town sub-district, and 115 in Brompton. The quarterly numbers were 238, 122, 76 and 173: 411 in the first and fourth, or colder quarters, and 198 in the second and third, or warmer quarters. The deaths under five years of age were 295, about 48 4 per cent., and at 55 and upwards 219, or nearly 36 per cent. of the whole number. These diseases are thus seen to be most fatal at the extremes of life ; but the prevalence of them varies considerably in different years, depending chiefly on the degree of cold in winter, and the general character of that season; they are always most fatal when with cold, fog, especially "London fog," is associated. The diseases in this order comprises Laryngitis 4 deaths ; Croup (transferred in the new classification from miasmatic diseases), 20 : Emphysema, Asthma, 13 ; Pleurisy, 14 ; Bronchitis, 38; 103 Pneumonia, 136 ; and Other diseases of the respiratory system, 27. Bronchitis and Pneumonia therefore, and they often occur together, were accountable for 521 deaths (including 258 under five years), and of this number 97 were registered in Brompton. 5. Diseases of Digestive System.—The diseases of the organs concerned in digestion were the causes of 157 deaths ; 123 in the Town sub-district, 34 in Brompton, and 48 under five years of age. In the new classification, Dentition is included in this order : it was the cause of 19 deaths, 11 of them under one year. Sore throat and Quinsy (the latter disease transferred in the new classification from miasmatic diseases), were the causes of 5 deaths. Diseases of Stomach caused 18 deaths ; Enteritis, 17 ; Obstructive diseases of intestines, 21, and Peritonitis, 12. Cirrhosis of Liver was the registered cause of 26 deaths ; Jaundice and other diseases of Liver of 33, and Other diseases of digestive system of 6. 6. Diseases of Lymphatic System, e.g., of Lymphatics and Spleen, were the causes of 3 deaths. 7. Diseases of Gland-like Organs of Uncertain Use (e.g., Bronchocele, Addison's disease), no deaths. 8. Diseases of Urinary Organs.—Of the 74 deaths assigned to these diseases, 55 were registered in the Town subdistrict and 19 in Brompton : only two were of children under five years of age. The diseases were, Nephritis, 10 deaths ; Bright's disease (Albuminuria), 34 ; Disease of bladder, or of prostate, 11, and Other diseases of urinary system, 19. 9. Diseases of Reproductive System.—(a) Of organs of generation : male organs, no deaths ; female organs, 8. (b) Of parturition, 9 deaths, viz., from Placenta prcevia (flooding), 5, and Other accidents of childbirth, 4. 10. Diseases of Bones and Joints are accountable for two deaths, registered as Caries, Necrosis. 11. Diseases of Integumentary System, 3 deaths, viz., Carbuncle, Phlegmon, 2 ; " Other diseases," 1, 104 Class 7.—Deaths From Violence. Sixty deaths, including 26 under five years of age, are distributed over the four orders comprised in this class, 19 of them belonging to the Brompton sub-district. 1. Accident or Negligence.—Total deaths 47, including 14 in Brompton; 25 under five years of age, viz., from Fractures and Contusions, 18; Burn, Scald, 6 ; Poison, 2 ; Drowning, 2 ; Suffocation (generally of infants " overlaid ") 15, including 13 under one year ; " Otherwise," 4. 2. Homicide.—Murder, 1. 3. Suicide. —Of the 12 suicidal deaths, seven occurred in the Town sub-district, and 5 in Brompton. Poison was the lethal agent in 3 cases only ; Hanging in 5 : Cut, Stab in 3 ; " Other- wise," 1. Class 8.— Deaths from Ill-defined and not Specified Causes. —This class has assumed great importance in the new arrangement, owing to the transfer of a large number of diseases from other positions in the old classification : 119 deaths, viz., 102 and 17 in the Town and Brompton sub-districts respectively, including 108 under five years of age, are embraced in it, the causes, and numbers, of deaths being as follows :—Dropsy, 3 ; Debility, Atrophy, Inanition, 97 (all under five years, 80 under one year) ; Mortification, 3 ; Abscess, 3, and Hemorrhage, 4 ; Sudden deaths (causes not ascertained). 0. Causes not specified or ill-defined, 9. DEATHS IN PUBLIC INSTITUTIONS. The "large public institutions" in which we are locally interested are the Parish Infirmary and Workhouse in the Town sub-district, and the Hospital for Consumption and Diseases of the Chest, in the Brompton sub-district. There are numerous minor public, or quasi-public institutions, but, with one exception, they do not furnish occasion for notice. The excepted institution is St. Joseph's House, Portobello Road, Notting Hill—a Roman Catholic Home for some 250 105 aged poor persons of both sexes, brought from various parts, and principally from Ireland, if one may judge from the large proportion of deaths of Irish persons. The Registrar General, however, does not regard St. Joseph's House as a public institution. The deaths of non-parishioners at the Marylebone Infirmary, Notting Hill, some 396 in number, have been entirely ignored in our statistics, but will furnish occasion for a few remarks in a subsequent paragraph. The deaths registered at the Parish Infirmary and Workhouse, at the Brompton Hospital, and at the Hospitals of the Asylums Board were 402, or nearly 15 percent, on total deaths, the percentage proportion of deaths in public institutions in the Metropolis generally being 18.9. The addition of the deaths at the Marylebone Infirmary would raise the percentage in Kensington to 25.7. The Parish Infirmary and Workhouse.—I am indebted to Mr. H. Percy Potter, Medical Superintendent of the Infirmary, and Medical Officer of the Workhouse, for the statistics of mortality at these important institutions ; the former being, as its name implies, a large hospital containing over 600 beds. The deaths, 307 in number, were equal to 11.4 per cent. of all deaths registered in the parish ; they were 34 in excess of the total in 1881 (273), and 71 in excess of the total in 1880 (236). The deaths comprised 172 of males, and 135 of females, the quarterly totals being 67, 74, 70, and 96; so that 163 deaths occurred in the first and last (or cold) quarters, and 144 in the second and third (or warm) quarters. More than a third of the deaths (107) were of persons aged 60 and upwards, (greatest age, female 99), and just one half (153) were caused by diseases of the organs of respiration ; these diseases being most fatal in cold weather and to aged people. The ages at death were, under one year, 40; between one and sixty, 160; sixty and upwards, 107. Six inquests were held; the causes of death in three cases being "natural," and in three "violent," viz.: male, aged 65, found dead in a bath, suffocation ; male, aged 26, injury to head, misadventure, and male, aged 3 days. found dead in bed, suffocation. 106 CAUSES OF DEATHS. Under one year. Between one year and sixty Sixty and upwards Total. Nervous System, Diseases of 0 15 22 37 Circulatory Organs ,, 0 7 9 16 Respiratory „ „ 12 97 44 153 Abdominal Viscera ,, 0 3 1 4 Urinary Organs „ 0 6 5 11 Tetanus 0 1 0 1 Measles 8 0 0 3 Typhoid Fever 0 1 0 1 Septicaemia 0 1 0 1 Pyaemia 0 1 0 1 Croup 1 1 0 2 Whooping Cough 0 1 0 1 Diarrhœa 1 1 0 2 Erysipelas 0 2 1 3 Syphilis 4 1 1 6 Want of Breast Milk 4 0 0 4 Cancer 0 8 8 16 Mortification 0 0 3 3 Tabes Mesenterica 4 1 0 5 Scrofula 0 2 0 2 Myxœdema 0 1 0 1 Convulsions 3 1 0 4 Premature Birth 6 0 0 6 Old Age 0 0 13 13 Suffocation l 0 0 1 Syncope 0 2 0 2 Dropsy 0 4 0 4 Embolism 0 1 0 1 Stomatitis 1 1 0 2 Cause not known 0 1 0 1 Totals 40 160 107 307 107 The Hospital for Consumption and Diseases of the Chest.— The deaths in this institution, or rather in that part of it situated in Kensington, a new hospital having been built on the opposite side of Fulham Road, in the parish of Chelsea, were 83, viz.: males 48, and females 35 : 21, 34, 15 and 13 in the four quarters of the year respectively. The ages at death were: under 20 years (youngest 9) 17; between 20 and 40, 55 ; between 40 and 60 (oldest 55) 11. Three only of the deaths were of parishioners. Thirty-six of the deceased had previously resided in the Metropolis ; 16 in the suburbs or Metropolitan Counties, and 31 in more distant parts of the country. The causes of death as registered, were ; Phthisis (consumption or decline) alone, in 64 cases; Phthisis associated with other forms of tubercular disease in 8 cases, and other visceral diseases, chiefly of the heart and lungs, in 11 cases. St. Joseph's House.—The deaths at this institution were 27, viz.: males 10 and females 17 ; all but two occurred at ages over 60, and twenty of them at ages over 70. Nineteen of the deceased had come from Ireland, two from France, and three from the provinces; one belonged to London, and the previous residence of two was not stated. The causes of death were: diseases of the heart and lungs, 16; of the brain, 5; cancer, 2 ; albuminuria, 1 ; old age, &c„ 3. Marylebone Infirmary.—At this important institution, which is even larger than our own infirmary, 396 deaths of non-parishioners were registered, but they have been ignored in the preceding statistical returns. It may be here stated, however, that they comprised 212 of males, and 184 of females ; that 208 of the deceased were aged 60 and upwards, and 13 under five years, including 7 under one year of age. A female died at the reputed age of 101 years. Ten violent deaths were registered, and inquests were held in nine cases. Two births were registered. 108 DEATHS NOT CERTIFIED. Six deaths, an unprecedentedly small number, were returned as "not certified," the deceased persons not having been attended in their last illness by any registered medical practitioner; viz. : male, aged one day, from convulsions; male, aged 9 days, from hemorrhage after circumcision; male, aged 11 weeks, from marasmus ; male, aged six months, from syphilitic cachexia, convulsions ; widow of a tailor, aged 39, from apoplexy, and a bricklayer, aged 85, from natural decay. The several cases were reported to the Coroner, who did not deem it necessary to hold inquests. The subject of uncertified deaths has, on more than one occasion, been discussed by the Society of Medical Officers of Health, and in December, 1880, the Society, on the recommendation of the Council, to which the subject had been referred for consideration, adopted the following resolution:— " That all cases of uncertified death should be reported by the local registrar of births and deaths to the Coroner, who should, when there is no prima facie ground for holding an inquest, direct such cases to be investigated by a registered medical practitioner." It had been suggested that the duty of making the investigation should devolve on the Medical Officer of Health, as a part of his ordinary work, but the Society did not adopt this view. Of all the unsatisfactory arrangements connected with the subject of uncertified deaths, perhaps the most unsatisfactory is the responsibility cast on the Coroner's Officer of making a preliminary enquiry, and of being the de facto judge whether an inquest should be held in any given doubtful case. The Society at my instance adopted the following resolution bearing on the subject:— " That in the opinion of this Society, the present system of investigation of deaths referred to a Coroner, vix., by an officer having no special qualification for the discharge of the duty, is unsatisfactory." 109 INQUESTS. One hundred and fifty six inquests, 121 in the Town subdistrict, and 35 in Brompton, were held in the year, the subjects being males 80, and females 76 ; 71 were under 5 years of age, including 47 less than a year old, and 23 were persons aged 60 and upwards : the cause of death in 114 instances was ascertained by post-mortem examination. The Violent Deaths were 66, of which 20 belong to the Brompton sub-district. The causes of sixty-two of these deaths are given below ; in other four cases there was no inquest, the causes of death being (1) injury during birth ; (2) hemorrhage after birth ; (3) hemorrhage after circumcision, and (4) meningitis from injury and exposure. The grounds for holding inquests are, usually, the suddenness of death, or the fact that death had been caused by violence. In many cases it was stated that the deceased had been found dead—often in bed. The causes of death, as found by the verdicts of the respective juries, may be classified as follows :— Deaths caused by disease 94 Accidental deaths 49 Suicidal „ 12 Homicidal „ 1 156 The diseases may be classified thus :— Diseases of the brain and nervous system 22 „ „ organs of respiration and circulation 60 Diseases of the organs of digestion 5 Other diseases 7 The violent deaths were caused as follows :— Accident: Suffocation (13 of infants under one year) 16 Poison (Winslow's Soothing Syrup 1, and Tartar Emetic 1) 2 110 Blood poisoning (putrid fish) 1 Drowning 1 Falls under various circumstances 14 Burn and Scald 6 Run over by, train 2, van 1, omnibus 1, 4 Thrown from carriage 1 Knocked down by horse 1 Chloroform, Syncope while inhaling 1 Hemorrhage from neglect at birth 2 Suicide: By hanging 5 By poison 3 By cut throat 2, stab 1 3 By fall from a window 1 Wilful Murder: 1 Among the deaths described as "sudden," there were, as usual, many of persons who had died from ordinary and curable visceral diseases, and it is impossible to resist the conviction that there had been culpable neglect on the part of someone, in the failure to obtain medical assistance for the deceased ; for the illnesses must have extended over many days, and been attended with obvious symptoms of a more or less serious and painful nature: there would have been no occasion for inquests, moreover, had medical certificates been forthcoming. The mere finding of the cause of death by a jury, in such cases, seems scarcely to satisfy the requirements of justice, considering that the death of any person —but particularly of one very young or very aged—from diseases like pneumonia and bronchitis, for instance, when there has been no medical treatment, raises a presumption of neglect which would justify a verdict of " manslaughter," equally as in the case of the " peculiar people," who, whilst treating their sick with care in other respects, refuse, on mistaken conscientious grounds, to employ medical assistance, and who, as a consequence of such refusal, death having ensued, have often been found guilty of manslaughter. 111 METEOROLOGY. The mean temperature of the air at Greenwich in 1882 was 490.7 Fahrenheit, or 0.3 above the average of 41 years. The means of the four quarters respectively were 42°.7, 53°.0, 58°.1 and 440.8. The highest reading by day (81°.0) was registered in the week ending August 12th, and the lowest reading by night (220.2) in the week ending December 16th ; the means of the highest readings by day, in the four quarters respectively, being 57.8, 72.1, 76.9 and 62.7, and the means of the lowest readings, by night, 26.3, 35.7, 42.1 and 25.7. The hottest week in the year was that which ended August 5th, (62.5), and the coldest week that which ended December 16th (34.l). July was the hottest month, mean temperature 60.4, and December was the coldest month, mean temperature 40.1. May was characterised by the greatest range in temperature, viz.: 42.0—from 76.5 to 34.5, while January exhibited the smallest range, viz.: 27.5—from 52.9 to 25.4. The dryness of the atmosphere, i.e., the difference between the dew-point temperature and air-temperature was 5.0 ; the average of 41 years being 5.6. Rain fell on 1 79 days, the total amount registered in the year being 25.16 inches, the average of 41 years being 25.09 inches. Most rain fell in October, 5.42 inches, and least rain in February and March, 1.14 inches. The means of the readings of the barometer were 29.758 inches; the means of January, 30.185 inches, and of December 29.493 inches, being respectively, highest and lowest. VACCINATION. Table X (Appendix) is a return respecting the vaccination of children whose births were registered in 1882, and for it I am indebted to Mr. Shattock, the Vaccination Officer, whose energetic discharge of the duties of his appointment it has always afforded me pleasure to recognise. The return show 112 a loss of 4.4 per cent. in the cases, as against 3.3 in the previous year. This moderate loss may even yet be somewhat reduced, as the Local Government Board allows Vaccination Officers a period of twelve months before presentation of a final return, in order that the statement in respect of the children born in any given year, may be made as complete as possible. I believe I am correct in stating that the " loss " in the column indicating " removal of children to places out of parish unknown, or which cannot be reached, and cases not having been found," in the Metropolis, as a whole, is almost double the loss in Kensington. It is due to the Guardians of the Poor, in this connexion, to mention that they, as the authority responsible for carrying out the Vaccination Acts, omit no opportunity of giving effect to the law, and cordially support their officer in the discharge of his duty. In regard to the protection against small-pox afforded by vaccination—differing in degree as this does in proportion as the operation is more or less perfectly performed—it might seem, to the majority of persons, well nigh superfluous to comment in these days; but unfortunately it is not so, for the perverse pertinacity with which a noisy, if not considerable, minority decry this most beneficent of all medical discoveries, shows no sign of abatement; the teaching of its opponents, moreover, being of a sort to impress the unthinking masses in a sense unfavourable to the continuance of the wise compulsion enforced by Parliament. This being so it becomes a duty, year by year, to refer to the subject, and on the present occasion I am glad to be in a position to quote some pregnant facts submitted to the Local Government Board by their Medical Officer, Dr. Buchanan, in his report for 1881. Dr. Buchanan, first of all, refers to the relative mortality from small-pox in the vaccinated, and in the unvaccinated, inhabitants of London, which formed the subject of a memorandum which he submitted to the Board in June, 1881, and containing the following table:— 113 Comparative Small-pox Death Rates among Londoners, Vaccinated and Unvaccinated respectively, for the 52 weeks ended 29th May, 1881. Death rate of people of subjoined ages. Per million of each age of the vaccinated class. Per million of each age of the unvaccinated class. All ages 90 3,350 Under 20 years 61 4.520 Under 5 years 40½ 5,950 Bat mainly he limits the scope of his further enquiry on the subject, to the mortality from small-pox among children under the age of ten years, for the sufficient reason that the limit embraces the period within which vaccination has been efficiently compulsory. The population of London under ten was 910,784 on census night, 1881, of whom, in round numbers, 55,000 were unvaccinated, and 861,000 were vaccinated. In 1881 some 782 smallpox deaths occurred among the 55,000 unvaccinated, as against 125 among the vaccinated. " Upon equal numbers of the two classes, therefore, the mortality from small-pox among the unvaccinated, was about a hundredfold the mortality from small-pox among the vaccinated. This degree of protection was given to children under 10, by the average current vaccination of London."* " If the London children under 10 who were unvaccinated, had had the protection which the current vaccination gives, not 782 of them, but at the outside nine would have died of smallpox during the year. "If the 861,000 vaccinated children had died at the rate of the 55,000 unvaccinated, we should not now be considering 125 •"The power of a thorough vaccination to protect against death from small pox " (it is stated) " is at least ten times greater than the power of much that passes under the name of vaccination." 114 small-pox deaths, and how they can be reduced, but we should be confronted with an additional 12,000 and more deaths from small-pox, occurring daring the year in the London population under 10 years of age." This " great saving of children from death by small-pox can only have been due to vaccination, and largely to the operation of vaccination law." It must be remembered, moreover, that the mortality of smallpox in vaccinated children, small though it be, is unduly high, for the reason, doubtless, that so much of the vaccination which passes current is imperfect, there still being many medical men who systematically evade the spirit of the law, and disregard the teachings of experience, as summed up in the instructions issued by the Board for the guidance of public vaccinators A prime condition of vaccination, "successful" from the official standpoint, is the production of four typical vesicles; but we are told that there is a "form of private vaccination that offers itself in competition with public vaccination, and which parades its inefficency as a reason for its acceptance by ignorant people. Its professors say to young mothers,' Do you come to me and I won't hurt your baby; I'll make only one place on its arm, not four, as those public vaccinators do.' ''It will excite little surprise therefore, that, whereas the vaccination is done in almost equal proportions by public vaccinators and private practitioners, the proportion of deaths from small pox, among children under ten, is far greater among the patients of private practitioners, than among children vaccinated by the public vaccinators; and this despite reasons, to which Dr. Buchanan refers, which might fairly lead us to expect a quite different result, were it not for the admittedly superior average vaccination conferred by the official operators. Here, then, we have a record of the "saving of 12,000 lives, by vaccination, to children under ten years of age" in the one year, 1881, when the total mortality from small-pox did not amount to one-third of the mortality in the epidemic of 1871. This saving is justly attributed to the operation of the 115 Vaccination Acts, of 1867 and 1871. It only needs further to be mentioned that in the "two periods of ten years immediately preceding 1871, 59 and 54 per cent., or more than half, of the total small-pox mortality, was borne by children under five years old," whilst ''now only 28 per cent., little more than a quarter of the total small-pox mortality, falls upon such children." Animal Vaccination—Calf Lymph.—A common objection to "arm to arm" vaccination is based on the fact that the lymph is passed through the human system, and therefore, it is said, may transmit disease : the dangers attending the use of humanised lymph, however, are so trifling as to be practically inappreciable. Nevertheless, and as it is desirable to remove, as far as possible, every obstacle to vaccination, it is satisfactory to know that the Local Government Board have made arrangements to give people the option of having their children vaccinated with calf-lymph at the public vaccination stations. The Government, moreover, will supply medical practitioners with "stock" lymph to enable them to start a series of vaccinations, leaving them to keep up their supplies afterwards—if they can. The use of animal lymph is common on the Continent, and the system has been carried to great perfection at Brussels under the direction of M. Warlomont. who sends supplies of lymph to this country regularly, and whose tubes and charged ivorypoints can be purchased at a moderate rate. A station, moreover, has been established by a private medical practitioner in the Marylebone Road, for the supply of calf lymph, and where persons can be vaccinated direct from the calf. SANITARY WORK. Tables VI and VIa (Appendix) summarise the chief items of Work done by the Sanitary Inspectors during the year. A not inconsiderable part of their work, however, scarcely admits of tabulation, many sanitary amendments being carried out at their instance, and under their supervision, without recourse to forms 116 which take up time, and are unnecessary when an owner or occupier is found willing to follow good advice. The total of "sanitary orders" issued, therefore, does not include cases in which work has been done by the owner or occupier at the request of the Inspector. The statements in previous reports, as to the " number of houses inspected," applied to primary inspections only. When a nuisance is found to exist, and it is not at once abated, repeated inspections may be required—as many as six should legal proceedings become necessary. In cases of infectious disease treated at home, under circumstances endangering the spread of disease, through the omission of proper precautions, numerous visits are paid to the infected house. During the last five years the abatement of nuisances has been accelerated by the plan of serving "preliminary notices " upon the parties liable, immediately on discovery. These notices are often as effectual as the more formal notice which, previously, it had been the rule to serve only after the nuisance had been reported to the Works, Sanitary, and General Purposes Committee, and upon confirmation by your Vestry of the recommendation of the Committee. When the notice is not complied with, recourse is had to a summons before a magistrate, a step which, when necessary, should always be taken with the least possible delay. In a previous Report I had to observe that " the difficulties which beset legal proceedings, i.e., at the Police Court, tend to cool the ardour of Sanitary Inspectors in having recourse to magisterial aid." The delays were simply intolerable. I am glad to bear witness to an improvement in this respect, since, acting upon a recommendation I made in 1878, your Vestry has authorised proceedings before the magistrates sitting at the Vestry Hall —an arrangement by which much time has been saved, besides securing in nearly every instance the object in view. We have cause to thank the magistrates for their willingness to take our cases, adding considerably as they do to the time devoted by them to the administration of justice, and for 117 the useful work they have done by their decisions in helping forward sanitary improvement. During the year ended March 25th, 1883, summonses were issued in 78 cases as compared with 104 in 1881-2, and " Orders " for giving effect to your Vestry's Notices were made by the magistrates in nearly every instance. Frequently one summons covered several requirements, as may be inferred from the following summary of works carried out under the orders. In connection with water supply, orders were made as follows Today on water where the supply had been ''cut off" in three cases; for the provision of new cisterns, or the repair of old ones, 18; for the abolition of waste-pipes 4 ; for the rectification of water-closet accommodation, including repair of fittings, 22; for the supply of water to closets 24 ; for the construction and amendment, including trapping and ventilation, of drains, sinks, &c., 35 ; for the repair of defective stack pipes 6; for the provision of new, or repair of existing, dustbins 16; for the cleansing and repair of dirty, unwholesome, or dilapidated houses 31, &c., &c. Penalties for neglect to comply with your Vestry's requirements are seldom inflicted, the parties summoned being usually called upon to pay the costs only; but penalties, ranging from five shillings to eleven pounds, were imposed on six persons who had disobeyed the magistrates orders, for the execution of sanitary works for the abatement of nuisances. Domestic Supply of Water : Powers of the Companies, &c.— It is by no means uncommon to find houses without water, the supply having been "cut off" by the Companies, as a coercive measure to obtain payment of the rate. A question arises whether this power should be left in the hands of the Companies ? or, whether they should not rather be left to their remedy,for the recovery of a debt, like other traders ? No doubt it seems, at first sight, not unreasonable to allow a company to discontinue the supply when a customer fails to pay; but water is a prime necessary of life, and the absence of a proper supply, in an inhabited house, constitutes a serious nuisance. The Com- 118 panies, moreover, enjoy a valuable monopoly, so that, economical laws notwithstanding, the legislature would probably be justified in dealing with the question in an exceptional way. Naturally a Sanitary Inspector has no option but to take measures to secure a restoration of supply when the water has been cut off, but it is not satisfactory that the powers conferred on your Vestry should have to be put in motion, practically, for the benefit of the Companies whose officers, indeed, are, not seldom, our informants. A good many instances of this sort came under my attention in the past year, and I was thus led to look into the powers and duties of the Companies ; and as it seems not improbable that, ere very long, the London Water Supply will have to be taken into consideration by Parliament, the following information, in view of such an event, may not be unacceptable. Every Company of course has its own " Special Act." What powers these confer I know not : but every Company has powers, also, under "The Waterworks Clauses Act, 1847 " (10 Vic., cap. 17), the 74th section enabling a Company to cut off the water for non-payment of the rate. The section reads as follows :— " If any person supplied with water by the undertakers, or liable as herein, or in the Special Act provided, to pay the water rate, neglect to pay such water rate at any of the said times of payment thereof, the undertakers may stop the water from flowing into the premises in respect of which such rate is payable, by cutting off the pipe to such premises, or by such means as the undertakers shall think fit, and may recover the rate due from such person, if less than twenty pounds, with the expenses of cutting off the water, and costs of recovering the rate, in the same manner as any damages for the recovery of which no special provision is made are recoverable by this or the Special Act; or if the rate so due amount to twenty pounds or upwards, the undertakers may recover the same, with the expenses of cutting off the water, by action in any court of competent jurisdiction." It may be mentioned here that the Company's servants, when they go to cut off the water for non-payment of the rate, are not allowed to take money, i.e., to receive payment of the rate, so that if the owner or occupier of a house, being in default, or if 119 the other occupants, being lodgers, were able and willing to pay the rate, rather than have the water cut off, the money would not be received. The full punishment for trouble given, whatever the cause, must be borne (viz., a pecuniary fine, i.e., the cost of laying-on the water) by the offending owner or occupier, to say nothing of the great, possibly dangerous, inconvenience occasioned to the innocent tenant or lodgers. In many cases, doubtless, the water is immediately laid on again,the cost to the owner or occupier not being considerable, nor the inconvenience to the lodgers great, because not of long duration ; but the public will have been put to a certain inconvenience by repeated opening-up of the public road, an operation which cannot fail of being more or less injurious to the general interests represented by the local authority. By section 70, a Company has power to require payment of the rate quarterly in advance, and by section 68 it is provided that the rate, " except as hereinafter and in the Special Act mentioned, shall be paid by, and be recoverable from, the person requiring, receiving, or using, the supply of water." By Section 54, where constant supply is not given the Company may cut off the supply, should the apparatus be out of order: the following section imposes a penalty for waste of water arising from defects in the supply apparatus, and Section 56 enables the Company to repair apparatus at the cost of the person allowing the same to be out of repair. These powers, so far as I know, are never put in force. Sections 58 and 59 have an important bearing on the question under consideration, and if they were put in force people would be careful to prevent the water from being cut off, or to secure its being laid on again speedily when cut off, for section 58 imposes a penalty, not exceeding five pounds, on any person giving away the Company's water, or allowing any person, other than a water-rate payer, to take water from a pipe or cistern, while section 59 imposes a penalty, not exceeding ten pounds, for (what practically amounts to the offence of) stealing a Company's water. 120 The Metropolis Water Act, 1852, section 22, extends the powers contained in the 54th section of The Waterworks Clauses Act, 1847, with reference to the water supply apparatus, by enabling a company to require the provision of proper apparatus or fittings—pipes, cocks, cisterns; and the removal of improper waste-pipes, herein properly so named, but only " whenever water shall be constantly laid on under pressure." &c. The powers, however, re-appear in the " water regulations," which apply to the intermittent system likewise, and appear to have been conferred chiefly in the interests of the ('ompanies and with a view to the prevention of waste or misuse of the water. Section 26 empowers the Companies to make regulations for the purpose of preventing the waste or misuse of water . . . to prescribe the size, nature, and strength, of the pipes, cocks, cisterns, and other apparatus to he used, and to interdict any arrangements, and the use of pipes, cocks, cisterns, or other apparatus, which may tend to such waste or misuse as aforesaid. The Companies did not avail themselves of the powers thus conferred. The Metropolis Water Act, 1871.—Two of the principal objects of this Act were, (1), to provide for constant supply— an object very imperfectly realized hitherto, and, (2), to compel the Companies to make " regulations," as authorized by section 26 of the Act of 1852. I have in former reports dealt with the subject of constant supply, which may be passed over here with the remark that the" Metropolitan Authority"(Board of Works), have not seen fit to exercise their powers under the Act to confer this boon on the Metropolis. Section 17 requires the Companies to make regulations for the purposes for which regulations may be made under section 26 of the Act of 1852, and the provisions of that section are made to apply to the " preventing of undue consumption or contamination of water." Section 32 reads as follows :— " Where in any district any Company is required, or has proposed, to provide a constant supply :— 121 " If any person supplied with water by such Company wilfully or negligently causes or sutlers any fittings to be out of repair, or to be so used or contrived as that the water supplied to him by such Company is or is likely to be wasted, misused, or unduly consumed or contaminated, or so as to occasion or allow the return of foul air or other noisome or impure matter into any pipe belonging to or connected with the pipes of such Company, he shall for every such offence be liable to a penalty not exceeding five pounds; or " If any person supplied with water by such Company wrongfully does, or causes, or permits to be done, anything in contravention of the provisions of the Special Act or this Act, or wrongfully fails to do anything which, under any of those provisions ought to be done for the prevention of the waste, misuse, undue consumption or contamination of the water of such Company, they may (without prejudice to any remedy against him in respect thereof) cut off any of the pipes by or through which water is supplied by them to him, or for his use, and may cease to supply him with water so long as the cause of injury remains or is not remedied; and in every case of so cutting off or ceasing to supply, the Company shall, within twenty-four hours thereafter, give to the nuisance authority, as defined by the Sanitary Act, 1866, notice thereof." The 33rd Section of the Act, moreover, provides that: " The absence in respect of any premises of the prescribed fittings after the prescribed time, shall be a nuisance within Section 11 and Sections 12—19 (inclusive) of the Nuisances Removal Act for England, 1855, and within all provisions of the same, or any other Act applying, amending or otherwise relating to those Sections; and that nuisance, if in any case proved to exist, shall be presumed to be such as to render the premises unfit for human habitation within Section 13 of the Nuisances Removal Act for England, 1855, unless and until the contrary is shewn to the satisfaction of the Justices acting under that Section." I have thought it right to quote the above Sections in their entirety, but I may at once state that I do not know of a single case in this parish in which a Company has cut off the supply by reason of the " absence of the prescribed fittings," or by reason of defective fittings leading to waste, misuse, undue consumption, or contamination of water; and this, possibly, may be the reason why not one of the Companies, in any case within my recollection, has ever given the statutory notice to your Vestry, as the nuisance authority, of their having cut off the 122 supply. It is a question whether such ''notice'" should not be given in every case, and therefore, when the supply is cut off for non-payment of the rate ? It seems an unreasonable thing that a water company should have the power of cutting off the supply because, to take an extreme case as an example, an iron pipe is used where a lead pipe should have been used; or because a lead pipe is used of less weight per lineal yard than the regulations require ; and I may remind your Vestry that it was on account of the unreasonableness of the regulations in these and similar respects, and the consequent expense they would have entailed on the ratepayers, that the Metropolitan Board of Works have refrained from exercising their powers under the Act to require the constant supply. In such a supposed case, "absence of prescribed fittings," the Company would be required to give your Vestry " notice," the " nuisance" being " presumed to be such as to render the premises unfit for human habitation although water mav flow into the cistern, and vet they are under no obligation to give such notice when they have cut off the water to compel payment of a debt, a step whereby nuisance is actually created. Hitherto we have not had occasion to exercise the power conferred by the 33rd section, and indeed it seems too strong a measure for any ordinary case, and, especially, for the purpose of enabling a water company to recover a debt. When we hear of a house being without a water supply (and the information often comes informally from a Company's Collector when meeting a Sanitary Inspector on duty), the practice is to serve a notice upon the owner or the occupier of the house, requiring him within a specified number of days to lay on the water. In default of compliance with such notice, wo proceed by summons under the provisions of the " Nuisances Removal Acts." The necessary " order " is usually made by the Justices, but oftentimes there is so much delay in getting the order carried out, that one is tempted to wish, on sanitary grounds, and in the interests of the occupants themselves, we had power to close houses without water as ''unfit for human habitation," 123 Water Regulations framed by the Companies and approved by the Board of Trade, whose powers under the Water Acts were subsequently transferred to the Local Government Board.— Some of the regulations, which have been in operation since August 10th, 1872, appear to have been framed in the public interests, regarded from a sanitary point of view. Regulation 13 requires that the " cistern " shall be " water-tight " and " properly covered," and " placed in such a position that it may be inspected and cleansed;" it must also be provided with a proper ball tap. The sanitary Inspectors, so far as they are able, take care that cisterns shall be kept watertight, clean, properly covered, &c., but the Companies do not appear to take much interest in the position of cisterns, though it is highly important, on sanitary grounds, that every cistern should be accessible for the purpose of cleansing, &c. Regulation 14 is -o important that I must quote it in extenso, not for the first time :— " No overflow or waste-pipe other than a 'warning pipe' shall be attached to any cistern supplied with water by the Company, and every such overflow or waste pipe existing at the time when these regulations come into operation shall be removed, or at the option of the consumer shall be converted into an efficient • warning pipe ' within two calendar months next after the Company shall have given to the occupier of, or left at the premises in which such cistern is situate, a notice in writing requiring such alteration to be made." The Companies have grievously failed in their duty, in having neglected to put this regulation into force, universally. Their officers, with whom I have had communication, allege that the object of the regulation is prevention of waste, and not sanitary. I need not discuss this question here, as it will be referred to again: but I will say it is imperatively necessary that the sanitary authority should have co-ordinate power with the Companies to put the provisions of this regulation into force. Regulation 16 forbids the use of buried cisterns without the sanction of the Company, but such cisterns ought not to be 124 allowed to exist at all, not even in stables. Cisternage can always be provided in the roof, if nowhere else. Regulation 17, which prohibits the bringing into use of wooden receptacles (e.g. butts) without a proper metallic lining, is constantly violated. The power to inflict penalties for breach of the regulations is conferred bv section 20 of the Act. The regulation relating to penalties (31) runs as follows:— " Every person who shall wilfully violate, refuse, or neglect to comply with, or shall willfully do or cause to be done, any act, matter, or thing, in contravention of these regulations, or any part thereof, shall for every such offence be liable to a penalty in a sum not exceeding £5." It would be well to ascertain by a test case whether a sanitary authority has power to enforce the regulations—other than 14 ? The validity of many acts done in the name of your vestry would depend on the reply to this question. Again, are the regulations to be read with the Acts, and can the Companies be compelled to carry out the regulations ? Surely some penalty should attach to their default ? The Companies have power, and may be required by the Local Government Board, to " repeal or alter any of the regulations ... or make new regulations " (section 18, Water Act, 1871); and should the Companies fail to make regulations the Local Government Board may. Section 19 is as follows:— " In case any Company does not make regulations within the time specified in this Act, or in case any Company, on being requested in writing by the Metropolitan Authority,* or by any ten consumcrt of the water supplied by that Company, to repeal or alter any of the regulations for the time being in force; or to make new regulations instead of any of the same, refuse so to do, the Local Government Board may, if they think fit, appoint a competent and impartial person, of engineering knowledge and experience, to report to them as to such regulations as may be necessary for the • The Metropolitan Board of Works is the Metropolitan Authority. In the section as enacted the official authority is the Board of Trade, whose powers were subsequently transferred to the Local Government Board, 125 execution of this Act; or, as to the expediency of altering or repealing such regulations, or of making new regulations, in conformity with such requests as aforesaid, and on the report of such person the Local Government Board may make such regulations repeal or alteration as they think fit." "No regulation, and no repeal or alteration of any regulation, has any force or effect unless and until the same be submitted to and confirmed by the Local Government Board (sec. 22), and no Company is bound to continue to supply water to any premises unless the regulations are duly observed in respect of such premises" (section 24). In more than one of my monthly reports I drew your Vestry's attention to the questions raised by the Water Acts and the regulations. I pointed out that if nothing more were to be gained by a revision of the regulations, a boon of incalculable magnitude would be conferred on the Metropolis if the 14th regulation were so altered as to compel the Companies (under heavy penalties for default) to abolish waste-pipes. I urged the desirability of Nuisance Authorities having co-ordinate power with the Companies to put in force such of the regulations as have a sanitary bearing,and recommended that application be made in the mode prescribed by section 19 (supra) for an alteration of regulation 14. I also recommended that the attention of the Local Government Board be directed to the need of further legislation to confer on the Nuisance Authority the power just mentioned, and to take away the power the Companies now have to cut off water from premises, substituting therefor such other powers to enable the Companies to recover rates, or make good fittings, &c., as to their wisdom should seem sufficient and equitable. Your Vestry referred my repot ts to the Works, Sanitary, and General Purposes Committee, who, after much consideration of the subject, reported as follows — (a) That the Water Companies should be requested, if they are not by law required, to give the Vestry notice in every case when they have cut off the supply of water from inhabited premises, from whatever cause. 126 (b) That as the existence of waste- pipes connecting water cisterns with drains, constitutes a dangerous nuisance, which ought to be universally abated, application should be made to the Local Government Board under section 19 of the Water Act, 1871, with a view to an alteration of the 14th regulation, so as to compel a Water Company to take measures for abolishing wastepipes connected with drains, and to give the Sanitary Authority equal power with the Company to abolish waste-pipes, and to en fore the regulations having a sanitary bearing, e.g., Nos 9, 11, 13, 14, 16, 17, 20, 21, 22, 24, 25, 31, and 32. (c) That if the existing law does not empower the Board to direct such alteration of the regulations, the Board should be requested to promote further legislation so as to confer such power and to compel the Companies to carry out the regulations generally. (d) That the Sections of the Acts conferring on the Water Companies the power of cutting off the water from premises should be repealed, such other powers to enable the Companies to recover rates or make good fittings, &c., being substituted, as to the wisdom of Parliament shall be deemed equitable and sufficient. The Committee recommended— (e) That this Report, together with the legal questions raised in the Reports of the Medical Officer of Health, dated February 1st and March 1st, 1882, respectively, be referred to the Law and Parliamentary Committee for consideration as to the best way of giving effect to the recommendations contained in such Reports. (/) That upon the receipt of a Report from the Law and Parlia- mentary Committee on the subject, a communication be sent to each Vestry and District Board of Works in the Metropolis, with a request that they would appoint three of their members to attend a conference upon the whole subject of water supply, at some convenient date, for the purpose of taking such action in the matter as may be deemed expedient. The Report was adopted by your Vestry, but the subject has not yet been taken into consideration by the Law and Parliamentary Committee, LICENSED SLAUGHTER-HOUSES. The licensed slaughter-houses are 26 in number, viz., 17 in the district north of Uxbridge Road, and 9 in the remainder of the parish south of that road. The names of the licensees and the localities of the licensed premises are set out in Table xi., 127 (appendix) The several premises were inspected in July by the Works, Sanitary, and General Purposes Committee, who reported that they were ''found in good structural condition, clean, and well kept." The Report continued as follows:— "Every slaughter-house now appears to be properly drained, and to have an 'appropriate' trap, the gully being covered with a fixed grating, as required by the bye-laws. "Wherever animals were found in the lairs, there also was found a supply of water for their use, but generally in moveable receptacles. "At some of the slaughter-houses there was a deficient supply of receptacles for the storage of offal, &c., and usually the receptacles for the storage of blood, which are supplied by the collectors, were ordinary iron buckets, with large and loose covers, instead of tight-fitting covers, as required by the byelaws. In no case, however, was there any offensive accumulation of blood, offal, or other refuse matter; nevertheless, steps should be taken to secure the provision of an adequate number of suitable receptacles. "Taken as a whole, your Committee have never before found the licensed premises in so satisfactory a condition .... and for the first time they have no occasion to report breaches of the bye-laws." It may be mentioned that at the date of the passing of the Slaughter-houses Act in 1874, there were some 1,429 slaughterhouses in the Metropolis; at the end of 1882 there were only 858. In Kensington the reduction has been from 54 to 26: the business of a slaughterer of cattle has not been "established anew in the parish since 1874. A society has been started in the Metropolis with the object of furthering slaughter-house reform, viz., by the provision of public abattoirs, and the promotion of painless methods of slaughtering. It has my best wishes for its success, although I felt unable to accept an invitation to occupy a seat on the Committee. The society proposes to erect model premises, with the view of illustrating, among other things, painless methods of slaughtering, an object with which every humane person cannot fail to sympathise. 128 LICENSED COWSHEDS. The licensed cowsheds are 18 in number, viz., 12 in the district north of Uxbridge Road, and 6 in the remainder of the parish south of that road. The names of the licensees and the localities of the licensed premises are set out in Table xii (appendix). The several premises were inspected in July by the Works, Sanitary, and General Purposes Committee, and were found in a clean and wholesome condition. The sheds, which in the aggregate are licensed for the keeping of 239 cows, were found to contain 122 cows only at the time of inspection. DAIRIES, COWSHEDS, AND MILKSHOPS ORDER OF 1879. Sanitary Supervision of Dairies, Cowsheds, &c.—The Metropolitan Board of Works is the "Local Authority" under this Order, which "provides for the registration of all persons carrying on the trade of cow-keeper and purveyor of milk, etc.," and under which 14,201 persons have been registered, of whom 931 are the occupiers of licensed cowsheds, the remainder being "dairymen or milk-sellers only." The Board state in their Annual Report that "in the larger dairies and milk stores much improvement has taken place, and they are generally in a satisfactory condition; and in the small shops where milk is sold there has been considerable improvement in point of cleanliness, and in the separation from the place of storage of substances likely to contaminate the milk." Registration appears to be enforced mainly in respect of shops where milk is the staple article of trade; many "general" shops, where milk is but one of a hundred articles sold, are still unregistered. It would involve endless trouble, doubtless, to register, regulate, and inspect such shops, and yet they might easily become the centres for the spread of disease by the sale of contaminated milk, as in case of an outbreak of scarlet fever, or typhoid fever, on the premises. The Board has taken 129 the very proper step of calling the attention of all persons engaged in the milk trade (other than the hucksters above referred to) to the precautions to be observed for the prevention of infection. I have always felt it to be an anomaly, that the carrying out of so important an Order should have been entrusted, as a rule, to bodies which have no sanitary machinery. Thus in the Metropolis (City excepted), the Metropolitan Board of Works, as already stated, is the ''Local Authority," and in the provinces the county magistrates, by virtue of the provisions of the Contagious Diseases (Animals) Act, 1878. The Board, in London, have delegated the duty of inspection of cowsheds and dairies to a very limited number of officers who have multifarious duties to perform under other Acts; in the country to whatever extent the duty is carried out it is usually entrusted to the police. Arrangements such as these are not calculated to ensure the results intended by the legislature, and they do not satisfy sanitarians, to whose representations the 34th section of the Act, and the Order itself, may be said to be due. The "Local Authorities" in the provinces, whence most of our milk comes, have always shown themselves keenly alive to the necessity of checking the spread of animal infectious diseases: one could have wished that they had been equally careful to make provision for the protection of human health, by measures designed to prevent contamination of milk, as required by the 9th section of the Order, viz., by prohibiting any person suffering from an infectious disease, or having been in contact with a person so suffering, from taking part in the conduct of the business of a cowkeeper or a dairman. Cattle however, being property, are much better looked after, as the law stands, than man in respect of the prevention of the spread of infectious diseases. The occurrence of animal diseases must be reported, infected animals being isolated and quarantined, if not at once slaughtered. 130 The unsatisfactory character of the arrangements under the Act, and the Order, formed the subject of discussion at a Meeting of the Society of Medical Officers of Health, held in December, 1880, when the following resolution was unanimously adopted:— "That in the opinion of this Society it is desirable, having regard to the more effectual prevention of the spread of zymotic disease by the agency of milk, that the special sanitary supervision and inspection of cowsheds, dairies, and milk shops, should be entrusted to the Local Authorities, the Medical Officers of Health, and the Sanitary Inspectors of the respective districts." The Government are now alive to the futility of the existing arrangements, and to the fact that, except for the purpose of registration, very few local authorities have carried out the provisions of the Dairies Order framed under the 34th Section of the Contagious Diseases (Animals) Act, as they have no special officers for the inspection of dairies, &c.; the question, moreover, relating to human health rather than to the prevention of animal disease.* A Bill to enable the question to be treated as one affecting the public health, has recently been brought in by the Lord President, under which the powers now vested in the Privy Council, with regard to dairies, cowsheds, and milk shops, including the power of making "Orders,'' are to be transferred to the Local Government Board. The "Local authority" is to be the urban or rural sanitary authority, in urban and rural sanitary districts; but in London the existing arrangements are to be continued, that is, the Corporation, a sanitary authority, will be the local authority in the City; and in the rest of the Metropolis, the Metropolitan Board of Works, which is not a sanitary authority, will continue to discharge the duties of local authority, if the Bill passes in its present form. "Without loss of time an effort was made to prevent the perpetuation of so obvious a mistake. * The Local Authorities for Middlesex and Surrey are deserving of honorable mention, having done their duty by appointing special officers. 131 T drew the attention of the Works, Sanitary, and General Purposes Committee to the subject, and on their recommendation your Vestry resolved:— "That a communication be addressed to the Lord President of the Council and to the President of the Local Government Board, calling attention to the fact that in all parts of the kingdom (the Metropolis excepted) the Sanitary Authority is the local authority under the above Bill, and suggesting the desirability of the Sanitary Authorities in the Metropolis—viz., the Vestries and District Boards of Works, being made the local authorities for the areas severally under their control the duty of the Metropolitan Board of Works (not being a sanitary authority) to be confined to the making of regulations uniform for the Metropolis, and subject to confirmation by the Local Government Board." The following letter, accordingly, was addressed to the Lord President:— " My Lord, "The Kensington Vestry have observed with satisfaction that it is proposed by the Public Health (Dairies, &c.) Bill,' to make the Sanitary Authority in all rural and urban sanitary districts, the 'Local Authority,' under the 34th Section of the Contagious Diseases (Animals) Act, 1878, and Orders made under it. "They regret to perceive, however, that the Bill, as it now stands, would except the Metropolis from this wise arrangement, as the Metropolitan Board of Works would continue to be the Local Authority. The Vestry desire to point out that the Metropolitan Board is not a sanitary authority, having no medical or sanitary staff properly so called. On the other hand, every Vestry and District Board possesses a sanitary staff—Medical Officer of Health and Inspectors, thoroughly acquainted with the work of inspection, and fully competent to discharge the duties devolving upon the Local Authority, which duties, in respect of cowsheds, at least, they, as a matter of fact, do actually perform at the present time. "The Vestry, therefore, would respectfully submit that it would be to the public interest that the Metropolitan Vestries and District Boards of Works, being the Sanitary Authorities, should also be, in their several districts, the Local Authority under the Bill. "But as regulations must from time to time be framed under the Dairies, &c., Order, 1879, or any subsequent Order, and as it is desirable 132 that the regulations should be uniform for the whole Metropolis, the Vestry would suggest that the power of framing regulations should continue to be vested in the Metropolitan Board of Works, the regulations so framed, however, to be subject to confirmation by the Local Government Board, the same as regulations framed by the Board under the Slaughter Houses (Metropolis) Act, 1874. "The Vestry feeling strongly the desirability of the above proposed modifications iu the Bill, earnestly commend them to your Lordship's favourable consideration. "I have the honor, &c.," A similar letter was addressed to the President of the Local Government Board. A copy of the letter was forwarded to each of the Vestries and District Boards of Works, together with a communication calling their attention to the subject, and suggesting the desirability of their taking immediate action in a similar direction, a course adopted without delay iu many instances. I forwarded a copy of the letter to the junior Member for the Borough, requesting his support of the views of your Vestry, and he promised to "look into the matter." I also drew the attention of the Society of Medical Officers of Health to the subject, with the result that the Secretaries were instructed to communicate with the Lord President ard with the President of the Local Government Board, urging a modification of the Bill in the direction indicated in the above letter. Lastly, I addressed a communication to the Secretary of the Veterinary Department of the Privy Council, and subsequently had an interview with him, at which I explained the grounds on which it appeared desirable that the inspection, &c., of Dairies, Cowsheds, and Milk-shops should be entrusted to the Vestries, &c., being Sanitary authorities, as "Local authorities" under the Act. More could not be done, and the result of the effort remains to be seen. At present (August 20) the Bill is set down for second reading, whether in its original state, or altered to meet the views of your Vestry, I cannot say.* * The Bill was dropped on the last working day of the Session, August 23. 133 BAKEHOUSES. The duties formerly devolving on your Vestry as local authority under the provisions of the Bakehouse Regulation Act, 1863 (26 and 27 Vict. Cap. 40), were transferred to Government Inspectors, January 1st, 1879, on the repeal of that Act by the "Factory and Workshop Act, 1878" (41 Vict. Cap. 16). The only reasonable surmise I can offer in explanation of the transfer, is that as "young persons," i.e., persons under 16 years of age, may not be lawfully employed in the business of a baker, which is largely a nocturnal one, between nine o'clock at night and five o'clock in the morning, such persons may have been deemed in need of the protection supposed to be afforded by the appointment of factory inspectors. It cannot be doubted that the supervision of several thousand bakehouses in the Metropolis, with the object of preserving cleanliness and preventing nuisance, could be better carried out by sanitary inspectors, a numerous body, than by so few as three factory inspectors, presumably having no special experience in sanitary matters; and it requires no great stretch of imagination to suppose that the protection of youthful employes might have been better secured, by enlisting, rather than by superseding, the services of sanitary officials. At any rate the supersession of these officers has been of no advantage to the employe's, for it is the fact, speaking of this parish, and probably it is true of the greater part of the metropolis, that official inspection of bakehouses has been discontinued since the "duty" was handed over to factory inspectors. Actual inspection of bakehouses, however, has not ceased in this parish, for, acting under my directions, the sanitary inspectors have continued to exercise supervision over them as a part of their routine duty, and in the past year 705 inspections were made of our 146 bakehouses. (Vide Tables VI. and VIa, Appendix) 134 The requirements of the law with regard to bakehouses are few and simple; whether they are adequate is another question: they may be summarised as follows:— Definition.—A "Bakehouse," a "non-textile factory," is "any place in which are baked bread, biscuits, or confectionery, from the baking or selling of which a profit is derived." Sanitary Provisions.—In respect of sanitary provisions the Bakehouse comes under the general law relating to factories and works. It is to be kept in a cleanly state, free from effluvia arising from any. drain, privy, or other nuisance; is not to be so over-crowded as to be injurious to the health of the workmen, and is to be ventilated. (Sec. 3.) A Bakehouse in which there is a contravention of this section, is deemed not to be kept in conformity with the Act, and the occupier then becomes liable to a tine not exceeding ten pounds. (Sec. 81.) Should the Inspector observe act or neglect in relation to sanitary matters, involving nuisance, punishable or remediable under the law relating to public health, but not under the Factory Act, it is his duty to give notice thereof to the Sanitary Authority, which will then make enquiry and take such action as may seem proper for the purpose of enforcing the law. The Inspector may for the purpose of this section (4) take with him into the bakehouse a Medical Officer of Health, or Inspector of Nuisances. Cleanliness.—Sec. 33 makes provision for securing cleanliness by periodical painting or varnishing, or whitewashing, of the bakehouse—walls, ceilings, passages and staircases; and for cleansing of painted or varnished wood by washing. Sleeping Accommodation.—A place on the same level with the bakehouse may not be used as a sleeping place if it be not effectually separated therefrom by a partition extending from floor or ceiling, or if it has not an external glazed window of at least nine superficial feet in area, of which at the least 1J superficial feet are made to open for ventilation (sec. 35). Employes.—As respects employes I need only mention that no "young person" under 16, may be employed in a bakehouse excepting between the hours of 5 in the morning and 9 at night, and with 7 hours at the least of rest; so that the actual period of labour may not exceed 9 hours; and the occupier who contravenes the section (45), becomes liable to heavy penalties (sec. 83). Powers of entry are given to the Inspectors (sec. 68). It may be mentioned that an Abstract of the provisions of the Act, containing all necessary directions for the guidance of employers and employed, has been prepared, and a copy thereof furnished to every occupier of a bakehouse. 135 The Regulation of Bakehouses.—In the "Report of the Chief Inspector of Factories and Workshops to Her Majesty's Principal Secretary of State for the Home Department," for the year ended 31st October, 1881, there are some striking, but rather general, observations by an Assistant Inspector on the condition of Metropolitan Bakehouses, observations which conclusively prove, if they prove anything, that the transfer of the supervision of these "non-textile factories" from the Sanitary Authorities to Factory Inspectors has not been to the public advantage in a sanitary point of view. It is unnecessary to reproduce here the unsavoury statements made in the Inspector's report, and which I quoted (at page 109) in my Annual Report for 1881. Suffice it to say that if the half were true of the bakehouses as a whole, the sooner a sweeping remedy for such a discreditable state of things is found the better. It may be asked why any bakehouses should have been suffered to fall into the deplorable condition implied by the terms of the Report ? The answer would appear to be twofold: (1) any person may setup a bakehouse anywhere; (2) systematic inspection of bakehouses, in most of the Metropolitan Districts, has been discontinued since the Factory Act came into operation in January, 1879: official Inspectors do not inspect, and Sanitary Inspectors have ceased to inspect. The publication of the Factory Inspector's Report had the good effect of drawing attention to the bakehouses and led, in many parts of the Metropolis, to an inspection of them by Sanitary officials, with the result of more or less occasion being found for the exercise of powers conferred by the Nuisances Removal and Sanitary Acts. In this parish the bakehouses, as already stated, have been inspected, since the passing of the Factory and Workshop Act, 1878, just the same as prior to the repeal of the Bakehouse Regulation Act, 1863, and no practical difficulty has been experienced in maintaining a fairly good sanitary condition of the several premises. But it has been alleged that sanitary officials have no right of entry into bakehouses: the high authority of the Home Secretary has been cited for this opinion, 136 and it appears to be the fact, that in some districts SanitaryInspectors have been refused admission on this very ground. Admitting that the special duties which formerly devolved on the Vestry, as "Local Authority" under the Bakehouse Regulation Act—in respect of the age of the employes, and the hours of employment of young persons, as well as in respect of the structural arrangements of the premises—were transferred to the Factory Inspectors under the Factory and Workshop Act, I hold that the Vestries, as Sanitary Authorities, still have a duty in relation to bakehouses, and that the powers conferred on them by the Sanitary Act, 1866 (Section 19, as amended by the Factory Act) and by the Nuisances Removal Acts, suffice for the discharge of that duty, viz., the prevention and the removal of nuisances, and that they have practically a power of entry, although of course the specific power of entry given by the Bakehouse Regulation Act ceased on the repeal of that Act. The Factory Act itself assumes a necessity for the interference of the Sanitary Authority, for, as already stated, it requires the Factory Inspector, should he observe any act or neglect in relation to sanitary matters involving nuisance "punishable or remediable under the law relating to public health, but not under the Factory Act," to give notice thereof to the Sanitary Authority, which will then make enquiry and take such action as may seem proper for the purpose of enforcing the law. The Inspector may for the purposes of this section (4), take with him into the bakehouse a Medical Officer of Health or Inspector of Nuisances. Under the Nuisances Removal Act, 1855, the word "nuisance" includes "any premises in such a state as to be a nuisance or injurious to health," a definition wide enough to include a dirty or unventilated bakehouse; whilst in the Sanitary Act, 1866 (Sec. 19), it is specifically enacted that the word" nuisances under the Nuisances Removal Acts, shall include . . . . any factory, workshop, or workplace not kept in a cleanly state, or not ventilated in such a manner as to render harmless, as far as practicable, any gases, vapour, dust, or other impurities generated in the course of the 137 work carried on therein, that are a nuisance, or injurious, or dangerous to health, or so over-crowded while work is carried on, as to be dangerous or prejudicial to the health of those employed therein." Under the Nuisances Removal Act, moreover, the local authority, i.e., the Vestry and their officers, have a power of entry for certain purposes of the Act, viz. : (1) To ground proceedings when they have reasonable grounds for believing that a nuisance exists on any private premises; between 9 a.m. and 6 p.m; this power of entry being extended by the Sanitary Act, 1866, so that it "may be exercised at any hour when the business in respect of which the nuisance arises is in progress, or is usually carried on." (2) To examine premises where nuisances exist, &c. (3) To remove or abate nuisance in case of non-compliance with, or infringement of, the order of Justices; or to inspect any . . . bread or flour; and for this purpose the local authority "may enter at all reasonable hours, or at all hours duing which business is carried-on, on such premises, without notice." Action of Vestries, &c. —I have already stated that the Assistant Inspector's Report had the good effect of drawing attention to the bakehouses in many quarters. Your Vestry received communications on the subject from the Vestries of St. Pancras, Islington, Newington and Chelsea, and from the Lewisham Board of Works. The Metropolitan Board of Works, always alive to the duty of increasing its really great importance, took it up, and the Home Secretary himself was both memorialized and interviewed by the operative bakers in the interests of their personal welfare. The observations of the right honourable gentleman encourage us to hope that at no distant time the subject of bakehouse regulation may be reconsidered in Parliament. I propose, therefore, for future use, to place on record a memorandum of the action recently taken with a view to amendment of a confessedly faulty system. 138 The St. Pancras Vestry appear to have been the first to take up the question, their attention having been drawn to it by their Medical Officer of Health, in an interesting report: a copy of the report was sent to the several Sanitary Authorities, who were invited to "express their views on the subject of the regulation of bakehouses," and to say ''how far the present position of legislation with reference to bakehouses is considered satisfactory ?" The Metropolitan Board of Works considered the subject, on a report by their Special Purposes and Sanitary Committee, pointing out that further legislation is now required to secure the efficient inspection, and the proper sanitary condition of bakehouses, and recommending that a communication be addressed to the Home Secretary, urging the early introduction into Parliament of a measure for enabling the Board to make regulations as to the sanitary condition of bakehouses in the Metropolis, with power to inspect and to enforce the regulations. A good deal may be said in favour of the suggestion that the Board should have the power to make bye-laws in order to secure uniformity, but the duty of inspection should be entrusted to the Sanitary Authorities, who already, and alone, possess a staff of officers adequate, in point of numbers and experience, to perform the duty satisfactorily. The Newington Vestry's communication, elicited by the abovementioned proposal that the Metropolitan Board should acquire statutory power to regulate bakehouses, expressed the opinion that if any change were to be made in the existing law relating to the inspection and regulation of the sanitary condition of bakehouses in the Metropolis, the powers vested in Vestries, &c., by the Bakehouse Regulation Act, 1863, should revert to those bodies. The communication from the Chelsea Vestry was to a similar effect. The Islington Vestry forwarded a copy of a resolution on the subject which it had sent to the Home Secretary. Action of the Vestry.—The communications from the several Vestries were referred for consideration aud report to 139 the Works, Sauitary, and General Purposes Committee, and acting on their recommendation your Vestry decided to address a communication to other Vestries, &c., as follows:— January 18th, 1883. To the Clerk of the Vestry. " Sir, "The Vestry have recently received, in common with other Vestries and District Boards of Works, communications from the Vestries of Newington and Chelsea, on the subject of 'Regulation of Bakehouses,' to which their attention had been previously drawn in August last by the St. Pancras Vestry. "This subject had on more than one occasion, in 1882, been under the consideration of the Works, Sanitary, and General Purposes Committee, whose final report thereon was received and adopted by the Vestry on the 8th November last. "Although the Vestry are of opinion that there is little probability of legislation with respect to Bakehouses in the ensuing Session of Parliament, the subject is so important that they have thought it desirable to place their views thereon before the several Vestries and District Boards of Works, and I am accordingly directed to forward for the information of your Vestry the report of the Committee above referred to, which, I may add, is in substantial agreement with the views of the Vestry's Medical Officer of Health, as set out in his Annual Report for 1881." I am, &c., The Report of the Committee was as follows:— "With reference to the letter from the Vestry of St. Pancras respecting the regulation of bakehouses, and enquiring how far the present position of legislation concerning bakehouses is considered satisfactory by this Vestry ?— "Recommending— "That the Vestry of St. Pancras be informed— (1.) 'That the Sanitary Inspectors of Kensington have continued to inspect bakehouses in the Parish under the provisions of the Nuisances Removal and Sanitary Acts, notwithstanding the repeal by the Factory and Workshop Act, 1878, of the Bakehouse Regulation Act, 1863. (2.) 'That this Vestry, nevertheless, do not consider the present position of legislation in respect of bakehouses satisfactory, and in their opinion 140 fresh legislation is desirable, with the object of replacing the sanitary supervision of bakehouses under the Sanitary Authorities, with increased powers to enable them to regulate bakehouses by bye laws, dealing with, (a) position and construction, including lighting and ventilation, and periodical cleansing of bakehouses, and (b) the materials and utensils employed in the manufacture of bread. (3) 'That in the opinion of this Vestry bakehouses should be licensed or registered the same as cowsheds or dairies.' " Reference having been made to my views, I should like to say that, in my judgment, the present state of legislation in respect of bakehouses is altogether unsatisfactory, and that, while I would not desire to take away from Factory Inspectors the duties they are now supposed to discharge, in relation to young persons employed in bakehouses, and the hours within which such employment may be lawfully carried on, it has been sufficiently proved Parliament made a mistake in handing over to Factory Inspectors a supervision of bakehouses, which has confessedly been exercised in the most perfunctory manner, and that steps should be taken to obtain a reversal sal of the policy inaugurated in 1878. I will only add that I long since formed definite opinions on this question,and expressed them as follows, in my last Annual Report (page 112)— "What really is required is a proper 'Bakehouse Regulation Act,' providing for the licensing of bakehouses, and conferring on Sanitary Authorities the power, which they should be obliged to exercise, of regulating the trade by bye-laws, uniform for the Metropolis, dealing with— (1) The position and construction, including lighting and ventilation of bakehouses. (2) The periodical cleansing of them; and (3) The materials and utensils employed in the manufacture of bread." Some time having elapsed, and nothing more heard from St. Pancras, application was made to the Vestry Clerk, who returned a printed summary of replies received from 18 of the Vestries, &c., which, speaking generally, were favourable to the principle of regulation of bakehouses by the Sanitary Authority, and 141 unanimous as to the unsatisfactory character of existing arrangements. The Clerk at the same time intimated that the Vestry would probably take no further action in the matter, and they did not. It was subsequently suggested that your Vestry should invite a Conference of Vestries, &c., to consider this important question, with the view of promoting an Amending Act, to replace the sanitary supervision of bakehouses under the Sanitary Authorities, and the only objection that could be urged to the suggestion was that, in the unsettled state of affairs in respect of the local government of the Metropolis, there was little ground for hope that the Government would introduce any such measure. The Society of Medical Officers of Health having taken the subject into consideration, resolved, on the recommendation of the council, to memorialise the Home Secretary, "praying that the powers originally possessed by the Metropolitan Sanitary Authorities under the Bakehouse Regulation Act should be restored to them, with power to make bye-laws regulating the structure of bakehouses, periodical cleansing, power of entry at any time, the utensils used in manufacturing bread or pastry, and also such other matters as the Local Authorities may deem necessary." A Memorial was subsequently presented, the terms of which, I believe, were in close, if not literal, agreement with the subjoined draft, which I prepared, showing:— "1. That prior to the passing of the Factory and Workshop Act, 1878, the Sanitary Authority in the Metropolis (as elsewhere) was the Local Authority under the Bakehouse Regulation Act, 1863. 2. That under the said Bakehouse Regulation Act the Bakehouses in the Metropolis were regularly inspected by the Sanitary Inspectors of the respective Parishes and Districts, and the sanitary provisions of the Act, however imperfect, were duly carried out. 3. That on the repeal of the Bakehouse Regulation Act by the Factory and Workshop Act the duty of inspecting bakehouses was transferred to the Factory Inspectors. 142 4. That from insufficiency in the number of Inspectors available for the duty, or other cause, official inspection of Bakehouses, as a regular and systematic proceeding, has practically ceased since the passing of the Factory and Workshop Act. 5. That as a consequence of such practical cessation of official inspection the bakehouses have fallen into an unsanitary condition, as testified in respect of some of them, by Assistant Inspector Lakeman (vide Annual Report for 1881 by the Chief Factory Inspector), and generally, by Reports presented to Vestries and District Boards of Works by Medical Officers of Health and Sanitary Inspectors, after inspection made by such officers, as a result of the revelations published in the said Annual Report of the Chief Factory Inspector. 6. That regular systematic inspection of Bakehouses is imperatively necessary for the protection of the interests of public health. 7. That such inspection could be best carried out by Sanitary Authorities, who have an ample staff of trained and efficient medical and sanitary officers available for the purpose. 8. That the provisions of the Factory and Workshop Act are insufficient to secure a proper sanitary condition of bakehouses, regarded as places in which a prime necessary of life, the daily food of man, is prepared. 9. That there is urgent necessity for fresh legislation, to secure such per sanitary condition; it being desirable, moreover, for the reasons above indicated, that the supervision of Bakehouses should be restored to the Sanitary Authorities. 10. That in the contemplated legislation provision should be made for Licensing or Registration of Bakehouses. Power of entry at all times by the officers of the Local Authority. Power to the Local Authority, being the Sanitary Authority, to frame bye laws to enable them to regulate bakehouses by bye laws dealing with (a) the position and the construction, including lighting and ventilation, and periodical cleansing of bakehouses, and (b) the materials and utensils employed in the manufacture of bread, pastry, &c. "The Society, therefore, respectfully recommend the introduction of a Government Bill to secure the above objects, being of opinion, moreover, that the principles applicable in respect of bakehouses might be judiciously extended to all other places in which articles of food of man are prepared for sale." 143 The Home Secretary was at the same time requested to receive a deputation from the society. In his reply he stated that he was in communication with the Local Government Board on the subject, and that he had referred the suggestions of the Society to that Board, postponing ''for the present the question of receiving the deputation.'' The Operative Bakers and Confectioners Union very properly took up the question of "unsanitary bakehouses," in the interests of their personal health and welfare, and obtained an audience with Sir Charles Dilke, in the absence of the Home Secretary, the Chief Inspector of Factories being present, to represent their grievances. Mr. Broadhurst, M.P., who introduced the deputation, stated that the main points they wished to bring before the Government were the desirability of appointing Government Inspectors of Bakehouses, and that the Government should bring in an Act, or a clause in an Act, to provide that for the future no bakehouse should be built underground. Mr. Broadhurst quoted a paragraph in a memorial presented by the deputation, as follows, the fact stated being only too true:—"At present almost any kitchen or cellar is turned into a bakehouse, often in close proximity to drains, many being even undrained, and totally unfit places for the manufacture of human food "Subsequently, as already stated, the Home Secretary received the deputation, when several of its members laid emphasis on the fact that the unsatisfactory condition of bakehouses seriously affected the wholesome character of bread. The right hon. gentleman, in reply, said that the Government would, by legislation, prevent—at least, so they proposed—the construction of underground bakehouses for the future. As to the question of inspection, he could not at present hold out any promise, but the memorial would be taken into careful consideration. 144 The Chief Inspector of Factories and Workshops, in his annual report for 1882, which did not come under my notice until after the above portion of my report was in type, again refers to the bakehouse question. It appears that Inspector Lakeman's report, referred to above, applied to a limited part of the Metropolis only, his own district in fact, "which lies between Farringdon Street and Cambridge Road, Bethnal Green." This gentleman, with his colleague, made about 1000 visits to bakehouses in the year ended October 31, 1882, and he states that:— "Every bakehouse visited by us there has been lime-washed more or less frequently during the year. The practice of accumulating heaps of refuse under troughs has been largely decreased; traps to sinks are not found broken or lost to the extent of last year, but no advance has been made in the ventilation of worst places, nor can there be in bakehouses situated under the shop. . . . We have endeavoured to improve the ventilation, and to secure a water supply for the abominable closets in bakehouses. . . Where there is a disinclination to erect flush cisterns, we cannot enforce it so long as care is taken to flush by hand." I have already (at page 134), given a summary of "the requirements of the law with regard to bakehouses," stating (inter alia) that the bakehouse is "To be kept in a cleanly state, free from effluvia arising from any drain, privy, or other nuisance . . and is to be ventilated : also that a bakehouse, in which there is a contravention of Section 3, is deemed not to be kept in conformity with the Act, and the occupier thus becomes liable to a fine (under Section 81) not exceeding ten pounds." The Inspector appears not to have had a fresh recollection with regard either to his own powers, or the duties of bakehouse keepers, and to have lost sight of a duty devolving on him, already referred to, as follows:— " Should the Inspector observe act, or neglect, or default, in relation to sanitary matters involving nuisance (e.g., 'in relation to any drain, water-closet, sink,' &c.), punishable or remediable under the law relating to public health, but not under the Factory Act, it is his duty to give notice thereof to the Sanitary Authority, which will then make 145 inquiry, and take such action as may seem proper for the purpose of enforcing the law. The Inspector may, for the purposes of Section 4, take with him into the bakehouse a medical officer of health or inspector of nuisances." It would be interesting to know on bow many occasions the Inspector availed himself of the services of sanitary officials,who, I venture to say, would have had little difficulty in abolishing "abominable closets in bakehouses," and none at all in "securing a water supply" for closets, or, wherever practicable, in cutting off sinks from drains, thus doing away with the occasion for "traps to sinks " in bakehouses. Another Inspector reports that in many bakehouses there are no drains; in some no sinks; but it is not clear whether this is said by way of commendation, or to express deficiencies. He, like his other two colleagues, complains of "defective ventilation," and of "refuse collections.'' "This latter offence against cleanliness . . . must be stopped," it is said, but there is no evidence of any attempt to stop it. The Chief Inspector refers to sundry reports on bakehouses by medical officers of health, elicited by his 1881 report. In these reports he says: — "An enumeration is given of various instances of accumulation of refuse under the troughs and of untrapped drains, of floors badly paved, of ceilings broken, of water-closets badly placed, of bakehouses badly lighted, and of the trade being carried on in places totally unfitted to be used for the preparation of food." "Proper inspection," he adds, "would mitigate the two first-named defects—dirty state and untrapped drains; but there is no power to order repairs to floorings or ceilings . . . or to prevent sinks and drains in bakehouses, and herein consists the weakness of the present bakehouse regulations." It is to be regretted that the Inspectors do not, by "proper inspection," mitigate or remove defects capable of mitigation or removal: or, if they doubt their own powers under the Act, that they should not systematically seek the co-operation of the sanitary authorities, who, probably, would show them how to get "badly paved floors" and "broken ceilings" repaired, 146 under the powers which enable them to enforce cleanliness, in the highly improbable event of the proprietor delaying to make such needful reparations on request. But the fact is, factory inspectors naturally think most of their duties in regard to the ''labour of young persons and children," which they have power to restrict, and the Chief Inspector appears to be conscious of their unfitness for the performance of merely sanitary duties, for he says: — "Upon a review of the condition of bakehouses, and the very slender chance of any real and effectual amelioration taking place in the making and baking of bread, without the interposition of authority, I would desire to see legislative enactments laying down some broad rules, placing the control over the construction of bakehouses, and the maintenance of them in a healthy condition, in the hands of the local authority." (The italics are mine.) He mentions ''the main points" which such "regulations" should embrace, and to which cordial assent may be given. It is satisfactory to note, moreover, that in his judgment " The authority having control over the construction of bakehouses, and power to frame bye-laws . . . should be the various local authorities having supervision over the sanitary condition of their districts." But, strangely enough, whilst he thinks sanitary authorities in urban and rural sanitary districts, competent for the discharge of these duties, he would hand over the bakehouses in London —like cowsheds, dairies,slaughter-houses, and offensive trades— to the Metropolitan Board of "Works, which is not a sanitary authority, and has no medical adviser, and no sanitary staff properly so called. Having regard to the desirability of uniformity in bye-laws, I should be content to see the power of framing such as are necessary for regulating the construction and sanitary supervision of bakehouses in the Metropolis, vested in the Metropolitan Board of Works, provided bye-laws so framed were submitted to the Local Government Board for confirmation, so as to ensure the revision of them by competent legal and medical experts; but 147 the duty of inspection, and generally of carrying out the bye-laws should be entrusted to the sanitary authorities, viz., the several vestries and district boards of works. [Addendum.—I had the satisfaction, in my tenth report for the current year (August 13, page 97), of reporting that the views of your Vestry on the subject of Bakehouse supervision had prevailed, a Government Bill, entitled "Factory and Workshop Amendment," having been introduced, one of the objects of which is to restore to Sanitary Authorities their former position as "local authority," so far as relates to cleanliness, ventilation, overcrowding, and other sanitary conditions of bakehouses, viz., by enabling them to enforce Sections 3, 33, 34, and 35 of the Factory and Workshop Act, 1878. The recommendations of your Vestry went considerably beyond this, being substantially in agreement with the views expressed in myAnnual Report for 1881*; but however desirable these recommendations, it was obvious that, at so late a period of the Session, it would have been useless to force them on the attention of Parliament: indeed, it is almost too much to hope that the Bill can be passed this year, as at the present writing (August 20) it still awaits second reading in the Commons. I felt it my duty, nevertheless, to request the consideration of the President of the Local Government Board to two proposed amendments of the Bill, as it stands, viz., (1) the insertion of words, in Section 19, to give the Inspector of Nuisances the same "powers of entry," &c., as the Medical Officer of Health; and, (2) the omission of words, in Section 17, which would appear to legalize, by implication, the continuance, within or near existing bakehouses, of water closets, ash-pits, dram-openings, &c.; although such nuisances should satisfy "a court of summary jurisdiction" that "a room or place used as a bakehouse "was" in such a state as to be, on sanitary grounds, unfit for use or occupation as a bakehouse," and so the occupier might be liable to pains and penalties, * Vide page 140, supra. 148 and to "orders" for "the purpose of removing the ground of complaint," viz., under Section 18. The president informed me that the Bill was in the charge of Mr. Hibbert, and that he would take care my representations were laid before that gentleman. Should it become necessary to withdraw the Bill, it is to be hoped a more comprehensive measure may be introduced next Session.*] HOUSE REFUSE. The collection of ashes, and miscellaneous refuse, from upwards of 20,000 houses, within an area of more than 2,000 acres, and to the extent of 30,000 loads in a single year, is no light task, and complaints of neglect on the part of the dustmen were habitual when the work was carried out under the contract system. So frequent, indeed, did complaints become at last, that your Yestry, desirous of satisfying the legitimate requirements of the parishioners, determined, in 1877, to abolish the contract system altogether, and to undertake dustcollection with an ample staff and plant. The results have justified the change: the work has ever since been done in an increasingly satisfactory manner; complaints are rare, and even applications for removal of ashes are comparatively few. Sometimes, moreover, when your Yestry, or the dustmen, have been censured for alleged neglect, it has turned out on enquiry that domestic servants were to blame: the hour of the dustman's call was "inconvenient;" "the steps had just been cleaned;" such excuses, or others equally valid from a servant's point of view, being deemed sufficient for the perpetuation of a nuisance. And nuisance, it may be averred, arises almost solely from the improper use of the receptacle by the deposit therein of animal and vegetable refuse; of which it may be said that the former has an appreciable value, and should be utilized, while the latter admits of being burned on the kitchen fire. A notification to this effect was left at every house in the parish in 1873, and is now in course of being repeated. * The Bill was passed on the last working day of the Session, viz., August 23. 149 A strong effort has been made to systematise the work of dust-collection by dividing the parish into districts, and by providing for the inspection of dust-bins, and for supervision of the "dusting-gangs." The one thing needful for success is a systematic call at every house once a week. Hitherto the rule, or at any rate the order, has been, that a dust cart should go through each street once a week, on a given day, and that a call should be made at each house once a fortnight. If the plan of a weekly call could be organised, it should be understood that if, through default of domestic servants, or any other cause beyond the control of your Vestry, the receptacle is not emptied on the appointed day, no further attendance will be given in the same week. Delay in the removal of ashes not unfrequently arises from the exceedingly inconvenient position of the receptacle, e.g., in a deep area, to which there is practically no access save by ladders—a short one on the foot pavement, and a longer one in the area. Apart from the question of danger to the dustmen in the use of the ladders, it is a question whether your Vestry should not insist on some more satisfactory provision being made, e.g., by steps and an area gate, giving safe and convenient access to the receptacle ? In some cases where there are steps, householders actually refuse to allow the gate to be unlocked. STABLE REFUSE. For several years I have felt it my duty to draw your Vestry's attention to the subject of the removal, or rather the non-removal, of stable refuse. Regulations have been framed and published enjoining "periodical removal of manure, etc.," by the owners, under the provisions of the Sanitary Act, 1866, which prescribes a penalty of twenty shillings a day for default. But still, the most frequent cause of complaint by parishioners, and the most frequent of recurring nuisances, arises from the neglect of this obligation. Proceedings have been taken occasionally to enforce the regulations, but not with uniform success, the 150 offenders having usually been able to satisfy the Magistrates that the duty required of them was beyond their power to perforin. The difficulty not seldom originates with tbe coachman, who will not give the refuse away, while the farmer or his carter will not pay for it. At certain seasons, e.g., haymaking time and harvest, there is a real difficulty in getting the receptacles cleansed, farmers being too busy to send their carts into town, or, when they do, to allow them to stay to collect the refuse. The refuse, nevertheless, has value, if it could only be got on to the land without undue cost: the quantity made in this large parish with its 150 mews is very great, and of an aggregate value probably more than sufficient to pay for collection and removal from London. It is a question whether your Vestry should not undertake such collection and removal, as the law allows, "with the sanction of the owner," a sanction which would be cheerfully given in many instances, and which, probably, it would not be difficult to obtain, in most cases, if it were understood that the "Regulations" would be enforced. The question is important any way, and I may state that the time of the Sanitary Inspectors is largely taken up in the endeavour to keep the mews clean, time which in different circumstances might be more profitably occupied in other directions. The regulations require that the manure should be removed "every alternate day." Twice a week in summer, and once a week in winter, would probably suffice for all practical requirements, in ordinary cases, if the manure were stored in properly constructed receptacles above ground. REFUSE. Great difficulty is experienced in preventing nuisance from accumulations of offensive matters coming under the general description, "refuse." The difficulty is common to all parts of the Metropolis, and calls for legislative interference for its abatement. With a view to such steps being taken, I brought the subject under the notice of the Society of Medical Officers of 151 Health in 1880, the result being that a special Committee was appointed to consider the subject, and who ultimately presented a report, which was re-produced in my Annual Report for 1880 (page 114). The conclusions at which the Committee arrived may be summed up as follows:— 1. Trade Refuse.—The Nuisance Authority should have power to collect, remove, and dispose of the trade refuse of butchers, fishmongers, poulterers, greengrocers, etc., at the reasonable cost of the producers. The collection of such refuse should be made in the early morning, and the removal effected in specially constructed vehicles : if practicable, the refuse should be utilized; otherwiseit should be destroyed by fire. 2. House Refuse.—In view of the increasing distance to brickfields, house refuse will have to be dealt with by tire in specially constructed apparatus of the "Destructor" type, by which its bulk may be reduced some 75 per cent., the resulting product moreover, being at at once innocuous, and useful for roadmaking and other purposes: the refuse should be collected daily, and " dust bins " abolished. 3. Stable and Cowshed Refuse.—The Nuisance Authority should have power to collect the refuse at the reasonable cost of the owner: cowshed refuse daily, in vehicles designed to prevent slopping and effluvium nuisance; stable refuse periodically: the refuse, meanwhile, to be stored in suitable receptacles—paved, drained, and enclosed within iron racks, above ground. 4. Conclusion.—Legislation is necessary to give effect to the above mendations, and to compel railway and canal companies to carry refuse from towns at a reasonable, while remunerative, rate. PUBLIC URINALS. There are only ten public urinals in this great Parish, a very inadequate number, and no public water closets save at the rear of the Vestry Hall. Your Vestry's powers to provide such "necessary accommodation" are ample, but difficulty has been experienced in giving effect to the provisions of the 88th section of the Metropolis Management Act, which enables the Nuisance Authority to "provide and maintain urinals, water closets, and like conveniences (for both sexes) in situations where they deem such accommodation to be required," &c. 152 Owing to the opposition raised by inhabitants in the neighbourhood of the sites selected for such proposed erections, a proposition was made, by a private individual firstly, and afterwards by a Company, to provide chalets for the convenience of the public, as a commercial speculation; but the Law and Parliamentary Committee having reported that your Yestry have no authority for placing obstructions in the public streets, the matter fell through. In some other parishes the scheme has been entertained favourably, and chalets have been erected: there is one at Shepherd's Bush Green. Should the system be found to work satisfactorily, means will doubtless be found to overcome any legal difficulties that may appear to stand in the way of its extension. PUBLIC BATHS AND WASHHOUSES. The Commissioners have recently published an interesting report, setting forth the steps taken to give effect to the resolution of your Yestry to provide public baths and washhouses. A site which appeared very suitable, had, it was thought, been secured at Notting Hill, in the centre of a large and somewhat poor district; your Vestry's sanction had been given to the purchase, whereupon the freeholder withdrew the terms on which it was understood he was prepared to cede his interests. The Commissioners are still making efforts to obtain a suitable site. Great good might be effected by the provision of a number of buildings, on a modest scale, in different parts of the parish, to which the poor might resort for the purpose of washing clothing, &c. The question of public wash-houses might with advantage be separated from that of public baths. MORTUARY. The Mortuary in the Parish Churchyard, at the rear of the Yestry Hall, was opened in July in the current year. It comprises two chambers, one for infectious, and the other for non-infectious, bodies, separated by a "place provided for post-mortem examinations." This 153 place" is designed "for the reception of dead bodies for and daring the time required to conduct any postmortem examination ordered by the Coroner," who "may order the removal of the body for carrying out such post-mortem examination, and the re-removal of such body, such costs of removal and re-removal to be paid in the same manner, and out of the same fund as the costs and fees for post-mortem examinations when ordered by the Coroner." (Sanitary Act, 1866, sec. 28.) The power of a Sanitary Authority to "provide a proper place for the reception of dead bodies," (Mortuary), is conferred by the preceding (27th) section of the same Act, which enacts that "Where any such place has been provided, and any dead body of one who has died of any infectious disease is retained in a room in which persons live or sleep, or any dead body which is iu such a state as to endanger the health of the inmates of the same house or room, is retained in such house or room, any Justice may, on a certificate signed by a legally qualified medical practitioner, order the body to be removed to such proper place of reception, at the oost of the nuisance authority, and direct the same to be buried within a time to be limited in such order, and unless the friends or relations of the deceased undertake to bury the body within the time so limited, and do bury the same, it shall be the duty of the Relieving Officer to bury such body at the expense of the Poor Rate; but any expense so incurred may be recovered by the Relieving Officer in a summary manner from any person legally liable to pay the expense of such burial." In congratulating your Vestry upon the completion of the handsome and appropriate building now dedicated to public use, I may perhaps be allowed to recall the fact that in my first annual report, for the year 1871, I drew attention to the need of a mortuary. Shortly afterwards a Special Committee was appointed to consider how this want might be supplied ? The Committee devoted much time to the subject, but were ultimately obliged to report that they could not obtain a site. In my annual report for 1873 I first referred to the Parish Churchyard as a suitable site, but the suggestion was not approved by the then senior ChurchwarJen. Gradually, 154 however, the idea of placing the Mortuary in this position grew into favour, and was ultimately accepted as the solution of the difficulty. A question has been raised, whether one Mortuary is sufficient for this large parish ? Without committing myself to a final answer to this question I would point out that the Mortuary site is central, and at no very great distance from any part of the parish. It is the fact, moreover, that, once a body has to be removed, the cost is much, if not quite, the same whether the distance be a hundred yards or a couple of miles. I could not recommend your Vestry, therefore, to entertain the question of a second mortuary until the present building had been proved to be of insufficient capacity, or inconvenient in position. It is a real difficulty to get people to avail themselves of the accommodation furnished by a mortuary ; this difficulty, however, I have always felt would be, to a certain degree, overcome by the sacred associations connected with the site on which your Vestry's Mortuary is placed. I trust the building will be used, and that it will prove a benefit to our poorer parishioners, who are now often condemned, in following an unwise custom, to retain their dead for many days in rooms occupied, by day and night, by the living. No doubt it will take some time to accustom them to appreciate the value of the Mortuary, but I hope that the good advice of medical men, clergymen, district visitors, parochial officers, &c., whose aid I have invoked, will be enlisted in the development of sound sanitary views on the subject. Your Vestry's Works, Sanitary and General Purposes Committee requested me to prepare a code of regulations for the guidance of parishioners and others with regard to the Mortuary and the post-mortem room, and rules prescribing the duties of the Mortuary Keeper. My draft having been carefully considered by the Committee, approved, and reported to your Vestry, was referred to the Law and Parliamentary Committee, and after revision by that Committee, was, with one or two minor alterations, finally adopted by your Vestry on the '28th Febi-uary last, as follows ;— 155 REGULATIONS Under which Dead Bodies are permitted to be placed in the Mortuary in the Parish Churchyard, at the rear of the Vestry Hall. (Sanitary Act, 1866. Section 27.) 1. Application for permission to deposit a body in the Mortuary shall be made to the Mortuary Keeper at the Mortuary, Hornton Place, Hornton Street, Kensington, or at the Offices of the Sanitary Department at the Town Hall, and such application shall be signed by a relative or friend of the deceased, or by the undertaker employed in the case, or other applicant. A body in case of emergency may be deposited at any hour of day or night; but in ordiuary cases application can be entertained between the hours of eight and twelve in the morning, and five and nine in the evening, only. 2. A body (except in case of emergency) shall be conveyed to the Mortuary in a hearse, or otherwise in a decent and proper manner, enclosed in a pitched shell or coffin, in which the body shall be buried, and it shall be removed therefrom for burial within five days from the date of death, or when required by the Medical Officer of Health. 3. No body shall be removed from the Mortuary, except for burial, without the permission of the Medical Officer of Health, and then only on condition that it shall have been first enclosed to the satisfaction of the Medical Officer of Health. 4. When death has arisen from an infectious disease, or when the body is in an offensive condition from decomposition or other cause, the coffin must be filled in with an approved disinfecting powder, and properly and securely fastened, before admission into the Mortuary. 5. In any case coming within the preceding rule (4), the coffin shall not be re-opened without either the order of the Coroner or the consent, in writing, of the Medical Officer of Health. 6. A body may be viewed by a friend or relative (except in cases where the death has occurred from an infectious disease) between the hours of one and four in the afternoon. A body may be viewed for identification at any reasonable hour. 7. On the admission of a body into, or its removal from, the Mortuary, no public procession or large assemblage of persons will be allowed within the building; the only persons to be then admitted shall consist of the nearest relatives of the deceased, the undertaker, and the bearers of the body. 8. The Mortuary being intended only for the reception and retention of the dead, the Vestry does not undertake to send for, nor send away, the bodies. 156 9. No body shall be admitted except such admission be subject in all respects to the Regulations from time to time in force for the regulation of the Mortuary. 10. It shall be the duty of the Mortuary Keeper to see that the above Regulations are carried out, and that all persons having occasion to visit the Mortuary conduct themselves in all respects with decency and propriety. The Mortuary Keeper, or others in service at the Mortuary, shall not be allowed to receive gratuities ot any kind from any person or persons whatsoever. COMPULSORY REMOVAL OF A DEAD BODY TO THE MORTUARY. (Sanitary Act, 1866. Section 27.) 1. This can be done by the order of a Justice of the Peace, on receipt of a certificate, signed by a legally qualified Medical Practitioner, by the Medical Officer of Health, to the effect that the body of one who has died of an infectious disease is retained in a room in which persons live or sleep, or that any dead body is in such a state as to endanger the health of the inmates of the house or room in which such body is retained. 2. The Medical Certificate and Justice's Order shall be retained by the Medical Officer of Health. On receipt of the said order for removal, the Medical Officer shall send instructions to the Contractor to remove the body to the Mortuary. 3. The Mortuary Keeper shall give a receipt for such body to the Contractor, and a duplicate shall be kept at the Mortuary. 4. On receipt of the body, the Mortuary Keeper shall enter all particulars in the book provided for such purpose, as required by the Regulations. 5. A notice shall be sent by the Medical Officer of Health to the Relieving Officer to bury the body within the time limited by the Justice's Crder, unless the friends or relatives of the deceased undertake to bury the body within the time so limited. The expense of such burial, if incurred, shall be subsequently recovered from the person or persons legally liable to defray such charges. REGULATIONS FOR THE MANAGEMENT OF THE PLACE PROVIDED FOR POST-MORTEM EXAMINATIONS. (Sanitary Act, 1866. Section 28.) 1. A dead body intended for posl-mortetm Examination, or for Inquest, (except in case of emergency), shall be conveyed in a sound and pitched shell or coffin, to be subsequently used for burial, or in a shell which, with its lid, is properly lined. Ordinary shells shall not be allowed to be taken away unless for use in burial in accordance with the Mortuary Regulations. The whole of such Regulations shall be deemed to be Regulations made for the management of the place provided for post-mortem Examinations so far as they may b® applicable thereto. 157 2. Any legally qualified Medical Practitioner shall be permitted to use such place, subject to the conditions prescribed by the Vestry. 3. No post-mortem Examination shall be made without either the order of the Coroner, or the written consent of the legal representatives of the deceased; such order or consent shall be produced to the Mortuary Keeper. 4. No post-mortem Examination shall be made on Sunday, unless in case of emergency. 5. The Mortuary Keeper shall not be allowed to interfere or take part, in any way, in a post-mortem Examination, beyond giving the attendance necessary upon the Medical Practitioner making the post-mortem. 6. No person shall be admitted to prepare for, or to commence, a post-mortem Examination, unless the Medical Practitioner authorised to make such postmortem, or his qualified assistant, being a duly registered practitioner, shall be present at the same time. 7. No part of a body examined shall be taken away from the place appointed for post-mortem Examination, except upon an order from the Coroner, or other person duly authorized. DUTIES OF THE MORTUA.RY KEEPER. 1. The Mortuary Keeper shall act under the direction of the Works, Sanitary, and General Purposes Committee, through the Medieal Officer of Health; and shall preserve and enforce decorum and due respect to the dead. 2. He shall reside in the place appointed by the Vestry, and shall be responsible for all arrangements connected with the reception, the care, and the removal of the dead. 3. He shall keep books in which he shall enter all such particulars with reference to bodies brought to the Mortuary as the Committee shall direct. 4. He shall aflix to the coffin a card bearing the name and age of the deceased. 5. He shall keep the Mortuary and the place appointed for post-mortem examinations in good order. 6. He shall deliver to the Medical Officer of Health, at ten o'clock of the morning on the day preceding the usual day of meeting of the Committee, a return of the work done since the previous meeting, and shall bring with him the book referred to in Rule 3. 7. He shall not engage himself directly or indirectly, or be concerned in any manner with any occupation whatever, that does not strictly belong to the duties of his office, as set out in these Rules and'the Rules for the Regulation of the Mortuary; but shall give the whole of his time and attention to his duties, unless he receive permission from the Committee. 8. He shall not receive gratuities of any kind from any person or persons whatever, 158 9. He shall not be allowed to interfere, or take part in any way, in the postmortem examinations. He shall give such attendance as is necessary upon the Medical Practitioner, who may have to make the post mortem; but shall not otherwise interfere in any way with the body. 10. He shall see that the Regulations for depositing bodies in the Mortuary— whether while awaiting post-mortem Examination, Inquest, or Burial —are duly carried out, and shall give notice to the Medical Officer of Health, from time to time, of any circumstances that may require attention. 11. Any legally qualified Medical Practitioner desiring to make a post-mortem examination, and being authorised to use the place provided for the purpose, shall give reasonable notice to the Mortuary Keeper, who shall cause the body to be placed upon the table in readiness for examination; and on the completion of such examination shall see that the body be either re-placed in the coffin in which it was brought to the Mortuary, or placed in a shell ready for burial, and that the table and all utensils and appliances be thoroughly cleansed. 12. He shall perform all duties from time to time directed by the Committee, or the Medical Officer of Health. CORONER'S COURT. It is now very generally the practice to provide in connection with a mortuary, a building in which the Coroner can hold his Court, thus rendering it unnecessary for the holder of that ancient and dignified office, to have to resort to apublic house for the needful accommodation. But this step seemed unnecessary in the present case, as there are rooms at the Vestry Hall, to which the mortuary is adjacent, convenient and suitable for the purpose. Accordingly, the Works, Sanitary, and General Purposes Committee authorized me to communicate with the Churchwardens, who. as trustees of the Vestry Hall, kindly consented to place a room at the disposal of the Coroner whenever required, on due notice being given, and subject to the payments which the Coroner is authorized to make, and does make, for such accommodation provided elsewhere for the same purpose. About 160 inquests ae held annually in the Parish, and the majority of them probably could in future be held at the Vestry Hall, should such be the pleasure of the Coroner. It is in the Coroner's power to order bodies to be removed to the 159 ''place provided for post-mortem examination," when such examination is necessary, and in such cases —about two-thirds of the whole number—the inquest would naturally be held in the Hall adjoining the Mortuary. By judicious arrangements on the part of the Coroner's officer, this plan could be carried out without imposing any undue strain upon the class of persons from which jurors are chosen. DISINFECTION. During the year ended March 25th, 1883, a large number of infected articles of clothing, bedding, furniture, &c., were satisfactorily disinfected by the contractor at the cost of your Vestry, the owners being too poor to bear the expense. The weight of the articles was more than 111 tons; their number 4,960; and the cost of the process £221 10s. Od. 2 48 rooms in 209 houses were disinfected with sulphurous acid by your Vestry's officer, no charge being made in the majority of instances. Many rooms, in addition, were disinfected by the contractor, as well as numerous parccls of clothing, bedding, &c , at the cost of persons able to pay. WATER SUPPLY. Professor Frankland's Report.—Believing it desirable that your Vestry, as the body responsible in this great Parish for carrying into effect the provisions of sanitary legislation, should receive, year by year, the best information on all points connected with the water supply, a very important question in relation to the public health, it has been my custom to summarise the report prepared annually by Professor Frankland, for the Registrar-General. I do so again this year. I also submit a summary of the information supplied in the report of Colonel Bolton, R.E., the "Water Examiner," under the "Water Act, 1871." Dr. Frankland deals mainly with the quality of the water in its chemical and microscopical aspects, and in respect to its fitness for dietetic and domestic purposes; 160 he being, as is well known, adverse to riparian sources of supply: Colonel Bolton's observations have reference, inter alia, to the condition of the water in bulk, at the intakes, and to its physical qualities when delivered to the consumer—in a word, to whatever relates to the collection, filtration, storage, and distribution of the water. London is mainly supplied from the rivers Thames and Lea, but a considerable and increasing quantity of water is obtained from deep wells sunk in the chalk, not only by the Companies which obtain their entire supply from that source, but also by some of the old Companies, which thus supplement their intake of river water. The average daily volume supplied per head of population in 1882 was 28.6 gallons. Dr. Frankland is consistent in his preference of "deep well water," taking it as the standard of purity in comparative observations on the waters generally. In a previous report he described it as being "delicious and wholesome," and uniformly excellent for dietetic purposes; maintaining that in the interests of temperance and public health, it should, as soon as possible, be substituted for that portion of the Metropolitan supply which is drawn from polluted rivers. This "pure spring water," he said, is "everywhere abundant in the Thames basin: in dry seasons it constitutes the sole supply of the Thames and the Lea, and even after the most protracted drought, more than 350,000,000 gallons of it daily flow over the weir at Teddington, whilst a further very large volume of it joins the Thames lower down." It would be a valuable boon to London if even a small fraction of this prodigal supply could be collected, preserved from irremediable pollution, and distributed to those portions of the Metropolis which are not at present supplied with such water. The principal objection to it is its hardness, but this is an objection easily surmounted by " Clark's process." The "hardness" of water represents the weight of carbonate of lime, or its equivalent of other soap-destroying substances, found in 100,000 parts of water. The average hardness of the Thames water delivered in London last year was 20.7; of the Kent Company's water 28.5; and of the Colne Valley Company's water only 5.5. All hard water must be softened before it can be used for washing linen: when it is softened in detail by the laundress, the operation costs, for an equal volume of water, at least eighty times as much (in soap and soda) as it costs when conducted on a large scale by a water company. The only water suitable for washing delivered in London during the past year was that of the Colne Valley Company, which was softened by Clark's process before distribution. All waters, save artificially prepared distilled water, contain more or less " solid matter." A large part of this solid matter is saline and unobjection able in drinking water, but the water is by it rendered hard. A small 161 tion of the solid matter is of an organic nature. Organic matter is always objectionable in water used for drinking, and such matter, when present in river water, is sometimes dangerous to health. The deep-well waters delivered by the Kent Company and by the Tottenham Board of Health, contained the largest proportions of solid matter; but the deep-well water, derived from the same source, and supplied by the Colne Valley Company, contained less than one-third the quantity found in the river waters, and less than one-fifth of that found in the Kent Company's water: this comparative freedom from saline matters being attained by adding a small quantity of slaked lime to the water before it leaves the Company's works. All the water supplied to the Metropolis would be improved by being submitted to the same (Clark's) process. The organic impurities found in the river waters, derive their importance from being chiefly of animal oirgin. Owing to the careful filtration to which the river water was generally subjected, together with the improved means of storage at the command of the Companies, it beiug no longer necessary to impound the worst flood waters, the average quality of the water supplied during the greater part of the year was better than usual: nevertheless the water in times of flood was often largely polluted with organic matter, and unfit to drink. The "noxious organic matters" are "in suspension," but in such a finely divided state as to render their removal by artificial filtration through sand impossible. A great improvement might, however, be effected, if to the sand an additional filter bed of spongy iron were added. The process of filtration through spongy iron has already been adopted on a large scale in Belgium with marked success. Deep-well waters undergo such a prolonged, exhaustive and inimitable natural filtration through great thicknesses of porous strata, as to render it extremely unlikely that any suspended organic matter known to be prejudicial to health, should have escaped removal. Hence these waters are "uniformly pure and wholesome." Of the river water abstracted from the Thames, the best average supply was furnished by the Lambeth Company. The water supplied by the West Middlesex Company was bracketted with that of the Southwark Company as containingthe largest amount of organic impurity. A marked and undeniable advantage of spring water is its evenness of temperature. The range of temperature of river waters is considerable, aud last year in the water of the Thames, as delivered by five of the Companies, it amounted to 28°.o Fahr., viz., from 40°.5 in January to 680.5 in August. The The following table exhibits the proportional amounts of organic elements (organic carbon and organic nitrogen) in the waters of the Companies which supply Kensington, the Kent Company's water being used as the standard of purity for comparison:—- Name of Company. Maximum. Minimum. Average. Kent 2 0 1.1 1.5 Chelsea 5.6 2.3 4.1 Grand Junction 6.2 3.1 4.1 West Middlesex 6.8 1.3 4.5 162 water was thus but little removed from its freezing point in winter, whilst its high temperature in summer rendered it vapid and unpalatable. The deep-well water sent out by the Kent Company varied in temperature from 43°.7 in December to 61°.2 in July (range 17°.5), whilst that of the Colne Valley Company maintained a constant temperature of 52°.0 Fahr. throughout the year. The transparency or otherwise of water is ascertained by its appearance in a tube two feet in length, and is expressed in arbitrary terms settled by common agreement, as in the following table, which shows the degree of efficiency of filtration of Thames water as supplied by the Companies in this parish, the examinations being made monthly Name of Company. When clear and transparent. Number of Occasions. When very turbid. When slightly tnrbid. Wnen turbid, Chelsea 7 5 0 0 West Middlesex 8 4 0 0 Grand Junction 8 4 0 0 The deep-well waters were clear and transparent on every occasion save one. When examined under the microscope the sediment deposited by turbid water, on standing, is generally found to contain living and moving organisms. During the year these organisms were not observed in the water on any occasion. The annexed table shows the results of such microscopic examin. ations during the past thirteen years:— Name of Company. Number of occasions when living organisms were found. 1869 1870 1871 1872 1873 1874 1875 187li 1877 1878 1879 1880 1881 1882 Chelsea 3 2 2 3 2 5 4 4 1 0 2 0 0 0 West Middlesex 0 0 0 0 0 0 0 0 0 1 2 0 0 0 Grand Junction 4 1 1 2 3 5 7 3 3 3 1 3 3 0 The subjoined table shows the annual averages of each determination, and thus summarises the average results of the analysis of the waters supplied by the local Companies during the year; the Kent Company's water being taken as a standard for comparison. The numbers in this table relate to 100,000 parts of the waters, but may be converted into grains per imperial gallon by multiplying them by 7 and then moving the decimal point one place to the left. Name ofComfany. Temoerature in Centigrade Degrees. Total Solid Impurity. Organic Carbon. Organic Nitrogen. Ammonia. Nitrogen as Nitrates and Nitrites. Total combined Nitrogen. Chlorine. Total Hardness. rtional amount of organic Elements, that in the Kent Company's Water during the 9 years ending Dec., /1876, being taken as 1. Chelsea 11-7 27.51 •199 •041 •ooo •165 •206 15 20.4 41 West Middlesex 13.0 27.88 •228 •039 •000 •184 •223 1.5 201 4.5 Grand Junction 120 28.70 •205 •036 .000 189 •228 1.5 20.7 41 Kent 11.8 4291 •077 015 •000 •428 •443 2.6 28.5 1.5 163 During the past year, the river water supplied by the several companies has been subjected to examination daily by Messrs. Crookes, Odling, and Tidy, on behalf of the companies, and the results of these examinations have been collected and published in the form of an annual report. The writers say that the water, as a rule, is efficiently filtered, the few samples not entirelv free from suspended matter being coincident with and dependent on the occurrence of periods of violent rain-fall. The water was fully aerated or oxygenated, a fact of great importance as demonstrating its high character in respect of its freedom from putrescent matter. Of ammonia "1/500th of a grain per gallon was the maximum amount found, and this on 12 occasions only: on 68 occasions the 1/1000th of a grain per gallon was recorded, whilst 192 examinations revealed no appreciable trace of ammonia whatsoever." "The quantity of nitrogen in the form of nitrate or nitrite, ranges from about one and a quarter tenths of a grain to two and a quarter tenths of a grain per gallon, the quantity being on the average somewhat lower in the summer and autumn than in the winter and spring quarters . . the quantity of chlorine amounts ... to either close upon or a little over one-tenth of a grain per gallon." "With regard to the mineral matter held in solution in the water it consists mainly of the carbonates of the alkaline earths, with a small quantity of sulphates.nitrates, and chlorides: no one suggests that the presence of these salts in the water is prejudicial to health; while there is, on the contrary, some reason to believe that they are actually useful to the animal economy, as one means of supplying constituents required for the organism." The examiners conclude their report with remarks on the "wholesomeness" of the water, and quote "the pith of the conclusion" of the last Royal Commission (1869) comprised in the following paragraph from their report:—"Having carefully considered all the information we have been able to collect, we see no evidence to lead us to believe that the water now supplied by the companies is not generally good and wholesome." In their previous report the examiners stated their opinion 164 "that the filtered water of the Thames and Lea is unimpeachable in respect of its wholesomeness and suitability for town supply," and they are evidently of the same opinion still. Colonel Bolton's Report.—I now turn to the Annual Report of Colonel Bolton, the Water Examiner appointed under the Act of 1871, in which are embraced many paiticulars of general interest relating to the water supply. Colonel Bolton, it should be mentioned, makes monthly examinations of the various waterworks, and in monthly reports duly sets out the results of such examinations. One of the most important of his duties is to ascertain whether or not the requirements of Section 4 of the Act of 1852 are complied with, viz., that "every Company shall effectually filter all water supplied by them within the metropolis before the same shall pass into the pipes for distribution." The effectual filtration of river water depends, he says, upou — 1. A sufficient area of properly constructed filter beds, constantly clean, and fresh sanded from time to time as the original thickness is reduced. 2. The rate of filtration being controlled and limited to a certain speed. 3. The water delivered into the filter beds having been previously stored in subsiding reservoirs, and the capacity of these reservoirs being such as to avoid the necessity for the intake of turbid and muddy water during the time of extraordinary and heavy floods, which tend to foul and choke the filters. The rate of filtration should not exceed 540 gallons per square yard of filter bed each 24 hours, or 2½ gallons per square foot per hour, and no Company now exceeds this rate, which, for all practical purposes, may be considered as a standard. The means of storage for subsidence, and the area of filter beds, possessed by the several local Companies, appear to be now adequate to secure effectual filtration as required by the Act. The filters of the several local companies are formed as follows:— 165 West Middlesex. Harwich sand, 2ft. Sin.; Barnes sand 1ft.; gravel screened to different sizes, and arranged in layers 2ft. 3in, Total thickness 5½ft. Grand Junction. Harwich sand, 2ft. Gin.; Hoggin, 6in.; fine gravel, 9in.; coarse gravel, 9in. ; boulders, 1ft. Total thickness, 5½ft. Chelsea. Thames sand, 3ft. 3in.; shells, &tc., 3in.; gravel, 4ft 6in. Total thickness, 8ft. It is to little purpose, however, that well filtered and "good" water should be supplied if the supply is allowed, as it so frequently is, to deteriorate in the cisterns of the consumers through the uncleanly condition of those receptacles, and the connection of them with the drains through the medium of "waste-pipes," which the Companies only have the power to abolish under the provisions of the water regulations (No. 14, vide p. 123). The remedy no doubt is a "constant supply;" but as we shall have to wait long for this, I would again urge that the Companies should be compelled to exercise their powers, or that the Sanitary Authorities should have equal power with the Companies to enforce the regulations. The quantity of water supplied daily, 294, 191, and 290 gallons per house, by the Grand Junction, West Middlesex, and Chelsea Companies respectively, was superabundant, and indicates great waste, amounting as it does, in the three districts respectively, to 30.80, 25.51 and 36.77 gallons per head of the population. The "intake" of the Chelsea Company is at West Molesey; of the others, at Hampton Court. The Grand Junction supply is supplemented from gravel beds at Hampton. The state of the water in the Thames during the months of January, February, parts of March and April, November, and December, was generally bad; and, owing to the frequent heavy floods, the water that had to be taken in by the Companies was much polluted, and was found to be extremely difficult to filter. The solid impurities in suspension, chiefly consisting of clay, marl, and chalk in a very finely divided state, can be got rid of only by long subsidence previous to filtration. The following particulars, among others, are given by Col. Bolton, in respect of the local Companies:— 166 Storage.—No new works have been found necessary by the Chelsea Company, the existing means being sufficient for the supply of effectually filtered water at all times; the West Middlesex Company have constructed a subsiding reservoir of 7½ acres area at Barnes to contain 21,000,00(1 gallons, and the Grand Junction Company have completed the construction of a storage reservoir holding 45 million gallons. Filtration.—The West Middlesex Company have completed the construction of two additional filter beds, upon an improved principle, area of each 11/8 acres, and now have 36 acres of subsiding and storage reservoirs of a capacity of nearly 116 million gallons. The Grand Junction Company have completed the construction of three filters capable of filtering five million gallons of water per day, with a covered reservoir to contain two million gallons of filtered water. The Chelsea Company have not found it necessary to undertake any new works in the last year. Constant Supply.—I have no means of ascertaining to what extent the constant supply has been extended to houses in this parish; but the following facts relating to the subject, as it concerns the Companies in which we are interested, may be acceptable. The West Middlesex Company are giving constant supply to all new estates and buildings, and where new services are laid down constant supply is made compulsory by the Company; 2,076 houses were put on constant supply during the year, making the number of houses on constant supply 11,197, out of a total of 61,702. The Grand Junction Company are giving constant supply to 18,401 houses, out of a total of 46,313. They are preparing to extend the system to North Kensington, and for this purpose the reservoirs at Campden Hill are kept filled by continuous pumping at Kew Bridge and Campden Hill. The reservoirs at Kew Bridge and Campden Hill have been connected with the mains of the East London Company in order to insure a supply of water from the works of that Company at Sunbury, in case of accident or emergency. The Chelsea Company are giving constant supply to 2,824 houses, out of a total of 31,846; and are fully prepared to extend the system as required; but judging from the few applications made for such supply, there appears to be no desire in the public authorities, or private individuals, in this, or either of the other districts, for the constant service. By way of contrast, and to show how backward the Western Companies are in this matter of constant supply, as compared with the Companies in the East of London, where the Companies have taken the initiative, it may be mentioned that the East London Waterworks Company now give constant supply to 106,043, out of a total of 137,283, houses supplied by them, and containing an estimated population of 1,029,622 persons. Considerable advance was made during the past year in London as a whole in extending the constant supply; 202,443 of the total number of 643,752 houses supplied, being now on constant service. 167 a considerable expenditure has been incurred by the West Middlesex and Grand Junction Companies during the year upon enlarged and extended mains, engines, boilers, pumps, &c. The number of miles of streets containing mains constantly charged, and in which hydrants for fire-extinguishing purposes could at once be fixed, in the districts of the local Companies are, West Middlesex, 86½; Grand Junction, 37½; and Chelsea, 67. The Companies are ready to affix hydrants on the mains whenever required to do so. In the Metropolis there are now fixed 6,163 hydrants, the total length of mains being 828¾ miles: the increase, in mams, during 1882 being 78½ miles, and in number of hydrants, 112. Deterioration of Water in Dirty Cisterns,—The Local Government Board not long ago addressed a circular letter to Nuisance Authorities in the Metropolis, stating that Colonel Bolton had drawn their attention to the serious deterioration which water frequently undergoes, after delivery, by being kept in impure cisterns, and enclosing an extract from his report of the examination of the water supplied by the Companies during the month of June, 1831. Colonel Bolton's observations were directed (1) to the deterioration of the water by the dirty and uncovered condition of the cisterns; (2) to the need for frequent cleansing of cisterns; and (3) to the misplacing of the cistern, where there is but one, and that one situated over a water closet, and having an untrapped waste-pipe communicating with the drains. The importance of the subject is undeniable; and your Vestry's Sanitary Inspectors have standing instiuctions to examine into the condition of the cisterns, and the water, in every house they inspect, where practicable. It is the fact, however, that cisterns are often so placed as to be inaccessible to inspection or for cleansing: the solitary cistern, moreover, is often placed immediately over the water-closet, as stated by Colonel Bolton. With respect to the improper placing of a cistern we have no power to interfere, but the Water Companies might, if so minded, do something to remedy the evil complained of. The 13th Regulation reads thus: " Every cistern shall be properly covered and placed in such a position that it may be inspected and cleansed." 168 The power to abolish waste-pipes universally, rests, as already stated, with the Companies alone, and some years ago I endeavoured to stimulate the local Companies to exercise their power. I was given to understand that the Chelsea Company—at the time they were short of water, prior to the construction of their new works at West Molesey—had taken steps to abolish waste-pipes, with a view to economise consumption, but I was quite unable to get the West Middlesex and Grand Junction Companies to move in the matter. Tho views expressed by the Secretaries were to the effect that the Companies, being trading bodies, did not care to offend their customers: the regulation was intended to prevent waste of water, simply, and as they had plenty of water they didn't care about the waste. I faile 1 in the attempt to convince these gentlemen that the Commissioners, in framing the regulation must have had in view the removal of a dangerous nuisance. I may add that under regulations for the construction of house drainage, which have been enforced for some time past in this Parish, waste-pipes are not allowed to have direct communication with the drains, while existing connections of this sort are invariably cut off whenever discovered. I need hardly remind your Vestry that the subject of water supply has constantly engaged my attention; or that the matters referred to in Colonel Bolton's above-mentioned report have always formed the subject of comment in my Annual Reports. I was glad therefore that the subject had attracted the attention of the Local Government Board, and I ventured to suggest the desirability of a reply being sent to the Board's communication, directed to calling their attention to the necessity of such an alteration in the law as would give Nuisance Authorities coequal powers with the Companies to enforce the regulations No doubt it is true, as Colonel Bolton 6tates, that, if not the "only," at any rate, a "remedy" for the state of affairs described by him will (ultimately) be found in the establishment of the "constant supply system," and the consequent abolition of unfit receptacles. To how slight an extent that system has been in- 169 troudced in this Parish the facts before mentioned sufficiently show. It is satisfactory to learn that "the Water Companies are being urged to extend the system in their respective districts with the least possible delay," it being now ten years since the Act was passed, the primary object of which was provision of a constant supply with the least possible delay. GAS. The subjoined tables based on the quarterly reports of the Chief Gas Examiner exhibit at a glance the principal results (averages) of the daily testings, at the Ladbroke Grove Station, of the "common gas," manufactured at Kensal Green by the Gas Light and Coke Company. 1. With respect to illuminating power. The maximum, min imum, and average illuminating power in standard sperm candles was as follows (statutory standard, sixteen candles): — Maximum. Minimum. Average. Quarter ended March 31st 18.4 16.3 17.2 Quarter ended June 30th 18.0 16.4 17.1 Quarter ended September 30th 17.7 16.8 17.0 Quarter ended December 31st 17.7 16.5 17.0 Averages, whole year 179 16.5 171 The minimum did not on any occasion fall below the standard, and the average was considerably above the standard. 2. With respect to parity. Sulphuretted hydrogen was not present in the gas at any time, and the proportion of sulphur in any other form was always considerably below the limit fixed by the Act of Parliament. 170 Grains of sulphur per 100 cubic feet of gas. Permitted maximum—17 grains in 100 cubic feet, between April and October, and 22 grains between October and April. Maximum. Minimum. Average. Quarter ended March 31 at 15.9 7.0 9.3 Quarter ended June 30th 15.3 10.0 12.5 Quarter ended September 30th 13.5 7.8 11.0 Quarter ended December 31st 14.0 6.2 9.4 Averages, whole year 14.7 7.7 10.6 With regard to Ammonia, a valuable residual product of gas manufacture, the limit allowed by the Acts of Parliament (4 grains in 100 cubic feet of gas) was not reached on any occasion. The Chief Gas Examiner is quite independent of the Company ; it is satisfactory therefore to note that his reports of the testings are so favourable, but I still think it would be well if an arrangement could be effected to obtain systematic records of pressure at all hours of the day and night, and at several points in the Company's District within the Parish. No complaint was received from any private consumer in respect of the illuminating power of the gas, in 1882, and I understand that Mr. Philip Monson,your Vestry's Superintendent of Street Lighting, is satisfied with the quality of the gas as supplied to the public lamps. The burners now in use are calculated to consume gas at the rate of 4.5 cubic feet per hour, whereas the burners formerly in use, originally provided when Cannel gas was employed, consumed only 3 feet per hour ; but notwithstanding the increased consumption of gas (50 per cent.) and the consequent improvement in the lighting of the public thoroughfares, the cost is not greater than under the old system of a fixed annual payment per lamp. 171 Conclusion.— It now only remains for me to discharge the pleasing duty of thanking those who have contributed by their assistance to whatever success may have attended the work of my Department in the past year. Of the sympathetic co-operation of the Board of Guardians I have already spoken, and it would be impossible to over-rate the importance of the assistance rendered by them, and their officers, in measures for preventing the spread of infectious diseases. The sub-district Registrars, Messrs. Barnes and Hume, and the Vaccination Officer, Mr. Shattock, have, as usual, very willingly complied with all my requests for information. The Members of the Sanitary Staff have discharged their numerous duties with zeal, intelligence, and success. My thanks are justly due to your Vestry for a continuance of the confidence and support which I have never failed to receive, and which have enabled me to carry out with satisfaction the duties appertaining to my office, and to superintend the working of a Department the importance of which is every year more fully recognised by the general public. I am, Gentlemen, Your obedient Servant, T. ORME DUDFIELD, M.D., Medical Officer of Health. Town Hall, Kensington. August, 1883. [appendix tables.] APENDIX. Note.—The forms for Tables I.—VI. were compiled by the Society of Medical Officers of Health with the object of securing uniformity in Statistical Returns. 175 TABLE I. Shewing the Population, Inhabited Houses, Marriages, Births, and Deaths for the Year 1882, and 10 years preceding. GROSS NUMBERS. The Year. Estimated Population. No. of Inhabited Houses.f Marriages. Registered Births. Deaths. Total ail Agest ‡ Under One Year. Under Five Years. In PublicInsti tutions§ 1882. 105,450 20,908 1,474 4,327 2,691 635 1,114 403 1881 163,540 20,666 1,461 4,400 2,726 644 1,067 437 1880 161,462 20,700 1,483 4,605 2,884 719 1,219 369 1879 158,316 20,240 1,428 4,790 2,992 722 1,218 424 1878 154,305 19,719 1,331 4,607 3,120 823 1,429 410 1877 151,360 19,330 1,411 4,648 2,625 648 1,040 420 1876 148,338 18,944 1,417 4,499 2,896 771 1,305 338 1875 144,488 18,444 1,346 4,478 2,786 686 1,119 338 1874 138,616 17,667 1,311 4,356 2,696 762 1,188 352 1873 132,826 16,915 1,243 4,182 2.439 656 979 272 1872 127,606 16,237 1,132 4,041 2,256 626 959 295 Average of 10 yrs.. 1872-1881. 148,080 18,886 1,356 4,460 2,742 705 1,152 365 NOTES. 1. Population at Census 1861, 70,108 ; 1871,130,234; 1881, 163,151. 2. Average Number of Persons in each house at Census 1871, 7.6; 1881, 8.1. 3. Area of Parish 2190 acres (according to the Registrar General). 4. Number of Persons to an acre (1882) 75.5. * For statistical purposes the Registrar-General estimates the population to the middle of the year on the basis of the rate of increase ruling between the two preceding Census periods. The estimate of population may be checked by the known number of inhabited houses, and by the average number of persons in a house, as ascertained at the preceding Census, † Mean of number on rate books in April and October yearly. ‡ The actual number of deaths registered in the Parish was 2,678, and it includes 80 deaths of non-parishioners at the Brompton Consumption Hospital, which are retained as a compensatory allowance for the deaths of parishioners that may have taken place in general hospitals, Ac., out of the Parish. The total, 2,691 is made up by the addition of 13 deaths of parishioners from infectious diseases at the hospitals of the Metropolitan Asylums District. § Viz: at the Parish Infirmary and Workhouse (307), the Brompton Hospital (83), and the Infectious Diseases Hospitals of the Asylum Board (13). The deaths of nonparishioners at the Marylebone Infirmary (396) are not included in the above total. TABLE II. Shewing the Annual Birth Rate and Death Rate; Death Rates of Children, and Proportion of Deaths in Public Institutions in a Thousand Deaths, for the Year 1882, and 10 Years preceding. The Year. Birth Rate per 1000 of the Population. Death Rate per 1000 of the Population. Deaths of Children under 1 year; per 1000 of Registered Births. Deaths of Children under lyear: per 1000 of Total Deaths. Deaths of Children under5years: per 1000 of Total Deaths. Deaths in Public Institutions: per 1000 of Total Deaths. 1882. 26.1 16.2 14.6 23.6 41.3 14.9 1881 26.9 16.6 14.6 23.6 39.1 16.0 1880 28.5 17.8 15.6 24.9 42.2 12.8 1879 30.2 18.8 15.0 24.1 40.7 13.3 1878 29.8 20.2 17.8 26.3 45.8 13.2 1877 30.7 17.3 13.2 24.6 39.6 13.5 1876 30.3 19.5 17.1 26.6 45.0 11.7 1875 30.9 19.2 15.3 24.6 40.1 12.1 1874 31.4 19.4 17.4 28.2 44.0 13.1 1873 31.4 18.3 15.6 27.0 40.2 11.6 1872 31.6 17.6 15.4 27.7 42.5 13.0 Average of 10 Years, 1872— 1881. 30.1 18.4 15.7 25.7 41.9 13.0 TABLE III. Deaths Registered from all causes in the year 1882. (Exclusive of the Deaths of non-parishioners at the Brompton Consumption Hospital but inclusive of the deaths of Parishioners in the Infectious Disease Hospitals). CAUSES OF DEATH. AGES. Total under Five Years of Age. Grand Total all Ages. SUB-DISTRICTS 0 to 1. 1 to 5. 5 to 15. 15 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 to 75. 75 to 85. 85 and upwards. Kensington Town. Brompton. (classes) I. SPECIFIC FEBRILE or ZYMOTIC DISEASES 132 195 47 10 15 14 7 6 ... 1 2 327 429 359 70 II. PARASITIC DISEASES 6 2 ... ... ... ... ... ... ... ... ... 8 8 8 ... III. DIETIC DISEASES 3 ... ... ... 4 1 1 ... 3 ... ... 3 12 10 2 IV. CONSTITUTIONAL DISEASES 65 58 38 48 67 92 73 58 31 14 1 123 545 437 108 V. DEVELOPMENTAL DISEASES 73 ... ... ... ... ... ... 1 11 38 23 73 146 122 24 VI. LOCAL DISEASES 254 192 39 35 61 82 119 168 209 118 25 446 1292 1022 270 VII. DEATHS FROM VIOLENCE 19 7 ... 5 5 6 6 8 3 ... 1 26 60 41 19 VIII. DEATHS FEOM ILL DEFINED AND NOT SPECIFIED CAUSES 83 25 1 1 1 1 1 2 2 2 ... 108 119 102 17 635 479 125 99 143 196 207 243 259 173 52 1114 2611 2101 510 I. SPECIFIC FEBRILE or ZYMOTIC DISEASES. 1. Miasmatic Diseases. Smallpox Vaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Unvaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... No Statement ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 22 51 4 ... ... ... ... ... ... ... ... 73 77 70 7 Scarler Fever 2 40 20 ... ... ... ... ... ... ... ... 42 62 49 13 Typhus „ ... ... ... 1 ... ... ... ... ... ... ... ... 1 1 ... Whooping Cough 36 74 8 ... ... 1 ... ... ... ... ... 110 119 97 22 Diphtheria 2 15 8 ... ... ... ... ... ... ... ... 17 25 16 9 Simple Continued or Ill defined Fever ... 1 1 ... 3 ... 1 ... ... ... ... 1 6 5 1 Enteric or Typhoid Fever 1 3 5 5 3 7 1 ... ... ... ... 4 25 22 3 Other Miasmatic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Diarrhœal Diseases. Simple Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diarrhœa, Dysentery 45 11 ... ... ... ... 2 1 ... ... 2 56 61 54 7 3. Malarial Diseases. Remittent Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4. Zoogenous Diseases. Cowpox, and effects of Vaccination ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6. Venereal Diseases. Syphilis 16 ... ... 1 ... 1 2 1 ... ... ... 16 21 18 3 Gonorrhoea, Stricture of the Urethra ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6. Septic Diseases. Erysipelas 8 ... ... ... ... 1 1 3 ... 1 ... 8 14 12 2 Pyæmia, Septiæmia ... ... 1 2 2 2 ... 1 ... ... ... ... 8 7 1 Puerperal Fever ... ... ... 1 7 2 ... ... ... ... ... ... 10 8 2 132 195 47 10 15 14 7 6 ... 1 2 327 429 359 70 II. PARASITIC DISEASES. Thrush, and other Vegetable Parasitic Diseases 6 2 ... ... ... ... ... ... ... ... ... 8 8 8 ... Worms, Hydatids, and other Animal Parasitio Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6 2 ... ... ... ... ... ... ... ... ... 8 8 8 ... III. DIETIC DISEASES. Want of Breast Milk—Starvation 3 ... ... ... ... ... ... ... 1 ... ... 3 4 4 ... Scurvy ... ... ... ... ••• ... ... ... ... ... ... ... ... ... ... Chronic Alcoholism ... ... ... ... 3 1 ... ... 2 ... ... ... 6 4 2 Delirium Tremens ... ... ... ... 1 ... 1 ... ... ... ... ... 2 2 ... 3 ... ... ... 4 1 1 ... 3 ... ... 3 12 10 2 IV. CONSTITUTIONAL DISEASES. Rheumatic Fever, Rheumatism of the Heart ... ... 2 1 ... 2 ... 1 ... ... ... ... 6 5 1 Rheumatism 1 ... ... 3 ... ... ... 2 1 1 ... 1 8 6 2 Gout ... ... ... ... ... 1 1 1 2 1 ... ... 6 5 1 Rickets 1 ... ... ... ... ... ... ... ... ... ... 1 1 1 ... Cancer, Malignant Disease ... ... ... ... 5 10 19 27 18 12 1 ... 92 66 26 Tabes Mesenterica 28 16 ... ... ... ... ... 1 1 ... ... 44 46 38 8 Tubercular Meningitis, Hydrocephalus 23 22 9 ... ... ... ... ... ... ... ... 45 54 41 13 Phthisis ... 2 18 28 59 76 51 23 6 ... ... 2 273 228 45 Other forms of Tuberculosis, Scrofula 12 17 9 4 1 1 ... ... ... ... ... 29 44 35 9 Purpura, Hæmorrhagic Diathesis ... ... ... ... 1 ... ... 1 ... ... ... ... 2 1 1 Anæmia, Chlorosis, Leucocythæmia ... 1 ... ... 1 1 1 ... 1 ... ... 1 5 5 ... Glycosuria, Diabetes Mellitus ... ... ... 2 ... 1 1 2 2 ... ... ... 8 6 2 Other Constitutional Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 65 58 38 48 67 92 73 58 31 14 1 123 545 437 108 V. DEVELOPMENTAL DISEASES. Premature Birth 62 ... ... ... ... ... ... ... ... ••• ... 62 62 52 10 Atelectasis 5 ... ... ... ... ... ... ... ... ... ... 5 5 5 ... Congenital Malformation 6 ... ... ... ... ... ... ... ... ... ... 6 6 5 1 Old Age ... ... ... ... ... ... ... 1 11 38 23 ... 73 60 13 73 ... ... .. ... ... ... 1 11 38 23 73 146 122 24 VI. LOCAL DISEASES. 1. Diseases of Nervous System. Inflammation of Brain or Membranes ... 2 2 3 •• ... 1 1 ... ... ... 2 9 7 2 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis 1 ... ... 1 1 10 16 30 31 22 7 1 119 91 28 Insanity, General Paralysis of the Insane ... ... ... ... ... ... 1 ... 3 ... ... ... 4 4 ... Epilepsy ... 1 ... 3 1 1 3 1 1 1 ... 1 12 11 1 Convulsions 53 23 1 ... ... ... ... ... ... ... ... 76 77 63 14 Laryngismus Stridulus (Spasm of Glottis) 3 4 ... ... ... ... ... ... ... ... ... 7 7 6 1 Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... 1 ... 1 1 1 2 2 3 ... ... 11 9 2 Other Diseases of Nervous System 1 4 2 ... 2 4 2 ... 2 3 1 5 21 19 2 2. Diseases of Organs of Special Sense. (e.g., of Ear, Eye, Nose) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Diseases of Circulatory System. Pericarditis ... ... ... ... ... ... 1 ... ... 1 ... ... 2 2 ... Acute Endocarditis ... ... 1 ... ... 1 ... 1 ... ... ... ... 3 ... 3 Valvular Liseases of Heart ... ... ... 3 ... 2 4 4 2 5 ... ... 20 10 10 Other Diseases of Heart 3 4 3 7 8 11 18 34 34 8 1 7 131 103 28 Aneurism ... ... ... ... 1 3 ... ... ... ... ... ... 4 4 ... Embolism, Thrombosis 1 ... ... 1 1 ... ... ... ... 1 1 1 5 5 ... Other Diseases of Blood Vessels ... ... ... ... ... ... ... 1 1 ... ... ... 2 1 1 4. Diseases of Respiratory System. Laryngitis ... 3 1 ... ... ... ... ... ... ... ... 3 4 2 2 Croup 2 17 1 ... ... ... ••• ... ... ••• ... 19 20 17 3 Emphysema, Asthma ... ... ... 1 ... 1 2 4 4 1 ... ... 13 12 1 Bronchitis 114 84 11 1 2 6 12 38 69 37 11 198 385 323 62 Pneumonia 34 26 4 5 9 11 13 14 13 6 1 60 136 101 35 Pleurisy 1 2 2 ... ... 1 2 1 1 4 ... 3 14 11 3 Other Diseases of Respiratory System 7 5 ... ... 3 3 4 5 5 4 1 12 37 28 9 6. Diseases of Digestive System. Dentition 11 8 ... ... ... ... ... ... ... ... ... 19 19 14 5 Sore Throat, Quinsey 2 2 ... ... ... ... 1 ... ... ... ... 4 5 5 ... Diseases of Stomach 2 2 2 ... 3 ... 4 1 3 1 ... 4 18 15 3 Enteritis 6 2 1 ... 2 1 ... 2 2 1 8 17 15 2 Obstructive Diseases of Intestine 5 ... 1 ... ... 1 6 2 3 3 ... 5 21 15 6 Peritonitis 1 ... 1 2 1 2 1 3 ... 1 ... 1 12 9 3 Ascites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver ... ... ... ... 1 7 8 5 2 2 1 ... 26 20 6 Jaundice, and other Diseases of Liver 2 ... ... 2 2 5 3 7 8 4 ... 2 33 24 9 Other Diseases of Digestive System 4 1 ... ... ... 1 ... ... ... ... ... 5 6 6 ... 6. Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) ... ... ... 1 1 1 ... ... •• ... ... ... 3 2 1 7. Diseases of Glandlike Organs of Uncertain Use (e.g., Bronchocele, Addison's Disease) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8. Diseases of Ueinary System. Nephritis ... ... ... 1 1 1 2 ... 3 2 ... ... 10 10 ... Bright's Disease, Albuminuria ... 2 2 ... 2 3 7 5 10 3 ... 2 34 23 11 Disease of Bladder or of Prostate ... ... ... ... ... 1 1 2 3 4 ... ... 11 7 4 Other Diseases of the Urinary System .. ... ... 2 ... 1 1 3 5 5 1 1 ... 19 15 4 9. Diseases of Reproductive System. a. Of Organs of Generation. Male Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Female Organs ... ... ... 1 4 ... 2 ... 1 ... ... 8 3 5 b. Of Parturition. Abortion, Miscarriage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Convulsions ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Placenta Prævia, Flooding ... ... ... ... 2 3 ... ... ... ... ... ... 5 5 ... Other Accidents of Childbirth ... ... ... 2 2 ... ... ... ... ... ... ... 4 3 1 10. Diseases of Bones and Joints. Caries, Necrosis ... ... 1 1 ... ... ... ... ... ... ... ... 2 ... 2 Arthritis, Ostitis, Periostitis ... ... ... ... ... ... ... .... ... ... ... ... ... ... ... Other Diseases of Bones and Joints ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 11. Diseases of Integumentary System. Carbuncle, Phlegmon ... ... ... ... ... ... 1 ... 1 ... ... ... 2 1 1 Other Diseases of Iutegumentary System 1 ... ... ... ... ... ... ... ... ... ... 1 1 1 ... 254 192 39 35 51 82 119 168 209 118 25 446 1292 1022 270 VII. DEATHS FROM VIOLENCE. 1. Accident or Negligence. Fractures and Contusions 1 3 ... 2 1 3 3 3 1 ... 1 4 18 11 7 Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Burn, Scald ... 3 ... 1 ... ... 1 1 ... ... ... 3 6 4 2 Poison 1 1 ... ... ... ... ... ... ... ... ... 2 2 2 ... Drowning ... ... ... ... ... ... ... 2 ... ... ... ... 2 2 ... Suffocation 13 ... ... 1 ... 1 ... ... ... ... ... 13 15 11 4 Otherwise 3 ... ... ... ... ... 1 ... ... ... ... 3 4 3 1 2. Homicide. Manslaughter 1 ... ... ... ... ... ... ... ... ... ... 1 1 1 ... Murder ... ... ... 1 ... ... ... ... ... ... ... 1 1 ... 8. Suicide. Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... 1 1 ... ... 1 ... ... ... 3 2 1 Poison ... ... ... ... ... ... 1 1 ... ... ... ... 2 2 ... Drowning ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Hanging ... ... ... ... 3 ... ... 1 1 ... ... ... 5 2 3 Otherwise ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... 1 4. Execution. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 19 7 ... 5 5 6 6 8 3 ... 1 26 60 41 19 VIII. DEATHS FROM ILL-DEFINED AND NOT SPECIFIED CAUSES. Dropsy ... ... ... ... ... ... 1 2 ... ... ... ... 3 3 ... Debility, Atrophy, Inanition 80 17 ... ... ... ... ... ... ... ... ... 97 97 84 13 Mortification ... ... ... ... ... ... ... ... 1 2 ... ... 3 3 ... Tumour ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Abscess 1 1 ... 1 ... ... ... ... ... ... ... 2 3 3 ... Hæmorrhage 2 ... ... ... 1 1 ... ... ... ... ... 2 4 4 ... Sudden Death (cause not ascertained) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Causes not Specified or Ill-defined ... 7 1 ... ... ... ... ... 1 ... ... 7 9 5 4 83 25 1 1 1 1 1 2 2 2 ... 108 119 102 17 CAUSES OF DEATH. 0 to 1. 1 to 5. 5 to 15. 15 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 to 75. 75 to 85. 65 and upwards. Total under Five Years of Age. Grand Total all Ages. Kensington Town. Brompton. AGES. Sub-districts. 178 TABLE IV. Shewing the Number of Deaths at all ages in 1882 from certain groups of Diseases, and proportions to 1000 of Population, and to 1000 Deaths from all causes; also the number of deaths of Infants under one year of age from other groups of Diseases, and proportions to 1000 Births and to 1000 Deaths from all causes under one year. Division I. (Adults). Total Deaths. Deaths per 1000 of Population, at all ages. Deaths per 1000 of Total Deaths, at all ages. 1. Principal Zymotic Diseases 376 2.2 189 2. Pulmonary Diseases 609 3.6 226 3. Principal Tubercular Diseases 364 2.2 135 Division II. (Infants under One Year. Total Deaths. Deaths per 1000 of Births. Deaths per 1000 of Total Deaths under One Year. 4. Wasting Diseases 145 33 228 5. Convulsive Diseases 87 20 121 NOTES. 1. Includes Small-pox, Measles, Scarlet Fever, Diphtheria, Whooping-cough, Typhus, Enteric (or Typhoid), and Simple Continued Fevers, and Diarrhoea. Thirteen of the deaths occuired in Hospitals outside the District. 3. Includes Phthisis, Scrofula, Tuberculosis, Rickets, and Tabes: the deaths of non-parishioners at the Brompton Consumption Hospital are excluded. 4. Includes Marasmus, Atrophy, Debility, Want of Breast Milk, and Premature Birth. 5. Includes Hydrocephalus, Infantile Meningitis, Convulsions, and Teething. (In Table III Hydrocephalus and Infantile Meningitis are classified with tubercular diseases, Convulsions with diseases of the nervous system, and Teething with diseases of the digestive system.) 179 TABLE V. Shewing the Number of Deaths from the principal Zymotic Diseases, in the 10 Years, 1872 to 1881, and in the Year 1882. Diseases. 1872. 1873. 1874. 1875. 1876. 1877. 1878. 1879. 1880. 1881. Annual average of 10 years, 1872-1881 Proportion of Deaths to 1000 Deaths in 10 years, 1872—1881 1882. Proportion of Deaths to 1000 Deaths in 1882. Small-pox 68 1 0 0 8 84 24 24 11 55 27.5 10.0 ... ... Measles 3 38 121 23 128 54 53 60 75 67 66.2 24.2 77 28.6 Scarlet Fever 9 10 32 83 59 31 77 51 105 38 51.3 18.7 62 23.0 Diphtheria 1 11 26 23 17 10 20 26 22 16 17.7 6.4 25 9.3 Whooping Cough 77 44 45 107 124 34 185 93 95 85 88.9 32.5 119 44.3 Fevers. Typhus 4 6 9 2 3 2 3 1 4 2 36 .1 1 11.9 Enteric 28 27 28 21 27 20 26 14 24 24 23.9 8.7 25 Simple Continued 10 8 15 6 6 5 4 8 5 5 7.2 3.6 6 Diarrhœa 110 145 112 107 126 99 181 71 128 101 118.0 43.2 61 22.6 Totals. Kensington 383 290 388 372 498 339 573 348 469 383 404.3 147.4 376 139.7 London 12699 11385 11230 13411 12565 12292 14734 12256 13681 13811 12806 154 13553 163 England and Wales 91743 70402 88200 82332 75506 66558 84624 62020 82537 58239 76216 148 69734 135 NOTE.—Deaths from infectious diseases at the Hospitals of the Metropolitan Asylums Board are included in the above totals. 180 TABLE VI. Inspectors' Report of the Sanitary Work completed in the Year 1882-3. Sanitary Districts * No. of Complaints received during the year. No. of Houses, Premises, &c., inspeoted. No. of Re-inspections of Houses, Premises, &co. Results of Inspection. House Drains. Water-Closets. Dust Bins. Water Supply. Miscellaneous. Orders issued for Sanitary Amendments of Houses and Premises. Houses, Premises, &c., Cleansed, Repaired, Whitewashed, &c. Houses Disinfected after illness of an Infectious Character. Repaired, Cleansed, Trapped, &c. Ventilated. Repaired, &c. Supplied with Water. New provided. New provided. Repaired, Covered, &c. Cisterns (new) erected. Cisterns Cleansed, Repaired, and Covered. Waste-pipes connected with Drains, &c., abolished. No. of Lodging Houses registered under 35th Section of the "Sanitary Act, 1866."† Dust Removal—No. of Communications received and attended to § Removal of Accumulations of Dung, Stagnant Water, Animal and other Refuse. Animals Removed, being improperly kept. Regularly Inspected. Legal Proceedings : i.e., Summonses.‡ Bakehouses. Licensed Cowsheds. Licensed Slaughter-houses. N.W. 54 1457 1724 575 168 80 71 76 22 161 11 39 9 57 81 36 ... 219 410 32 36 8 11 60 N.E. 71 1209 1208 345 163 73 115 8 225 199 1 10 10 10 56 38 ... 456 147 6 46 3 6 24 Centrl. 86 1642 1781 342 336 48 72 110 23 45 ... 30 31 12 42 36 ... 539 38 16 30 3 7 8 South 56 2275 1530 486 695 41 146 70 80 102 4 5 100 14 144 31 ... 663 110 3 34 4 2 9 Totals 267 6583 6243 1748 1362 242 404 264 350 507 16 84 150 93 323 141 ... 1877 705 57 146 18 26 101 * The North-East and North-West Districts are north of the centre of Uxbridge Road; to the East and West of Ladbroke Grove, and Ladbroke Grove Road respectively : the Central and South Districts are south of Uxbridge Road. + This Aet has not been put into operation. § The actual complaints of neglect, made by letter, were 58. ‡ Inclusive of proceedings, in 5 cases, under the Food and Drags Adulteration Act, the Inspector for the North-West District being the Inspector under the Act, and in 22 cases of "obstruction, &c.," on and over the public ways. 181 TABLE VIa. Summary of Monthly Returns of Work, done by the Sanitary Inspectors. Date of Report. Houses Inspected. Mews Inspected. Slaughter Houses Inspected. Cowsheds Inspected. Bakehouses Inspected. Offensive Trades. Inspected. Sanitary Notices Issued. Removal of Dust, Ashes, &c., Letters of Request received and attended to. Date of Report. District. District. District. District. District. District. District. District. N. W. e. c. s. N.W. N.E. c. s. N. w. N. E. c. s. N.W. N. E. c. s. N. W. N. e. c. s. N. w. N. E. c. s. N W. N. E. c. s. N. w. N. e. c . s. 22,1882 102 Ill 93 174 106 251 78 118 5 8 9 8 10 8 5 12 12 14 12 2 23 7 10 4 53 23 35 42 20 66 43 53 A.p. 22,1882 20 „ 150 133 136 199 124 254 89 160 13 8 6 8 10 6 3 16 20 28 9 16 27 22 18 4 47 42 47 50 25 42 80 84 May 20 ,, 3 17 „ 160 81 148 219 99 250 82 135 13 9 9 9 10 8 6 16 13 14 3 54 20 26 12 4 51 39 28 47 35 43 94 97 June 17 ,, 15 „ 119 117 176 196 103 252 87 157 10 13 8 8 9 5 4 16 26 26 10 1 24 7 13 5 41 28 22 54 23 70 69 85 July 16 ,, ■ 12 „ 108 122 94 208 79 250 42 145 12 6 3 9 12 6 2 18 15 27 3 5 22 23 6 6 36 15 15 43 18 37 54 64 Aug. 12 „ t. 9 „ 84 18 151 30 124 63 71 32 10 3 6 0 8 2 4 11 1 12 45 4 15 1 43 11 16 7 8 26 50 28 Sept. 9 „ 7 „ 67 83 132 141 47 285 81 102 3 6 6 5 5 9 5 13 21 17 5 8 25 25 12 2 54 29 27 36 12 23 15 33 Oct. 7 „ • 4 „ 136 111 151 201 146 252 67 170 3 10 5 9 10 5 3 17 12 28 14 23 23 4 8 9 61 19 30 42 14 24 21 30 Nov. 4 ,, • 2 „ 92 91 123 173 108 248 83 70 12 6 5 10 5 4 4 17 13 13 7 17 18 25 15 4 44 38 16 39 10 20 12 17 Dec. 2 „ . 30 „ 112 73 87 160 106 236 64 176 16 7 1 8 13 4 3 17 19 14 6 15 27 5 12 4 54 16 23 25 15 25 14 42 Dec. 30 ,, .27,1883 114 48 140 195 136 127 89 208 12 4 8 8 7 4 5 17 14 17 9 13 22 23 11 4 45 18 17 30 24 42 25 68 Jan 27,1883 .24 „ 118 127 132 191 124 253 79 206 9 4 7 9 7 4 4 12 12 16 9 14 22 7 17 5 28 29 37 35 7 24 36 26 Feb. 24 ,, -.24 „ 95 94 79 188 110 252 78 211 10 6 10 7 10 6 5 15 12 29 7 7 20 22 10 4 18 38 29 36 8 14 26 36 Mar. 24 „ 'otals . 1457 1209 1642 227E 1412 2973 990 1990 128 90 83 98 116 73 53 186 200 244 106 155 318 200 159 56 575 345 342 486 219 456 39 663 Totals. 182 TABLE VII. Showing the Death-rate per 1,000 persons living: the annual rate per 1,000 from the "seven" principal Diseases of the Zymotic class; and the proportion of deaths from these Diseases to total Deaths, in Kensington and all London, in 1882, and in ten years preceding The Year. Deaths per 1,000 living. Total Deaths from seven Zymotic diseases, Kensington. Annual rate of Mortality per 1000 living from seven Zymotic Diseases. Proportion of Deaths to 1000 Deaths from seven Zymotic diseases. The Year. Kensington. London. Kensington. London. Kensington. London. 1872 17.6 21.4 383 3.0 3.8 169 179 1872 1873 18.3 22.5 290 21 3.3 118 149 1873 1874 19.4 22.5 388 2.8 3.3 144 147 1874 1875 19.2 23.7 372 2.5 3.9 133 164 1875 1876 19.5 22.3 498 3.3 3.6 171 162 1876 1877 17.3 21.9 339 2.2 3.5 129 160 1877 1878 20.2 23.5 573 3.7 4.1 183 175 1878 1879 18.8 23.3 348 2.2 3.3 116 143 1879 1880 178 22.2 469 2.9 3.7 162 170 1880 1881 16.6 21.2 383 2.3 3.6 140 172 1881 averages of ten years. 18.4 22.4 404 2.7 3.6 146 162 averaoes of ten years. 1882 16.2 21.4 376 2.2 3.5 139 163 1882 183 TABLE VIII. Comparative Analysis of the Mortality in all London and in Kensington, in 1882. LOCALITY. Annual Death Rate per 1000 living from all causes. Annual Death Rate per 1000 living from 7 principal Zymotic diseases. Percentage of Deaths under 1 year to Births Registered. PERCENTAGE OF DEATHS TO TOTAL DEATHS. Under 1 year of age. At 60 years of age and upwards. From 7 principal Zymotic diseases. From Violence. Registered upon information of the Coroner. (Inquests.) Registered at large Public Institutions. London 21.4 3.5 15.1 24.2 20.7 16.3 3.6 6.8 18.9 Kensington 16.2 2.2 14.6 23.6 22.4 13.9 2.4 5.8 14.9* * Irrespective of 396 deaths of non-parishioners at the Marylebone Infirmary, Notting Hill: inclusive of these deaths the percentage would be 25.7. 184 TABLE IX. Showing the Localities in which Fatal Cases of some of the Principal Zymotic Diseases occurred in 1882. KENSINGTON TOWN REGISTRATION SUB DISTRICT Locality. DISEASES. Total. Locality. DISEASES. Total. Locality. DISEASES. Total. Small Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhœa. Small Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhœa. Small Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhœa. Typhus. Enteric. Sim.Con. Typhus. Enteric Sim. Con. Typhus. Enteric. Sim.Con. Abingdon Road ... ... 1 ... 3 ... ... ... ... 4 Hurstway Street ... 4 ... ... 1 ... ... ... ... 5 Rendle Street ... ... 1 ... ... ... ... ... ... 1 Absalom Road ... ... ... ... ... ... 1 ... ... 1 Infirmary & Workhouse ... 4 ... ... 2 ... ... ... 2 8 St. Alban's Road ... ... ... ... 1 ... ... 1 ... 2 Addison Gardens ... ... ... ... ... ... 1 ... ... 1 Kensington Park Road ... ... ... ... 1 ... 1 ... ... 2 „ Ann's ... ... ... ... 3 ... ... ... 1 4 Admiral Terrace ... ... 1 ... ... ... ... ... ... 1 Kensington Square ... ... ... 1 ... ... ... ... ... 1 „ Ervan's ... 1 1 ... 4. ... ... ... 1 7 Alfred Place ... ... ... 1 1 ... ... ... ... 2 Ladbroke Road ... 1 1 ... 1 ... ... ... ... 3 „George's ... 1 ... ... ... ... 1 ... ... 2 Bangor Street ... 2 ... ... 1 ... ... ... 2 5 Ladbroke Grove Road ... ... 1 ... 2 ... ... ... ... 3 „ Katherine's Road ... 3 ... 1 3 ... ... ... 1 8 Bevington Road ... ... 1 ... ... ... ... ... ... 1 Lancaster Road ... 2 2 ... ... ... ... ... 1 5 „ Mark's Road ... ... 1 ... ... ... ... 1 ... 2 Blechynden Street ... 2 ... ... 4 ... 1 ... 2 9 Lockton Street ... ... 1 ... 1 ... 1 ... ... 3 Silchester Road ... 2 1 ... 2 ... ... ... ... 5 Bosworth Road ... 1 1 ... ... ... ... ... 1 3 Lonsdale Road ... ... ... ... 1 ... ... ... 2 4 „ Terrace ... 2 ... 1 1 ... 1 ... ... 5 Bramley Road ... 2 1 ... ... ... ... 1 1 5 Mall Chambers ... ... ... 1 ... ... ... ... ... 1 Southam Street ... 1 ... ... 3 ... 1 ... 2 7 Campden House Road Mews ... ... ... 1 ... ... ... ... ... 1 Manchester Road ... 2 ... ... ... ... 1 ... ... 3 South End ... ... ... ... 2 ... 1 ... ... 3 „ Street ... ... 1 1 ... ... ... ... 1 3 Stockton Mews ... ... 1 ... ... ... ... ... ... 1 Charlotte Terrace ... 1 ... 1 ... ... ... ... ... 2 Marru Place, &c., Notting Dale ... 8 1 ... ... ... ... ... ... 9 Stoneleigh Street ... 1 ... ... ... ... ... ... 2 3 Colville Gardens ... ... ... ... ... ... 1 ... ... 1 Swinbrook Road ... 2 1 ... 4 ... ... ... 1 8 Cornwall Road ... ... ... 1 ... ... 1 ... ... 2 Merton Road ... ... ... ... 3 ... ... ... 2 5 Talbot Grove & Mews ... 2 ... ... ... ... ... ... 2 4 Crescent Street ... 1 1 ... 1 ... ... ... 1 4 Napier Road ... ... 1 ... ... ... ... ... ... 1 Tavistock Crescent ... 1 ... ... ... ... 1 ... ... 2 Earl's Terrace ... ... 1 ... ... ... ... ... ... 1 Peel Place ... ... ... i ... ... ... ... ... 1 Testerton Street ... 1 ... 1 1 ... ... ... 2 5 Elgin Mews ... ... 3 ... ... ... ... ... ... 3 „ Street ... 1 ... ... 1 ... ... 1 ... 3 Walmer Road ... 2 ... ... 5 ... ... ... 5 12 Golborne Gardens ... 2 2 ... 2 ... ... ... 1 7 Portland Road ... ... ... ... 2 ... 1 ... 1 4 „ „ Nott. Dale ... 4 4 ... ... ... ... ... 1 9 Golborne Road ... ... 1 ... 1 ... ... ... ... 2 Portobello Road ... 1 5 ... 9 ... ... 1 ... 9 Warwick Gardens ... ... ... ... ... ... 1 ... ... 1 Holland Road ... ... ... ... ... ... 1 ... ... 1 Princes Place ... 1 ... ... ... 1 ... ... ... 2 Wheatstone Road ... ... ... ... 2 ... ... ... ... 3 Hornton Street ... ... ... ... ... ... 1 ... ... 1 Wornington Road, Connaught Terrace, &c. ... 1 2 ... 2 ... ... ... ... ... BROMPTON REGISTRATION SUB DISTRICT. Atherstone Mews ... ... ... ... 2 ... ... ... ... 2 Kramer Mews ... ... 1 ... 1 ... ... ... ... 2 Seymour Place ... ... ... ... 1 ... 1 ... ... 2 Child Street ... ... ... ... 1 ... ... ... 1 2 New Street ...1 ... ... 1 ... ... ... ... 2 Sloane Place ... 1 1 ... ... ... ... ... ... 2 Crescent Place ... ... 1 ... ... ... ... ... ... 1 Onslow Gardens ... ... ... 2 ... ... ... ... ... 2 South Street ... ... 1 ... ... ... ... ... 1 2 Cromwell Road ... ... ... 2 ... ... ... ... ... 2 Pleham Place ... ... ... ... ... ... 1 ... ... 1 Stamford Cottages ... ... 4 ... ... ... ... ... ... 4 Earl's Court Road ... ... ... ... 1 ... ... ... 1 2 Penywern Road ... ... 1 ... ... ... ... ... ... 1 Thistle Grove ... ... ... ... ... ... 1 ... ... 1 „ „ Square ... ... ... 1 ... ... ... ... ... 1 Redcliffe Gardens ... ... ... ... ... ... 1 ... ... 1 Warwick Road ... ... ... 1 ... ... ... ... ... 1 Ensor Slews ... ... ... 1 ... ... ... ... ... 1 Reece Mews ... ... ... ... 2 ... ... ... ... 2 Yeoman's Row ... ... 1 ... 2 ... ... ... ... 3 Fulham Road ... ... ... 2 ... ... ... ... ... 2 Richmond Road ... ... ... ... 1 ... ... ... 2 3 Ifield Road and Adrian Terrace ... 2 4 ... 3 ... ... ... 1 10 185 TABLE X. PARISH OF ST. MARY ABBOTTS, KENSINGTON. Return respecting the Vaccination of Children whose Births were Registered in the year 1882. DATE. Registration Sub-Districts comprised in Vaccination Officer's District. Number of Births returned in Birth List Sheets. Number of these Births duly entered in Columns 10, 11, and 13 of the Vaccination Register (Birth List Sheets), viz.: Number of these Births which are not entered in the Vaccination Register, on account (as shown by Report Book) of Column 10 Successfully vaccinated. Column 11. Column 13. Dead. Un-vaccinated. Postponement by Medical Certificate. Removal to District, the Vaccination Officer of which has been duly apprized. Removal to places unknown, or which cannot be reached, and cases not having been found. Cases still under proceedings by summons and otherwise. Insusceptible of Successful Vaccination. Had . Small-pox. 1882 l 2 3 4 5 8 9 10 1st January to 30th June Kensington Town 1777 1529 4 ... 139 15 3 87 ... Brompton 423 373 2 ... 24 4 l 19 ... 1st July to 31st Dec. Kensington Town 1717 1427 8 ... 158 45 8 70 1 Brompton 415 359 2 ... 29 6 2 17 ... Total 4332 3688 16 ... 350 70 14 193 1 186 TABLE XI. LICENSED SLAUGHTER-HOUSES. SOUTH OF UXBRIDGE ROAD. LOCALITY. LICENSEE. 1, Church Street, Kensington Mr. Stimpson 11, Peel Place, Silver Street „ Osborn The Mall, Silver Street „ Wright 183, Brompton Road Mrs. French 60, Kensington High Street Mr. Evans 15, High Street, Notting Hill „ Short 133, ditto ditto „ Candy 6, Addison Terrace,ditto „ Beall 35, Earl's Court Road ,, Matson NORTH OF UXBRIDGE ROAD. 13, Archer Mews Mr. Bawcombe 195, Clarendon Road „ Rea 10, Edenham Mews ,, Gibson 8, Vernon Mews,PortobelloRd. „ Young Ledbury Mews „ French Lonsdale Mews „ Green 50, Princes Road „ Parratt 10, Princes Mews „ Dormain 10, Princes Yard „ Coles Clarendon Mews „ Colley 41, Princes Place „ Grant 23, Norfolk Terrace „ Harris 61, Silchester Road „ Crawforth 235, Walmer Road „ Van Mary Place, Notting Dale „ Arnsby Royal Crescent Mews „ Brooker Ditto ditto „ Down 187 TABLE XII. LICENSED COWSHEDS. SOUTH OF UXBRIDGE ROAD. LOCALITY. LICENSEE. St. Mark's Road, Fulham Rd. Mr. Cotchings Newland terrace „ Tisdall Stratford Road „ Clarke Addison Cottage, Lome Gds. „ Glenie Newcombe Street „ Lunn Earl's Court Road (rear of 117) West London Dairy Society NORTH OF UXBRIDGE ROAD. 3, 4, 5, Angola Mews Mr. Jennings Ledbury Mews „ Liddiard 187, Walmer Road „ Arnsby 235, Walmer Road „ Van 47, Tobin Street, Notting Dale „ Reeves Ditto ditto - „ Skingle, Jun. 12, Blechynden Mews „ White 14, ditto „ Copperwheat 4 & 5, Archer Mews „ Skingle 23, Bramley Road „ Tame 27, Queen's Road, Norlands„ „ Williams Elm Cottage, St. Mark's Road „ Bowyer To be Preserved. THE VESTRY OF THE PARISH Of St. Mary Abbott's, Kensington. SUGGESTIONS FOR PREVENTING THE SPREAD OF Infectious Diseases, SUCH AS SMALL POX, SCARLET FEVER, TYPHOID FEVER, &c. GENERAL SANITARY NOTICE, &c., &c. The Bestrg of the Parish of St.. Marg Abbotts, Kensington. INFECTIOUS DISEASES. Attention is requested to the following suggestions drawn up with the view of preventing the spread of infectious diseases. A sick person who cannot he treated at home without risk of infecting others, should be removed to hospital : this can usually be done free of expense. For further information apply at the offices of the Sanitary Department, at the Town Hall. When a sick person is without proper lodging or accommodation, any Justice may, by order, on a certificate signed by a medical practitioner, direct his removal to hospital. If the sick person be kept at home, no visitor should be allowed to enter the infected room; the visitor may escape infection and yet be the means of carrying infection to others. Children living in an infected house should not go to school, or visit other houses, until a medical man has certified that they may do so without risk of spreading disease. Laundresses should not carry on business in an infected house, and should not wash infected articles until after they have been properly disinfected. MEDICAL MEN, CLERGYMEN, DISTRICT VISITORS, SCHOOL-OFFICERS, and others, are earnestly requested to report cases of infectious disease to the Medical Officer of Health. 3 DIRECTIONS IN CASE OF ILLNESS. Place the sick person on the top floor in a light and airy room ; keep a fire burning, if the weather permit, and ventilate by opening the window at the top. A sheet wetted with Carbolic Acid, Chloralum, Sanitas, or Terebene diluted with water, may be hung in the doorway. Sprinkle the floor with Chlorinated Soda, Condy's Fluid, Chloralum or Sanitas, diluted. Place Chloride of Lime, mixed with water, or Carbolic Acid, or Oil of Turpentine, in saucers about the room; and, if practicable, purify the atmosphere by vaporising Condy's Fluid, Chloralum or Sanitas, by means of a spray apparatus. Disinfect washable things in Condy's Fluid or Chloralum diluted, by placing them in a pan or tub kept ready, and before they leave the room. Disinfect whatever passes from the sick person (in typhoid fever especially), by receiving it into a vessel containing Copperas water (see Disinfectants). Pieces of rag should be used instead of pocket handkerchiefs, and then burned. The sick person should spit into a basin containing a disinfectant. Disinfect glass, crockery, spoons, &c., with Condy's Fluid diluted, and cleanse them with hot water before they are used by other persons. Food left by the sick person, or that has been in the sick room, should not be used by others. Nurse and Doctor only should enter the sick room; the nurse should wear washable cotton dresses, and change her clothes (taking a bath if possible) before mingling with other people or leaving the house: she should wash her hands frequently, using Carbolic, Sanitas, or Coal-Tar Soap. SMALL-POX. Vaccination gives great protection against small-pox, and during epidemics should be done as soon as possible after birth, at the discretion of the doctor. Revaccination after twelve years of age is strongly recommended; it gives nearly complete security against an attack of small-pox; revaccinated persons moreover, very rarely die if attacked with small-pox. Parishioners may be vaccinated or revaccinated gratuitously, at No. 216, Cornwall Road, Notting Hill, any Monday morning, at 10 4 o'clock; or at the Chapel in Hornton Street (near Kensington High Street Station), any Tuesday afternoon, at 3 o'clock. The Vaccination Officer will be glad to receive information of any unvaccinated child at his office, Marloes Road, Kensington, W. SCARLET FEVER. After Scarlet Fever the sick person will require anointing all over, not forgetting the hair, and warm disinfecting baths at the discretion of the doctor. He is not safe from after consequences, and is a source of danger to others, until the skin has done "peeling." HOUSE DISINFECTION. Disinfect drains, sinks, water-closets, dust bin, &c., daily; and air the house by keeping open windows. ON RECOVERY FROM ANY INFECTIOUS DISEASE, however slight the illness, the patient should not leave the sick room to mingle with the family, or go out of the house, without the consent of the doctor, nor without bathing, change of clothing, &c. SHOULD THE ILLNESS END FATALLY, the body should be placed as soon as possible in a coffin, containing a layer of sawdust, o which has been added a pound of Carbolic or Sanitas Powder. The lid should be at once screwed down, and burial should take place quickly. PUBLIC MORTUARY. A Mortuary has been erected in the parish churchyard, behind the Vestry Hall, to which it is recommended that all infectious dead bodies should be removed. In certain cases, viz., when there is danger to the health of the living, any Justice may, by order, on a certificate signed by a medical practitioner, direct the removal of a dead body to the mortuary. Application for permission to deposit a body, and for further information, to be made at the offices of the Sanitary Department, at the Town Hall. 5 DISINFECTANTS. FRESH AIR. By open windows where practicable, and a fire burning in the sick room. HEAT. (a) In Chambers specially constructed for the reception of bedding, &c.; (b) by boiling infected clothing, after washing with Carbolic, or Sanitas Soap. CARBOLIC ACID (poisonous), Condy's Fluid, Chloralum, Sanitas, Terebene, Chloride of Lime or Soda, diluted according to the directions on the bottle: for use in nightstools, water-closets, drains and sinks; either may be used for wetting a sheet to hang in the doorway of the sick room. Carbolic and Sanitas soaps are useful for the cleansing of floors, furniture, &c. GREEN COPPERAS, a cheap preparation of iron (to be obtained at a chemist's), in the proportion of a pound to a gallon of water, is useful for sink, drain, night-stool and water-closet. CONDY'S FLUID, CHLORALUM, SANITAS or CHLORINATED SODA, diluted, may be used for gargling the mouth, washing hands, baths, and for disinfecting washable articles of clothing, bedding, &c. These should be allowed to soak for a time and then be rinsed in clean water. When Condy's Fluid loses its color it is inert ; it stains if the clothes are left in too long, or if the solution be too strong. Tobacco smoke and perfumes are useless for the purpose of disinfection. N.B.—DISINFECTANTS are supplied gratuitously to the poor on application at the offices of the Sanitary Department at the Town Hall. 6 DISINFECTION Of Clothing, Bedding, &c., by heat, can be carried out efficiently only in a specially constructed chamber. For information on the subject apply at the offices of the Sanitary Department at the Town Hall. Washable things must not be sent to a laundry until they have been disinfected. Infected articles should not be exposed in yards, gardens, &c. Useless things, or things of little value, should be burned. DISINFECTION of the Infected Room by Sulphurous Acid. With paper and paste, securely close all cracks and openings in and about the doors, windows, &c. Stop the chimney-opening with a fire board, or a bag of straw. Take from a quarter to half a pound of roll-brimstone broken in small pieces; place the pieces in a pot lid or fryingpan, and stand this on two bricks or a piece of stone. Set the brimstone on fire with live coals, close the door of the room quickly, and paste up the crevices and the key-hole. Leave the room closed for 24 hours if possible. Then open windows widely. Strip the paper off the walls and burn it. Limewash the ceiling, and cleanse the floor, furniture, &c., with Carbolic or Sanitas Soap. If time is not an object, the bedding, &c., may be partially disinfected at the same time, by being spread about the room, hung upon lines, &c. 7 PENALTIES Are recoverable under the Sanitary Acts If any person knowingly exposes himself or others in a public place, when suffering from a dangerous Infectious disease, without taking proper precautions against spreading the disease. If any person, when suffering from an infectious disease, enter a public conveyance without first informing the driver or owner of the fact. If the owner or driver of any such conveyance does not provide for the disinfection of it, after use by an infected person. (A cab may be disinfected by sulphurous acid as previously described.) If any person refuses to cleanse and disinfect any house or room, or articles contained therein, when required by the Sanitary Authority. If any person gives, lends, sells, exposes, or transmits (except for disinfection) any infected clothing, bedding, or other articles without previous disinfection. If any person knowingly lets a house or a room in which a person suffering from an infectious disease has been, without having disinfected it to the satisfaction of a medical man, testified by his certificate. If any person wilfully disobeys the order of a Justice for the removal of a sick person to a hospital, or obstructs the officer in his execution of the order. GENERAL SANITARY NOTICE. DUST-BIN. Vegetable refuse should not be placed in the dust-bin, the decay of such matters, especially in hot weather when few ashes are made, causing offensive smells injurious to health. Vegetable refuse being, after slight drying behind the fire, combustible in ordinary grates, may and should be burned, small quantities being placed on the fire at a time. The dust-bin should be emptied once a week. 8 WATER-CISTERNS should be carefully covered, to exclude dirt, and cleansed once a month. The waste-pipe, if connected with the drain or soil-pipe, should be disconnected, and converted into an overflow or warnirig-pipe; otherwise the water may become polluted by foul air, to the danger of health and life. WATER CLOSETS should have an independent water supply, either by a separate cistern or a service-box. The soil-pipe, whenever practicable, should be carried up to the roof, full size, for the purpose of ventilation. BATE AND SINK WASTES. Waste-pipes should be disconnected from the drain, and when practicable carried through the outer wall, and made to discharge on a trapped stoneware gully in the open air. RAIN-WATER-PIPES should be disconnected from the drain, and made to discharge on a trapped stoneware gully. HOUSE-DRAINS should be ventilated by a fourinch pipe, carried from the highest part of the drain to the roof. The joints of the pipe must be carefully stopped, and the open end of the pipe should not be near a window or chimney. Impure air and polluted water being fertile sources of illness, especially of diarrhoea, so fatal to young children in hot weather, and of communicable diseases like typhoid fever, the importance of attending to the above recommendations must be obvious. By order of the Vestry, T. ORME DUDFIELD, M.D., Medical Officer of Health. Offices of the Sanitary Department, Town Hall, Kensington High Street, W. July, 1883.