VIII 2 KEN 115 THE ANNUAL REPORT on the HEALTH, SANITARY CONDITION, &c., &c., of the Darish of St. Mary Abbotts, KENSINGTON, FOR THE YEAR 1888, by T. ORME DUDFIELD, M.D., Medical Officer of Health. PRINTED BY J. WAKEHAM AND SON, 4, BEDFORD TERRACE, KENSINGTON; And 116, Uxbridge Road, Shepherd's Bush, W. 1889. THE ANNUAL REPORT on the HEALTH, SANITARY CONDITION, &c., &c. of the Darish of St. Mary Abbotts, KENSINGTON, FOR THE YEAR 1888, by T. ORME DUDFIELD, M.D., Medical Officer of Health. PRINTED BY J. WAKEHAM AND SON, 4, BEDFORD TERRACE, KENSINGTON; And 116, Uxbridge Road, Shepherd's Bosh, W. 1889. TABLE OF CONTENTS. page Prefatory Remarks on Death-rate—Parochial; Metropolitan; Urban ; and National 1 Registration District: "Kensington" 4 ,, Sub-Districts Kensington Town," and " Brompton" 5 Wards, Division of Parish into 6 Kensington, Population and Rateable value of; 1801-1888 6 Vital Statistics, 1888, Summary of 7 Zymotic Diseases, General Remarks on the " Seven Principal " 12 ,, ,, Number of Deaths from the ,, ,, in 1888 15 ,. „ Death-rate from; in Kensington, in London and other large Towns, and in England and Wales 15 ,, „ Monthly Return of Deaths from, in Kensington 16 Small-Pox, Low rate of Mortality from, in London 16 Measles 17 „ Hospital Accommodation for 9 Scarlet Fever 21 „ ,, In London 23 ,, ,, Cases of, recorded in Kensington, 1879-87 and in 1888 25 „ ,, Alleged Dissemination of, by the Milk of Diseased Cows 27 Diphtheria 29 ,, Endemic of 30 ,, Hospital Accommodation for 33 ,, ,, ,, Action taken by the Vestry to obtain 34 „ ,, „ Action taken by the Society of Medical Officers of Health 36 „ ,, ,, Action taken by the Asylums Board 37 „ „ ,, Decision of the Local Government Board securing 38 ,, ,, ,, Provision of, Reported to Medical Practitioners and the Head Teachers of Public Elementary Schools 40 ii. PAGE Whooping Cough 41 Fever 42 Diaerhœa 43 Metropolitan Asylums Board, The Work and Proceedings of the 43 „ „ „ The Annual Report of the Chairman 44 ,, „ „ The Annual Report of the Statistical Committee 47 Ambulance Service of the Asylums Board 51 ,, „ ,, Stations 51 ,, „ ,, Wharves 51 ,, ,, „ River Service 52 ,, ,, ,, Annual Report of the Committee 52 ,, ,, Metropolitan: A Desideratum 54 ,, „ Objectionable employment of Public Vehicles for conveyance of the Infectious Sick 54 „ ,, Views of the Medical Officer of Health endorsed by the Asylums Board 55 „ „ Asylums Board willing to be the Ambulance Providing Authority for London 55 Small-pox; Hospital Accommodation for, largely increased 65 „ ,, „ The Hospital Ships 56 Fever; Hospital Accommodation for 57 Western District Hospital (Fulham) ; Alleged to be inadequate for the needs of he West District : Proposal to enlarge 59 Non-Pauper Infectious Sick: „ Regulations (new) of the Asylums Board for the Removal of Patients 61 ,, Mode of Admission of Patients to Hospital 62 Status of Patients : Erroneous views with reference to 63 The question of Payment for, in Hospital 64 Expenditure for Maintenance of, sanctioned by the Local Government Board 65 Hospitals and the Sanitary Acts re Compulsory Removal to Hospital of the Sick who are without proper lodging or accommodation 66 Hospitals, Clinical Instruction afforded at the 67 „ Table shewing Quarterly and Total Admissions of Patients at; from each Parish and Union, in 1888; and Population of the several Districts in 1881 68 Metropolitan Asylums Board, The future of the 70 ,, „ Views of, in respect of a Central Authority for providing Hospital for the Infectious Sick 70 iii. PAGE Metropolitan Asylums Board, Views of the Sanitary Authorities and of the Vestry in respect of a Central Authority for providing Hospitals for the Infectious Siek 71 Hospitals for Infectious Diseases, Views of the Medical Officer on 72 Free Hospitals for Infectious Diseases, ,, ,, 73 Central Hospital Authority, ,, ,, 74 Depauperisation of Relief in Infectious Hospitals ,, 75 Notification of Infectious Disease, Voluntary 76 ,, ,, Compulsory: A Retrospect 77 ,, ,, Communication from the County Council 79 Compulsory Removal to Hospital of the Infectious Sick, being without proper lodging or accommodation 79 Hospitals Commission on Infectious Disease Hospitals (1882): Resume of its recommendations; and the extent to which they have been carried out in practice 80 Public Health Legislation 81 A Retrospect ; 1856-1888: The Frails of Sanitation 84 Population of Sub-Districts, Number of Inhabited Houses, &c 87 ,, Relative Numbers of Males and Females; at different ages ; in Parish, and in Sub-Districts, in 1881 (Tables) 88 Marriac.es and Marriage Rate 89 Births and Birth Rate 89 Deaths and Death Rate 90 Infantile Mortality 91 ,, „ Among Illegitimate Children 91 Senile Mortality 92 J>hath Rate at Different Age-Periods (Table) 92 ,, Mean Temperature, etc., Monthly 93 Death, Summary of causes of (Table) 94 Death, Assigned Causes of 95 ,, ,, Specific Febrile or Zymotic Diseases 95 „ ,, „ Venereal Diseases 96 ,, ,, ,, Puerperal Fever 96 „ Parasitic Diseases 97 ,, Dietetic Diseases 97 ,, „ „ Alcoholism 97 ,, Constitutional Diseases 97 „ ,, „ Cancer 98 ,, ,, ,, Tubercular 99 ,, Developmental Diseases 101 iv. PAGE Death, Assigned Causes of (Contiiued). „ Local Diseases 101 ,, ,, Nervous System, Diseases of 101 „ Local Diseases, Circulatory System. Diseases of 102 „ „ Respiratory ,, „ 102 ,, Digestive ,, ,, 103 „ Urinary „ ,, 103 „ „ Reproductive ,, ., 104 „ Violent Deaths 104 ,, Ill-defitied and Not Specified Causes of 104 Public Institutions, Deaths in 105 ,, „ Parish Infirmary and Workhouse 105 ,, Outlying Hospitals, &c. 107 „ „ St. Joseph's House 108 ,, ,; Consumption Hospital. Brompton 108 ,, ,, Marylebone Infirmary, Notting Hill 108 Deaths, " Not Certified," in Kensington 109 ,, „ The subject of, considered generally 109 ,, „ The position and duties of Coroners and their Officers in relation to 110 Inquests 112 ,, Dealhs from Violence: Accidental 113 „ „ „ Suicidal, Homicidal 114 „ Why so many become necessary 114 Meteorology 115 Vaccination 116 „ Officer's Return for 1887 116 ,, Evidence furnished by Medical Officer to Local Government Board, as to the Protection afforded by, in the Small-pox Epidemic at Sheffield, 1887.8 118 ,, Animal; Calf Lymph 123 Sanitary Legislation 124 Sanitary, Nuisances Removal, and other Cognate Acts, Report on, by the Law and Parliamentary Committee 124 Bye-Laws for Sanitary Administration Purposes, The need of 126 Sanitary Administration: The views of the President of the Local Government Board in respect of the Labouring Classes Lodging Houses Acts; the Artizans' Dwellings Acts; and the Aitizans and I.aboureis' Dwellings Improvement Acts 128 v page Housing of the Working Classes : The Proceedings of the County Council with reference to 131 Emigration, regarded as a means for reducing Overcrowding: A Government Enquiry promised 133 Offensive Businesses 134 ,, ,, Fat Extractor 134 ,, ,, Marine Stores 134 Refuse Matters, Production of 134 Offensive Substances, Conveyance of, through Streets 135 Brick Burning: Nuisance arising from 137 „ ,, Judicial Decisions with reference to 137 „ ' ,, Legislation required for dealing with 137 Nuisances Removal Acts : Committee appointed by the Vestry for carrying out the provisions of the 138 Sanitary Inspectors, The Work of the 138 Slaughter Houses (Metropolis) Act, 1874: A Retrospect 140 ,, ,, Licensed 141 Cowsheds, Dairies, etc. : Contagious Diseases (Animals) Act: Dairies Order: A Retrospect 142 „ Licensed 143 Bakehouse Legislation: A Retrospect 144 Refuse Matters, Nuisance arising from Removal of 145 „ House: The Work of " Dust " Collection and Removal 115 ,, ,, Metropolitan Board requested to promote Legislation to abolish Dust Bins 146 „ The Board makes inquiry, but takes no other action 146 ,. ,, Daily Collection of, from Moveable Receptacles: A desideratum 147 „ ,, Difficulty and Expense of finding "Shoots" for, always on the increase 148 ,, „ Veslry purchases Land at Purfleet, in Essex, for a Dust and Slop Depot 148 ,, Stable, should be collected by Vestry 148 „ Trade : The Law on the subject of Removal of 149 Disinfection in 1888-9 150 Necessary Accommoration : Public, and Public House Urinals 150 Public Baths and Washhouses Opened : Washhouses apart from Baths, a Desideratum 151 Mortuary, Public : Observations with reference to the 151 ,, ,, Particulars with reference to Bodies admitted to 152 „ ,, Views of the Hospitals Royal Commission 153 Coroner's Court, provided by the Vestry at the Town Hall 153 vi. PAGE Houses Let in Lodgings, Regulations for : under Sanitary Act, 1866... 154 „ „ Vestry's Instructions for the guidance of the Sanitary Inspectors 156 Housing of the Working Classes : Report of the Royal Commission 157 ,, Public Health (Metropolis) Bill, 1885 158 Unhealthy Houses: The Liabilties of Landlords : Legal decision 158 Metropolitan Sewage Question 159 ,, The (late) Metropolitan Board of Works' decision to deal with Sewage at the Outfalls by Chemical Precipitation of the Solid Matters, and, when necessary, by Deodorizaof the Effluent, followed by immediate discharge into the River, contrary to the Recommendation of the Royal Commission in favour of a System of Land Filtration of the Effluent, prior to its discharge into the River 159 ,, ,, Sir Henry Roscoe retained as Scientific Adviser by the Board: His reports on the subject 160 ,, Deodorization of the Sewage at the Outfalls and in the Sewers 160 ,, ,, „ „ TheVestry's views of the inutility of, as practised 161 ., ,, ,, ,, Proceedings in 1888: Abstract of Sir H. Roscoe's Final Report 162 ., Chemical Examination of the Foreshores and Mud Deposits of the Thames and its Estuary ; Abstract of a Report by Sir H. Roscoe 164 ,, „ Sir H. Roscoe sums up the whole question, unofficially, in 1889, and condemns the proceedings of the late Board, which are being continued by the County Council 167 Water Supply : Cutting-off Powers o! the Companies, etc. 168 ,, ,, Abstract of Report on, by Professor Frankland 169 ,, ,. ,, ,, The Water Examiner 169 Gas, Results of Examination for ascertaining the Illuminating Powei and Purity of the 171 „ Proposed New Standard for ascertaining the Illuminating Power of 177 Conclusion 179 vii. APPENDIX. STATISTICAL AND OTHER TABLES. Page Table I. Estimated Population in 1888, and ten previous years, 1878—87: Number of Inhabited Houses, and of Marriages, Births, Deaths, Ac. 183 II. Birth Rate and Death Rate; Death Rates of Children : Deaths in Public Institutions, in 1888 and 1878-87 184 III. Deaths Registered from all Causes in 1888 185 ,, IV. Deaths from the Seven Principal Zymotic Diseases ; and from Pulmonary Diseases ; Tubercular Diseases ; Wasting Diseases of Infants, and Convulsive Diseases of Infants ; Gross and Proportional Numbers 187 ,, V. Deaths in 1888 and in 1878-87 from the Seven Principal Zymotic Diseases : in the Parish ; in the Metropolis; and in England and Wales 188 ,, VI. Summary of Inspectors' Reports of Sanitary Work completed in the year 1888-9 189 ,, VIa. Summary of Monthly Returns of Work done by the Sanitary Inspectors in the year 1888-9 190 ,, VII. Death Rates, General and Zymotic, in Kensington and London; and Proportion of Deaths from Zymotic Diseases to Total Deaths, in 1888 and 10 previous years 191 ,, VIII. Comparative Analysis of the Mortality in London and Kensington in 1888; Percentage of Deaths under one year to Births registered; and percentages of Deaths under one year, and at 60 and upwards, from the Principal Zymotic Diseases, and from Violence; of Inquest ca3es, and of Deaths at Public Institutions, to Total Deaths 192 ,, IX. Localities where fatal cases of the more important of the Zymotic Diseases occurred in 1888 193 „ X. Vaccination Officer's Annual Return (1887) 195 ,, XI. Slaughter-houses, Licensed: and names of Licensees 196 ,, XII. Cowsheds „ „ ,, 197 THIRTY-THIRD ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, BEING FOR THE YEAR 1888. To the Vestry of the Parish of St. Mary Abbotts, Kensington. Gentlemen, The vital statistics in the following report are for the registration year ended December 29th, 1888; the sanitary statistics being for the statutory year ended March 25th, 1889. The vital statistics are calculated upon an estimated population of 177,000, a total arrived at on data furnished by the census of 1881, corrected as far as practicable by the number of inhabited houses. The deaths registered were 2,825, being 47 below the number in 1887 and 167 below the decennial average corrected for increase of population. The death rate, 15.9 per 1,000, was 0 5 below the rate in 1887, and 0.9 below the decennial average (16.8). It was 2'6 below the rate in London, as a whole (18.5), and 1.9 below the rate in England and Wales (17.8). The death rate in London shows a decrease of 1.1 upon that of 1887 (19.6), which was the lowest on rccord. The rate in li 2 England and Wales, moreover, shows a decrease of 1.0 per 1,000, compared with 1887, and was the lowest recorded in any year since civil registration began in 1837. The subjoined table shows the annual-death rate per 1,000 persons living, in each of the last eleven years, in Kensington, in London as a whole, and in all England:— 1888. 1887. 1886. 1885. 1884. 1883. 1882. 1881. 1880. 1879. 1878. Kensington 15.9 16.4 15.9 16.1 15.1 15.5 16.2 16 6 17.8 18.8 20.2 London 18.5 19.6 19.9 19.7 20.3 20.4 21.4 21.2 21.7 22.6 23.1 W. Districts 16.9 19.0 19.2 19.2 19.2 19.5 19.9 19.6 19.8 20.9 21.6 North „ 16.4 17.8 18.1 18.5 19.1 19.1 19.7 20.6 20.8 21.5 22.0 Central „ 27.2 26.0 23.6 23.0 23.8 23.2 23 9 23.2 23.4 26.0 25.1 East ,, 21.1 22.5 23.3 22.5 23.0 24.1 25.3 24.2 24.3 25.5 25.0 South „ 17.3 18.6 19.1 18.5 19.8 19.4 20.7 20.5 21.3 21.8 23.0 England & Wales 17.8 18.8 193 19.0 19.6 19.5 19.6 18.9 20.5 20.7 21.6 The Registrar-General, in his "Annual Summary of Births, Deaths, and Causes of Death in London," speaks of 1888 as " a year of remarkably low rates; the marriage-rate and the deathrate being each the lowest on record, and the birth-rate the lowest since 1841." Referring to the low death-rate in 1886, the Registrar-General made an observation, equally true in regard to the still lower death-rate in 1888, to the effect that the "marked decline in the death-iates of recent years," for the decline has been continuous since 1882 (21.4)," has been doubtlessly in some part due to the decline in the birth-rate, which must have materially diminished the proportion of children under five in the total population. Had the birth-rate in the successive five years 1882-86 been equal to the birth-rate in the ten years 1871-80, there would have been, as nearly as can be estimated, some 50,000 more children under five living in 1886, and as the mortality in this first life-period is high, the general death-rate would have been raised, and at a rough estimate would have been about 20.4, instead of being, as it was, 19.9. It would still, therefore, have been exceptionally low." The Registrar-General, as usual, has prepared a table showing diminution or excess of deaths in 1888, compared with annual 3 deaths in 1878-87, corrected for increase of population, from which we learn that there was a marked diminution in the number of deaths from small-pox (857), measles (94), scarlet fever (742), whooping cough (327), "fever" (351), and diarrhœal diseases (1.249). There was a diminution in deaths, among other causes, from phthisis and tubercular diseases (2,433), diseases of nervous system (821), diseases of respiratory system, including croup (2,554), and "all other causes" (2,182); the total diminution being 11,931. On the other hand, there was an excess under several heads—viz., diphtheria (459), cancer (181), premature birth (85), diseases of circulatory system (478), diseases of urinary system (143), and suicide (10). The excess (1,346) being deducted from the diminution, a balance of diminution and excess shows a net diminution of 10,585. In other words, " there was a net gain in the year of 10,585 lives : that is to say, had the death rate been equal to the mean rate in the ten preceding years, 10,585 more persons would have died in London in the year 1888 than was actually the case." This saving of life was shared very unequally by the different causes, and there were six from which, as we have seen, the mortality was in excess. The increased mortality from these diseases, moreover, has been continuous for some years, not in London only but throughout the country generally. Similarly with regard to the diseases which show diminished mortalities: here, also, most of the changes are not peculiar to the year 1888, but are parts of a change that has been going on for a considerable time; for, in regard to the fifteen causes above named, "there are ten under which there was also a diminution in each of the five precedingyears—viz., scarlet fever, typhus, simple and ill-defined fever, enteric fever, diseases of the nervous system, diseases of the respiratory system, accident, murder, and the aggregate of other causes." "This persistency of decrease," it is added, "affords good grounds for believing that the diminution under, at any rate, some of these headings will be permanently maintained." B 2 4 The death rate in the "Outer Ring" of Suburban Districts around London, with a population slightly exceeding a million persons, after correction for the County Lunatic Asylums, did not exceed 15.0, against 15.9 in the preceding year. The death rate in "Greater London," which is co-extensive with the Metropolitan and City Police Districts, was 17.8 against 18.9 in 1887. The death-rate in twenty-seven Cities and Boroughs, having an aggregate population exceeding five millions, was 19.2; ranging from 16.1 in Brighton, 16.3 in Derby, and 16.4 in Hull, to 23.9 in Preston and Blackburn, and 26.1 in Manchester, without correction for differences between one town and another in regard to the age and sex distribution of their respective populations. With such correction, Brighton shows a death rate of 16.6, Derby 16.9, Hull 16.9, Preston 25.9, Blackburn 26.0, and Manchester 29.0. In twenty-two of the largest European cities, having an estimated population of more than eleven millions of persons, the mean rate of mortality was 25.4 per 1.000, and exceeded by 6.2 the mean rate in the twenty-eight largest English towns including London, having an aggregate population exceeding nine millions. The lowest rates were 19.8 in Stockholm, 20.3 in Berlin,, and 20 5 in the Hague, ranging upwards to 31.6 in Buda-Pesth, 31.9 in Prague, 34.6 in St. Petersburgh, and 36.8 in Moscow. The rate in Paris, 22.6, was lower than in either of the three preceding years, although it exceeded the rate in London by 4*1. The rate in Berlin was 20-3. Having premised so much by way of general introduction, it will be well, before proceeding to deal in detail with the statistics of our own parish, to say a few words with respect to the REGISTRATION DISTRICT AND SUB-DISTRICTS, in which we are locally interested. 5 "Kensington," prior to 1st January, 1885, was the title of a Registration District, No. 1 on the Registrar-General.s list, comprising the parishes of Kensington and Paddington. Since that date the parish of Kensington has been constituted a separate Registration District, and is numbered 1b. It contains 2,190 acres according to the Registrar-General; but in your Vestry.s Annual Report the area is given as 2,245 acres. In 1871 the enumerated houses were 15,735, in 1881, 20,103 ; increase, 4,368. In 1871 the population was 120,299 ; in 1881, 163,151 ; increase, 42,852. At the middle of 1888 the inhabited houses were some 21,566, and the estimated population 177,000. Registration Sub-Districts.—For registration purposes the parish is unequally divided into two sub-districts, " Kensington Town," hereinafter for brevity designated "Town," and " Brompton .. The Town sub-district comprises an area of 1,497 acres, the area of Brompton being 693 acres. The population of the Town sub-district at the middle of 1888 was about 129,500, and that of Brompton 47,500. The Town sub-district still includes some open spaces, as Holland Park and NottingBarn Farm. The Brompton sub-district, in which the builder has been busy of late years, many of the new houses being of a palatial character, is now nearly covered. The West London or Brompton Cemetery, Government property, is in this subdistrict ; the Kensal Green Cemetery, in private ownership, in the Town sub district. The sub-districts present marked differences, which must 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 considerable and probably an increasing percentage of persons of the poorer classes. The poor in Kensington, however, are better off in one respect than the poor in some other parts of the Metropolis, in that, for the most part, they live in houses fairly 6 well-built and obviously intended for occupation by the lower middle class : miles of streets of such houses are now inhabited by persons of a class who in some of the older parts of the Metropolis live in dwellings that by comparison might be termed squalid. 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 Statue Acres. Inhabited 1871. houses. 1881. Increase in 10 years. Population. Increase in 10 years. 1871. 1881. St. Mary Abbotts 846 4,781 6,573 1,792 35,696 48,831 13,135 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 rateable annual value of property in the several wards, in 1871, was as follows:—St. Mary Abbotts, £323,992 ; Holy Trinity, £246,716; St. John, and St. James, Norland, £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); the rateable value of St. John and St. James being £501,704 (increase, £136,692). Total, whole parish, £1,580,216 (increase, £644,496). The subjoined figures illustrate 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 70,108 444,030 1863 1871 120,299 975,046 1873 1881 163,151 1,711,495 1883 1888 (July) 177,000 1,902,163 (November) 1888 7 SUMMARY OF VITAL STATISTICS, &c. The year 1888, regarded merely from the point of view of the death-rate, was not a bad one, the rate (15* 9) being 0.9 below the decennial average. But it was characterised by an excessive mortality from two of the zymotic diseases, measles and diphtheria. Diphtheria, it may be mentioned, was more prevalent and more fatal in 1888 than in any previous year. Nevertheless in nine of 13 four-weekly periods I had to report a rate below the decennial average ; the deficiency ranging from 0.3 in the four weeks August 12th to September 8th, to 3.5 in the four preceding weeks, July 15th to August 11th. The lowest rate (13.0) was recorded in the four weeks ended July 14th, the highest (18.3) in three four-weekly periods ended January 28th, April 21st, and December 1st. The summer monihs were characterised by a low rate of mortality, resulting from the comparative absence of infantile diarrhoea, this immunity being due to the coldness of the season. The deaths in the year from diarrhoea were only 58, scarcely more than half the corrected decennial average number. There was no death from small-pox or typhus fever during the year ; but the total deaths from the " seven principal diseases of the zymotic class " (420) were 18 above the corrected average, the excess as already stated being from measles (124 deaths), and diphtheria (89 deaths). Enteric fever deaths (21) were average, those from scarlet fever (26) being scarcely more than half the corrected average. The mean temperature of the air (47°*7) was 1.0 below the average of 117 years. The death rate in the first four weeks of the year (ended January 28th) was 18.3 per 1,000 persons living, being 2.5 below the decennial average. It was also 4.9 below the rate in the Metropolis as a whole (23.2), this moreover being 0.9 below the decennial average. The deaths from the principal 8 diseases of the zymotic class were 37, and 10 above the decennial average. Whooping-cough and measles were the causes of 18 and 7 deaths respectively, diphtheria, scarlet fever and enteric fever of 5, 4 and 3. The deaths of children under five years of age were 91, those of persons aged 60 and upwards being 82. The diseases of the respiratory system were accountable for 76 deaths—the largest number recorded in 1888—including 56 from bronchitis, and 11 from pneumonia. The mean temperature of the air during the four weeks was 38°.4 Falir. and 1°.4 above the means in the corresponding weeks in the previous ten years. In the second four-weekly period of the year (5th—8th weeks, January 29th to February 25th), the death rate fell to 171 per l.000. It was 1.9 below the average, and 7.3 below the Metropolitan rate (24.4), this being 0.2 above the average. The deaths from the principal zymotic diseases were 20—and 6 below the average—including 10 from whooping-cough, 3 each from scarlet fever and measles, and 2 from diphtheria. The deaths of children under five fell (from 91) to 69, but those of persons aged 60 and upwards rose (from 82) to 92, the highest total recorded in 1888. Seventy-one deaths were caused by the diseases of the respiratory organs, including bronchitis 46, and pneumonia 20. The mean temperature was 35°.3, being 5°.0 below the decennial average, and the lowest recorded in any four-weekly period in 1888. In the third four-weekly period (9th—12th weeks, February 26th to March 24th), the death rate was again 17.1 per 1,000, and 1.9 below the average. It was 4.5 below the rate in the whole Metropolis, this being 5.1 below the decennial average. The deaths from the principal zymotic diseases were 25 (the same as the corrected average), and included 14 from whooping-cough, 4 from scarlet fever, and 2 from enteric fever. The deaths of children under five rose (from 69) to 80, including 53 under one year, but the deaths of persons aged 60 and upwards fell (from 92) to 77. The deaths from the diseases 9 of the respiratory system were 67, including 44 and 14 from bronchitis and pneumonia. The mean temperature was 36°.5, and 5°.l below the average. In the fourth period (13th—16th weeks, March 25th to April 21st), the death-rate rose to 18.3, but was 0.4 below the average, and 1.5 below the Metropolitan rate (19.8). this being 2.9 below the average The deaths from the principal zymotic diseases were 36—and 9 above the average—including 23 from whooping-cough—the highest number recorded in 1888—six from measles, and 3 from scarlet fever. The deaths of children under five further rose (from 80) to 107, including 64 under one year ; but the deaths of persons aged 60 ard upwards further fell (from 77) to 55. The deaths from the diseases of the respiratory system were 64, including 45 and 11 from bronchitis and pneumonia respectively. The moan temperature was 41°.9, and 3°.0 below the average. In the fifth period (17th—20th weeks, April 22nd to May 19th), the death-rate declined to 17.0, but was 13 above the average. It was only 0.3 below the Metropolitan rate (17 3), this being 3.0 below the average. The deaths from the principal zymotic diseases were 40—the highest number recorded in 1888—and 14 above the average; whooping-cough and measles being accountable for 16 and 15 deaths respectively; the deaths from diphtheria and scarlet fever were 5 and 3. Diphtheria had at this time become endemic in the Northeastern part of the parish, and so continued till the end of the year. The deaths of children under five fell (from 107) to 92, inchiding 50 under one year; but the deaths of persons aged 60 and upwards rose (from 55) to 61. The deaths from the diseases of the respiratory organs were 49, including 26 and 15 from bronchitis and pneumonia. The mean temperature was 50°.2, and 0O.4 above the average. In the sixth period (21st—24th weeks, May 20th to June 16th), the death rate fell to 14-2, and was 1.9 below the average. It was 1.2 below the Metropolitan rate, which was 10 extraordinarily low—15.4, and 31 under average. The deaths from the principal zymotic diseases were 24, and 6 below the average, including 7 each from measles and whooping-cough, 8 each from diphtheria and diarrhœa, and 2 from enteric fever. The deaths of children under five fell (from 92) to 64, and those of persons aged 60 and upwards (from 61) to 54. The deaths from diseases of the respiratory organs were 41, including bronchitis 17, and pneumonia 15. The mean temperature was 560,4, corresponding with the average. In the seventh period (25th—28th weeks, June 17th to July 14t,h) the death rate further fell to 13.0, the lowest recorded in 1888, and 1.7 below average. It was 2.0 below the Metropolitan rate (15"0) this being 4.2 below average. The deaths from the principal zymotic diseases were 26—and I3 below the average— including diphtheria and measles each 8. The deaths of children under five rose (from 64) to 71, while those of persons aged 60 and upwards fell (from 54) to 39—the lowest number recorded in 1888. The deaths from the diseases of the respiratory system were 25 only, including bronchitis 11, and pneumonia 7. The mean temperature was 57°.1, and 4°.2 below the average. In the eighth period (29th—32nd weeks, July. 15th to August 11th) the death rate rose 0.l to l3.l, but was 3.5 below the average, and 3.3 below the Metropolitan rate (16-4), this being 5.6 below average. The deaths from the principal zymotic diseases were 16—the lowest number recorded in 188b, and 42 below the average—including 5 from diphtheria. The deaths of children under five fell (from 71) to 55—the smallest total recorded in 1888, while those of persons aged 60 and upwards rose (from 39) to 47. The deaths from the diseases of the respiratory organs were 24 only, including bronchitis 12, and pneumonia 8. The mean temperature was 60°.1—the highest recorded in any of the four-weekly periods—and l0.4 below the average. 11 in the ninth period (33rd—36th weeks, August 12th to September 8th) the death rate rose to 13.7. It was 0.3 below the average, and 2.8 below the metropolitan rate (16.5), this being 2.3 below average. The deaths from the principal zymotic diseases were 32 — and 4 below the average — including diarrhoea 19, and diphtheria 10. In this period only did the mortality from summer infantile diarrhoea approach the average. The deaths of children under five rose (from 55) to 71, and those of persons aged 60 and upwards (from 47) to 57. The deaths from the diseases of the respiratory organs were 20 only —the smallest total recorded in 1888—including bronchitis 11. The mean temperature was 57°.5, and 20,8 below the average. In the tenth period (37th—40th weeks, September 9th to October 6th) the death rate fell to 13.4. It was 0.8 above the average, but 2.7 below the metropolitan rate (16.l), this being 1.4 below average. The deaths from the principal zymotic diseases were 29 — and 8 above the average — including diphtheria 12, measles and whooping cough each 4, and enteric fever 2. The deaths of children under five rose (from 71) to 74, including 42 under one year. The deaths of persons aged 60 and upwards rose (from 57) to 91. The deaths from diseases of the respiratory system were 30, including bronchitis 15, and pneumonia 5. The mean temperature was 52°.5, and 2°.5 below the average. In the eleventh period (41st—41th weeks, October 7th to November 3rd), the death rate rose to 17.0, being 1.9 above the average. It was, however, 2.9 below the metropolitan rate (19.9), this being 0.2 above average. The deaths from the principal diseases of the zymotic class were 37—and 15 above the average—including measles 17 and diphtheria 14, the highest monthly number of deaths from the latter disease recorded. The deaths of children under five rose (from 74) to 93, including 52 under one year. The deaths of persons aged 60 and upwards fell (from 91) to 63. The deaths from the diseases 12 of the respiratory system were 52, including bronchitis 37, and pneumonia 5. The mean temperature was 47O.0, and 0O.3 below average. fn the twelfth period (45th—48th weeks, November 4th to December 1st) the death rate rose to 18.3, and was l.0 above the average and 0.3 above the Metropolitan rate, (18.0) which was 34 below average. The deaths from the principal zymotic diseases were 55, and 37 above the average, including 33 from measles (the largest number recorded in 1888), 11 from diphtheria, and 3 from enteric fever. The deaths of children under five rose (from 93) to 109—the highest number recorded in 1888—including 54 under one year, and those of persons aged 60 and upwards (from 63) to 65. The deaths from the diseases of the respiratory system were 51, including bronchitis 34 and pneumonia 9. The mean temperature was 46°.8 and 40.7 above the average. In the thirteenth and last four-weekly period (49th—52nd weeks, December 2nd to 29th) the death rate fell to 16.5. It was 1.2 below the average and 2.9 below the Metropolitan rate (19-4), this being 3.6 below average. The deaths from the principal zymotic diseases were 4:5—and 18 above the average —including measles 18, diphtheria 14, and enteric fever 4. The deaths of children under five fell (from 109) to 101, including 51 under one year. The deaths of persons aged 60 and upwards fell (from 65) to 59. The deaths from the diseases of the respiratory system were 52, including bronchitis 34 and pneumonia 10. The mean temperature was 41°.3 and 3°.3 above the average. THE ZYMOTIC DISEASES. Before entering into details with respect to population, births, deaths, etc., I propose to consider the sickness and mortality from the principal diseases of the zymotic class, and subjects naturally arising out of this topic. 13 The "Class" of diseases called Zymotic comprises, in the Registrar-General's arrangement of the "causes of death," six "Orders." The first and second Orders ("Miasmatic" and " Diarrhceal") include the diseases which the Registrar-General describes as " the seven principal diseases of the zymotic class," grouping, as he does, under the generic term " Fever," the three distinct fevers, " Typhus," " Enteric," and " Simple Continued." These zymotic diseases have a special interest for sanitarians, arising out of the fact that, being admittedly of a more or less preventible character, the absence or the prevalence of certain of them is regarded as a test of the sanitary condition of a district. But, without under-rating the importance of this test, it must be said that there are limitations to its applicability necessary to be borne in mind in drawing inferences from mere numbers. 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 prevalent in 1885, the deaths being considerably above the average: it was the zymotic disease that gave a special character to the year. In the year 1886, on the other hand, the deaths from measles were below the average : but the lowered mortality, regarded as evidence of the diminished prevalence of the disease, was the result of its excessive prevalence and fatality in the preceding year. In saying this, 1 must not be thought to ignore the fact that one epidemic of a zymotic disease may be more severe than another ; or that the severity of an epidemic may be influenced by the measures taken, or the neglect to take any measures, to check 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. In our own parish the large total of 185 deaths from this disease in 1878 followed the minimum return of 34 iu the previous yeai, 14 Diarrhoea may be cited as an illustration of qnite another kind. The mortality from this disease, amongst infants, was excessive in 1878; the mortality in 187 ) was much below the average ; but the diminished mortality in 1879 had no relation to the excessive mortality in 1878. The conditions were altogether different: the summer of 1879 was cold and wet; and, as always happens in these circumstances, the mortality from infantile diarrhoea was low ; just as it is always high when the summer is hot and dry, as in 1878. Again, the significance of a high rate of prevalence of Enteric Fever varies widely in different circumstances. This disease may be constantly present in one district as a result of drainage defects or of a polluted water supply ; whilst in another district its introduction may be wholly accidental, as when it is due to casual pollution of water, or to a specifically contaminated milk supply introduced from without. These and like circumstances must be kept in view if we would draw sound conclusions from a high or a low rate of prevalence of zymotic diseases particularly in relation to the sanitary condition of a district. Subject to corrections for local circumstances, for climatic influences, and for high rates in previous years, the concurrence of a low zymotic death rate, with a low general death rate, furnishes just ground for satisfaction. For some years past the general rate and the zymotic rate have both been below the decennial average in Kensington. But in 1888 it was otherwise, for although the general death rate was below, the zymotic death rate was rather above the average. It need hardly be said that a persistently high rate of mortality from zymotic diseases furnishes matter for serious consideration. Kensington has hitherto been fortunate in having a death-rate from these diseases much below that of the Metropolis generally. 15 The subjoined Table sets out necessary particulars of the mortality from the principal zymotic diseases in 1888, together with the decennial average, etc:— Disease. Sub.districts. In Hospitals. Total. Decennial Average. Town. Brompton.i Town. Brompton. Uncorrected. Corrected for increase of Population. Small.pox - - - - - 16.7 17.8 Measles 112 11 1 — 124 07.8 72.2 Scarlet Fever 8 2 15 1 26 44.1 47.0 Diphtheria 61 1 26 1 89 23.4 25.5 Whooping-cough 80 18 — 2 100 96.8 103.2 Typhus Fever — — — — — 1.3 1.4 Enteric Fever 12 1 5 3 21 20.1 21.4 Simple continued Fever 2 — — — 2 3.7 39 Diarrhoea 44 12 1 1 58 103.2 110.0 319 45 48 8 420 377.1 402.4 It appears, then, that the deaths from these diseases were 18 above the corrected decennial average. They were also 4 more than in 1887. As usual, the deaths in the Brampton sub-district (53) were fewer in proportion to population than in the Town sub-district, and even to a greater extent than in immediately preceding years. The total deaths were equal to 148 per 1,000 deaths from all causes in Kensington (Metropolis, 137), and to a rate of 2.3 per 1,000 persons living (Metropolis, 2.5) ; the decennial average being 2.2 in Kensington, and 3.2 in London. In England and Wales the deaths from these diseases were 100.7 in each 1,000 deaths ; and the rate was 1.8 per 1,000 persons living, the decennial average being 2.4 per 1,000. In the 27 Cities and Boroughs grouped by the Registrar. General with the Metropolis, the zymotic death rate was 2.4 per 1,000, ranging from 1.15 in Halifax to 4'13 in Blackburn. 16 The following Table shews the distribution of deaths in Kensington from the principal diseases of the zymotic class, registered in thirteen four-weekly periods, corresponding with ny monthly reports:— Report for Four Weeks ended. Small-pox. Measles. Scarlet Fever. Diphtheria. Whooping-cough. Typhus Fever. Enteric Fever. Simple Continued Fever. Diarrhoea. Total. Jan. 28, 1888 ... 7 4 5 18 ... 3 ... ... 37 Feb. 25, „ ... 3 3 2 10 ... 1 ... i 20 Mar. 24, ... 3 4 14 ... 2 ... 2 25 April 21, ,, ... 6 3 21 ... 1 ... 3 36 May 19, „ ... 15 3 5 16 ... 1 ... 40 June 16, ., ... 8 1 3 7 ... 2 ... 3 24 July 14, „ ... 8 1 8 2 ... 1 ... 6 26 Aug. 11, „ ... 2 1 5 1 ... 1 ... 6 16 Sept. 8. „ ... 2 10 1 ... ... 19 32 Oct. 6, , ... 4 1 12 4 ... 1 ... 7 29 Nov. 3, ... 17 14 ... 1 1 4 37 Dec. 1, ... 33 2 11 2 ... 3 1 3 55 Dec. 29, „ ... 18 1 14 2 ... 4 ... 4 43 Totals ... 124 26 89 100 ... 21 2 53 420 I now proceed to make a few observations with regard to each of the above-mentioned diseases. SMALL-POX. No case of small-pox was recorded during the year. The recorded cases in the three previous years were 180, 8, and 1 respectively. Small-pox was almost entirely absent from the Metropolis in 1888. The deaths were 9 only (tho same as in 1887), shewing a diminution of 857 deaths, compared with annual deaths in 1878-87 corrected for increase of population. These deaths, in both years were fewer—not merely relatively to population, but absolutely—than in any year since the present system of civil registration began ; the years which most nearly approached this minimum being 1875 (46 deaths), 1874 (57 17 deaths), 1873 (113 deaths), 1883 (136 deaths), and 1886 (24 deaths). The mean annual mortality from this disease in the deeennium, 1878-87, was 0*21 per 1,000, and lower than in any previous deeennium. The Registrar-General, in his Annual Summary for 1886, stated that London, " in spite of the disadvantage it suffers from its perpetually shifting population, and its comparative neglect of vaccination, has improved its position in regard to small-pox among the great towns since 1861-70. But the case is otherwise if London be compared with the aggregate provinces—i.e., the whole of England and Wales without London itself—for while the provincial rate has fallen very greatly, the London rate has lagged behind, so that the difference has become wider and wider." It having been suggested that this may be attributable to the opening of the Metropolitan Hospitals in 1871, the Registrar-General stated that " an examination of the successive rates shows that the increase in the difference between the London and the provincial rates dates from a long time anterior to the opening of the hospitals, and, if successive decennia be compared with their immediate predecessors, was indeed greater in the deeennium 1861-70, which preceded the opening of these hospitals, than in 1871-80, the deeennium which followed it. . . . Whatever, therefore, may be the cause why London does not improve in its relation to small pox to the same extent a.s the provinces, it is something that came into operation long before the hospitals were opened." Granting this, I have no doubt that the diminution in small-pox mortality in the Metropolis during the last three years was largely due to the perfected system of removing the sick direct from their homes to the Ship Hospitals, situated as these are outside the London Registration District — a system which was initiated upon my recommendation made to the Asylums Board and the Local Government Board in 1881. MEASLES. The deaths from this disease in 1888 were 124 (11 of them in Brompton), being 40 above the corrected c 18 decennial average. One hundred and sixteen of the deaths occurred under five years of age, including 22 under one year. The disease was more or less prevalent throughout the year, seeing that it appeared as a cause of death in all but one of my thirteen four-weekly reports. Sixty-eight, or more than half of the deaths, however, occurred in the last quarter of the year (vide Table, page 16). In the majority of the fatal cases, some intercurrent disease—of the respiratory organs usually—complicating the original malady, was the immediate cause of death. Comparatively little care is taken by parents among the poorer classes to prevent the spread of measles, Not regarding it as a serious disease, considering it, moreover, to be just as inevitable as teething, they naturally enough rather like to have all of the children down with it at one time. We must allow, however, that it is difficult to prevent measles from spreading, the disease being highly infectious from an early stage, if not from the commencement of the attack. The circumstances, moreover, in which the poor live in London—two or more families generally occupying one house and using a common staircase—almost preclude the possibility of isolation. But more care might be taken to protect the sufferers against secondary affections, which, as already stated, are, as a rule, the immediate causes of death. There was a very serious outbreak of measles in London, commencing about the first week in October, after which the mortality rose very rapidly to a maximum in the middle of December, when as many as 184 deaths were registered in a single week. The Registrar-General remarked in his Annual Summary for 1887 that " a very insignificant proportion of the deaths from measles occur in hospitals, and the tendency on the part of the public to estimate the prevalence of a disease merely by the pressure to which it subjects hospital authorities is well illustrated by the fact that while much alarm was felt as to scarlet fever, which was in reality less than averagely prevalent, no such general alarm was felt as to measles which was more than 19 averagely fatal." The deaths from measles in 1887 were 2,894, and in 1888, 2,401, being exactly double the fatality from scarlet fever—1,447 in 1887, and 1,209 in 1888. Hospital Accommodation for Measles.—The excessive mortality in London from measles towards the close of the year naturally suggested to many minds the question. Whether this disease, equally with diphtheria, should not be treated at the Managers' Hospitals? in which there were, and for a considerable time had been, many empty beds. Communications on the subject were addressed to the Board : one by a Coroner for Surrey, and another by the Battersea Vestry—the latter requesting that, as measles is ''a dangerous infectious disease of a febrile character, the Managers will take such steps as they may consider advisable with a view to arrangements being made for the reception of sufferers therefrom into their hospitals." The several communications were referred to the Committee for General Purposes, who, in a report dated January 22, 1889, recommended that, " as it appears doubtful whether the Managers at present have legal powers, except under Section 15 of the Poor Law Act, 1879, to admit into their hospitals patients suffering from measles," the said letters " be forwarded to the Local Government Board with a request that the Board will inform the Managers whether they are legally empowered to receive, through the Guardians, cases of Measles, into their hospitals, and, if not, whether the Local Government Board will take steps to obtaiu the necessary legislative authority, if, in their opinion, it is expedient from a medical point of view to do so?" The report was considered by the Board at their meeting on the 26th January, when a resolution was carried to the effect that the Managers had no legal power to treat cases of measles, and the authorities above referred to were so informed. The Managers, doubtless, only intended to deny their authority to treat cases of measles "received through the 20 Guardians," inasmuch as it would appear probable that, as measles may be classed as a " dangerous infectious disorder," the Managers could, with the approval of the Local Government Board, contract, under section 15 of the Poor Law Act, 1879, with any Nuisance Authority, for the reception and maintenance in their hospitals of any person suffering from this disease. As a matter of fact, however, and for reasons to which I need not refer here, no such contract has ever been entered into, nor do I think it probable that the Local Government Board would approve of the use of the Managers' Hospitals for the treatment of measles. Measles, like diphtheria, is not" fever," in the sense in which the term is used in the Metropolitan Poor Act, 1867 ; but the Boaid might authorise the Managers to admit persons suffering from measles, as they have already approved the admission of sufferers from diphtheria. The latter disease, however, is undoubtedly a u dangerous infectious disorder," with a high case - mortality, and early removal of a first case, moreover, almost certainly prevents the spread of disease by contagion. Measles stands in a somewhat different position. The disease is almost infinitely more common; the casemortality is low, and it is probably infectious from the first commencement of illness three or four days prior to the appearance of the rash. The isolation of sufferers in hospital, therefore, would not have the same decisive effect as the early removal of cases of diphtheria (and scarlet fever) in preventing the spread of disease. And it must be borne in mind that in order to deal effectively with epidemic measles, a large extension of hospital accommodation would be necessary ; the % probability being that, in an ordinary epidemic, more thousands of children suffer from the disease than hundreds from scarlet fever in such an epidemic as that of 1887, when the epidemic was at its highest. It is the comparatively low case-mortality of measles, and I may add of whooping-cough also, which seems to remove these diseases somewhat out of the category of " dangerous infectious disorders." But unfortunately it is the fact that the actual deaths from both measles and whooping- 21 Cough exceed the total deaths from small-pox, scarlet fever, diphtheria, and " fever " combined. Thus in 1888, the deaths from measles and whooping cough, in London, were 2,401 and 3,087=5,488 ; the deaths from small-pox (9), scarlet fever (1,209), diphtheria (1,301), and "fever " (720), being 3,239 only. It is right to add, and it is a very important consideration, that admission to hospital would be of the highest value to individual sufferers from measles, by removing them from homes too often wholly unfit for the treatment of a disease which is apt under insanitary conditions, to assume an unfavourable type and to kill by complications which might be averted, could the sufferers be placed where they would have pure air and suitable diet, with proper medical attendance and nursing. This being granted, it must be conceded that a case has been made out in support of the request addressed to the Managers by the Battersea Vestry. At the same time time it has to be borne in mind that sufferers from measles are admitted at the Workhouse Infirmaries, and it is a question whether sufficient accommodation might not be found in those establishments for such cases as need isolation or the special treatment rendered necessary by complicating affections. Otherwise, and especially when there are many empty beds at the hospitals, I should regard the admission of cases of measles, if only for a time, as an experiment of value. SCARLET FEVER. This disease, which was the cause of seven, eleven and forty deaths in 1885, 1886 and 1887 respectively, proved fatal to 26 persons only, in 1888, the corrected decennial average being 47. Only three of the deaths belonged to the Brompton subdistrict. Sixteen of the deaths occurred in hospitals, to which 184 out of 252 recorded cases were removed for treatment. Of 22 the 252 cases 125 belonged to North Kensington—viz., that part of the parish north of Uxbridge Road ; and 127 to South Kensington—the remainder of the parish south of that road. The cases in the three preceding years respectively were 110, 100, and 465. The disease was epidemic in the latter half of 1887, the cases recorded being 389 against 76 in the first half of the year. In 1888 the cases in the first six months were 168 against 84 in the second half of the year. As usual, the occurrence of the disease was concealed in several instances until recovery had taken place, and the cases were then reported only for the purpose of obtaining disinfection at the public expense. In some instances, moreover, when the existence of the disease became known at an early period, parents refused to allow their children to be removed to hospital, these cases, however, being fewer than usual. A certain number of home patients were, to all appearance, properly isolated, and the removal of them to hospital was deemed unnecessary ; but proof was not wanting that, even when the sufferers had what might be fairly described as " proper lodging or accommodation," due care could not have been taken to prevent spread of the disease; unless, indeed, it be the fact that no amount of care suffices to prevent it from spreading when once it has found admittance into a family of susceptible persons. Occasionally when removal was obviously necessary to security difficulty was experienced in obtaining the parents' consent, but in no case was recourse had to the compulsory powers of removal, such as they are, which the Sanitary Act of 1866 confers. The patients were generally children of school age. No child was knowingly allowed to go to school from an infected house. The existence of the disease was revealed occasionally by the registration of a death, and its spread was in several instances the result of keeping patients at home under circumstances that rendered nugatory any attempt at isolation. It is satisfactory, however, to find less unwillingness, year by 23 year, on the part of parents to avail themselves of the advantages afforded by the Hospitals of the Asylums Board, for treatment, and for isolation when this is necessary for preventing the spread of the disease. Evidence of this fact may be seen in the Table at page 25. The deaths in London from this cause were 1,209, the corrected decennial average being 1,960. The type of the disease was mild, the case-mortality in the Hospitals being low. In Kensington the mortality in respect of known cases was 10-3 per cent., a rate in excess of the true proportion, as many cases, doubtless, occurred of which we had no information. Still, we have reason to believe that the occurrence of the disease is much more generally reported now than in byegone years. Thus if we compare the figures in the Table for the year 1887 with those for tbe year 1880, we note that the number of cases recorded was the same in both years, but that the case-mortality in 1880 (22'5 per cent.) was more than double that in 1887 ; the only conclusion at which we can arrive therefore is that in 1880 the concealed cases must have been considerably more numerous than in 1887. It may be added that the deaths in London in 1880 were more than twice as numerous as in 1887; and yet we had then no such alarm as in the latter year. The reason is not far to seek, Peojjle did not use the hospitals eight years ago as they do now. The bulk of the sick were kept at home. Most of the deaths occurred in private houses, and so there was no particular strain on the hospitals to awaken public attention to the epidemic. Our local experience may be cited by way of illustration of this statement. In 1887 the hometreated cases were 316 out of 466 cases recorded, only 150 cases having gone to hospitals ; whereas in 1887 the home-treated cases were only 149, the cases removed to hospital being 316 an exact reversal of the figures of 1880. The percentage of removals, moreover, which iu 1880 was 32, had risen in 1887 to 68 ; it further rose in 1888 to 73. The percentage of deaths in 24 hospitals, which was 21 in 1880, rose to 52 in 1887, and to 61 in 1888. And what is true in regard to Kensington is true also in the main in regard to all of the other Metropolitan districts. In 1878 the scarlet fever deaths in the hospitals were only 7 percent. of the total mortality from the disease in London ; in 1888 they were 43"4 per cent. STATISTICAL RETURNS. The Asylums Board addressed a circular letter to the Vestries and District Boards, in October, 1887, making application for information to enable them to ascertain " the extent, as compared with previous years, to which scarlet fever had been prevalent during the year " in the several districts; their object being to form " as correct an estimate as possible of the accommodation to be provided in future " for cases of this disease. The reason for inquiry was " the difficulty of obtaining reliable information on the subject in the absence of any system of notification of infectious disease "—a difficulty enhanced, perhaps, by the fact, that although " the numbers of patients under treatment in the hospitals" were, in October, " more than double the numbers under treatment at any one time during the past ten years," yet " the mortality . . . was below, rather than above, the general average." It was reasonably assumed, however, that as the deaths in the hospitals " form, year by year, an increasing percentage of the total number of deaths, . . . the numbers in the hospitals had also assumed a correspondingly increased proportion of the total number of persons attacked in the Metropolis." At the request of your Vestry I drew up the desired information, in the form of the subjoined Tables, which are selfexplanatory, and to which I have now added the figures for the year 1888:— 25 Statistics of Scaelet Fevee in Kensington in 1888 and in Nine* Peevious Yeaes. ]The Year. No. of Recorded Cases. Total Number of Recorded Gases. Percentage of Removals to total Recorded Cases. Deaths. Total Deaths. Percentage of Deaths. Percentage of Deaths to Recorded Cases. Deaths in London from Scarlet Fever. Treated at Home. Removed to Hospital. At Home. In Hospitals At Home. In Hospitals 1888 68 184 252 73 10 16 26† 39 61 10 3 1209† 1887 149 316 465 68 21 23 44 48 52 9.4 1447 1886 37 63 100 63 8 3 11 73 27 11.0 688 1885 68 42 110 38 5 2 7 72 28 6.3 707 1884 115 87 202 43 11 7 18 61 39 90 1444 1883 141 90 231 40 22 6 28 79 21 120 1989 1882 199 120 319 40 51 11 62 82 18 19.4 2004 1881 177 110 287 39 30 8 38 79 21 13.2 2108 1880 316 150 466 32 83 22 105 79 21 22.5 3073 1879 174 103 277 37 41 10 51 80 20 18.4 2706 * The returns prior to 1879 are incomplete. † The corrected decennial average number of deaths from scarlet fever in Kensington was 47, and in London 1.960. 26 Scarlet Fevee Cases Recorded in Kensington in 1888, and in Nine Peevious Years*, in Thirteen Four.Weekly Periods. The Year. Weeks. 1-4 Weeks. 5-8 Weeks. 9-12 Weeks. 13-16 Weeks. 17-20 Weeks. 21-24 Weeks. 25-28 Weeks. 29-32 Weeks. 33-36 Weeks. 37-40 Weeks. 41-44 Weeks. 45-48 Weeks. 49-52 TOTAL 1888 46 40 29 19 16 10 15 13 12 7 7 20 18 252 1887 10 8 9 5 16 12 31 14 55 115 92 64 34 465 1886 10 17 7 4 4 7 3 4 8 13 11 9 3 100 1885 7 12 12 3 9 8 11 9 9 12 7 3 8 110 1884 21 23 11 17 10 29 17 5 2 24 4 19 20+ 202 1883 21 6 5 9 22 26 10 14 5 19 37 30 27 231 1882 19 18 14 6 23 11 5 21 28 31 53 38 42 319 1881 24 31 18 27 18 14 17 16 18 33 24 30 17 287 1880 34 19 29 39 35 23 17 17 31 46 59 58 59 466 1879 18 12 9 9 13 11 9 11 35 22 28 74 26 277 Average 21.0 18.6 14.3 13.8 16.6 15.1 14.5 12.4 20.3 32.2 32.2 34.5 25.4 270 The returns prior to 1879 are incomplete. ‡ Return comprises five weeks. ‡Without correction for increase in population. 27 SCARLET FEVER ALLEGED TO BE DISSEMINATED BY THE MILK OF DISEASED COWS. In my Animal Report for 1885 I stated that scarlet fever had recently acquired a new interest for sanitarians, as the result of an outbreak in certain districts in London and at Hendon, inquiry into which had led Mr. W. H. Power, Second Assistant Medical Officer to the Local Government Board, to believe that the disease might be of bovine origin. Dr. Klein subsequently confirmed the views expressed by Mr. Power, which, moreover, commended themselves to Dr. George Buchanan, Medical Officer to the Local Government Board. It need hardly be said that the subject would be one of equal interest and importance should the views of Mr. Power and Dr. Klein be ultimately sustained. But their views have been contested by more than one subsequent investigator. The first note of opposition was sounded by Professor J. Wortley Axe, of the Royal Veterinary College, in a report dealing, as he believed, with the eruptive malady now commonly described as the " Hendon Cow Disease." This disease, he states, is at once common, well known to farmers, innocuous, and has no relation to human scarlatina. He further states that milk from other dairies infected by cows fiom the same herd as those which infected the Hendon cows was supplied to the public at the same time without evil effect, though of course, I may add, in contravention of the provisions of the " Dairies Order." He believes that the Hendon milk received its infective power from " some obscure source connected with the dairy by channels which inquiry has failed to reveal." Professor Axe did not see the Hendon cows during the critical period, but he speaks of the disease as an eruptive one, usually confined to the teats, " and as being known among dairy farmers as cow-pox." He admits that it is transmissible to man by inoculation in the form of vesicles (vaccinia), but avers that it is " incapable of communicating scarlatina or other epidemic fever." 28 Professor Crookshank, of the Bacteriological Laboratory, King's College, subsequently investigated a bovine affection which he believes to have been the same as the Hendon cowdisease, and arrived at the conclusion that it is cow-pox. He states that this disease is not scarlatina in the cow; that the milk of affected animals does not produce scarlet fever in man, and that (as Professor Axe had previously assumed) infsction in the Hendon milk must have been derived from "some hitherto unascertained human source." The reading of Professor Crookshank's paper at the Pathological Society gave rise to a vigorous controversy, in which each side stuck to the views of the respective principals in the debate. The latest contribution to the discussion is supplied in a report by Professor Brown, C.B., of the Agricultural Department of the Privy Council, the most important item in which is the statement that Professor Axe had ascertained, subsequently to the issue of his first report, that there did exist at Hendon " a possible source of infection (of scarlatina) by the agency of persons who visited the Hendon cow-sheds, coming direct from a fever district, even from premises in which scarlatina existed. So that," he adds, "there is an alternative solution to the problem," set by Mr. Power, who, it is assumed, but incorrectly I believe, was unaware of the existence of scarlet fever in the locality, and who, therefore, had stated that the Hendon cows " had not acquired the power to cause scarlatina in any commonly accepted way, as by agency of persons carrying scarlatina infection." The question must be considered as still sub judice, and for practical purposes we are left pretty much in the position occupied prior to Mr. Power's report, for that the poison of scarlet fever may be conveyed in milk infected by human agency is a well-established fact. Against the danger thus arising consumers have it in their power to guard by complying with the oft-repeated advice to boil their milk. And for the rest, we must at present trust to the good sense of milk producers, who in these days, when sanitary knowledge is 29 permeating all classes, may be expected to take an increasing interest in the preservation of the health of their stock; and, above all, to the strict performance of their duty by Local authorities, who are responsible for the due carrying out of the provisions of the Dairies, Cowsheds, and Milkshops Order, which enable them to make regulations for prescribing precautions to be taken by purveyors of milk against infection or contamination. The Order enacts that " if at any time disease exists among the cattle in a dairy or cowshed, the milk of a diseased cow therein shall not be mixed with other milk, and shall not be sold or used as human food." DIPHTHERIA. Diphtheria was very prevalent in several districts of London during the greater part of 1888. For some years past this disease has been on the increase, and in 1887 the deaths were 961, the corrected decennial average number being 781.In 1888 the deaths rose to 1,301, being 549 above the average, and 92 in excess of the number of deaths from scarlet fever. The deaths in the four quarters respectively were 415, 523,238, and 125. In this year diphtheria was, for the first time in my experience, distinctly endemic in the North-west portion of Kensington contiguous to the parish of Paddington, from which it would appear to have extended. Daring the first quarter 32 deaths from this cause were registered in Paddington, and five only in the Town sub-district of Kensington. Other adjacent parishes appear to have been as comparatively free from the disease as Kensington. In the second quarter the deaths registered in Paddington were 20, those in Kensington being nine, including eight in the Town sub-district. In the third quarter the registered deaths were 23, those in Kensington, still in the Town sub-district, being also 23. In the fourth quarter the deaths in Paddington were again 23, while those in (the Town sub-district of) Kensington rose to 28. In this quarter, moreover, a marked increase in mortality from diphtheria was 30 observed in Hammersmith, the deaths being 22, those in the contiguous parish of Fulham being 10. The above figures, taken from the Quarterly Returns of the Registrar-General, do not correctly represent the actual deaths belonging to the several parishes. Deaths are registered in the districts where they occur, and 20 deaths of persons removed to hospitals were registered in the sub-districts in which the hospitals are situated, without reference to the localities from which the patients came. The deaths registered in Kensington from diphtheria were, as above stated, 65 (one only in the Brompton sub-district), but the actual deaths of Kensington parishioners, including those which occurred in hospitals were 89 ; two only in Brompton. The quarterly totals were 7, 10, 30, and 42 respectively. The ages at death were :—Under 5 years, 56, including 4 under one year ; between 5 and 15, there were 29 deaths , between 25 and 35, there were 2 deaths, and there were 2 between 3 5 and 45. The cases of illness recorded were 144, but taking the mortality at the high rate of 50 per cent., at least 180 cases must have occurred. Of the recorded cases, 129 were in North Kensington, i.e., north ofUxbridge Road ,and 15 in South Kensington, i.e., the remainder of tha parish south of Uxbridge Road. Of the 129 cases in North Kensington, 7 occurred between January and May. The other 122 cases, constituting the "endemic," to which my further remarks will be restricted, originated between June and December, viz., in June 5, in July 6, in August 15, in September 21, in October 37, in November 23, and in December 15. These 122 cases occurred in 91 families, living in 84 houses, and in 43 streets. Sixteen of the streets are in the North-west District, i.e., to the west of Ladbruke Grove and Ladbroke Grove Road, and 27 in the North-east District, between those roads and the adjacent parish of Paddington and the detached Kensal Green portion of Chelsea at Kensal Green. In 28 of the 43 streets one house in each street was invaded , in 8 streets two houses were invaded; in 2 streets, three houses ; in 1 street, four houses ; 31 in 2 streets, five houses ; in 1 street, seven houses ; and in 1 street, 13 houses. Of the 28 streets in which one house only was invaded, 15 are in the North-West District, and 13 in the North-East District. Of the other 15 streets wherein from 2 to 13 houses in each were invaded, all save one (Calverley Street) are in the North-East District. The total cases in the North-West District were 25, in the North-East District 97. The streets in which two houses were invaded are Grolborne Road, Telford Road, Hazlewood Crescent, Bevington Road, Queen Anne's Terrace, Lionel Mews, and Ledbury Mews. The streets in which three houses were invaded are Southam Street and Swinbrook Road. Four houses were invaded in Wornington Road, five in Faraday Road, and five in St. Ervan's Road, seven in Portobello Road, and thirteen in Wheatstone Road. In each of 62 houses there was one case only ; in each of 18 houses there were two cases; in three houses there were three cases in each ; and there were four, five and six cases respectively in other three houses. The second and subsequent cases in a house were usually the result of defective isolation of the primary case. The sufferers comprised 63 males and 59 females ; 58 of them were under five years of age, 54 between 5 and 12 years (the usual public elementary school age), 5 between 12 and 21, and 5 upwards of 21 years. Their position in life may be summarised as follows :—Sis were adults, viz., teacher, teacher's wife, messenger, porter, wife of a milk seller, and a female servant. One hundred and sixteen were children, viz., of artizans 38 (including painter 20, carpenter, joiner, etc., 9, plasterer 3), of labourers, etc., 20; of carman, cabman, horsekeeper,'busman 13, of persons employed on railways 9, of shop assistants, etc., 6, of agents 4, of teacher, of fireman, of sweep, and of messenger, 2 each, and other single cases (including 5 of persons whose occupation was unknown) 18. 32 I have already said that the disease appears to have extended from the adjoining parish of Paddington. I have to add that, whilst in Kensington it appeared to centre around a large Board School in the Wornington Road : altogether some 44 cases of children living in 29 houses in 12 streets were connected with this school, the period of invasion being the month of August in 11 cases, September in 7 cases, October in 15 cases, November in 10 cases, and December in one case. Eight eases were connected with the Portobello Road Board School ; 3 in October, 3 in November, and 2 in December. Four cases were connected with the Edinburgh Road Board School; 3 (in one house) in July, and one in October. Four cases were connected with the Buckingham Terrace Board School ; 3 in October, and one in November. Four cases were connected with the Latymer Road (Hammersmith) Board School ; three in September, and one in October. Five Church Schools had 10 cases—one in each of 4 schools, and six in another school, St. Andrew's. One of these six cases occurred in June, one in September, two in October, one in November, and one in December. In all, therefore, 74 of the 122 sufferers were school children, and 44 of them were pupils at Wornington Road Board School, and almost exclusively in the Infants' Department. It is to be noted, however, that several children belonging to this school had been attacked with diphtheria during the summer vacation— a fact which puzzled me until I discovered that the disease had been prevalent in the adjacent parish, from which it travelled westward into the streets—already named—clustering round the school buildings. The school authorities were assiduous in their efforts to prevent the spread of the disease by exclusion of suspicious cases, which were duly reported to me; but they laboured necessarily under a difficulty arising from the fact that diphtheria presents no external eruption to attract attention to it as something different from a common or non-specific sore throat. Slight cases, therefore, are liable to escape notice, and to the occurrence of 33 such unrecognized cases spread of the disease through the agency of schools may be reasonably attributed. By direction of the School Managers the Infants' Department of the school was at my request closed for a time for the purpose of disinfection and cleansing. In a few instances sanitary defects were found in the invaded houses, but these were few compared with the total number ; in some of the streets, moreover, offensive sewer manholes or gullies were observed. But for the most part the cases occurred singly in houses, and on the whole the information collected seemed to point to direct infection, especially through schools, as the more probable cause of the spread of the disease. HOSPITAL ACCOMMODATION FOR DIPHTHERIA. I stated, in my Report for 1887, that the Managers of the Metropolitan Asylums District had been willing, since 1886, to admit sufferers from diphtheria to their hospitals, but that the Local Government Board, acting upon a medical opinion that this disease does not fall within the category of "Fever," as that term is used in the Metropolitan Poor Act, 1867, deemed it desirable that if cases of diphtheria were to be admitted there should be express legislation for the purpose. The Board promised to give their consideration to the question whether such legislation slioidd be proposed. After waiting eighteen months the Managers again resolved, in March, to direct the attention of the Board to the subject. Nothing came of the reference, and so in my ninth Monthly Report (September 10th, page 86) I recommended " that the President of the Local Government Board be asked to bring in a Bill (in the Autumn session) to enable the Managers to admit cases of diphtheria, and that the several Vestries, &c., be informed of the application.'' The report was referred to the Works, Sanitary, and D 34 General Purposes Committee, and at the meeting of your Vestry held on the 3rd of October, it was resolved, upon the recommendation of the Committee:— " That application be made to the President of the Local Government Board to bring in a Bill, in the forthcoming Autumn Session, to enable the Asylums Board to admit to their hospitals persons suffering from Diphtheria ; that the Asylums Board be informed of the step taken, and that the Sanitary Authorities of the Metropolis be requested to support the Vestry's application." In conformity with the above resolution, a letter was addressed to the President (on the 4th October) as follows:— " Sib,—I am directed by the "Vestry of Kensington to invite your attention to the spread of diphtheria in certain portions of the Metropolis, due, in large measure, as they believe, to the want of adequate hospital accommodation for persons suffering from that disease and being in need of isolation. " The deficiency of accommodation appears mainly to arise from the inability of the Local Government Board, without express legislation, to issue an Order authorising the Managers of the Metropolitan Asylums Board to receive at their hospitals cases of diphtheria, under the provisions of the Metropolitan Poor Act of 1867. " The question whether such legislation should be proposed is understood to be receiving the consideration of the Local Government Board. " This being so, I am respectfully to refer to the anomalous fact that although the Managers cannot admit paupers suffering from diphtheria with an order of a Relieving Officer, they might, under the provisions of Section 15 of the Poor Law Act, 1879, admit non-paupers were they, with the approval of the Local Government Board, to contract with a local authority for the reception and maintenance in their hospitals of persons suffering from ' any dangerous infectious disorder—a term wide enough to include diphtheria. " The Vestry, taking note of the fact that Managers are willing to receive these cases, are of opinion that it would be well were the above-mentioned anomaly removed, being convinced that it would be for the public interest that persons suffering from diphtheria should be admitted into the Managers' Hospitals. " They therefore hope that the Local Government Board may be able to arrive at a decision that cases of diphtheria can properly be admitted to the 35 said hospitals, and that you may find it practicable to introduce in the Autumn Session of Parliament a measure enabling the Board to issue an Order authorising the Managers to receive such cases." A copy of the above letter was forwarded to the Asylums Board and to the several Vestries and District Boards of Works ; to the Medical Officers of Health acting 'within the Metropolis and to the Boards of Guardians—who are equally interested with the Sanitary Authorities in this matter— requesting their co-operation. In the letter addressed to the Asylums Board (October 5th), it was stated that your Vestry " Have noted with satisfaction the steps taken by the Managers in reference to this matter, and hope that their own action, which they intend to make known to the other Sanitary Authorities, may contribute to bring about a much needed alteration of the law." The letter to the Vestries, &c., was as follows :~ " Sib,—I am directed by the Kensington Vestry to forward, for the information of your Board, copy of a communication they have addressed to the President of the Local Government Board on the subject of Hospital Accommodation for persons suffering from diphtheria and being in need of isolation. " As you are probably aware, the Managers of the Asylums Board are willing to admit cases of this disease to their hospitals, subject to the approval of the Local Government Board. But the Board state that they cannot issue the necessary Order to authorise the reception of such cases ' without express legislation for the purpose.' The Vestry, it will be observed, invite the President of the Local Government Board to propose such legislation, and should your Board coincide in the views expressed in the Vestry's letter to the President, their co-operation would doubtless strengthen the hands of the President—there being no reason for supposing that the Local Government Board are adverse to the admission of cases of diphtheria into the hospitals under the control of the Managers." Many of the Vestries, etc., signified their concurrence with the views of your Vestry, and addressed communications to the Local Government Board in support thereof. d 2 36 The School Board for London, recognizing the question as one deeply affecting the interests committed to their charge, responded to my request for their support by addressing to the Local Government Board a communication endorsing your Vestry's application for the introduction of a Bill in the Autumn Session. The Society of Medical Officers of Health, moreover, at their meeting in October, unanimously passed resolutions on the subject, moved by myself, as follows:— "1. That in the opinion of this Society it is expedient that the Managers of the Metropolitan Asylums District should be empowered to admit into their Infectious Hospitals persons suffering from Diphtheria or any other ' dangerous infectious disorder within the meaning of the expression as used in the Sanitary Act, 1866, and in Section 15 of the Poor Law Act, 1879. " 2. That this Society, noting with satisfaction the expressed willingness of the Managers to admit cases of Diphtheria, and having regard to the spread of Diphtheria in certain portions of the Metropolis at the present time, request the Local Government Board to re-consider whether it may not be in their power to issue an Order forthwith, to enable the Managers to admit persons suffering from that disease. " 3. That in the event of the Local Government Board being still of opinion that they have no power to issue such an Order, this Society would respectfully request the President of the Board to bring in a Bill in the Autumn Session of Parliament, to confer power upon the Board to make an Order to enable the Managers to admit persons suffering from any ' dangerous infectious disorder.' " i. That a copy of the foregoing Resolutions be forwarded to the Local Government Board, to the Asylums Board, and to the several Vestries and District Boards of Works, and that the said Vestries, &c.,be invited, in the interests of public health, to support the action of the Asylums Board in this matter, and to endorse the request of the Society as set out in the preceding resolution." The Asylums Board directed the above resolutions to be entered on the minutes. 37 A letter was subsequently received from the Clerk to the Asylums Board acknowledging receipt of vonr Vestry's communication, and forwarding a copy of the Report of the General Purposes Committee, relating to the reception of cases of Diphtheria into the Managers' Hospitals. In the said report, which was submitted to and approved by the Managers at their meeting on the 6th October, after reference to a " Memorandum " on the subject by the Clerk, the Committee — " Having regard to the length of time which has elapsed since the decision of the Local Government Board was arrived at, recommend that a further communication be addressed to that Board, asking whether they are yetable to sanction the admission of Diphtheria into the Managers' Hospitals, and pointing out that Dr. Markham, in his Report of 1866, speaks of 'the necessity for the non-admission into Workhouses of patients suffering from contagious Fevers,' including in that phrase Diphtheria and Small-pox ; further, that the Royal Commission in their Report, 1882, page xxix., refer especially to Diphtheria as one of the diseases which require isolation, and also to the fact that in the classification of the Registrar-General, Diphtheria is assigned a position amongst the zymotic diseases after Scarlet Fever but before Enteric Fever. " In the meantime, enquiries are being made of the Medical Superintendents of the several Fever Hospitals as to whether, in their respective opinions, it would be practicable to make arrangements at the establishments under their control for the treatment of cases of Diphtheria, and, if so, to what extent and in what manner." At the meeting of the Board on the 6th October, the Chairman of the Committee, Mr. Augustus C. Scovell, stated that the reports he had received from the Medical Officers of the Hospitals satisfied him that there would be no difficulty in the way of the Managers making provision for cases of diphtheria, and that if the Local Government Board could see their way to reconsider their last decision, and alter it, there would be no delay in making the necessary arrangements for the removal of such cases to the Board's Hospitals, and placing them under treatment in isolation wards. Referring to an objection raised that the provision for diphtheria cases would reduce the accommodation for scarlet fever, he observed that the two diseases 38 were not likety to prevail in an epidemic form at the same time. Cases of diphtheria were admitted to the Workhouse Infirmaries, where they ought not to be treated, and it was justly remarked that the Managers could treat such cases better and in a more effective way, for the protection of the public, than they could be treated in Infirmary Wards. The Managers adopted a resolution to again bring the matter before the Local Government Board, and to ask for a decision. A communication was received in due course from the President of the Local Government Board, in answer to your Vestry's letter, dated October 4th (page 34 ante), to the effect that "the matter was engaging the attention of the Board," and a further communication was subssquently received, from which it appeared that the difficulty which had existed, owing to the inability of the Board to issue an Order, might be practically overcome. The letter was as follows:— " Local Government Board, Whitehall, S.W., 20th October, 1888. " Sir,—I am directed by the Local Government Board to advert to your letter of the 4th instant, and to transmit to you for the information of the Vestry of the Parish of St. Mary Abbotts, Kensington, the accompanying copy of a letter which the Board have addressed to the Managers of the Metropolitan Asylums District upon the subject of the admission into their Hospital.3 of persons suffering from Diphtheria. I am, &c., (Signed) EDMUND J. WODEHOUSE, Assistant Secretary [Copy.] " 17th October, 1888. " Sib,—I am directed by the Local Government Board to advert to your letters of the 24th ult., and 8th inst., with reference to the admission into the Hospitals of the Managers of the Metropolitan Asylums District of persons suffering from Diphtheria. The Board direct me to state that they have been advised that, for the purpose now under consideration, persons suffering from this disease cannot be regarded as patients suffering from fever. The 39 point, however, is not altogether free from doubt, and it is the intention of the Board to introduce into Parliament a Bill which shall make it clear that the Managers can deal with cases of Diphtheria. In the meantime, if the Managers determine to admit such cases into any Hospital under their control, the Board, with the view of removing any difficulty with the Auditor, would be prepared, on application from the Managers, to sanction any expenditure incurred in the treatment of such cases which, in the opinion of the Auditor, was not open to question otherwise than on the ground above referred to. I am, &c., (Signei) S. B. TBOVIS, Assistant Secretary. W. F. Jebb, Esq." The Asylums Board lost no time in giving effect to the o o implied consent of the Local Government Board to the admittance of cases of diphtheria. The General Purposes Committee reported, on the 23rd October, that they had that day instructed the Committees for the Eastern, the Western, the NorthWestern, and the South-Eastern Hospitals to "forthwith take the necessary steps for the reception and treatment of 50 cases (or thereabouts) of Diphtheria, in the first instance, into each of those Hospitals and had at the same time " instructed the Ambulance Committee to make the necessary arrangements for the distribution and removal to the Managers' Hospitals of cases of Diphtheria arising in the several Parishes and Unions comprised in the Metropolitan District." On the 30th October, moreover, the Clerk to the Managers was instructed to address a circular letter to the several Boards of Guardians, forwarding a copy of the Local Government Board's letter, and " intimating that under the circumstances the Managers are now prepared to take into their Hospitals patients duly certified to be suffering from Diphtheria." A cony of this circular letter and enclosure was also forwarded to the several Sanitary Authorities in the Metropolis. It may be here mentioned that the cases of diphtheria are treated in wards set apart for the purpose, and that up to the 40 close of the year 90 cases had been admitted, of which number Kensington contributed one-fifth. Thus another step has been gained in the effort to make the Hospitals available for the treatment of Infectious Diseases occurring in all classes of the community in need of isolation ; and your Yestry having, as usual, taken a leading part in the movement now brought to a successful conclusion, it appeared to me just and proper that the history of the movement should be placed on record. All that the Managers could do to make publicly known this new and important departure having been done, I lost no time in addressing a communication to the medical men practising in this parish intimating that the Managers "now admit cases of Diphtheria." I also invited the co-operation of Head Teachers of all Public Elementary Schools, to each of whom a copy of the subjoined circular letter was forwarded :— INFECTIOUS DISEASE. " Diphtheria is prevalent in some portions of the Parish, and there is reason for believing' that the disease has been spread—it certainly may be spread—through the instrumenta'ity of Public Elementary Schools. " A rule of the School Board for London forbids children to attend school from a house where any dangerous infectious disease exists, even although there be no case of the disease in the family of which the children are members. The same rule probably is in force in regard to all other Public Elementary Schools. " The School Board, moreover, have instructed the Visitors and the Head Teachers to report to the several Medical Officers of Health any cases of infectious disease in children that may come to their knowledge in the discharge of their official duties : it is desirable that Head Teachers in all Public Elementary Schools should report such cases. Forms have been provided by the Yestry for this purpose. " Attention is desired to the Note (2) at the foot of the Form, and it is particularly requested that the absence from school of children, due to .illness, may be reported only when there is reasonable ground for suspicion that the illness is of an infectious character. 41 " It is perhaps hardly necessary to add that children should not be allowed to return to school after infectious illness, until their infected clothing and the sick rooms with their contents have been thoroughly disinfected." The Form referred to was as follows :— VESTRY OF THE PARISH OF ST. MARY ABBOTTS, KENSINGTON. Confidential. INFECTIOUS DISEASE " (Small-pox, Scarlet Fever, Diphtheria, Typhus, Typhoid Fever, &c.) 18 " I have reason to believe that there case of at No. Name of Head of Family [or of Sick Person] Remarks Signature Department. School. " N.B.—1. That no child should be allowed to attend School from any house in which Infectious Disease exists. 2. That the Medical Officer of Health will be glad to receive, for the purpose of enquiry, the name and address of any child whose absence from School is suspected to be due to Infectious Disease." Reports of suspected cases soon began to arrive from Head Teachers, and from School Board Visitors also, who employed forms supplied to them a long time previously ; for, after all, what was done in 1888 was but a repetition cf what had been done in 1877, when the School Board complied with my suggestion by issuing instructions, first to the Visitors, and subsequently to the Head Teachers, to report cases of infectious disease to the several Medical Officers of Health in the Metropolis. WHOOPING-uOUGH. Whooping-cough, the cause of 86 deaths in 1887, proved fatal in 1888 to 100 children under five years of age, 46 of them 42 under one year. The corrected decennial average is 103. Eighty of the deaths were in the Town sub-district, and 89 were registered during the first half of the year. Reference has already been made to the indifference of parents in regard to the spread of measles in their families. The observation is even more generally applicable in regard to whoopingcough, the danger of this always distressing malady being unappreciated by the poor, who, in the engrossing struggle of life, pay scant, attention to an ailment which they deem at once inevitable and seldom dangerous. Often enough, when the disease ends fatally, the event comes as a surprise, being due commonly to some secondary disease—of the respiratory organs, or of the nervous system: few deaths are registered from whooping-cough alone. These secondary diseases cannot always be prevented; but the occurrence of bronchitis or pneumonia, for instance, is often owing to want of care in the management of the sufferers. The little ones it may be are not confined to the house; 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 patient is but too frequently beyond the reach of help. The deaths in London from whooping cough (2,987) were 327 fewer than the decennial average; but the disease was unusally prevalent during the first quarter of the year; it then, after some irregular fluctuations, fell below the average, and remained so throughout the rest of the year, so that the effects of the severe outbreak in the first quarter were more than counterbalanced in the remaining nine months. FEVER. No death was registered from Typhus Fever, and only two from Simple Continued Fever. The deaths from Enteric Fever were 21, the same as the corrected decennial average. Seventeen of the deaths were registered in the Town sub-district, and four in Brompton. Eight of the deaths took place in hospitals, to 43 which fifteen patients were removed. The recorded cases were 40; 24 in North Kensington and 16 in South Kensington, the Uxbridge Road being the dividing line. There were only 10 deaths in London from Typhus, and 33 from the ill-defined forms of Continued Fever, the numbers being fewer than in any previous year, but the deaths from Enteric Fever were 677, and more numerous than in any of the three preceding years. They were nevertheless far below the decennial average. DIARRœA. Diarrhoea was the cause of 58 deaths, 45 in the Town sub-district, and 13 in Brompton, being 52 below the corrected decennial average. Fifty-two of the deaths were of children under five, including 47 under one year. Of the total number, 38 were registered in sixteen weeks, June 17th to October 6th inclusive. The deaths from diarrhœal diseases in London generally (2,176) were 1,249 below the corrected decennial average. This low mortality was due to the unusually cold and wet weather that prevailed during July and August, the mean temperature in these two months having been 2'8 Faht. below the average of 117 years. The Registrar-General observes that " the effect of a hot or cold summer upon the diarrhoea mortality is well shewn by comparing the years 1887-1888, for neither the number nor the sanitary condition of the population can have differed materially in these two consecutive years, which stood, however, widely apart in the matter of temperature. In 1887 the mean temperature of the third quarter was 61° 0 Faht., and the deaths in that quarter from diarrhoea were 3,200, while in 1888 the mean temperature was 57.6, and the diarrhœal deaths only 1,439." METROPOLITAN ASYLUMS BOARD. The work and proceedings of the Asylums Board, important at all times to those concerned in sanitary administration within the metropolis, have acquired additional interest in 44 recent years, owing to the steps taken by the Managers to make the Hospitals more than ever a refuge for the infectious sick in need of isolation. Accommodation has been, or shortly will be, provided adequate to the needs of the population; and, during the last two years, beds have been placed at the disposal of registered practitioners, as well as sanitary officials and the resident medical officers of General Hospitals, whose applications for the admission of patients, when made in compliance with the reasonable requirements of the Board's regulations, are now invariably attended to without question or delay. The Board indeed have become in practice the Central Hospital Authority for London in regard to infectious diseases, and they discharge right well the duties of the position. THE CHAIRMAN'S ANNUAL REPORT. The Chairman of the Board, Sir E. H. Galsworthy, in his Report for the year ended March 25th, 1889, refers with satisfaction to the comparative freedom from Scarlet Fever in the Metropolis during that period, and to the marked diminution in the average and aggregate number of patients for whom the Managers had to provide accommodation. In 1887, 5,900 Scarlet Fever patients were admitted; in 1888, 4,408. In the former year the maximum number under treatment at one and the same time was 2,611; in 1888, 954. This diminution in the number of patients enabled the Managers to discontinue the use of the Plaistow Hospital, to temporarily close the Southwestern Hospital at Stockwell, and the Northern Hospital for convalescing patients, at Winchmore Hill, and to make a reduction in the staff of officers at each and all of the infectious hospitals. Reference is made to the ill-effects consequent on the reduction in the staff of officers, on grounds of economy, it being difficult to replace the discharged officers. It is justly observed that such discharging of the staff is not conducive to the good working of the Institutions, inasmuch as it causes dissatisfaction to officers cast adrift after having borne the heat 45 and burden of an epidemic, and makes the service unpopular. A further ill-effect is that, when an emergency arises, it takes time to get together an efficient set of officers, and persons with inferior qualifications have to be relied on at the beginning of an epidemic. The Managers desire if practicable, on the closing of any hospital, to find work for the most valuable members of the staff at other hospitals, so as to form a nucleus of skilled nurses, especially for service at the opening of a hospital on the occurrence of an epidemic. They have decided to complete the Northern Hospital, which, by receiving convalescing patients, enables a larger number of patients in the acute stage of fever to be treated at the Town Hospitals. They have found the Western Hospital inadequate for the Parishes and Unions allocated to it, and desire to obtain the means of enlarging it by the acquisition of four additional acres of land adjacent to the existing site. (The London and North-Western Railway Company are seeking to acquire this land, and the Managers have petitioned against the Bill promoted by the Company, who contest the locus standi of the Board.) The Local Government Board having implied an authority to the Managers to admit cases of Diphtheria to their hospitals, the first patient was received October 23rd. (In all 138 beds have been allocated to this disease, 50 at the Eastern Hospital, 46 at the North-Western, 20 at the Western, and 22 at the SouthEastern.) The President of the Local Government Board proposes to introduce a Bill to enable the Managers lawfully to deal with cases of this disease; meanwhile the Board sanction the expenditure incurred. Application was made to the Managers to admit cases of Measles in the autumn, when the disease was very prevalent and fatal, the deaths during the months of November, December, and January averaging no less than 133 weekly. Measles being "a dangerous infectious disease of a febrile character,” the Chairman considers it reasonable to suppose that it might to a considerable extent be mitigated by the prompt and proper isolation of cases which cannot be isolated in their own homes. The Managers, 46 ever, felt that they had no legal power to admit cases of Measles upon the application of Poor Law Authorities. The Chairman nevertheless holds that the question of the isolation of Measles is one which can hardly be indefinitely delayed, as the disease has increased in extent and virulence during the past few years. He considers, moreover, that equal precautions should be adopted whether deaths are occasioned by Small-pox, Fever, Diphtheria, or Measles, it being the paramount duty of a Sanitary Authority to prevent death from preventible causes. (It is probable, however, for reasons that I have elsewhere set out, that admission to the hospitals of sufferers from Measles would not have the same effect in controlling an epidemic as in the case of an epidemic of Scarlet Fever or Small-pox.) Only 62 cases of Small-pox were admitted during the year, two at the Eastern Hospital, and the rest on board the Hospital Ships at Long Reach. These eases, and indeed all cases of infectious disease received by the Managers, were notified without loss of time to the Medical Officers of Health of the districts whence the patients came. In June the Managers accepted a tender for the construction of a permanent hospital for convalescing Small-pox patients at Darenth, which will accommodate 600 patients, in addition to 200 patients for whom infirmary accommodation has been made by the removal and consolidation, at the site of Camp No. 2, of the wooden buildings which constituted the Camps 1 and 2 during the last epidemic. Provisiou is to be made for a few Small-pox patients at the Western Hospital. The legal position of the Managers in regard to the admission into the hospitals of patients is described as " anomalous and unsatisfactory." The Local Government Board sanctions the expenditure incurred in the treatment of non-pauper patients, admitted on the certificates of Sanitary Officers and private Medical Practitioners, without the intervention of the Relieving Officer, but the President of the Local Government Board has not been able to carry out his intention to propose legislation for the purpose of removing any doubt as to the legality of expenditure of this character. 47 The Managers have accommodation (including temporary additions to three of the hospitals) for 2,308 fever patients, and for 350 small-pox patients on board the hospital ships. Sixtyfour additional beds for fever patients at the Northern Hospital, and 800 for small pox patients at Darenth, will shortly raise the accommodation for infectious cases to the magnificent total of 3,522 beds. Ambulance Arrangements.—No reference is made by the Chairman to the correspondence with the Local Government Board on the subject of the Managers' willingness to become the Ambulance Authority for the removal of all cases of infectious disease in the Metropolis. The delays of the Board are difficult to understand. It is satisfactory, however, that in the long run they usually concur in the forward movements, to which, not seldom—as in this case—it has been my privilege to point the way.* I note with pleasure the absence from the Report of strictures on the alleged shortcomings of the Vestries and District Boards with respect to provision of Hospitals, &c., for the infectious sick. Practically there is now a consensus of opinion that the duty of providing Hospitals, Ambulances, &c., can be more efficiently and more economically performed by one Central Sanitary Authority than by numerous Local Sanitary Authorities. THE STATISTICAL COMMITTEE'S ANNUAL REPORT. It may be stated that the Reports of the Medical Superintendents of the several hospitals, etc., are now published together under the direction of the Statistical Committee, whose own *Reference to the work of the Ambulance Department will be found on page 52—in an abstract of the Annual Report of the Ambulance Committee. 48 report is one of much interest and considerable utility. It embraces a map of London showing most of the thoroughfares and the outlines of the several Metropolitan Poor Law Districts, and it is intended that in future years the maps shall be "spotted" to represent the cases of infectious disease removed to the Managers' Hospitals. These maps, the Committee rightly believe, will be of "great practical value to the Managers and the public." A complete set of maps for 1889 will be "spotted," from day to day, at the Ambulance Stations, to represent the cases of Scarlet, Enteric, and Typhus Fevers, Diphtheria, and Small-Pox. The Report contains "returns showing the admissions and deaths of patients at the Hospitals, with mortality percentages during each year since the establishment of the first Hospital in 1870, together with extracts from the RegistrarGeneral's Returns showing the annual mortality per 1,000 persons living of the population of the Metropolis, from Scarlet, Typhus, and Enteric Fevers, and Small-Pox, and the average annual mortality per 1,000 of such population, from those diseases, for certain specified years before and since the establishment of the Managers' Hospitals. A Fever Chart, showing the monthly admissions of fever patients from 1870 to 1888 inclusive, has also been prepared. Tables have also been prepared showing the mortality at various ages of some 34,000 cases of 'fever' that have been treated in the Managers' Hospitals." The Annual Report of the Ambulance Committee is included in this volume, thereby increasing its utility and convenience, for, as it is pointed out, it will be "easier to refer to the particulars of work done in any or all of the various departments than was possible when the Reports of each establishment were published separately." The total admissions of "fever" cases in 1888 were 5,152, of which 4,408,or 88 per cent. were scarlet fever cases. The mortality of all fever cases, and of scarlet fever cases, was in round numbers 10 per cent. The mortality of enteric fever cases was 14.6 per cent., and that of diphtheria cases about 46 per cent. 49 It is stated that the monthly admissions of scarlet fever cases were highest in the month of January, being 589. This was "unusual, and was probably owing to the influence and continuance of the epidemic of 1887. To that cause may also be attributed the comparatively slight autumnal increase of the disease." The regularity of the rise and fall of scarlet fever is clearly defined in a chart, from which it appears that during the 17 years (1872-88) the admissions fell to the minimum four times in February, four times in March, five times in April, twice in June, once in September and (in 1888) in December, while the maximum number was attained once in January (1888), once in July, three times in September, seven times in October, three times in November, and twice in December. In October, 1887, an unprecedented rise to 1,272 admissions occurred ; the next highest total (420) was in September, 1888 ; the next (300) in October, 1886. It must not be forgotten that the Hospitals have been growing in public favour of late years, and that some portion of the increase in the number of admissions is due to that fact. Still, after all is said, the epidemic of 1887-8 was remarkable, and not less for the smallness of the mortality than for the rise in the number of cases, which, commencing in July, culminated in October, thence declining until May and June, 1888. In considering the statistics in the Committee's Report showing the admissions to hospitals from the several parishes and unions, it must be remembered that the number of cases sent to hospitals from different districts should not be regarded as an absolute standard of the relative prevalence of disease in them; owing, among other reasons, as the Statistical Committee rightly say, "to the great difference in the number of population," and "also to the different practices adopted with regard to the proportion of patients making use of the Managers' Hospitals or being treated elsewhere." In Kensing- E 50 ton, for instance, no effort is spared to induce poor persons to avail themselves of the advantages afforded by the hospitals, and a large percentage of the known cases is removed, hence the high totals in for Kensington the several columns of the Table referred to. "The death-rates on the admissions of all cases" vary much in respect of the parishes and unions sending patients to the hospitals, the highest rates occurring in parishes, &g., where the conditions of life generally are the most unfavourable. The Committee draw attention to the fact that the condition of patients in regard to their general health, and to the stage reached by the disease before transfer to hospital, varies sensibly in different parishes. The Medical Superintendent of the "Western Hospital, we are told, reports an excessive prevalence of albuminuria amongst the scarlet fever cases, which he attributes to the concentration of acute cases during the time of the drafting of convalescents to Winchmore Hill (Northern Hospital). This view will doubtless be subjected to the test of further observation in the future. The effects of aggregating a number of diphtheria cases on one site is engaging the attention of the several Medical Superintendents of the hospitals. There were not any cases of diphtheria admitted from eleven out of the thirty poor-law districts. The highest numbers were contributed by Kensington (17) and Lambeth (14) It is said of relapsing or famine fever, which was extremely prevalent in the Metropolis during 1869-70, that very few cases have been admitted for many years past, and this, "taken in conjunction with the decline of typhus fever, is clearly indicative of the improved condition of the Metropolitan poor, particularly as regards overcrowded dwellings," whilst ''to the progress made in drainage and domestic sanitation may, in a great measure, be attributed the steady and continuous decline in the mortality from enteric fever." 51 AMBULANCE SERVICE. The recommendation of the Royal Commission, that the Asylums Board should have "entire control of the ambulances, by which all other modes of conveyance should be as far as possible superseded," has been carried out by the establishment of Ambulance Stations at three of the Managers' Hospitals (Eastern at Homerton, South-Eastern at Deptford, and Western at Fulham), under the provisions of Section 16, Poor Law Act, 1879. Small-pox patients are taken down the river in Ambulance' Steamers, specially built or fitted for the purpose, embarking at Wharves which the Managers were authorized to provide by Section 6 of the Diseases Prevention (Metropolis) Act, 1883. Kensington patients are removed by the ambulance staff at the Western Station, Seagrave Road, Fulham. Between 8 a.m., and 8 p.m., on week-days, cases for removal are reported at the Managers' Central Offices, Norfolk Street, Strand, these being in telephonic communication with the Station. During the night, and on Sunday, application for a patient's removal is forwarded direct to the Ambulance Station. WHARVES. The Managers have acquired or constructed three Wharves for the embarkation of patients, etc., named respectively, North, South, and West. The North Wharf is at Blackwall, the South Wharf at Rotherhithe. The West Wharf, at Fulham, near Wandsworth Bridge, at which, in the event of an epidemic of small-pox, Kensington patients will embark for the voyage to the hospital ships at Long Reach, and the hospital at Darenth, but which is also intended for the accommodation of the Western District generally, has long since been completed. But hitherto it has not been thought desirable to bring it into use. Owing to the great distance between the Western Hospital and the districts allocated to it, 52 and the South Wharf, at Rotherhithe, to which the patients are at present sent for embarkation, the number of miles travelled by the ambulances is excessive. RIVER AMBULANCE SERVICE. The Managers possess in their three Ambulance steamers, Red Cross, Maltese Cross, and Albert Victor, together with the steam pinnace Swallow and the steam launch Marguerite, a fleet equal to all probable demands. The demands, however, as indicated by the number of admissions to the hospitals, are very unequal at different periods of the year, and in different years. REPORT OF THE AMBULANCE COMMITTEE. Arrangements in connexion with the transit of the sick, between home and hospital, and back again, are under the control of a Committee of the Asylums Board, whose Annual Report states that in 1888, 5,114 Fever and Small-pox patients were removed from their homes to the Board's Hospitals, as compared with 6,456 in 1887. The average daily removals in the first six months of the year were 15.4, and in the latter six months 12.8, as compared with 6.7 and 29.1, respectively, in 1887. The average length of journey of the Fever patients removed did not exceed 3½ miles. During the year, 107 persons certified to be suffering from Small-pox were removed, 43 of whom were found not to have the disease, and were accordingly taken back direct to their homes; the remaining cases (64), in which the diagnosis was confirmed by a Medical Superintendent in London, were conveyed to the Hospital Ships at Long Reach. The Local Government Board approved of the reception of Diphtheria cases on the 20th October. The first removals took place on the 23rd October, and from that date to the end of the year 96 sufferers from the disease were removed to the Board's Hospitals. The transport of patients, by land and 53 water, was accomplished without any accident, involving personal injury. On the first day of January there were 2,214 patients in the Managers' Hospitals, seven in number. The Plaistow Hospital and the South-Western Hospital were successively closed, the latter on the 24th February. The highest number of patients, 1,045, was recorded on the 5th November: the numbers thenceforth steadily declining, the Committee ceased to send patients to the North-Western Hospital on the 3rd December. The Committee state that delay in removal of patients is caused by the supposition that the order of a Relieving Officer is indispensable, and they regret that the pressure of Parliamentary business has prevented the Local Government Board from procuring legislation on this subject. Their practice is to comply with applications made by any person, but the rule that the patient shall not be removed unless either a medical certificate, or a Relieving Officer's order, is handed to the Ambulance Nurse, is strictly enforced. It may be mentioned that since the establishment of the Land Ambulance Service in 1881, no fewer than 35,183 Fever and Small-pox patients have been removed from their homes to the various Hospitals, and 12,775 recovered patients have been removed from the Hospitals to their homes. From 1884 to the end of 1888, 4,859 Small-pox patients were transferred from the London Hospitals to the Wharves on the Thames en route for the Hospital Ships at Long Reach; and since the opening of the Northern Hospital, in September, 1887, 4,248 convalescing Fever patients have been removed thereto from the London Hospitals, and 3,798 recovered patients have been brought back to London. In all 60,863 removals have been effected since the establishment of this Service. The River Ambulance Service was not established until the outbreak of the last Small-pox epidemic in February, 1884. From that date until the end of 1888 the Ambulance Steamers have carried 1.1,306 acutely sick Small-pox patients to the Hospital Ships, and have brought back 10,329 recovered patients. The total removals effected by the Land and River Ambulances number 54 82,449, without including the conveyance of visitors to patients, staff, etc. These removals have been carried out in all weathers and throughout all seasons of the year, and to a great extent during the hours of darkness, without detriment to the patients and without accident or mishap to any person. A truly magnificent record! METROPOLITAN AMBULANCE SERVICE: A DESIDERATUM. The Poor Law Act, 1879, sec. 16, conferred on the Asylums Board one of its most valuable powers, that ot' providing Ambulances for the conveyance of the infectious sick to the Hospitals of the Managers. Previously, the Boards of Guardians had removed the sick in carriages few of which were wholly satisfactory, and under conditions occasionally prejudicial to the public health. The work of removal—whether by land or water—is now effected in an unexceptionable manner. This remark, however, applies only in the case of patients in course of transit to or from the Managers' Hospitals. It is often quite otherwise in respect of private patients. The law does not forbid the use of public vehicles (cabs) for the removal of infectious persons, provided that the vehicles are afterwards disinfected. But the driver of a cab may be unaware of his fare's illness: the efficacy of any practicable disinfection, moreover, may be reasonably doubted. Consideration of these and other objections to the existing law, led me to the conclusion that cabs, etc., should never be used for this purpose, and that it would be to the public advantage to make the Asylums Board the Ambulance Authority for removal of the infectious sick of all classes. In 1884, therefore, I addressed a communication to the Managers, proposing that they should place their ambulances at the service of the medical profession and Medical Officers of Health, with or without payment, for the conveyance of infectious sick persons. The Managers replied that they were, at that time, 55 "not in a position to undertake the removal of any cases of infectious disease beyond those which are to be received into hospitals under their own control." Commenting on this reply in my Annual Report for 1884, I ventured to express a conviction that the Managers would, in course of time, recognize the desirableness of giving effect to my views. That time has arrived, the Managers having, in 1888, stated their opinion "that the conveyance of infectious cases by public vehicles should be prohibited by law," and expressed willingness to "use the machinery they possess for the prompt and economical removal of infectious cases." They doubted their " power to use their Ambulances for other cases than those contemplated by the Poor Law Act of 1879," but were ready "to co-operate with the Commissioner of Police with the view of obtaining for the Board the power to undertake the general removal of infectious cases in the metropolis." The Police Authorities had communicated with the Board (as well as with the Sanitary Authorities) with a view to the disinfection of cabs that had been used for the conveyance of infectious cases. The views of the Managers were communicated to the Local Government Board, and it cannot be doubted that ere long the Managers will be the Ambulance Authority, as well as the Infectious Hospital Authority, for all London. SMALL-POX HOSPITAL ACCOMMODATION. The Royal Commission (of 1882), in one of their "practical recommendations," proposed that provision should be made of sites and buildings which could without difficulty be made capable of receiving 2,100, or by special exertion, 2,700, small-pox patients. The actual accommodation falls very far below the smaller of these totals, consisting as it does of some 350 beds at the Hospital Ships, and 60 beds, in all, at the three London Hospitals, to which Ambulance Stations are attached (beds for exceptional patients, and which the Asylums Board will not E 2 56 suffer to be occupied except in case of urgent necessity), and 800 beds at Darenth. Total, say, 1,200 beds. But it must be borne in mind that the Managers' Estate at Darenth, comprising 135 acres, is always available upon emergency for the erection of huts, tents, &c., equal to any probable demand for accommodation. It may be hoped, moreover, that as the Managers will remove every small-pox patient out of London, when removal can be effected with safety—and, happily, this is usually the case—hospital accommodation in the future will not be required to the amount provided during recent epidemics. The Hospital Ships.—A proposal to close the Hospital Ships was sometime since pressed upon the Asylums Board, upon the ground that money would be saved if the sporadic cases of small-pox which occur between epidemic periods were treated in the London Hospitals, instead of being taken down the river. The money saving would not be considerable in any case, and certainly not so large as believed, for it would be necessary to make provision at three of the hospitals, (viz.:—the Eastern, the South-Eastern, and the Western), for the reception of occasional cases, and it is not probable that the expense of maintaining the necessary staff, for the male and female wards, in these hospitals, would fall far short of the cost of maintaining the ships in a state of constant readiness, now that the expenditure of the Managers appears to be governed by strict economy. It has to be remembered, moreover, that on every occasion when small-pox has been treated in the town hospitals, the disease has spread around those hospitals, with the effect that for many years, until patients were taken direct to the ships, small-pox was rarely, if ever, absent from the Metropolis. The existence of the disease entailed heavy expenditure in maintenance of the Hospitals in London, and of the Ships at Long Reach, as well as of the Camps at Darenth, to say nothing of the money value of an annual average number of precious lives, upwards of 1,000, sacrificed to the loathsome disease. Since it has been the rule to take the sick out of 57 London altogether, a plan which I proposed in 1881, the epidemic, which was chronic before, has practically ceased. If this result is due to the fact of removal, which has been made possible by the existence of the Ships, no better investment of public money was ever made. The Managers by a large majority rejected the proposal to close the Ships, and they have kept steadily to their resolution to remove every case to the Ships, when removal is not likely to prove prejudicial to the patient's prospect of recovery. Extravagant outlay, properly so described, is to be condemned, but it is true economy to be prepared for every emergency, and, in my opinion, the Local Government Board did wisely in making the suggestion a few years ago that the Managers should endeavour to obtain a further site to the west or south-west of the Metropolis, which should be available for an additional hospital for convalescent patients—having in view the possible exigencies of an epidemic, and taking into account the requirements of London as a whole. FEVER HOSPITAL ACCOMMODATION. The Royal Commission recommended provision of sites and buildings capable of accommodating 3,000 fever patients. "Of the 3,000 cases, those in the earlier stages, probably about half, should be provided for in the near neighbourhood of London; the other half—the convalescents—in two other country hospitals." The recommendation of the Committee that the Town Hospitals should "become in the main Fever Hospitals," has been carried into effect. These hospitals, the Commission thought, would, "with the aid of another hospital, which appears to be indispensable for the East of London, fully accommodate all the cases requiring London treatment." With a view to give effect to the recommendation of the Commission, the Managers originally intended to provide another hospital for East London. This intention was subsequently abandoned, 58 a site being obtained at Winchmore Hill, nine miles north-east from Charing Cross, on which the "Northern Hospital" for a large number of convalescent patients has been erected. The total provision for "Fever" is now 2,308 beds, a number that falls considerably short of the recommendation of the Commission; many of the beds, moreover, being in "temporary" additions to three of the hospitals. On the other hand," as we were told by the Asylums Board in May, 1887, "the number of fever patients annually under treatment at any one time during 1886, though in advance of those of the eight previous years," did not exceed 742, so that, as it was further stated, "up to the present time the recommendation that the Managers should provide for 3,000 fever patients has not been justified by subsequent experience." The recommendation of the Commission, however, was justified by the experience of 1887, when the requirements of the epidemic of scarlet fever obliged the Managers to re-open the hospitals that had been closed, exhausted the accommodation at all of the Town hospitals, compelled them to hire the Plaistow Hospital at West Ham, and to open the new Northern Convalescent Hospital at Winchmore Hill: it also necessitated the erection of temporary huts at the Eastern, the SouthEastern, and the South-Western Hospitals, and at the Northern Hospital, where at one time upwards of 700 patients were accommodated. In all some 2,700 beds were provided by the Managers, the maximum number of patients at one time being 2,611. What happened in 1887 may happen again, for the very satisfactory reason that the Managers' Hospitals have attained a popularity certain to lead to increased use of them in the future by people in need of isolation; the fact being that the strain in 1887 was due in no slight degree to the greater proportion of the sick removed to hospital as compared with previous years. Evidence of this fact is furnished, as regards our own parish, by the figures set out in the Table at page 25. 59 The experience of 1887 accentuates the necessity for additional accommodation as recommended by the Commission, and the matter should be taken in hand while the temporary huts remain. The outlay incurred in erecting these huts was almost sufficient to defray the cost of a brick hospital. WESTERN (FULHAM) HOSPITAL. In February, 1888, the General Purposes Committee of the Asylums Board were instructed to consider and report to the Managers as to how far it may be practicable to increase the accommodation for fever patients at the several Hospitals, and at the meeting of the Managers on the 21st April, the Committee submitted a Memorandum, received from the Western Hospital Committee respecting the necessity of providing further accommodation for fever patients at that Hospital— a course which would involve the acquisition of additional laud, as no more accommodation can be provided on the existing site. The Hospital contains at present only 252 beds, and the experience gained during the prevalence of scarlatina in 1887 shows that it is not large enough to receive all the cases arising in the districts allotted to it, inasmuch as, after the Hospital was filled, cases to the number of 355 that should have been admitted, had to be taken to other Hospitals—a course which necessarily occasioned great loss of time and waste of labour, as well as an increased expense to the Ambulance Department. The administration of the Hospital is very expensive pro rata with the number of patients: the present staff, with a few additional nurses and other subordinate officers, would be sufficient for a Hospital twice the size. Therefore, and taking into account the large and increasing population of the district, as well as the increasing use made of the hospitals, the Committee considered it advisable to add considerably to the existing accommodation, and they submitted that beds should be provided for at least 400 fever cases, irrespective of those to be allotted to small-pox. The 60 General Purposes Committee recommended that the Memorandum he forwarded to the Local Government Board, "with the view to the attention of the President being especially directed thereto in connection with a recent resolution of the Managers regarding the compulsory acquisition of additional land adjacent to the existing sites of the Infectious Hospitals of the Board." The report of the Committee was adopted by the Managers. The Local Government Board (in May) expressed an opinion that if compulsory power of purchase was given it should only be to enable the Managers to obtain a Provisional Order, such Order requiring confirmation of Parliament. The Managers thereupon expressed their desire to obtain an Order for the compulsory purchase of four acres of additional land, adjoining the Hospital at Fulham, which it was considered would be amply sufficient to accommodate 150 additional beds, at the rate of 50 beds to the acre, leaving the fourth acre, with the exception of a small portion reserved as an addition to the adjoining Ambulance Station, as neutral ground between the (proposed) new buildings and the boundary wall, on which, in times of exceptional pressure, temporary structures might be erected. In November the Board informed the Managers that there was no authority under which an Order could be issued authorising them to acquire land compulsorily; so, of course, nothing could be done. Considerable opposition was offered to the proposal to enlarge the hospital, and meanwhile the London and North-Western Railway made arrangements for securing the land for their own purposes. The Managers thereupon petitioned against the Company's Bill, and the Company objected to the locus standi of the Board. Thus the matter rests at the present time.* * The Court of Referees decided against the Managers on the question of their locus standi for petitioning against the Bill; the Managers thereupon took the necessary steps to present a petition against the Bill in the House of Lords, and to instruct Counsel to support their locus standi. 61 The Committee for the Western Hospital proposed to make provision for a few small-pox patients, too ill to be removed to the Hospital Ships. Their intention was to build two wards on a plan proposed by Dr. Burdon Sanderson, one of the Royal Commissioners on Infectious Hospitals, so that the infected air might be purified by passing it through fire. The Managers declined to proceed upon these lines, but the Committee were subsequently empowered to obtain a plan and estimate for adapting an incomplete Ward for the isolation of a few patients. REGULATIONS FOR THE REMOVAL OF SMALL POX AND FEVER PATIENTS. New Regulations were framed in June, 1887, by the Asylums Board, with the obvious intention of giving effect to their resolution to facilitate the admittance to their hospitals of patients suffering from infectious disease, without unnecessary formalities. Regulations 2 and 3 read as follows:— "2. Every application (i.e., for admission) must state the name, age and full address of the patient, from what disease suffering, and in case of fever the particular kind of fever, and also the name of the person making the application, and the Parish he represents. "Applications which do not give these particulars will be referred back to the applicant for the required information to be furnished. "3. The Medical Certificate or Order (i.e., of a Relieving Officer or Master of a Workhouse) for the admission of the patient must be handed to the nurse in charge of the Ambulance. Should neither of these documents be handed to the nurse, the patient will not be removed," 62 Regulation 3 was necessary for the security of the Board and its officers; Regulation 2 provides, so far as public officials —Medical Officers of Health, Sanitary Inspectors, etc.—are concerned, all the facilities that could be desired, and under this regulation we are now enabled to remove patients withouttroubling the Relieving Officer for his order, or the District Medical Officer for his certificate. The Metropolis is indebted, in no slight degree, to your Vestry's action for the introduction of the new system of admission adopted by the Board—a system which places London at the head of all great cities in regard to facilities for isolating infectious persons in hospitals; the hospitals themselves, and the ambulance service by which the patients are transported, being second to none, whether regard be had to the accommodation provided or to the speed and comfort with which the sick are removed. MODE OF ADMISSION TO INFECTIOUS HOSPITALS. The Asylums Board being a branch of Poor Law Administration, legal admission to the Board's Hospitals was originally to be obtained only through Poor Law agency, viz.: by the Order of a Relieving Officer or the Master of a Workhouse, and upon the certificate of a Poor Law Medical Officer. In 1875 I proposed that, with a view to facilitate removal, the Relieving Officer should be authorized to act upon the certificate of any registered medical practitioner. Not until July, 1887, did the Local Government Board give authoritative sanction to my views, viz.: by the issue of an Order validating the certificate of any registered practitioner as evidence of the infectious character of the disease. At the present time there is no legal admission to the 63 hospitals save by the Relieving Officer's Order; but since 1884 many patients have been admitted upon the application of Medical Officers of Health, and latterly upon application by any registered practitioner which is supported by the production of a medical certificate. Now, probably a moiety of the patients are admitted without the Relieving Officer's Order; and in course of time cases admitted upon this Order may become quite exceptional, inasmuch as the President of the Local Government Board proposes to ask Parliament to confer powers upon the Asylums Board to admit patients, whether for isolation or for treatment, upon the application of Registered Medical Practitioners, a course which will obviate the necessity of application to the Poor Law Authority. THE STATUS OF HOSPITAL PATIENTS. On various occasions statements have been made to the effect that many patients enter the Asylums Board's Hospitals who are able, and ought to be made, to pay for the relief afforded. That now and again such cases do occur I am not concerned to deny, but I am confident that the cases are fewer than might be supposed from the general character of the statements referred to. It is said, for instance, that four-fifths of the patients (80 per cent.) are not "paupers," and some years back a statement was made that 90 per cent. of the patients had not previously been in receipt of parochial relief. This may be true, but it does not follow that the patients were able to pay, and information respecting the status of persons removed to hospital which 1 published in my last Annual Report (for 1887) fairly demonstrated the fitness of such cases for free treatment, even apart from the fact that it was for the public interest to promote the isolation in hospital of persons who otherwise might have spread disease. 64 The Managers themselves now, and I believe I may safely add, the Local Government Board also, recognize not merely the desirability, in the interests of public health, of admitting all comers, but the fact that few of the patients are able to pay. The subject came under the Managers' notice in March, when it was stated that the facts would show that not five per cent. of those thus admitted were of a class who could pay, and that not ten per cent. had friends who could pay part of their cost— statements well borne out by our experience in this "rich" parish, as I shewed in my Annual Report for 1887 (page 67). It was further stated that the admissions had greatly benefited the Metropolis, in removing the fever-stricken from among the population—a fact the accuracy of which will not be questioned by anyone conversant with the subject, but of which the importance is perhaps scarcely realized even now by a not inconsiderable section of those concerned in the "medical relief" of the infectious sick. PAYMENT FOR NON-PAUPER CASES IN HOSPITAL. The Asylums Board issued a return in May, 1888, of fever patients admitted to the hospitals, with and without Relieving Officers' orders, shewing that 40 per cent. of the cases in a specified time bad been admitted without orders. Thereupon a ratepayer expressed his intention of appealing, and be did appeal, to the Auditor to surcharge the cost of the maintenance of all patients admitted without Relieving Officers' orders during the half-year ended at Lady-day. The Auditor in due course had the matter under consideration; but to avoid the delay involved in the process of getting a surcharge remitted, in the event of the Auditor making one, the Clerk to the Managers, under their authority, applied to the Local Government Board to sanction the expenditure incurred in the maintenance of such 65 patients, under the power conferred upon the Board by section 3 of the Local Authorities (Expenses) Act, 1887, which enacts that "Expenses paid by any local authority whose accounts are subject to audit by a district auditor, shall not be disallowed by that auditor if they have been sanctioned by the Local Government Board." The Board's reply, dated 21st August, was as follows:— “Sir,—I am directed by the Local Government Board to advert to the application contained in your letter of the 31st ultimo, and to state that they hereby sanction the expenditure incurred by the Managers of the Metropolitan Asylum District in respect of the maintenance, during the half-year ended at Lady-day last, of Smallpox and Fever patients who have been admitted into the Asylums of the District on Certificates signed by Sanitary Officers and private Medical Practitioners without the intervention of the Believing Officer. It was the intention of the President of the Board to introduce a Bill for the purpose of removing any doubt which may exist as to the legality of expenditure of thi3 character, but circumstances have not admitted of legislation being proposed on the subject during the present year. "The sanction of the Board is given so far as the expenditure referred to may, in the opinion of the Auditor, not be open to any question, except in consequence of no Certificate of a Poor-Law Medical Officer or Believing Officer having been obtained. I am, &c., (Signed) S. B. PROVIS, Assistant Secretary. "To W. F. Jebb, Esq." Upon the reading of the above letter, the Chairman, Sir Edwin Galsworthy, commented upon the importance of the step taken by the Local Government Board, and it was agreed to inform the local authorities of the Metropolis of the correspondence. About the importance of the Board's decision there can be no doubt, and I need hardly remark that in taking this step, the Board have given practical effect to the proposal made by myself, and approved by your Yestry many F 66 years ago, that the expenditure incurred in the treatment, in the Managers' hospitals, of all cases of infectious disease, should be a charge upon a Metropolitan Common Fund, by whatever name called. It is to be hoped that the President will be enabled in the current session to give effect to his intention to deal effectively with the question by special legislation. THE HOSPITALS AND THE SANITARY ACTS. A Justice is enabled—sec. 26 Sanitary Act, 1866—by Order, on a certificate signed by a duly registered medical practitioner, to direct the removal of any person suffering from a "dangerous infectious disease," and ''being without proper lodging or accommodation," to a hospital "within the district" of the Nuisance Authority. It is in the power of the Local Government Board to issue an Order, under section 51 of the Sanitary Law Amendment Act, 1876, declaring the Managers' Hospitals to be "within a convenient distance" of any of the sanitary districts in the Metropolis for the purpose of the section first cited. Upon the issue of such an Order every hospital named therein "shall be deemed to be within the district" of the named Sanitary Authority. The Board have not issued an Order hitherto, but it is desirable that such an Order should be issued (although the occasions are few on which it is found necessary to exercise the compulsory powers of removal), seeing that the hospitals are only six in number, while the Sanitary Districts are forty. Certain of the Sanitary Authorities, whose districts are more or less remote from the hospitals, having made application to the Board to issue an Order, their communications were referred by the Board to the Asylums Board for "any observations that the Managers may desire to offer upon this question." The Managers, having considered the question, stated that they "had 67 110 observations to offer although they would be prepared to carry out any instructions which the Local Government Board may issue in reference to the section of the Act referred to"—an important proviso, seeing that before any person can be removed to a "hospital for the reception of the sick " by justice's order, "the consent of the superintending body of such hospital" must be obtained. CLINICAL INSTRUCTION. The Managers, desirous of making their hospitals availabl for clinical instruction, upon conditions embodied in a report dated February, 1886, and as contemplated by Section 29 of the Metropolitan Poor Act, 1867, obtained from the Local Government Board the necessary authorisation, and registered practitioners are now eligible to be appointed, with the status of assistant medical officer, the period of residence being limited to three months. The arrangement is advantageous, seeing how greatly the opportunities of medical students for studying infectious diseases have been curtailed, not to say annihilated, as regards small-pox, scarlet fever, etc., by exclusion from general hospitals of sufferers from these diseases. Reference to the work of the Asylums Board in 1888 may be fitly concluded by the following Table, shewing the number of cases admitted to the Managers' Hospitals from the several sanitary districts:— 68 Table shewing Quarterly and Total Admissions of Small-Pox and Fever Patients at the Asylums Board Hospitals in 1888, and Population Of the several Parishes, Unions, and Districts in 1881. Parishes, Unions, &e. Small-Pox. Total. Scarlet Fever. Total. Enteric Fever. Total. Diphtheria Grand Total Small-Pox, Fever, and Diphtheria. Population in 1881. 1st Qtr. 2nd Qtr, 3rd Qtr. 4th Qtr. 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr 1st Qtr 2nd Qtr. 3rd Qtr. 4th Qtr. 4th Qtr. Western District. Kensington 1 ... ... ... 1 77 46 34 38 195 1 4 3 4 12 17 225 163,251 Fulham 1 ... ... ... 1 50 44 42 27 163 10 3 3 7 23 6 193 114,839 Paddington ... ... ... 1 50 31 12 13 106 1 2 ... ... 3 5 115 107,218 Chelsea ... ... ... ... ... 45 38 28 15 126 2 ... 3 ... 5 2 133 88,128 St. George's ... ... 1 ... 1 81 39 25 18 163 2 ... ... ... 2 4 170 49,748 Westminster ... ... ... ... ... 24 30 21 5 80 5 ... ... 1 6 ... 86 922 46,549 669,633 Northern District. St. Marylebone ... ... ... ... ... 59 38 26 25 148 4 3 1 4 12 ... 160 154.910 St. Pancras 5 ... 1 ... 6 81 72 152 80 385 9 4 1 14 3 408 236,251 Hampstead ... ... ... ... ... 2 1 3 15 21 ... ... ... ... ... 1 22 45,452 Islington 1 ... ... ... 1 56 44 55 32 187 18 8 11 12 49 1 238 282,865 Hackney ... ... ... ... ... 66 42 56 79 243 13 8 13 4 38 3 284 1112 186,462 905,947 Central District St. Giles and St. George ... ... ... ... ... 22 6 11 7 46 1 1 ... ... 2 ... 48 45,382 Strand ... ... ... ... ... 18 9 7 7 41 1 ... ... ... ] ... 42 33,582 Holborn 1 2 ... ... 3 78 78 91 76 323 9 11 4 8 32 ... 358 151,835 London, City of ... 1 ... ... 1 11 18 27 11 67 1 ... ... ... 1 ... 69 517 57,439 288,238 69 Eastern District. Shoreditch ... ... ... ... ... 36 28 28 14 106 16 7 8 6 37 ... 143 126,591 Bethnal Green 8 2 ... ... 10 20 26 47 54 147 3 7 4 5 19 10 186 126,961 Whitechapel ... 1 ... ... 1 32 25 38 14 109 ... ... ... 5 5 4 119 71,363 St. George's-in-the-East 4 1 ... ... 5 12 11 9 6 38 6 1 1 2 10 5 58 47,157 Stepney 1 ... ... ... 1 8 3 7 7 25 2 3 1 3 9 2 37 58,243 Mile End Old Town 4 4 1 ... 9 22 12 28 24 86 8 4 1 3 16 3 114 105,613 Poplar 5 1 ... ... 6 44 36 29 44 153 13 22 27 9 71 3 233 890 156,510 692,438 Southern District. St. Saviour's ... ... ... ... ... 52 42 43 54 191 4 1 5 3 13 2 206 195,164 St. Olave's ... ... ... ... ... 15 13 13 17 58 8 7 5 1 21 1 80 134,632 Lambeth ... 1 ... ... 1 150 78 108 84 420 7 3 4 2 16 12 449 253,699 Wandsworth and Clapham ... 6 2 ... 8 134 88 46 47 315 30 9 4 12 55 3 381 210,434 Camberwell 1 1 ... ... 2 88 46 43 53 230 6 5 4 15 9 256 186,593 Greenwich 3 3 1 ... 7 54 29 37 18 138 10 8 8 3 29 ... 174 131,233 Woolwich ... ... ... ... ... 13 39 15 6 76 7 2 1 1 11 ... 84 80,845 Lewisham ... ... ... ... ... 12 8 19 38 77 2 ... ... 1 3 ... 80 1710 73,337 1,265,937 35 23 6 1 65 1412 1020 1100 928 4460 199 118 113 100 530 96 5151 5151 In addition to the cases in the Table, five cases of typhus were admitted, 3 from Stepney and one each from Mile End Old Town and St. Saviour's, Southwark: 55 cases of "other diseases" were admitted through error in diagnosis. At the close of the year there were remaining 853 cases, viz., scarlet fever 733, diphtheria 42, enteric fever 72, and "other diseases" 6. 70 THE FUTURE OF THE METROPOLITAN ASYLUMS BOARD. At a meeting of the Managers in October, 1887, Dr. J. H. Bridges, Poor Law Inspector, expressed his satisfaction that the Board was "working in the direction of what he hoped it would become, viz., the Hospital-providing Authority for all poor people of London not paupers." His remarks were received with an approval which must be taken to mark a further advance by the Board in the direction of that goal to which I have for many years urged the Managers to aspire. For it is not to be supposed that Dr. Bridges was, in the above utterance, expressing his merely personal views. He spoke, doubtless, under a sense of official responsibility, and we may conclude that the Board which he represents is no dissatisfied spectator of the process of evolution by which the Asylums Board is being transformed into a Central Authority, acting for the whole Metropolis, to provide hospital accommodation for all classes in need of isolation. The subject was not new, it having been carefully considered by the Managers in February, 1877, when they took counsel with the Sanitary Authorities and with the Medical Officers of Health. Expressing "the belief that adequate provision for the isolation and treatment of epidemic disease in the Metropolis" did not then exist, the Managers arrived at the following conclusions:— (а) “That such provision could be best made in a comprehensive and systematic manner by one Central Authority acting for the whole Metropolis not only for pauper patients, but for other classes desirous of Hospital accommodation. (b) "That such Central Authority should not be merely a Department of Poor Law Administration, but should have the powers of the Sanitary Acts conferred upon it. (c) "That either the Board should be merged into such Central Authority or should itself be that Authority, in which case its constitution should be altered and adapted to its enlarged duties and responsibility." A Conference of the Sanitary Authorities was held at the Cannon Street Hotel, June 16th, 1878, at the invitation of the 71 Limehouse Board of Works, to consider the subject of "provision of Hospital accommodation for persons suffering from Infectious Disease;” and at an adjourned meeting held 16th July, the delegates unanimously adopted a resolution which, in March, 1879, was presented by a deputation to the President of the Local Government Board, as follows:— "That in the opinion of this Conference, many almost insurmountable o bstacles 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, 1860, 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 Disease, and is further of opinion that such Authority should be as far as possible representative." The views of your Vestry on the subject, as summarised for the information of the delegates prior to the second meeting of the Conference, were to the effect:— (а) " That the Managers of the Metropolitan Asylums Board should be empowered to make adequate provision of hospital accommodation for infectious disease for all classes of the population in need of such accommodation. (b) "That patients should be admitted into the Managers Hospitals, upon certificates signed by any duly qualified medical practitioner. (c) "That as the hospitals of the Managers have been established for the common good at the public cost, no compulsory payment should be exacted from persons whom the Sanitary Authority may deem it necessary or expedient to remove to the hospitals for the purpose of isolation. (d) "That all expenses inoident to the maintenance and treatment of such persons in the hospitals should be defrayed out of a Common Sanitary Fund, the Metropolis being treated for the purpose as a single district; and (e) "That steps should be taken to alter, by Act of Parliament, the constitution of the Board, by severing its connection with pauperism in so far as relates to the treatment of infectious disease, and by 72 providing for the election of a certain proportion of the Managers by the several Sanitary Authorites, i.e., the Vestries and District Boards of Works." My own views were set out in a Report dated 10th January, 1877, at a time when small-pox was severely epidemic in the Metropolis. With reference to HOSPITALS FOR INFECTIOUS DISEASES, I contended that the provision of them should be regarded as a Metropolitan question, and opposed the local or district Hospital system. The Local Government Board had advised the Vestries and District Boards to provide hospital accommodation for "that large class of persons not needing relief, but whose isolation in hospitals is necessary for preventing the spread of the disease"—although it was known that not ten per cent. of the persons admitted into the Asylums Board Hospitals had previously been in receipt of "parochial relief." The Vestries had power to do as advised under the provisions of section 37 of the Sanitary Act, 1866. The Asylums Board constituted under the Poor Law Act, 1867, were legally bound to provide for the needs of the pauper class only. But the Managers had provided accommodation nearly sufficient for all classes of the population, and were able by extension to provide, as they have since done, for the exigencies of the severest epidemics. My contention was, that "the work of hospital provision can be done more cheaply, more speedily, and more efficiently by one Central Board than by numerous local Sanitary Authorities." I contended, moreover, that not only was it undesirable upon sanitary grounds to multiply hospitals, but also that local opposition would defeat any attempts in that direction, as subsequent experience amply proved. These views, regarded with little favour at the time, have gradually prevailed, and now, practically, there is no difference of opinion on the subject, the Asylums Board being regarded as the Central Hospital Authority. 73 FREE INFECTIOUS HOSPITALS. In the same report (January 10th, 1877), I pleaded for free admission of all persons whose isolation in Hospitals was necessary for preventing the spread of infections disease. I pointed out that in a large proportion of the cases such isolation was necessary for the protection of the public, quite as much as for the welfare of the sufferers, and that in a multitude of such cases the sufferers had gone voluntarily, or, in the case of children, had been allowed to be removed to hospital, from a sense of duty. This being so, it was unreasonable, I said, to demand from the individual sufferer repayment of expenses incurred in the interests of the public. I compared the outbreak of infectious disease to the outbreak of fire. The extinction of fires, I said, was undertaken at the common cost for the common good: in like manner the charge for hospitals should be regarded as a premium of insurance against a danger as much more serious than fire as life is more precious than property. These views met with much opposition, based, to some extent, on the supposition that there was already a large recoup which would have to be sacrificed. But at a later date (1881), I was enabled to show that only about £58 had been contributed by 79 patients, out of 3,100 admitted to the hospitals, from 20 Unions and Parishes, in one year (1880-81). There is now a consensus of opinion that my views were correct, and the " Asylums " have become in practice, but as yet are not in law, Free Hospitals. I may add that by section 15 of the Poor Law Act, 1879, the Asylums Board was enabled, with the approval of the Local Government Board, to contract with any Vestry, &c., "for the reception and maintenance in the hospitals of the Managers of any person suffering from any dangerous infectious disorder within the district of the said Vestry, &c." This section remained a dead letter for several years, because the majority of the Boards of Guardians, cordially co-operating with the Sanitary Authorities, removed the sick upon application, whether by the friends or the 74 Medical Officer, or the Sanitary Inspector, or the private medical practitioner. But in 1884 more than one of the Boards of Guardians having refused to remove non-pauper patients, and the Managers themselves having been reproached for "extravagance " by some of the Sanitary Authorities who had benefited largely by their liberality, the Asylums Board sought to reduce the expenses chargeable to the poor-rate, by transferring the cost of treatment of non-paupers to the general rate, viz., by making contracts with the Vestries under the provisions of the Act above cited. Recognising the danger thus likely to arise from conflict of opinion, as to what patients were to be regarded as paupers, and what as non-paupers—a conflict which would inevitably have led to delay in the removal of the sick — I opposed the proposal. Your Vestry adopted my views, and communicated to the Managers, to the Local Government Board, and to the Sanitary Authorities generally, the report in which they were set out, the result being that the proposal to contract fell through, and has not hitherto been revived. CENTRAL HOSPITAL AUTHORITY. In the same report (January 10th, 1877), I wrote "The present outcry is for a 'Central Health Board for the Metropolis.' The Asylums Managers practically constitute such a Board, and they could be endowed with legal powers to provide all the hospital accommodation required for the safe treatment of the infectious diseases A measure to extend their powers in this direction would be tantamount to a consolidation of Sanitary Authorities—a Central Board to provide Hospitals, Local Boards with an efficient staff to carry out the details of Sanitary work, to visit the sick, to remove suitable cases to the hospitals, and to see to disinfection The benefit to the Metropolis would be incalculable." In a communication to the Asylums Board (March, 1877), I said, "Seeing that 90 per cent. of the sick in the Asylums are not paupers, I should 75 prefer a severance of the connection between Poor Law Administration and the hospital treatment of infectious diseases, which might be effected by the constitution of a Central Authority, to be elected by the Vestries and District Boards of Works, and having power to provide accommodation for all persons whose isolation in hospitals is necessary for preventing the spread of disease." DEPAUPERISATION OF MEDICAL RELIEF IN INFECTIOUS DISEASE HOSPITALS. I pointed out in the same report (Jan. 10th, 1877), the injustice of branding as paupers those who went into the hospitals for the public good, and claimed that "relief" in hospitals should be placed upon the same footing as public vaccination. Any man, I said, may avail himself of the services of the public vaccinator without being pauperised—without losing his privilege as an elector. Why? In order to lesson the risk to himself and to the community, of his catching small-pox, which is justly regarded as a public danger. Is it reasonable, then," I asked, "to pauperise an artisan when he is so unfortunate as to suffer in his family, or in his own person, from the disease we are so anxious to prevent, because he, unwillingly indeed, but from a sense of duty, and for the benefit of the community, consents to go, or let his child go, to a 'ratesupported' hospital? Would not a Vestry Hospital be a 'ratesupported 'hospital? I fail to see any practical difference between hospitals supported by rates. It is a question of taking the money out of the right-hand-pocket or the left. In such a case all distinctions of pauper and non-pauper should be abolished. Treat all alike as suffering from a personal calamity which may grow into a public danger, and act on the maxim, salus populi, suprema lex." These views found little favour at the time, but in the Diseases Prevention (Metropolis) Act, 1883 (sec. 7), they received the high sanction of Parliament. 76 NOTIFICATION OF INFECTIOUS DISEASE. Voluntary Notification.—Upon ray appointment, in 1871, I set about getting information of the occurrence of dangerous infectious diseases. An arrangement was made for immediate report by the sub-district registrars of deaths from these diseases. The aid of the Guardians' officers was enlisted, and subsequently that of the Authorities of General Hospitals and Dispensaries. Medical men, Clergymen, and District Visitors were requested to co-operate; and in 1877 the School Board for London assented to my request, that their "Visitors" should report to Medical Officers of Health all cases of infectious disease coming to their knowledge in the course of visitation of the homes of absentee children. Later, the Board at my request instructed the Head Teachers to render the same service, and I sought also the help of the Head Teachers of all other public elementary schools. The Police and Postal authorities moreover, were successfully requisitioned for assistance. From these various sources information has been obtained—information rendered doubly valuable by the facilities afforded for isolating the sick in the Asylums Board Hospitals. Desiring to form an opinion on the probable results of Compulsory Notification, I made an enquiry, in 1883, as to the results that had attended voluntary notification as practised in Kensington. I compared two periods of twelve years each—the first period, 1859-70, without notification and without hospitals; the second period, 1871-82, with voluntary notification and with hospitals. The results were striking, shewing that in the second period of twelve years, the deaths, after correction for increase of population, were 1,441 fewer (annual average 120) than in the first period; the decrease in scarlet fever and enteric fever being especially conspicuous. During the last four years a further source of information has been opened up; the Asylums Board reporting daily to the Medical Officer of Health, all admissions to their Hospitals from his district, and once a week sending to every Medical Officer of Health a list of all eases admitted 77 in the previous seven days. In 1887 the system of voluntary notification was made as perfect as it can be by your Vestry agreeing, upon my recommendation, to pay a fee to medical men for each case reported. As at this time, moreover, the Asylums Board were admitting patients upon the application of medical men, your Vestry further agreed to pay a fee for the certificate upon which any case should have been removed to hospital. Compulsory Notification.—Valuable as voluntary notification has proved, it is necessarily imperfect. In 1880, therefore, I advised your Vestry to make an effort to obtain Compulsory Notification. A conference of Sanitary Authorities was convened at the Town Hall. As a preliminary proceeding, I drew up a Memorandum on the subject, a copy of which was placed in the hands of each member of the several Vestries and District Boards, nearly 3,000 in number. At the Conference, held in March, 1881, 24 of the 39 Sanitary Authorities were directly represented, and 23 Medical Officers of Health were present, six of them indirectly representing their respective authorities. The resolutions which I had drawn up to be submitted to the Conference, had been forwarded with the Memorandum, to the Vestries and Vestrymen, and were unanimously adopted by the meeting. These resolutions were in favour of (1) Compulsory Notification, (2) Compulsory removal to hospital when the patient cannot be isolated at home, and (3) Free admission of the sick to hospital, without loss of social or political status. It was agreed that the resolutions should be transmitted to the Sanitary Authorities, and that a Deputation should present them to the Local Government Board. The President of the Local Government Board received the deputation in April, 1881. It comprised the representatives of the Sanitary Authorities—none of these bodies dissenting—the Council of the British Medical Association, the Society of Medical Officers of Health, the Social Science Association 78 (Public Health Section), and the National Health Society. The President promised to give the representations made to him careful consideration; but little would have come of the great effort that had been made, save for the removal of small-pox cases out of London for treatment, which was an immediate result of the deputation, and for the evidence it supplied of the strong hold on public opinion which the subject had obtained. Subsequently, the Asylums Board and the Metropolitan Poor Law Guardians Association passed resolutions in favour of Notification. And, ere long, similar utterances proceeded from representatives of the Local Government Board—from the Medical Officer in 1882, and from the President in 1883. Not the least important testimony to the value of Notification was that contained in the "Practical Recommendations" of the Report of the Royal Commission on Infectious Hospitals—in 1882. Parliament itself has repeatedly signalised its appreciation of the value of the system by enacting in Local Acts the model clauses of a Select Committee of the House of Commons, providing for Notification, which is now in force in nearly sixty towns having a population largely exceeding that of London. As no steps had been taken to provide for Notification in London, your Vestry, upon my recommendation, in 1887, resolved to make a further effort, by requesting the President of the Local Government Board to bring in a Bill. The Asylums Board, the Vestries and District Boards, the Society of Medical Officers of Health, and the Sanitary Institute, were asked to, and did, endorse the application. The obvious desire of the Sanitary authorities to obtain this power, in aid of their efforts to deal effectively with infectious diseases, was not without effect on the Local Government Board, which, in November, 1887, caused a series of questions to be addressed to the authorities of the towns where compulsory notification is in force, as to the working of the system. No detailed account of the replies has been published, but it is understood that they 79 were almost uniformly favourable, and the President of the Local Government Board has announced his intention to bring in a general Bill during the present Session to provide for Notification. Compulsory Removal to Hospital of the Infectious Sick.—The 26th section of the Sanitary Act, 1866, authorises a Justice to make an Order, upon production of a medical certificate, for the removal of any person suffering from an infectious disease, and being "without proper lodging or accommodation." It has been held that all that the law requires is, that the accommodation shall be proper for the safety of the sick person. The Conference of Sanitary Authorities, above referred to, held that the safety of the other inmates of the house should be taken into consideration and that the sick person should be compulsorily removed to hospital if he could not be isolated at home. The law remains unaltered. The 26th section of the Sanitary Act, 1866, above cited, is defective, inasmuch as it contains no direction as to the person on whom the Justice's order is to be made, and therefore does not provide for any peoalty for obstruction or disobedience. Having experienced difficulty in enforcing the Justice's order, your Vestry, on my representation, called the attention of the Local Government Board to the subject, with the result that in the Sanitary Law Amendment Act, 1874, sec. 51. it was enacted that the Justice's order shall be addressed to such police or other officer as he shall consider expedient. A penalty not exceeding ten pounds is now enforceable for obstruction or disobedience. Free Hospital Treatment, and Depauperisation of Relief in the Hospitals, the subjects of the third of the Conference resolutions, have, as already shown, been practically secured (vide pages 78 and 75). [Addendum.—After the above Section on Notification was in type, a circular letter was received from the Sanitary Committee of the London County Council to the effect, that 80 they had under consideration the question of the desirability of the Council introducing into Parliament a Bill to compel the registration, by all Medical practitioners, of cases of infectious disease which they are called upon to treat; and asking to be favoured with the views of your Vestry generally on the compulsory registration of infectious diseases, and particularly as to whether such registration should be at the office of the local Sanitary Authority? I dealt fully with this question in my Annual Report for 1887, giving a history of the action taken thereon by the Sanitary Authorities of the Metropolis, upon the initiative of your Vestry, both in 1881 and in 1887. A copy of the Report was forwarded to every member of the Council in February last. In the reply to the circular letter (in June) it was thought sufficient to send the report to the Council as an expression of the views of your Vestry generally, on the subject, and to intimate that "the registration should be at the office of the local Sanitary Authority." It may bo observed that the Council cannot introduce a Bill this Session, and that their action, whenever taken, would concern the Metropolis only. Possibly any action on the part of the Council will be unnecessary in view of the fact that, as already stated (page 79), the President of the Local Government Board has announced his intention to introduce a general Bill which would apply to the whole country. The matter is a fitting one to be dealt with by the responsible Government of the day, although it has hitherto been promoted exclusively by the sanitary authorities of provincial towns, in local Acts.] HOSPITALS COMMISSION. In 1881, a Royal Commission was appointed to consider the question of Hospital Accommodation for infectious diseases, and I was invited to give evidence. The Commission made a number of "Practical Recommendations" ill their Report (1882), which were in accord with the principles in regard to sanitary administration for which I had long contended. Among 81 these may be mentioned: (1) Compulsory notification in all cases of infectious disease; (2) Compulsory removal of the sick when necessary for isolation; (3) Unity in Hospital Administration, and representation of the Sanitary Authorities on the Hospital Board; (4) Separation of Hospital treatment from all connection with poor-relief; or, in other words, Abolition of distinction of Pauper and Non-Pauper, in respect of the treatment of infectious disease; (5) Free Hospital-treatment of infectious diseases, with pay-wards for those who desire special or separate accommodation; (ti) Provision of additional Hospitals in Loudon, with skeleton staff of doctors, nurses, and other officers, capable of extension so as to cope with all emergencies; (7) Provision of Hospitals in the country for removable cases of small-pox, and for the reception of convalescents generally; (8) Transference of vaccination arrangements to the Hospital, i.e., the Sanitary Authority. W ith respect to the greater number of the above recommendations, Parliamentary sanction has yet to be obtained to give them legel effect: some of them have long since been carried out in practice. PUBLIC HEALTH LEGISLATION. A "Synopsis of various matters relating to the extension of the duties and powers of the Managers with respect to Infectious Disease, which are still under the consideration of the Local Government Board," was prepared by direction of the General Purposes Committee of the Asylums Board at the latter end of the year, and a copy thereof forwarded to the President of the Local Government Board "for his information and consideration in connection with any Bill affecting the duties and responsibilities of the Managers, which it may be his inten tion to submit to Parliament." This document is of interest, inter alia, as showing the willingness of the Managers to under- G 82 take the duties of a Central Hospital Authority in regard to measures for checking and preventing the spread of Infectious Disease. The subjects referred to, in the Synopis, are as follows— (1.) Admission of all classes of Infectious Patients.—This is a matter that has been pressed upon the attention of the Asylums Board by your Vestry on more than one occasion. A deputation of the Managers waited upon the President of the Local Government Board (12th December, 1887), the Managers being willing to receive all classes of patients. The Board subsequently (16th December, 1887) promised to consider the question with a view to legislation in the then ensuing session (1888) if circumstances should admit of it. The Managers having admitted many patients on certificates signed by Medical Officers of Health and private medical practitioners, without the intervention of the relieving officer, the Local Government Board stated (21st August, 1888), that it had been the intention of the President to introduce a Bill for the purpose of removing any doubt which might exist as to the legality of expenditure incurred, as much bad been, in respect of the maintenance of patients so admitted. Circumstances did not admit of legislation in 1888, but the Board, as elsewhere explained (page (15), sanctioned the expenditure so incurred by the Managers in doing that which your Vestry had advised should be done. (2.) General Conveyance of Infectious Persons to Hospital.— The Ambulance Committee of the Asylums Board reported (21st April, 1888), that it was desirable, in the public interest, that the Managers' ambulances should be made generally available for the conveyance of any persons suffering from infectious disorders within the Metropolitan District, a system the desirability of which I had ventured to suggest to the Managers in 1881. The Managers approved the report, and empowered the Committee to confer with the President thereon. The President's engagements did not enable him to receive a 83 tion, and the Managers have not, so far as I am aware, received a reply to their letter on the subject sent to the Board on the 25th April, 1888. (3.) Diphtheria.—"The question of the admission to the hospitals of patients suffering from this disease has now been tentatively dealt with by the Local Government Board" (vide p. 38). (4.) Compulsory Notification of Infectious Diseases.—A communication on this subject, which has been before your Vestry frequently, was addressed by the Managers to the Local Government Board (5th November, 1887), in favour of the extension of the system to the Metropolis. The Board promised that the subject should receive their attention, but nothing has been done; save that, as explained elsewhere (page 78), the Board made an inquiry, at the end of 1887, into the working of the system in the towns where it is in force, in the form of queries addressed to the respective sanitary authorities. (5.) Compulsory removal of the Infectious Sick to Hospital when without proper lodging or accommodation.—Compulsory removal can be effected (on medical certificate and Justice's order) only when the Hospital is within the district of a Nuisance Authority. The suggestion had been made that the Hospitals of the Asylums Board should be declared to be "within a convenient distance" of the various districts of the Sanitary Authorities, for the purposes of the removal of the sick under Section 26 of the Sanitary Act, 1886. The Managers stated (28th January, 1888) that they were prepared to carry out any instructions which the Local Government Board might issue in reference to the section, should the Board see fit to make the said section operative in the Metropolis. Nothing has yet been done. (6.) Compulsory Purchase of Land. —This subject has been referred to (page 59) in connection with an application of the G 2 84 Managers for powers to acquire additional land adjoining the Western Hospital at Fulham, to which the Local Government Board have given scant attention. The Board do not appear to have taken any action on the general question. (7.) Ghargeability of Patients admitted from the Tower of London.—This subject does not call for remark here. (8.) Contracts with Sanitary Authorities for the Reception and Maintenance in Hospitals of Non-Paupers, under Section 15 of the Poor Law Act, 1879.—Many of the Sanitary Authorities, following the lead of your Vestry, as previously explained (page 73), declined to enter into contracts with the Managers, for reasons which I stated in my Annual Report for 1884, the principal one being that it was desirable, in the public interest, to throw the entire cost of the hospitals upon a Common Sanitary Fund, making it, in fact, a Metropolitan charge. The Managers forwarded to the Local Government Board in October, 1886, a synopsis of the replies that had been received to the communication addressed by them to the several Sanitary Authorities. The Managers were unable to See that they could "take any further action in the matter, unless and until the Local Government Board should see fit to obtain from Parliament such additional powers as will render compulsory instead of optional the conditions of the section in question." The Local Government Board have not taken any further action in the matter up to the present time, and it is to be hoped that no action may be taken, excepting for the purpose of giving effect to the views of which your Vestry have been the exponents, as set out in my monthly and annual reports. A RETROSPECT. "Reform" of Local Government, as carried out by the Vestries and District Boards, being to all appearance near at hand, it will not be out of place to review, in a very few 85 sentences the results, as they are indicated by the state of the public health, attained under the system initiated in 1856, by the passing of the Metropolis Management Act, 1855, supplemented as that Act has been by others entitled "Sanitary," "Nuisances Removal," etc. The effects of these Acts, as carried out by the several Local Authorities, are apparent enough in the reduced death-rate by which London compares favourably with the great cities of the civilized world. The statistics at my command go back to 1841, and I find that in the three quinquennial periods—1841-5, 1846-50, and 1851-55, the death-rate in London was 24.2, 25.4,and 24.8 per 1,000 persons living; or for the fifteen years prior to the passing of the Metropolis Management Act, 24'8 per 1,000. In the following fifteen years, 1856-70, the rate had fallen to 23.9, the rate in the three five-yearly periods being—in 1856-60, 22.7; in 1861-65, 24.4; and in 1866-70, 24'3. In the next fifteen years, 1871-85, the average rate fell to 21.3 per 1,000; the rate in the three quinquennial periods being—in 1871-75, 22.9; in 1876-80, 22.2; and in 1881-85, 20.7. In 1886 the death-rate was 19.9; in 1887 it was 19.6, and in 1888 it further fell to 18.5, the lowest rate recorded since the present system of civil registration began. It is almost needless to observe that this remarkable decline implies the saving of many thousand lives, to say nothing of illnesses prevented. It is not in my power to furnish a similar return showing the results of the administration of the Acts in this parish; there are no statistics for the period antecedent to 1856, and the figures relating to 1856-60 are unreliable. But the statistics for subsequent years may be relied on, and these years may be grouped for comparison into quinquennial periods. The deathrate, then, in the five years, 1861-65, was 20.3 per 1,000 persons living, that in 1866-70 being 20'2 per 1,000. In 1871, upon my appointment, a more vigorous sanitary administration was 86 organized by your Vestry, which soon began to produce good results, for in the quinquennium, 1871-75, the death-rate fell to 18.9, and in the next five years, 1876-80, to 18.7. A still larger decline was observed in the quinquennium, 1881-85, the deathrate in those years being 15.9 per 1,000 only. If to these five years we add 1886-87, it will appear that the death-rate in the septennial period, 1881-87, was 16.1 per 1,000. In 1888 the rate was 15.9 per 1,000. In Kensington, as in London, an eminently satisfactory improvement in the public health has taken place in regard to "preventable" diseases, i.e., of the zymotic class. This improvement has been largely due to the legislation of 1866 ("The Sanitary Act") and 1867 (''The Metropolitan Poor Act"), the Metropolis having been provided under the last-named Act with a magnificent system of Hospitals for Infectious Diseases, organized by the Metropolitan Asylums Board. It is not probable that the good results of the past thirtythree years of Sanitary Administration will be far surpassed in time to come ; but something may be done by legislation to facilitate the proceedings of those, authorities and officers, alike engaged in the great work. What is most wanted is machinery whereby a nearer approach to Unity in carrying out the provisions of law may be attained. Measures for the Consolidation of Sanitary Laws and for Compulsory Notification of Infectious Diseases, together with a settlement of the Hospital Question on the principles which I have ventured to lay down, are among the most pressing needs of the Metropolis at the present time. Consolidation and Notification may possibly be obtained during the current session of Parliament, and as regards the hospitals it may be reasonably hoped that ere long the advantages to the Metropolis of the existing practice, by which admission is made easy and treatment is afforded at the common cost, will be permanently secured by legislation, 87 POPULATION, INHABITED HOUSES, &c. The population of Kensington, estimated to the middle of the year was, in round numbers, 177,000 (=81 per acre); males. 71,500, and females, 105,500 : excess of females, 34,000. The population of the Town sub-district was, approximately, 129,500, and that of the Brompton sub-district 47,500. The natural increase during the year, represented by the excess of births over deaths registered, was 951; an estimated further increase of 1,049 represents the excess of immigration over emigration: total increase, 2,000. It is always difficult to estimate with accuracy the number of persons living in a large and populous place still, like Kensington, in the process of growth. The best available test, perhaps, is the number of inhabited houses : if these show an increase, an increase in the number of people may be inferred, and vice versa. At the present time of writing, however, I have no very reliable information as to the number of inhabited houses as compared with previous years since the census of 1881. Probably they were about 21,000 at the middle of the year. In places with stationary population the birth-rate may serve as a guide in estimating the population. But this test is of little practical avail in a parish like Kensington where it is the fact that, with a constantly increasing population, not merely the birthrate, but the absolute number of births also, has constantly declined in recent years (vide Tables I. & II. Appendix). The most remarkable feature, however, in connection with the population of Kensington, one, moreover, which, to a large extent, accounts for the small and diminishing birth-rate, is the inordinate excess of females. It was thought surprising when the Census of 1871 revealed a majority of 22,000 females; the majority now is probably not less than 34,000. Females are in excess in the population generally; in London the excess is about 12 or 13 per cent.; in Kensington it is nearly 50 percent. 88 The subjoined Tables show the relative number of persons of each sex at the Census of 1881, grouped according to age, (a) in the entire parish, (b) in the Kensington Town sub-district and (c) in the Brompton sub-district. (a) ENTIRE PARISH. All ages. Under Five Tears. 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 to 95. 95 and upwards. All Ages. Females . 97,700 8753 15361 23391 19789 12606 8339 5472 2901 965 115 8 97,700 Females. Males 65,451 8832 13501 12452 10793 8397 5549 3619 1748 502 58 - 65,451 Males. Excess of 32,249 79 1860 10939 8996 4209 2790 1853 1153 463 57 8 32,249 Excess of Females Females. Total of 163,151 17585 28862 35843 30582 21003 3888 9091 4649 1467 173 8 163,151 Total of both sexes both sexes (b) KENSINGTON TOWN SUB-DISTRICT. All Ages. Under Five Years. 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 to 95. 95 and upwards. All Ages. Females 70,134 6952 12141 15640 13453 8996 6031 3968 2168 701 79 5 70,134 Females. Males 50.007 6969 10986 9205 7936 6404 4099 2669 1310 386 43 - 50,007 Males. Excess of 20,127 -17 1155 6435 5517 2592 1932 1299 858 315 36 5 20,127 Excess of Females Females. Total of 120,141 13921 23127 24845 21389 15400 10130 6637 3478 1087 122 5 120,141 Total of both sexes. both sexes (c) BROMPTON SUB-DISTRICT. All Ages. Under Five Years. 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 to 95. 95 and upwards. All Ages. Females 27,566 1801 3220 7751 6336 3610 2308 1504 733 264 36 3 27,566 Females Males 15,441 1863 2515 3247 2857 1993 1450 950 438 116 15 - 15,444 Males Excess of 12,122 62 705 4504 3479 1617 858 554 295 148 21 3 12,122 Excess of Females Females. Total of 43,010 3664 5735 10998 9193 5693 3758 2454 1171 380 51 3 43,010 Total of both sexes bath sexes 89 MARRIAGES AND MARRIAGE RATE. The marriages in 1888 were 1,497, and 64 fewer than in 1887. Of these there were celebrated — By the Church (73.9 per cent, of total marriages) 1,106 At Roman Catholic places of worship 155 At other Nonconformist places of worship 51 At the Superintendent Registrar's Office 185 Total 1,497 The marriage rate, i.e., persons married to 1,000 inhabitants, was 17. The marriage rate in England and Wales was 14.2 per 1,000, corresponding with the rate of 1887, and being 0.6 below the mean rate in the ten years 1878-87. The marriage rate in London was 16.1, the lowest rate yet recorded; the five next lowest rates, moreover, being those recorded in the five immediately preceding years, 1883-7, in which the rates were successively 17.9, 17.6, 16.9, 16.6, and 16.3 per 1,000. BIRTHS AND BIRTH RATE. The births registered in 1888 were 3,776—males, 1,914, and females, 1,862: in the Town sub-district, 3,063, and in the Brompton sub-district, 713. The births in 1887 were 3,941, or 165 above the number last year, in which the births, 860 below the decennial average corrected for increase of population, were fewer by 265 than in 1872, when the population was smaller by 49,000 than in 1888. The birth rate in Kensington, considerably lower than the London rate (30.7), and that of England and Wales (30.6),has been declining since 1868, when it was 331 per 1,000. In 1888 it was 21.3, being 4.9 below 90 the decennial average. The rate in the Town sub-district was 23.6 and in Brompton 15.4. There was one birth to 46.8 inhabitants and 102.7 births of males to 100 of females. The births of illegitimate children were 193 (five more than in 1887), viz., males 120 and females 73. Of these births 180 were registered in the Town sub-district, which includes the parish workhouse, at which institution there were 139 births, of which 103 were illegitimate. In the parish generally, the illegitimate births formed 4.7 per cent, of total births, as against 5.8, 4.7, and 4.7, in 1885-6-7 consecutively- The subjoined Table shows the quarterly number of births of males and females in each of the sub-districts. Kensington Town Sub-district. Brompton Sub-district Grand Total Whole Parish. Males. Females. Total. Males. Females. Total. 1st Quarter 393 428 821 96 96 192 1013 2nd „ 390 382 772 92 87 179 951 3rd „ 362 369 731 98 68 166 897 4th „ 398 341 739 89 87 176 915 1543 1526 3063 375 338 713 3776 For particulars respecting the annual number of births and birth-rates, in the decennial period, 1878-87, see Tables I. and II., Appendix. DEATHS AND DEATH RATE. The deaths registered in 1888, inclusive of 227 at outlyingpublic institutions, but exclusive of deaths of non-parishioners at intra-parochial public institutions, were 2,825, and 167 below the decennial average corrected for increase of population: 2,250 of the deaths belong to the Town sub-district, and 575 to the Brompton sub-district. The death rate, whole parish, was 15.9 per 1,000, compared with l6.1, 15.9, and 16.4 in the three 91 preceding years; being 0.9 below the decennial average and 2.6 below the London rate (18.5); this, moreover, being 2.6 below the average (21.1), and the lowest on record. It was 1.9 below the rate in England and Wales (17.8), also the lowest on record. The rate in the Town sub-district was 17.3, and in Brompton 12.1, as against 18.0, and 11.8 in 1887. The rate in the male sex was 18.9, and in the female sex 13.9 per 1,000, as against 20.0 and 14.0 in 1887. There was one death to every 62.6 inhabitants, as against one to 60.9 in 1887. Out of 71,500 males, 1,353 died, equal to one in 52.8, against one in 50 in 1887; whilst only 1,472 females died out of 105,500 or one in 716, against one in 71.4 in 1887. The deaths in the first and fourth, or colder quarters (1,527), exceeded those in the second and third, or warmer quarters (1,298), by 229. In the three preceding years the difference in favour of the warmer quarters was 22, 320, and 272 consecutively. INFANTILE MORTALITY. The deaths of young children always bear a high ratio to total deaths. The deaths under five years were 1,077 (587 in the first and fourth quarters, and 490 in the second and third quarters), compared with 1,085, 1,029, and 1,129 in the three preceding years; being equal to 38.1 per cent, on total deaths, and to 28.5 on births registered: the equivalent percentages for the whole Metropolis were 41.2, and 24.8. Under one year of age the deaths were 604 (compared with 653, 636, and 680 in 1885-6-7 consecutively), and were equal to 21.4 percent, on total deaths, and to 16.0 per cent, on registered births: the equivalent percentages for the whole Metropolis being 24.3 and 14.6. The deaths of illegitimate children under five years of age were 101—males 54, females 47 (of which 82 were registered in the Town sub-district) as against 86, 104, and 104 in the three 92 preceding years, and were equal to 50.6 per cent, on births registered as illegitimate. Of these 101 children only 23 outlived their first year, and 16 died in the second year of life. The causes of death, as registered, were atrophy, debility, inanition, 21; premature birth, 9; tubercular diseases, 15; zymotic diseases, 16 (diarrhoea, 9; measles, 4; whooping-cough 2; and diphtheria, 1); syphilis, 3; lung diseases, 23; convulsions, 4; diseases of the digestive organs, 2; teething, 2; and one each from brain disease, spasm of the glottis, kidney disease, congenital malformation, privation, and wilful murder. Illegitimate children are commonly brought up by hand, under the charge of strangers. The evidence of improper feeding, and of the lack of maternal care, is apparent enough in the above list of fatal diseases. Senile Mortality.— At sixty years of age, and upwards, there were 84.2 deaths, against 736, 747, and 773 in the three preceding years, or 29.8 per cent, on total deaths, the equivalent percentage in London as a whole being 23.2. The Death—Rate per 1,000 persons living, at different periods of life, was as follows:— 1888. 1887. 1886. 1885. Under Five years of age 56.4 60.0 55.0 58.4 Five and under 15 4.4 3.4 3.2 2.9 Fifteen „ „ 25 2.4 2.8 3.1 2.8 Twenty-five „ 35 5.2 4.4 5.5 5.4 Thirty-five „ 45 8.7 10.0 9.5 9.7 Forty-five „ 55 15.8 15.5 14.8 16.3 Fifty-five „ 65 28.5 32.5 29.5 27.6 Sixty-five „ 75 64.1 61.2 65.8 63.2 Seventy-five „ 85 151.6 151.6 144.9 142.7 Eighty-five and upwards 300.0 367.8 338.0 340.3 93 The subjoined Table shews the quarterly number of deaths of parishioners, males and females, in each of the sub-districts, including: those that occurred at outlvins' miblic institutions:— Kensington Town Sub-district. Brompton Sub-district. Grand Total. Whole Males. Females. Total. Males. Females. Total Parish. 1st Quarter 278 340 618 73 85 158 776 2nd „ 262 300 562 71 62 133 695 3rd „ 246 222 468 66 70 156 604 4th „ 293 309 602 64 84 148 750 1079 1171 2250 274 301 575 2825 The Births were, Males 1914 The Deaths were, Males 1353 Females 1862 Females 1472 Total births 3776 Total deaths 2825 2825 Deaths - 951 Excess of Births over Deaths. The subjoined Table shows the rate of mortality and the mean temperature of the air in each of thirteen periods of four weeks corresponding with my monthly reports. Date of Report. Death rate per 1,000 persons living. Above or below Decennial Average Mean Temperature, of the Air. 1888. Decennial Average Above or below Decennial Average. 1888. 10 years 1878-87. For four weeks to Jan. 28. 18.3 20.8 —2.5 38°.4 37.0 + 1.4 Feb. 25. 17.1 19.0 —1.9 35.3 40.3 —5.0 March 24. 17.1 19.0 —1.9 36.5 41.6 —5.1 April 21. 18.3 18.7 —0.4 41.9 44.9 —3.0 May 19. 17.0 15.7 + 1.3 50.2 49.8 + 0.4 June 16. 14.2 16.1 —1.9 56.4 56.4 — July 14. 13.0 14.7 —1.7 57.1 61.3 —4.2 August 11. 13.1 16.6 —3.5 60.1 61.5 —1.4 Sept. 8. 13.7 14.0 —03 57.5 60.3 —2.8 Oct. 6. 13.4 12.8 +0.6 52.5 55.0 —2.5 Nov. 3. 17.0 15.1 + 1.9 47.0 47.3 —0.3 Dec. 1. 18.3 17.3 + 1.0 46.8 42.1 +4.7 Dec. 29. 16.5 17.7 —1.2 41.3 38.0 + 3.3 Averages whole year 15.9 16.8 47.7 48.9 94 The subjoined Table, a summary of Table 3 (Appendix) shows the numbers of deaths of parishioners in each Class and Order, according to the Registrar-General's re-arranged classification. I. SPECIFIC FEBRILE OR ZYMOTIC DISEASES. No. of Deaths. 1. Miasmatic diseases 65 2. Diarrheal „ 58 3. Malarial ,, — 4. Zoogenous ,, — 5. Venereal ., 14 6. Septic „ 28 465 II. PARASITIC DISEASES 2 III. DIETETIC DISEASES 17 IV. CONSTITUTIONAL DISEASES 569 V. DEVELOPMENTAL DISEASES 155 VI. LOCAL DISEASES 1. Diseases of Nervous system 310 2. Diseases of Organs of Special Sense 2 3. Diseases of Circulatory system 196 4. Diseases of Respiratory system 622 5. Diseases of Digestive system 157 6. Diseases of Lymphatic system — 7. Diseases of Glandlike Organs of uncertain use 5 8. Diseases of Urinary system 77 9. Diseases of Reproductive system:— a. Diseases of Organs of Generation 7 b. Diseases of Parturition 10 10. Diseases of Locomotive system 12 11. Diseases of Integumentary system 3 1,401 VII. VIOLENCE 1. Accident or Negligence 53 2. Battle — 3. Homicide 2 4. Suicide 9 5. Execution — 64 VIII. ILL-DEFINED AND NOT SPECIFIED CAUSES 152 Total 2,825 95 ASSIGNED CAUSES OF DEATH. Having already (at page 24) treated of the deaths from the "principal diseases of the zymotic class," I now proceed to deal with the mortality from the remaining diseases in this class. But before doing so I think it right to mention that the classification of the causes of deaths in the "Weekly Returns" of the Registrar-General was considerably modified at the beginning of 1882. "The list of causes, in its new form," as the Registrar-General stated in his Annual Summary for that year, "is an abbreviation of the much more detailed "list which has 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." Table 3 in my reports prior to 1882 was framed upon the lines of the less abridged list of the causes of death contained in the Annual Summary, and it was the basis, to a large extent, of some of the other Tables. As it was not possible to accept the more abridged list contained in the Annual Summary for 1882, and yet, at the same time, desirable to frame Table 3 in close accordance with the more detailed list drawn up for use in the Annual Report, the Society of Medical Officers of Health revised certain Tables, which, at my instance, they had framed for the sake of uniformity, some ten years previously, and ultimately settled the forms of Tables I.— VI. inclusive, as they appear in the Appendix. It results, therefore, that these Tables will be found to differ to some extent from similarly numbered Tables in the Annual Reports prior to 1882. With this explanation I pass on to deal with the remaining diseases in Class 1.—Specific Febrile or Zymotic Diseases. This class comprises six "Orders;" the first and second, "Miasmatic" and "Diarrhœal," including the diseases already dealt with (at page 24). 96 Order 3, Malarial Diseases, includes Remittent Fever and Ague; Order 4, Zoogenous Diseases, includes Cowpox and Effects of Vaccination, Hydrophobia, Glanders and Splenic Fever. No death was registered from any of these causes. Order 5, Venereal Diseases, includes Syphilis, Gonorrhoea, Stricture of the Urethra. Syphilis was the registered cause of 13 deaths, as against 26, 21, and 17 in 1885-6-7. Ten of these deaths occurred in the Town sub-district; 11 of them were of children under one year of age. If the truth could be discovered, it would probably appear that this Protean malady was accountable, directly or indirectly, for a number of deaths considerably in excess of the record. There was one death from stricture of the urethra. Order 6, Septic Diseases. This order comprises Erysipelas, Pyaemia, Septicaemia., and Puerperal Fever, the total deaths registered being 28, against 40, 29, and 35 in 1885-6-7. Erysipelas was the cause of 12 deaths, against 26, 7, and 11 in 1885-6-7, five of them only in the Town sub-district. One of the deaths was of a child under one year of age. Pycemia and Septicaemia were the cause of 7 deaths; 6 of them in the Town sub-district. There were 7, 3, and 7 deaths from these causes in 1885-6-7. Puerperal Fever was the registered cause of nine deaths, against 7,19, and 17 in 1885-6-7 respectively: seven of them in the Town sub-district. Three of the deaths were of women between 15 and 25 years of age, four between 25 and 35, and two between 35 and 45. In addition to these nine deaths, ten deaths, six of them in the Town sub-district, were registered as having occurred in " childbirth," as against 9, 15, and 13 in the three preceding years. Puerperal fever is a communicable disease depending on "blood poisoning," whereas other causes of death connected with child-birth are, so to say, accidental, e.g., hemorrhage ("flooding"). The deaths registered as having 97 been caused by diseases and accidents associated with parturition (19) were equal to 5 per 1,000 live births, against 4.0, 5.8, and 7.6 per 1,000 in 1885-6-7 respectively. Class 2.—Parasitic Diseases Include Thrush and other Vegetable Parasitic Diseases, two deaths; and "Worms, Hydatids, and other Animal Parasitic Diseases," no death. Class III.—Dietetic Diseases Were the causes of 17 deaths, 14 of them in the Town subdistrict. To Want of breast milk and Starvation 3 deaths were classified, and to Scurvy none. Delirium tremens was the cause of deaths, against 2, 10 and 4 in 1885-6-7: Chronic alcoholism of ten deaths, against 4, 10 and 9. Of the 14 deaths in 1888,11 were registered in the Town sub-district. It is scarcely necessary, perhaps, to remark that, if all the deaths due, directly or indirectly, to the immoderate use of intoxicating liquors could be ascertained, "Alcoholism" would occupy a more prominent position in the "Bills of Mortality but many deaths due to the abuse of alcohol get certified, and therefore are classified, to visceral and degenerative diseases, caused or aggravated by "drink." Man's ingenuity in the discovery of alcohol, it may be truly said, is accountable for a large share of the misery of his race. "The drink" is a 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 comprises the causes of 569 deaths (=20 per cent, of total deaths), including 123 of children under the age of five years; 443 of the deaths were registered in the Town sub-district, and 126 in Brompton. h 98 Rheumatic Fever and Rheumatism of the Heart caused 18 deaths, four of them in the Brompton sub-district; Rheumatism, two deaths. In fatal cases of rheumatic fever the immediate cause of death, not unfrequently, is disease of the heart arising in the course of the malady; and of the deaths certified from heart disease at later periods of life, not a few might properly be ascribed to rheumatism as the primary cause. But the connexion between the two diseases is either overlooked or, it may be, unknown to the certifying practitioner. In the new classification, deaths due to rheumatic disease involving the heart are distinguished from deaths due to rheumatism without such complication. Gout was the cause of nine deaths (five of them in the Town sub-district), and Rickets of five. Cancer, Malignant Disease, was accountable for 121 deaths; 92 in the Town sub-district, and 29 in Brompton. Cancer is on the increase in the country generally: possibly, however, some portion of the increase in deaths classified to this cause may be due to more accurate diagnosis. The deaths in Kensington from this cause in the previous ten years were 79, 95, 90, 112, 92, 128, 117, 119, 128, and 117 respectively. Deaths from cancer are usually more numerous, proportionally to population, in the Brompton sub-district, than in the relatively poorer Town sub-district. Cancer, in fact, is quite as prevalent, probably even more prevalent, amongst well-to-do people, than in 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, moreover, being for the most part one of later life. One hundred and four of the deaths took place at ages above 45, and 12 between 35 and 45. It is proper to mention that in Table 3 (Appendix) the deaths assigned to cancer have been classified to cancer irrespective of the question whether any other disease was named in the medical certificate, or whether cancer was the immediate cause of death. 99 Purpura, Hemorrhagic Diathesis, was the cause of two deaths, Anæmia of one death Glycosuria, Diabetes Mellitus, was the cause of 14 deaths, nine of them in the Town sub-district. The remaining diseases in this Class belong to the group designated 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 population. Generally hereditary, these diseases are nevertheless susceptible of considerable amelioration under improved sanitary arrangements. Scrofula is unknown in Hygieapolis ! Pure air and sunlight, efficient drainage and its corollary, a dry subsoil; good food warm clothing, and temperance in all things, are powerful antidotes to the bane of tubercle, which is fostered by dirt and squalor, by cold and nakedness, by vice and intemperance, by the want of the proper necessaries of life, by over-crowding in ill-constructed, uuventilated, 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 amongst the well-todo classes are frequently traceable to the influence of heredity : modern researches, however, which have thrown great light on the origin of tubercle, raise a presumption that tuberculosis may be an infectious disease—a specific fever of slow progress with a veiled resemblance to other specific eruptive fevers ; we are encouraged to hope, therefore, that a remedy may ultimately be found for this great scourge of the human race. Tubercular diseases were the registered causes of 400 deaths (against 441, 440 and 393 in 1885-6-7), viz , 320 in the Town sub-district, and 80 in Brompton; 117 of the deaths being of children under five years of age. The numbers in the four quarters of the year respectively were 93, 10 5, 98, and 106: 199 in the winter and 201 in the summer quarters. In a few instances phthisis was returned as the cause of death in earliest infancy, a period of life at which the tubercular diathesis commonly manifests itself H 2 100 in other parts of the body than the lungs; e.g. brain, bowels, etc. Such deaths have been classified, in Table 3. with those certified from "other forms of tuberculosis, scrofula," the total being 63 (of which 44 occurred under five years of age), including 11 registered in the Brompton sub-district. Tabes Mesenterica, popularly known as "consumption of the bowels," was the cause of 27 deaths, including two only in Brompton; all of them under five years of age, and 15 under one year. Tubercular Meningitis and Hydrocephalus (water on the brain) were the causes of 51 deaths, 10 of them in Brompton, and 45 under five years of age. Phthisis, popularly known as "decline," or "consumption," was the cause of 259 deaths; one under five years of age, eight between 5 and 15 years, and 239 between 15 and 65; viz., 26, 72, 70, 45, and 26 in the five decades consecutively; eleven deaths were registered at ages over 65. The quarterly numbers were 64, 66, 60, and 69. Of the total 202 belong to the Town sub-district, and 57 to Brompton. The deaths from tubercular diseases were, as usual, disproportionately more numerous in the Town sub-district than in Brompton, a fifth of them 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 that the deaths ascribed to tubercular diseases do not comprise all of the deaths originating in the tubercular diathesis, and that many deaths of children classified to premature birth, atrophy, debility, convulsions, &c., were primarily due to the scrofulous taint. In numerous instances some other disease, e.g., of the lungs, as bronchitis, pneumonia, &c., was associated with phthisis in medical certificates of the cause of death ; but all such associated diseases have been disregarded in the preparation of Table 3 for when phthisis was returned the death is classi6ed to that heading, it being assumed that the tubercular diathesis was underlying the other disease, and was in fact the primary cause of death. 101 Class 5.—Developmental Diseases. In this Class the total deaths were 155, viz., 118 in the Town sub-district, and 37 in Brompton Premature Birth was the assigned cause of 55 deaths; Atelectasis of 3, and Congenital Malformation of 11. Old Age was the registered cause of 86 deaths, 81 of them at ages over 65 : between 75 and 85 there were 50 deaths so classified, and 23 at 85 and upwards. Class 6.—Local Diseases. The diseases in this ('lass, containing eleven Orders, named after the systems or organs to which the diseases relate, were accountable for 1,401 deaths, or 49.6 per cent, of the deaths from all causes: 1,106 were registered in the Town sub-district, and 295 in Brompton; 39.5 were of children under five years of age. 1. Nervous System.—Diseases of the nervous system were the registered causes of 310 deaths (against 288, 302, and 289 in 1885-6-7); viz., 243 in the Town subdistrict, and 67 in Brompton: 71 of the deaths were of children under five years of age. The quarterly numbers were 72, 67, 86, and 85. The fatal diseases were Inflammation of Brain or Membranes, 21 deaths ; Apoplexy, Softening of Brain, Hemiplegia, Brain-Paralysis, 147 (111 in the Town sub-district, 36 in Brompton, and 134 at ages over 45); Insanity, General Paralysis of the Insane, 1; Epilepsy, 15, Convulsions 54 (all under five, and 47 under one year); Laryngismus Stridulus (spasm of glottis), 5 ; Disease of Spinal Cord, Paraplegia, Paralysis - Agitans, 12; Other Diseases of Nervous System, 52. Convtdsions 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 disease 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, is not 102 frequently the assigned cause of death of children "found dead in bed." 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 in some of the cases the children had been "overlaid," i.e., suffocated—a remark equally applicable to deaths attributed to convulsions, in the case of children found dead in bed. The cause of death in such cases—whether spasm of the glottis or convulsions be returned—can be only guessed — at when the child has not been seen to die; for examination after death cannot prove the occurrence 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). Two deaths were registered from these causes. 3. Circulatory System.— The deaths due to diseases of the organs of circulation, heart and blood vessels, were 196 against 170, 163, and 200 in 1885-6-7: 146 were registered in the Town sub-district, and 50 in Brompton. The quarterly numbers were 63, 39, 48, and 46. To specified forms of disease 33 deaths were assigned, viz., Pericarditis, 1; Valvular Diseases of Heart, 24; Aneurism, 2; Embolism and Thrombosis, 6. Other Diseases of Heart caused 159 deaths, and Other Diseases of Blood Vessels, 4 deaths. 4. Respiratory System.— The deaths from the diseases of the chest, phthisis being excluded, were 622; 27 fewer than in 1887, and 22.0 per cent, of total deaths. Of this number 517 were registered in the Town sub-district and 105 in Brompton. The quarterly numbers were 224 and 164 in the first and fourth, or colder quarters, and 160 and 74 in the second and third, or warmer quarters. The deaths under five years of age were 264=42.4 per cent, (against 41.6, 35.4, and 42.7 in 103 1885-6-7); and at 55 and upwards, 244=39.2 per cent, of the whole number (against 42.0, 42.4, and 41.7 in 1885-6-7). These diseases are thus seen to be most fatal at the extremes of life. The prevalence of them varies considerably in different years, depending on the degree of cold in winter and the general character of that season: they are always most fatal when fog, especially "London fog," is associated with low temperature. The fatal diseases were Laryngitis, 16 deaths; Croup (transferred in the new classification from miasmatic" diseases), 27; Emphysema, Asthma, 9; Bronchitis, 388; Pneumonia, 132; Pleurisy, 15; Other Diseases of Respiratory System, 35; Bronchitis and Pneumonia, therefore, were accountable for 520 deaths (including 218 under five years of age), 85 of them registered in Brompton. 5. Digestive System.— The diseases of the various organs concerned in digestion were the causes of 157 deaths; 48 of them under five years of age; 115 in the Town sub-district, and 42 in Brompton. In the new classification, Dentition is included in this Order; it was the cause of 19 deaths under five, 13 of them under one year. Sore Throat, Quinsy, (the latter disease transferred in the new classification from "miasmatic" diseases), were the causes of 6 deaths; Disease of Stomach, 9; Enteritis, 21; Obstructive Diseases of Intestines, 21; Peritonitis, 20. Cirrhosis of Liver was the cause of 24 deaths; Jaundice and Other Diseases of Liver, 31 (including seven under one year); Other Diseases of Digestive System, 6. 6. Diseases of Lymphatic System (e.g., of Lymphatics and of Spleen). No death registered. 7. Diseases of Gland-like Organs of Uncertain Use.—(e.g , Bronchocele, Addison's Disease). Five deaths. 8. Diseases of Urinary Organs.—Of the 77 deaths assigned to these causes, 60 were registered in the Town subdistrict, and 17 in Brompton; three were of children under five 104 years of age. The diseases were Nephritis, 13 deaths; Bright's Disease (Albuminuria), 34; Diseases of Bladder or of Prostate, 15; Other Diseases of Urinary System, 15. 9. Diseases of Reproductive System.— (a) Of Organs of Generation; Male Organs, no deaths; Female Organs, 7; (b) Of Parturition, 10 deaths, viz., from Placenta Prcevia (flooding), 1; Puerperal Convulsions, 2 ; Other accidents of Childbirth, 7. 10. Diseases of Bones and Joints.— Twelve deaths; Caries, Necrosis, 8; Arthritis, Ostitis, Periostitis, 4. 11. Diseases of Integumentary System. — Three deaths. Class 7.—Deaths from Violence. Sixty-four deaths, including 16 under five years of age (10 under one year), are distributed over the four Orders comprised in this Class: 11 of them belong to the Brompton sub district. 1. Accident ok Negligence.— Total deaths, 53 including 7 in Brompton, and 15 under five years of age: viz., from Fractures and Contusions, 32; Burn, Scald, 6; Poison, 3; Drowning, 2; Cut, Stab, 1; Suffocation, generally of infants "overlaid" 9 (including 7 under one year), all but one in the Town sub-district. 2. Homicide.— Two deaths. 3. Suicide.— Of nine suicidal deaths, five belong to the Town sub-district, and four to Brompton. Poison was the cause of death in four cases; Gunshot Wound in two; Drowning, Hanging, and Cut, Stab, in one each. Class 8.—Deaths from Ill-defined and not Specified Causes. This Class has acquired increased importance in the new classification, from the transfer to it of a certain number of ill- 105 defined causes of death from other positions in the old classification. It includes the causes of deaths, 152; 114 under five years of age, and 115 and 37 in the Town and Brompton subdistricts, respectively. The Diseases named are—Debility, Atrophy, Inanition, 100 deaths (all but one under five years, and 99 under one year); Dropsy, 2; Mortification, 4; Abscess, 3; and Haemorrhage, 2; Causes not specified or ill-defined (or such as find no place in Table 8), 41 deaths. DEATHS IN PUBLIC INSTITUTIONS. The only "large public institution" within the parish, in which we are directly interested, is the Parish Infirmary and Workhouse, situated in the Town sub-district. There are several minor public, or quasi-public, institutions; but, with one exception, they do not furnish occasion for special notice. The excepted institution is St. Joseph's House, Portobello Road, Notting Hill—a Roman Catholic Home for aged poor persons of both sexes, brought from various parts, largely from Ireland: but the Registrar-General does not class it as a "public institution." The deaths of non-parishioneis at the Marylebone Infirmary, Notting Hill (349). and at the Brompton Consumption Hospital (106), are excluded from our statistics, but will furnish occasion for a few remarks later on. The deaths of parishioners registered at the Parish Infirmary and Workhouse (352), at the Brompton Consumption Hospital (8), and at outlying institutions, etc. (230), were 590, or 20.8 per cent. on total deaths, the percentage proportion of deaths in public institutions in the Metropolis generally, being 22.5. The Parish Infirmary and Workhouse.— I am indebted to Mr. H. Percy Potter, Medical Superintendent to the Infirmary and Medical Officer to the Workhouse, for the statistics of mortality at these important institutions. The deaths registered in 1888 were 352 compared with 355, 417, and 391 in the three previous years, and were equal to nearly 12.5 per 106 cent, on total deaths. Mr. Potter informs me that the actual deaths in the year were 355, the quarterly numbers being 112, 79, 80, and 81: so that 196 deaths occurred in the first and fourth (or cold) quarters, and 159 in the second and third (or warm) quarters. The deaths of males were 192, and of females 163. The ages at death were, under one year 50 (50 in 1887 also), between one year and 60 years 143 (195 in 1887), and at 60 years and upwards 162 (159 in 1887). Four inquests were held: in one case death was caused by opium poisoning, in one case by burn, in one by convulsions, and in one by heart disease. Summary of Causes of Death. diseases. Between 60 and Under 1 year. 1 year and 60. up wards Total. Nervous System, Diseases of (including Apoplexy and Epilepsy) 1 18 37 56 Circulatory System, Diseases of ... 7 19 26 Respiratory System, Diseases of (including Phthisis) 11 81 60 152 Urinary System, Diseases of ... 5 9 14 Digestive System, Diseases of 1 5 5 11 Tubercular Diseases (excluding Phthisis) 21 2 ... 23 Measles ... 1 ... 1 Diphtheria ... 4 ... 4 Croup ... 2 ... 2 Enteric Fever ... 1 ... 1 Pyæmia (Chronic) ... 1 2 3 Syphilis 3 ... 1 4 Erysipelas ... 1 1 2 Gangrene 1 ... 1 2 Gout ... 1 ... 1 Asthenia 3 ... ... 3 Senile Decay ... ... 15 15 Eheumatism ... 1 1 2 Cancer ... ... 9 14 Trismus (lockjaw) ... l ... 1 Puerperal Mania ... l ... 1 Convulsions 1 1 ... 2 Privation ... ... ... 2 Purpura ... ... 1 1 Premature Birth 8 ... ... 8 Phlegmasia Dolens ... 1 ... 1 Pernicious Anæmia ... l ... 1 Burn ... ... 1 1 Opium Poisoning ... 1 ... 1 50 143 162 355 107 Outlying Public Institutions, Etc.— By virtue of an arrangement between your Vestry and a gentleman in the office of the Registrar-General, I receive, weekly, a return of the deaths of Kensington parishioners occurring in public institutions and other places outside the Parish. In Table 3 (Appendix) all such deaths, 230 in number (against 191, 183, and 213 in 1885-6-7, respectively) are included. The deaths occurred in the following institutions, viz.:— St. Mary's Hospital 68 St. George's „ 30 West London „ 12 Middlesex ,, 6 King's College „ 6 Westminster ,, 4 St. Bartholomew's Hospital 2 St. Thomas's ,, 2 Charing Cross ,, 2 University College „ 1 Royal Free ,, 1 Brompton Consumption Hospital (south branch) 7 Western District Hospital 25 Eastern ,, „ 4 North-Western,, „ 1 South-Eastern ,, ,, 1 Northern „ ,, 1 London Fever „ ,, 1 Cancer (Fulham Road) Hospital 5 Queen Charlotte's ,, 3 Children's (Paddington) „ 14 Children's (Great Ormond Street) Hospital 3 Children's (Victoria) Hospital 4 Lock ,, 1 French (Soho) ,, 1 Heart Disease (Soho) ,, 1 Homoeopathic ,, 1 Station (Westminster) „ 1 Bolingbroke House „ 1 Samaritan „ 1 St. Raphael's „ 1 St. Gabriel's ,, 1 St. Elizabeth's Home 2 St. Saviour's ,, 1 St. John and St Elizabeth Home 1 Lying-in (St. John the Divine) ,, 1 Camberwell House Asylum 1 Paddington Workhouse Infirmary 4 St. George's Union ,, 1 Chelsea Parish „ 1 St. Giles's Workhouse 1 225 The deaths of five male parishioners, in addition to the above, were recorded as follows:— One of a person who died in a cab near St. Mary's Hospital; one drowned in the Grand Junction Canal, Paddington (suicide); one who committed suicide at the Zoological Gardens; and two of men who were killed by the fall of a house in course of erection at Great Titchfield Street. The deaths at Queen Charlotte's Hospital, at the Lock Hospital, and at the Lying-in Home of St. John the Divine, were of children born at those institutions. Deaths from Zymotic Diseases occurred as follows:— Western District (Asylums Board) Hospital, 25 (scarlet fever, 15; diphtheria, 6; enteric fever, 3; measles, 1); Eastern District Hospital, 4 (diphtheria and enteric fever, 2 each); Northern District Hospital, 108 1 (diphtheria); North-Western District Hospital, 1 (scarlet fever); London Fever Hospital, 1 (diphtheria); St. Mary's Hospital, 13 (diphtheria, 12; enteric fever, 1); St. George's Hospital, 2 (diphtheria and diarrhoea, 1 each); West London Hospital, 2 (diphtheria and enteric fever, 1 each); King's College Hospital, 1 (diphtheria); Children's Hospital, Paddington, 1 (diphtheria); French Hospital, Soho, 1 (enteric fever); Homoeopathic Hospital, 1 (diphtheria); and St. Gabriel's Hospital, 1 (whooping-cough). Total, 54. St. Joseph's House, Portobello Road.— The deaths at this quasi-public institution are included in Table 3 (Appendix). They were 30 in number: males 14 and females 16. All of the deaths save two occurred at ages over 60; 19 of them at ages over 70. Fourteen of the deaths were of persons who had been imported from other Metropolitan parishes: eight of the deceased had previously resided in Ireland, and three in the Provinces; four were stated to be parishioners. The causes of death were: diseases of the heart and lungs, 12; diseases of the nervous system, 6; phthisis, 3; old age, 2; and one each from hernia, liver disease, joint disease, Bright's disease, diarrhoea, bed sores, and "fall from a window." The Hospital for Consumption and Diseases of the Chest.—The deaths at this institution, or rather in that part of it—the original hospital—situated in Kensington (a " South Branch" having been established on the farther side of the Fulham Road, in the parish of Chelsea), were 114, viz.: males, 73, and females 41. Eight of the deaths were of parishioners, and are included in Table 3 (Appendix): the remaining deaths, of non-parishioners, are excluded from that Table- Marylebone Infirmary, Notting Hill.— At this hospital, which is under the control of the Guardians of the Poor of the Parish of St. Marylebone, and is even larger than our own Parish Infirmary, 349 deaths of non-parishioners were registered, all of which are excluded from Table 3 (Appendix). 109 DEATHS NOT CERTIFIED. Twelve deaths, males 6 and females 6 (against 12, 25, and 20 in the three preceding years), were returned as not having been certified, either by a registered medical practitioner or by a coroner. None of them occurred in the practice of unregistered male practitioners. One of the deaths was stated to have been registered on the information of a midwife. In the remaining cases there appears to have been no medical attendance. The several cases Were duly reported to the Coroner, who did not deem it necessary to hold inquests. The causes of death, as registered, were: in four cases, diseases of heart, lungs; in three cases, old age; in two cases, paralysis; and in one case each, premature birth, and epilepsy. In one case the cause of death was "unknown." Nine of the deceased were adults (six of them 60 years of age and upwards), three were children, two of them aged one day and one four years. The attention of the Metropolitan Sanitary Authorities was called in 1887 to the subject of uncertified deaths, by the Vestry of St. James, Westminster, that body being of opinion that "no death should be registered unless the cause thereof is certified either by a qualified Medical Practitioner, or by the Medical Officer of Health for the District, or by the Coroner upon inquisition." If it is meant that the Medical Officer of Health should, as a part of his duty in that capacity, inquire into and, if practicable, certify the cause of death, I for one should respectfully prefer not to come under any such obligation. It was stated that "at present three to four per cent, of the total deaths are not certified at all." The proportion of uncertified deaths has steadily declined from 4.7 in 1879 to 3.1 in 1888. The percentage varies within wide limits. In 1888 it was l.0 per cent, in London; 0.4 in Kensington; ranging upwards to 7.0 in Wales, where probably certification is often impracticable, because, by reason of the inaccessibility of the place of death, or remoteness from a doctor's residence, medical 110 attendance cannot be obtained. In such cases, which, I believe, constitute a large proportion of the total number, the suggested duty would be altogether impossible of performance. It would take up too much space to deal exhaustively with the subject, but I may further remark, speaking now from my experience in this parish, that of the 12 to 20 uncertified deaths that occur annually, nearly all are referred to the Coroner, and registration of death takes place only after the Coroner's decision that inquisition is not necessary. The inquiry by Coroners' officers is not satisfactory, and in cases like many of those in which inquisition is now held, it is probable that inquiry by an expert—e.g., a Medical Officer of Health—would save the time of Coroners and jurors, and some expense to the rates—if his decision that there was no necessity for inquest were to be accepted. In this case the Medical Officer would practically become "Coroner's Officer," as the St. James's Vestry propose. If suitably remunerated for his task, he might reasonably be authorised to inquire, in the first instance, into the cause of uncertified deaths; and to certify in proper cases, referring those from violence to the Coroner. Any such change would require legislation to give it effect; but it may be doubted whether the legislature, would entrust to any individual powers of such an exceptional nature. In the case of deaths registered as "not certified," after report to the Coroner, it cannot be doubted that inquiry and report by a Medical Officer would be more satisfactory than that by a Coroner's Officer, and could be obtained were provision made for payment of a suitable fee. Presumably, the deaths "not certified" in mountainous districts are not even referred to a Coroner. In some of the manufacturing towns there is much "medical" practice by unregistered persons, upon whose information, probably, many deaths are registered*; registration being required by law, which medical certification is not—excepting in the case of patients who have * The percentage of uncertified deaths to total deaths in 1888 was 5.6 in Hull, 5.5 in Sheffield, 5.4 in Halifax, and 5 in Liverpool, 111 been duly attended in their last illness by a registered practitioner. I am of opinion that when death ensues in the case of persons attended by unregistered practitioners an inquiry should be made, for the fear of inquisition would tend to limit illicit practice, which, as a very general rule, must be to the public detriment. The subject of uncertified deaths has engaged the attention of the Society of Medical Officers of Health on more than one occasion, and some years ago this Society passed the following resolution, viz.:— "That all cases of uncertified deaths 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 proposed investigation should devolve on the Medical Officer of Health as a part of his ordinary work, but the Society did not approve this view, the adoption of which would impose on the Medical Officer an onerous and responsible duty, seeing that "uncertified "deaths include all "inquest cases" as well as those deaths described as "not certified." Of all the unsatisfactory arrangements connected with uncertified deaths, it was felt that the least defensible is that which makes the Coroner's Officer de facto judge, in a doubtful case, whether an inquest should be held, and the Society, at my instance, adopted the following resolution bearing on the subject:— "That the present system of investigation of deaths referred to a Coroner, viz., by an officer having no special qualifications for the discharge of the duty, is unsatisfactory." It follows as a corollary to this proposition that the firstinstance inquiry should be made by an expert, 112 INQUESTS. One hundred and sixty-four inquests were held on parishioners, 115 in the Town sub-district, 24 in Brompton, and 25 at places beyond the parish, mostly at public institutions (hospitals) to which the deceased had been removed for treatment. Twenty of these cases belong to the Town sub-district, and 5 to Brompton. The subjects of inquest were males 87, and females 77. The ages at death were: Under five years 48, including 35 under one year; between 5 and 60 years, 84; at 60 and upwards, 32. The cause of death is stated to have been ascertained by post-mortem examination in 107 cases. Eleven of the subjects were illegitimate infants. The Deaths from Violence were 64, of which 11 belong to the Brompton sub-district. The grounds for holding inquests are, usually, the suddenness of death, or the circumstance that death had been caused by violence. In many instances the Coroner's returns show that the deceased had been "found dead," in bed, or otherwise. The causes of death may be classified as follows :— Deaths caused by disease 100 Deaths caused by Violence— Accidental - 53 Suicidal 9 Homicidal 2 64 164 113 The fatal diseases may be classified as follows:— Diseases of the brain (including convulsions, 9, and spasm of the glottis, in infants, 2) 23 Diseases of the heart (38), and of the lungs (19) 57 Other visceral diseases 5 Tubercular diseases 3 Wasting diseases of infants 4 ''Syncope" 2 Hemorrhage (in parturient women) 2 Alcoholism, Hemorrhage, Teething, and Congenital malformation (one each) 4 100 The violent deaths were classified as follows: — Accident: Suffocation (in bed) of infants under one year 7 Choked with food (female set. 53), and suffocated by a fall from bed (female set. 60) 2 Burn (4), Scald (2) 6 Drowning - 2 " Poisoned (by over-dose of chloral hydrate" 2) 3 Cut, stab 1 Fractures and Contusions (32), viz.— Run over 5 Falls, under a variety of circumstances 23 Crushed and suffocated by fall of a house in course of erection 2 Other injuries 2 Forward 53 114 Brought over 53 Suicide: By hanging 1 By gun-shot wound 2 By drowning 1 By poison 4 By cut throat 1 Homicide: Wilful murder (infant) 1 Manslaughter 1 Total 64 The Suicidal Deaths, 9, of which 3 belong to the Brompton sub-district, comprise 7 of males and 2 of females. The females, aged 31 and 38 respectively, died by drowning, and by cut throat. The cause of death in the male sex was poison, 4, pistol-shot wound, 2, and hanging. The specified poisons employed were bichromate of potash, sulphuric acid, laudanum, and strychnine. Two deaths by chloral hydrate were not returned as suicidal, and therefore have been classified as accidental. In other two violent deaths, open verdicts were returned, and the deaths therefore have been classified as accidental. The Homicidal Deaths registered were 2, viz., of a man aged 30, who was killed in a fight or scuffle by falling against the kerb (manslaughter), and of a newly-born infant found in a mutilated condition in a drain. The verdict of "wilful murder," in this case, however, was not ratified upon further inquiry. Among the deaths described as "sudden/' "found dead," etc., there were, as usual, many due to curable visceral diseases, and there must have been culpable neglect of the deceased, in that medical attendance had not been procured, although the illnesses probably extended over many days, and could scarcely 115 fail to be marked by obvious symptoms of a more or less serious and painful nature. The mere finding of the "cause of death," in such cases, seems scarcely to satisfy the requirements of justice; considering that the death of any person—and particularly of one very young or very aged—from such diseases as pneumonia, bronchitis, &c., when there has been no medical attendance, 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, on several occasions, been found guilty of manslaughter. The inquest cases in Kensington were in the proportion of 5.8 per cent, of the total deaths; the rate in the Metropolis being 7.4 per cent., and in England and Wales 5.6 per cent. The reported deaths from different forms of violence were equal to 2.3 per cent, of the deaths from all causes in Kensington, the proportion in the Metropolis being 3.7 per cent., and in England and Wales 3.3 per cent. METEOROLOGY. The mean temperature of the air at Greenwich, in 1888, was 47°.7 Fahrenheit, 10 below the average of 115 years and 1.6 below the average of 45 years: the means in the four quarters respectively were 36.9, 51.6, 57.6, and 44.6. The highest reading by day (89.0) was registered in the week ended June 9th, and the lowest reading by night (18.4) in the week ended February 4th. The highest weekly readings by day, in the four quarters respectively, were 56.5, 89.0, 87.7, and 684; and of the lowest readings by night, 18.4, 26.3, 414, and 24.8. The hottest week was that which ended August 11th (mean temperature, 63.9), and the coldest week that which ended I 2 116 February 25th (mean temperature, 29.8). August was the hottest month (mean temperature, 59.1); and February the coldest (mean temperature, 35.0). May exhibited the greatest range in temperature, viz., 43.0:— from 76.8 to 33.8; and November the smallest range, viz., 25.9:— from 59.4 to 33.5. The dryness of the atmosphere, i.e., the difference between the dew-point temperature and air temperature, was 5.2, or 1.3 below the average of 45 years. Rain fell on 167 days, the total amount registered in the year being 27.49 inches, 2.44 more than the average of 72 years. Most rain fell in July (6.75 inches), and least in September (0.73). The means of the readings of the barometer were 29.777 inches; the means of January, 30.053, and of March, 29.432, being, respectively, highest and lowest. The relative proportion of wind was: north, 90; east, 67; south, 103; and west, 106. VACCINATION. Table X (Appendix) is a return respecting vaccination in 1887, compiled by Mr. Shattock, the Vaccination Officer, whose energetic discharge of the duties of his appointment it is always a pleasing duty to recognise. The return shows a loss of 5.9 per cent in the cases, against 3.9, 4.6, and 5.4 in the three preceding years, "from 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, the loss is somewhat greater than in Kensington. In England and Wales, as we learn on the authority of Dr. George Buchanan, Medical Officer to the Local Government Board, "the returns give evidence of about 95 per cent, of the infantile population having received the benefits of vaccination within the first year" after their birth; it follows that the infant population is made up of "19 vaccinated to each unvaccinated individual." With regard to the protection against small-pox afforded by vaccination—differing in degree as this does according as the vaccination is more or less "successful"—it should be unneces- 117 Sary to say anything; hut the pertinacity with which some misguided persons still decry the most beneficent of medical discoveries shows no sign of abatement, and as their teaching is calculated to prejudice the general public against the wise compulsion authorized by law, I do not hesitate to refer again to the pregnant proofs of the efficacy of vaccination, as a protection against small-pox, contained in the annual report for 1881 of the Medical Officer to the Local Government Board, not long since re-published. Dr. Buchanan refers, in the first place, 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 from which I extract the following Table:— Comparative Small-pox Death Bates 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 Dr. Buchanan's further remarks went to show the great reduction in small pox mortality in children under ten years of age, a limit which in 1881 embraced the period within which vaccination had been efficiently compulsory. In children under 10 the deaths from this disease in 1881 were a hundredfold more numerous among the unvaccinated than among the vaccinated; or, to put it in another way: If the vaccinated children had died at the same rate as the unvaccinated, not 125 deaths, but more than 12,000 would have happened, and if the mortality 118 among unvaccinated children had been at the same rate as among the vaccinated, not 782, but nine deaths would have happened. In an Appendix to Dr. Buchanan's last Report, the protective influence of vaccination is dealt with in the form of an introduction to Dr. Barry's Report on an Epidemic of Small-pox at Sheffield during 1887-88. In that town, with an estimated population of 320,000, a vaccination census was made under Dr Barry's direction during the continuance of the epidemic, the result being to show that two per cent, of the people were without the protection afforded by vaccination. Small-pox death-rates were calculated for different ages, between April, 1887, and March, 1888, and it is stated that "the one fact" (as to protection conferred by vaccination) "turns out to be uniformly the same, for sub-districts, for locality, for infected house or institution, for age or for previous health." Dr. Buchanan sets out the results of the enquiry as follows:— A. First of the children under 10 years of age living in Sheffield, during 1887-8, under the common conditions of the whole borough. Per thousand of the number of children in each class : The attack rate of the vaccinated was 5 The attack rate of the unvaccinated was 101 The death-rate of the vaccinated was 0.09 The death-rate of the unvaccinated was 44.0 Or to state the difference in other terms: For 100,000 vaccinated children the rate of small-pox mortality actually observed in Sheffield gives nine deaths; for 100,000 unvaccinated children tne rate of small-pox mortality actually observed gives 4,400 deaths. Under the general circumstances of the Sheffield epidemic, therefore, the vaccinated children had, as compared with the unvaccinated children living in the town, a twenty-fold immunity from attack by small-pox, and had a 480-fold security against death by small-pox. The above relates to the general children-population of the borough. 119 Children living in houses actually invaded, were of course exposed to an intenser and more continuous infection. Per thousand of the number of children of each class living in invaded houses:— The attack rate of the vaccinated was 78 The attack rate of the unvaccinated was 869 The death rate of the vaccinated was 1 The death rate of the unvaccinated was 381 Under these extreme yet identical circumstances, therefore, the vaccinated children had, as compared with the unvaccinated, an 11-fold immunity from attack by small-pox and a 381-fold security against death by small-pox. In bye-gone days the rate of small-pox mortality was much higher among children under 10 years of age, than in persons above that age. The converse is now the fact, owing to the superior protection afforded to the children under Compulsory Vaccination Law. B. The protective influence of vaccination is further illustrated by Dr. Buchanan, as follows:— Concerning persons over 10 years of age under the common conditions of infection in the borough. Per thousand of the number of persons over 10 in each class : The attack rate in persons twice vaccinated was 3 The attack rate in persons once vaccinated was 19 The attack rate in persons not vaccinated was 94 The death rate among persons twice vaccinated was 0.08 The death rate among persons once vaccinated was 1.0 The death rate among persons not vaccinated was 51.0 Or to state the difference in other terms: For 100,000 persons over 10 years old and twice vaccinated, the rate of small-pox mortality actually observed would give eight deaths. For 100,000 120 persons over 10 years old and once vaccinated, the rate of smallpox mortality actually observed, would give 100 deaths. For 100,000 over 10 years old and not vaccinated, the rate of small-pox mortality actually observed, would give 5,100 deaths. Under the general conditions and circumstances of the Sheffield epidemic therefore, the twice vaccinated persons over 10 years of age as compared with the unvaccinated persons of the same age living in the town, had a 31-fold immunity against attack by smallpox, and had a 640-fold security against death by small-pox. Next is considered the position of vaccinated persons, aged over 10 years, who live in houses actually invaded by small-pox. The attack rate of the vaccinated was 281 The attack rate of the unvaccinated was 686 The death-rate of the vaccinated was 14 The death-rate of the unvaccinated was 371 Thus the vaccinated people over 10 years of age had as compared with the unvaccinated, a more than double immunity from attack by small-pox, and a 26-fold security against death by small-pox. The difference between vaccinated and unvaccinated when persons over 10 are in question, is vastly less than in the case of children. C. Influence exerted by vaccination upon the people of all ages living in Sheffield, under the common conditions of small-pox infection in the Borough generally. Per thousand of the number of persons of all ages in each class:— The attack rate in the vaccinated was 15.5 The attack rate in the unvaccinated was 97.0 The death-rate in the vaccinated was 0.7 The death-rate in the unvaccinated was 48.0 It follows that under the general circumstances of Sheffield during the epidemic, the vaccinated persons of all ages had, as compared with unvaccinated persons of all ages, a 6-fold immunity against attack by small-pox. and that they had a 64-fold security against death by small-pox. 121 Restricting the comparison to the vaccinated and unvaccinated people of all ages who lived in invaded houses. Per thousand of the two classes of people:— The attack rate in the vaccinated was 230 The attack rate in the unvaccinated was 750 The death-rate in the vaccinated was 11 The death-rate in the unvaccinated was 372 Thus people if they were vaccinated had a more than treble immunity against attack by small-pox, and a 34-fold security against death by small-pox, as compared with their not vaccinated fellows, residents in invaded houses. The following facts are interesting as showing the comparative protection afforded by vaccination to persons actually attacked by small-pox against the more severe form of the disease, which is often followed by disfigurement, and by a variety of sequela; more or less serious. The experience of 1,741 patients treated in hospitals gave 17.2 severe and confluent cases out of every 100 small-pox patients of all ages who had been vaccinated, and 81.5 of the same forms of small-pox out of every 100 attacks in people of all ages who had not been vaccinated. For children under 10 the corresponding figures were 9 and 78. In the hospitals the familiar immunity of revaccinated persons in attendance on the sick was observed. Of 161 employed 18 had had small-pox and none of these fell ill: 02 persons had been vaccinated in infancy only, and of these 6 were attacked and 1 died; the remaining 81 persons had been successfully revaccinated, and not one of these contracted smallpox. Of 830 troops nominally all revaccinated, 12 men were attacked by small-pox and one died. The operation of revaccination had been attempted on these 12 men, but had been unsuccessfully performed. Of 372 men in the police force 10 constables who had been vaccinated, but not re-vaccinated, took small-pox before February 10,1888, when an order for universal revaccination of the force was issued: thenceforward till the end of the epidemic, there was no other attack among the police. Of 290 men and boys on the permanent staff of the Sheffield Post Office, 122 the whole had been revaccinated at the time of their engagement. Throughout the epidemic, up to August, 1888, no member of the staff contracted small-pox. It may here be mentioned that the epidemic of small-pox, 1887-88, gave rise during the two years to 22.2 attacks and 2.07 deaths per 1,000 population of all ages, and that the whole population of the Borough has now-a-days, owing solely to the enormous reduction of the death-rate in children, a small-pox death-rate of 72 per cent, below its former amount. Where people over 10 have undergone a second vaccination, they have recovered the immunity from small-pox which they had as children. The following further illustration of the protection afforded by vaccination is given:— If the vaccinated children of Sheffield up to the date of the vaccination census had been attacked at the rate that the unvaccinated were attacked, there would have been 7,000 attacks among such children in the place of the actual 353, and there would have been close upon 3,000 deaths amongst such children in the place of the actual 6 deaths; or there would have been up to the conclusion of the epidemic, 4,400 deaths among such children in place of the actual 9 deaths. This is what vaccination has done for Sheffield children under 10 years of age. Dr. Buchanan makes the following reflection: If we can imagine a complete forfeiture in 1887 by all the inhabitants of the protection they have from vaccination, the 200,000 people over 10 living in Sheffield would (at the current rate of death observed among unvaccinated persons of that age up to the date of the census) have experienced over 10,000 deaths instead of the actual 368. In a concluding paragraph Dr. Buchanan observes that Dr. Barry says nothing in his report of deaths resulting from the vaccination of 9,000 children each year in Sheffield; he himself therefore states, as regards the last three years (having no earlier data) that no death certificate received from Sheffield has made any mention whatever of vaccination. The current rate of the country would give for a population of 300,000 persons 0.5 (or 1 in 600,000) as the yearly number of such death certificates. 123 Animal Vaccination; Calf Lymph.— An objection to "ann-to-arm" vaccination has been based on the fact that, as the lymph is passed through the human system, it may become the means of transmitting enthetic disease. This danger, however, though by no means to be disregarded, appears to be slight, and in practice almost inappreciable, seeing that Dr. Buchanan states that he "cannot learn of communication of syphilis in vaccination being actually effected once in a million of vaccinations." Nevertheless, and it being desirable to remove every impediment to the full acceptance of vaccination, it would be satisfactory to know that the Local Government Board had made arrangements for affording to parents the option of having their children vaccinated with calf-lymph at the public vaccination stations.* The Government at present only supplies medical practitioners with "stock" lymph from the calf to enable them to start a series of vaccinations. The use of calf-lymph is common on the continent, and the system of animal vaccination has been carried to great perfection at Brussels, whence regular supplies of lymph are forwarded to this country, tubes and charged ivory points being procurable at a moderate price. Stations, moreover, public and private, have been established in London, at which persons can be vaccinated direct from the calf. This direct vaccination is highly successful at the Government Stations, an average of 988 vesicles resulting from 1,000 insertions of calf-lymph. "This rate of success," Dr. Buchanan observes, "is nowise to be had when the lymph" (human or animal) "is used in any preserved condition." Preserved lymph, indeed, is said to be attended with perfectly successful results, in the Army Medical Department, in only 40 per cent, of the cases; so that the protective power of vaccination cannot be fully and universally obtained, excepting by the use of lymph taken direct from a vesicle, whether human or animal. * This option is now given at the Vaccination Stations in Kensington, the Guardians having made arrangements for a supply of fresh calf-lymph weekly, on the days appointed for Vaccination. 121 SANITARY LEGISLATION. Before entering upon customary details of the work of the Inspectors, Tinder the Nuisances Removal and other Acts, I may again refer to the "Special Report on Sanitary, Nuisances Removal, and other cognate Acts," by the Law and Parliamentary Committee, resulting from an enquiry, on reference by your Vestry, "Whether the provisions of the various Acts have been and are being enforced by the Vestry as fully as the circumstances of the Parish demand; and if not, to advise as to the steps it is desirable to take for their better enforcement; and also whether any amendment of the law may appear necessary ?" The first step taken by the Committee was to obtain reports from the Surveyor and the Medical Officer of Health, "with respect to any special matters which in their judgment have not hitherto received, but which should receive, the attention of the Vestry." These reports, in the result, formed the basis of the Committee's enquiry and report, and with that report, which was unanimously adopted by your Vestry, were published and widely circulated. It will suffice, therefore, to say, for my own part in the matter, that attention was frankly called to all of the points which appeared to me to require consideration, whether regard be had to failure to exercise existing powers or to the need for additional powers. The Committee expressed their views on each point raised, and made valuable suggestions in regard to "better enforcement" of the law, and to the need for ''amendment of the law." Their conclusions, however, were reassuring, for they found that "the Acts referred to are, upon the whole, satisfactorily administered in Kensington," and that the Acts themselves are also fairly sufficient, defect taking the form rather of difficulty in putting the law into speedy operation than in the terms of the law itself. The reports were, by your Vestry's direction, reprinted lately, and forwarded for the information of the members of the London County Council. 125 My report, elated March 13th, 1885, dealt, in sections, with the following subjects:— 1. The Housing of the working classes. 2. Underground rooms. 3. Construction of drains. 4. Inspection of drains, &c. 5. Vestry to cause work to be done at owner's expense. 6. Vestry's mode of procedure. 7. Rules with respect to house drainage, &c. 8. Power of Metropolitan Board of Works to make Bye-laws, &c. 9. Public conveniences. 10. Drinking fountains. 11. Paving and drainage of private mews, courts, &c. 12. Consumption of smoke. 13. Periodical removal of manure, and other refuse matter. 14. Trade refuse. 15. Infectious-disease hospitals: Ambulances. 16. Disinfecting chamber. 17. Defective enforcement of tary Law. 18. Amendment of the Law ; mary powers needed. 14 & 15 Vic., c. 34; 29 Vic., c. 28 ; 30 Vic., c. 28. 18 & 19 Vic., c. 120, s. 103, p. 57*; 25 & 26 Vic., c. 102, s. 62, p. 207; 18 & 19 Vic., c. 122, s. 23, p. 266. 18 & 19 Vic., c. 120, B. 79, p. 42. 18 & 19 Vic.,c. 120, s. 82, p. 44. 18 & 19 Vic., c. 120, ss. 73, 81, 85, pp. 38, 43, 45 ; & 25 & 26 Vic., c. 102, s. 64, p. 208. 18 & 19 Vic., c 121, s. 14, p. 438; s. 12, p. 436; & s. 13, p. 437. 18 & 19 Vic., c. 120, ss. 73, 76, pp. 38, 40; s. 83, p. 44. 18 & 19 Vic., c. 120, s. 202, p. 126 ; s. 138, p. 83. 25 & 26 Vic., c. 102, s. 83, p. 223. 18 & 19 Vic., c. 120,s. 88, p. 46. 25 & 26 Vic., c. 102, s. 70, p. 212. 18 & 19 Vic., c. 120, s. 100, p. 56, 25 & 26 Vic., c. 102, ss. 80, 81, pp. 222, 223. 29 & 30 Vic., e. 90, s. 19, p. 468. 29 & 30 Vic., c. 90, s. 53, p. t79. 25 & 26 Vic., c. 102, s. 95, p. 231. 18 & 19 Vic., c. 120, s. 202,p.l26. 18& 19 Vic., c. 120, s. 128, p. 72. 29 A 30 Vic., c. 90, s. 22, p. 470. 46 & 47 Vic., c. 35. s. 5. 29 & 30 Vic., c. 90, s. 23, p. 470. 25 & 26 Vic., c. 102, s. 64, p. 208. Various Acts. * The pages referred to are in " Woolrych," 3rd edition, 126 The Committee's report was adopted by your Vestry (January 8th, 1886), and, subsequently, a further joint report by the Committee and the Works, &c., Committee, "as to the best means to be adopted for carrying out the recommendations " contained in the Law Committee's report. The said reports were communicated to the several Vestries and District Boards, and met with considerable approval. They were also forwarded to the Metropolitan Board of Works with a request that action might be taken to obtain amendment of the law in certain respects. The Board, however, "while fully recognizing the importance of the suggestions contained in the ably-prepared documents," "regretted that, in view of the wide range of subjects which are sought to be dealt with," it was not prepared to " proceed to legislation in the direction indicated." THE COUNTY COUNCIL AND BYE-LAWS. In the report above adverted to, I drew attention to the powers of the Board under section 202 of the Metropolis Management Act, 1885, to make Bye-laws for the guidance of the Vestry with respect to house drainage; and, under section 138, with respect to the construction of sewers, adding that they had not exercised these powers. The Law and Parliamentary Committee, commenting upon my observations in their Special Report, expressed the opinion that the said powers might be exercised with advantage, and recommended that the attention of the members representing Kensington at the Board be called to the subject, with a view to their advising the Board to exercise the powers conferred by the Act. I further drew attention to the fact that under section 202 (d) the Board had power to make Bye-laws for "works of cleansing and of removing and disposing of refuse," which 1 thought might ''cover the removal of refuse from houses and other premises," and so enable the Sanitary Authority to deal with the difficult subject of the removal of 127 trade refuse of an offensive character produced upon the premises of fishmongers, poulterers, greengrocers, &c." The Committee recommended that the attention of the Kensington members of the Board be requested to the further question, Whether the Board's power to make Bye-laws for the above purpose might not be exercised so as to assist the Sanitary Authorities in the removal of refuse of an offensive nature ? The Members representing your Yestry on the Board did as requested, but their representations produced no effect. The powers of the Board having devolved upon the London County Council, and it appearing to your Vestry undesirable that the work of the two Committees should fall to the ground, fruitless, it was resolved, at a meeting in April last, to reprint the two Reports, and to forward them, together with the Reports of the Surveyor and of the Medical Officer of Health, to the Council and to the several members thereof. The Reports were forwarded on the 3rd May ; the covering letter stating that "the Vestry, believing that legislation framed upon the lines of the suggestions (contained in the Reports) "would be conducive to the interests of public health in the Metropolis, earnestly hoped that the Reports would receive early consideration from the Council." Shortly afterwards a circular letter (dated 10th May) was received from the Sanitary and Special Purposes Committee of the Council, requesting to be informed whether your Vestry had made Bye-laws "in pursuance of Section 202 of the Metropolis Local Management Act, 1855," for any of the purposes therein referred to, under headings marked respectively (a) (b) (c) and (d). The heading (c) relates to house drainage; the heading (d) to cesspools and privies and ''other works of cleansing and of removing and disposing of refuse." The answer returned was to the effect that "no such Bye-laws have been made by the Vestry, for the reason that the Vestry has no power to make such Bye-laws. The powers originally vested in the Metropolitan Board of Works," it was added, to make Bye-laws for the purposes named, "now vests in the 128 London County Council only." The attention of the Committee was drawn to your Vestry's letter of May 3rd, covering the above-named reports, and special attention was directed to the paragraphs dealing with the subject of Bye-laws. "One of the objects" of tour Vestry's communication, it was stated, "was to press upon the Council the desirability of the exercise by it of the powers conferred by the 202nd section to frame Byelaws." I may perhaps be permitted to add, that, in an Address which I delivered before the Society of Medical Officers of Health, in October, 1884, I dwelt strongly upon the importance of Bye-laws being framed under the provisions of section 202 of the Metropolis Management Act, 1855, and that in April last I sent a copy of the Address to each member of the Council. The Sanitary Committee, it may be hoped, will see their way not only to recommend the Council to frame Bye-laws under the section named, but also to promote legislation upon the other matters of admitted importance brought to the attention of the Council. SANITARY ADMINISTRATION: THE VIEWS OF THE PRESIDENT OF THE LOCAL GOVERNMENT BOARD. The need for improvement in Sanitary Legislation and in Sanitary Administration has not escaped the attention of the President of the Local Government Board, who, in the House of Commons, in March of the present year, made a statement indicating the views and intentions of the Government in regard to these matters, especially in connection with the Housing of the Labouring Classes. Premising that it was "not so much legislation that was wanted as a reform of administration," Mr. Ritchie nevertheless admitted that "much still remained to be done, in the way of legislation, to give effect to the Report of the Royal Commission, 1885, by means of the consolidation and amendment of the Sanitary Acts." He hopes 129 to bring in a Bill in the present Session, which presumably will be drawn oil the lines of measures introduced by Mr. SclaterBooth in 1877, and by Lord Salisbury in 1885, under the title Public Health (Metropolis) Bill. The first measure was opposed by the Sanitary Authorities, and was withdrawn ; the second was brought in too late in the Session to be passed. Your Vestry, upon my recommendation, requested Lord Salisbury to re-introduce the Bill, in the Session of 1887. In acknowledging the communication his lordship expressed his fear that the chances of any such measure becoming law were then very remote. The chances have improved, and it is probable that if the Bill should be introduced this Session it will become law. Your Vestry's Law and Parliamentary Committee reported on the measure (in 1886) as "mainly a Consolidation Bill, but with a few amendments recommended by the Royal Commission on the Housing of the Working Classes." They observed that "it does not in any way touch the Metropolis Local Management Acts; but as it will finally clear the Statute Book of 14 Statutes, all of which are already repealed as regards the rest of England, it cannot fail, if passed, to prove very useful to sanitary authorities and sanitary officials alike." * Mr. Ritchie quoted with approval an observation by Lord Shaftesbury that the Labouring Classes Lodging Houses Acts (1851 to 1885) known as "Lord Shaftesbury's Acts," would, "if properly carried out, meet almost every requirement in regard to the Housing of the Working Classes, and remedy a great part of the existing evils ": he added, however, that although the Housing of the Working Classes Act, 1885, had made the administration of the Acts metropolitan instead of parochial, nothing had been done. Your Vestry's Law Committee, in the report cited above, commenting on my Special Report of March 13, 1885, expressed an opinion that these Acts "could be dealt with satisfactorily only by an authority having power to consider the requirements of the labouring classes in London as a whole.'' Such an authority * Special Report on Sanitary, Nuisances Removal, and other Cognate Acts: January 8th, 188G, page 16. K 130 is the London County Council, which has already shown its interest in the question by appointing a Housing of the Working Classes Committee, whose first report (dated March 12th) intimated that they had "caused an abstract of the Acts relating to the Housing of the Working Classes to be made, with a statement as to the extent to which the powers have hitherto been exercised by the Metropolitan Board of Works aud other local authorities." Mr. Ritchie stated that Lord Shaftesbury's Acts enable the Council to "hire, purchase, erect, furnish, manage, and let houses as lodgings for the working classes." The Council, he added, would also have power to carry out the Artizans' Dwellings Acts, 1868 to 1885 (Torrens's Acts), which deal with small unhealthy areas—e.g., courts and alleys—with single houses, and with "obstructive buildings," which may be demolished. The Metropolitan Board, it may be added, had this power, but never exercised it. The Acts are complicated. By consolidation and amendment their operation might be made more speedy and more effectual. As regards single houses, the power conferred upon the Justices by the Nuisances Removal Act to close a house unfit for human habitation, until specified works of reparation shall have been carried out, would probably suffice for sanitary purposes, especially if reinforced by a provision corresponding to section 96 of the Public Health Act, 1875, which enables the Justices to inflict a substantial penalty on the person responsible for the creation of a nuisance. The Council will have power to deal with large unhealthy areas under Lord Cross's Acts {Artizans' and Labourers' Dwellings Improvements Acts, 1875 to 1888), to which the Metropolitan Board some years since gave extensive effect, having carried through 22 "Schemes," whereby 59 acres of land were acquired and cleared, on which accommodation has been provided for 38,231 persons of the working classes. The amount expended by the Board in giving effect to the Acts exceeded a million and a half sterling (or about £40 per head) ; this being irrespective of the outlay on Model Dwellings erected on the cleared sites by such bodies as the Peabody Trustees. 131 The Board, after taking necessary steps for giving effect to eight additional Schemes, stayed proceedings under the A cts on account of the tremendous cost, to the ratepayers of the metropolis involved in carrying them into effect. It has been alleged that a third of the cost of acquiring the sites was due to excessive valuation of property so bad that demolition was the only possible remedy for the evils to which it gave occasion. Provision against a repetition of this excessive compensation has been attempted to be made in amending Acts passed in 1879, 1882, and 1885; with what effect we may expect shortly to learn, as the County Council have taken in hand two of the Schemes pigeon-holed by their predecessors. Under Cross's Acts the owners of insanitary dwellings have hitherto received more than the fair marketable value of their property. In this respect they have been better off than the owners of houses dealt with under Torrens's Acts, for these may be required to demolish them without compensation; a course for which, but too often, justification might have been found in the condition of houses dealt with under Cross's Acts. THE COUNTY COUNCIL AND THE HOUSING OF THE WORKING CLASSES. The Housing of. the Working Classes Committee of the Council are desirous of working Cross's Acts and Lord Shaftesbury's Acts together, i.e., to build lodging-houses under the last-named Acts upon sites cleared under the first-named Acts. A desirable course, doubtless, but apparently not practicable under existing law. It will be well, however, should it become possible for the Council to enter into competition with the owners of insanitary property, by providing decent homes for the working classes at a moderate but remunerative rent under Lord Shaftesbury's Acts, which certainly should have a trial. The Acts enable the local authority (i.e., the Council) to erect, purchase, or hire houses, etc., either within or without the metropolis. The question will naturally arise, k 2 132 therefore, whether something might not, be done to remedy the evils of overcrowding by schemes providing for the migration of numbers of the people to workmen's towns a little way out of London, where land is less costly—a plan which, with a service of cheap trains, should be practicable. The carrying out of Cross's Acts in London must needs be a costly procedure at all times, and probably much more so than schemes for migration, which, by lessening the present excessive demand for lodgings, might lead to reduction in rents, and thus enable the poorer classes to obtain more and better accommodation. A rent equal to that paid for a model lodging in London would probably provide a remunerative return for the outlay on a cottage and garden within a moderate train-distance of the centre of the metropolis. By a large scheme for migration overcrowding might be diminished, and with it preventible disease resulting from this, the most perilous of insanitary conditions. It is the fact, I believe, that the Model Dwellings erected on the sites cleared under Cross's Acts are not tenanted very largely by the poorest grades of the labouring classes, those who have been displaced by the clearings. Clerks, and superior artizans able to command constant work, commonly occupy these healthy homes. Plenty others of the like class would doubtless be forthcoming were the accommodation greatly extended. These, however, are the classes for whom it might be practicable to provide out of London. For persons in the lower ranks of the labouring classes nothing better, perhaps, than the system in vogue at Glasgow could be devised. In that city "the lowest class of the population, the waifs and strays, too poor or too improvident to be able to rent houses, are provided with furnished airy lodging-houses, with large day rooms, lavatories, &c., where each has a separate clean bed, at the charge (including use of cooking range and utensils) of 3½d. per night ; and these institutions are so managed as to be self-supporting, including 5 per cent, interest on the capital."* This would be *Memorandum by Mr. (now Lord) Cross, Home Secretary, in the Supplementary Eeport of the Royal Commission on the Housing of the Working Classes, 1885 (page 66). 133 an improvement upon our Common Lodging-house system, administered under the supervision of the police, and which I once heard Lord Shaftesbury commend as "the perfection of sanitary administration as applied to the housing of the poor." This system is not so perfect as his lordship supposed, and in view of recent disclosures in connection with it, the County (Council have deemed it desirable to make inquiry into the working of municipal common lodging-houses in Glasgow and elsewhere, and have referred the subject to the Housing of the Working Classes Committee to report thereon. EMIGRATION AS A REMEDY FOR OVERCROWDING. Emigration would seem, at first sight, to be an obvious means of reducing overcrowding, and it is satisfactory to know that the Government have resolved to appoint a Committee whose duty it will be to inquire into various schemes which have been proposed of State-aided emigration from congested districts of the United Kingdom (London included) to British Colonies and elsewhere; to examine the results of schemes that have had a practical trial, and to report generally on the means and conditions under which such emigration may be best carried out, and the countries to which it should be directed. That emigration would be a boon to those who may be assisted to leave this overcrowded metropolis goes without saying; but it must be borne in mind that immigration might, and probably would, neutralize the good effects anticipated from the exodus. The estimated annual increase of the population of London in the eight years, 1881-9, was 65,000. The annual excess of births over deaths accounts for 52,000 only, the remaining number, 13,000, being due to immigration, which probably would increase in extent when it became known that better prospects of work were being opened up by a Government scheme of emigration. 134 OFFENSIVE BUSINESSES. In my last Annual Report I stated that "the only businesses coming under the statutory description 'offensive,' other than that of a 'slaughterer of cattle,' carried on in this parish, were those of 'tallow-melter' and 'fat-extractor.' "The business of the tallow - melting establishment, known as "Tucker's," has now, I am glad to state, been removed to the other end of London; the fat-extracting business, however, is still carried on at Tobin Street, Notting Dale, and gives rise to more or less effluvium - nuisance, notwithstanding improved arrangements and care on the part of the proprietor. But the people living thereabouts are not of a particularly squeamish nature, and do not often complain. Marine Stores.— Every year, during the hot weather, complaints are received in regard to stenches arising in the collection, storage, and removal of bones, fat, and other animal matters in a putrid condition on the premises of "marine store dealers." Other businesses, such as those of fishmonger, poulterer, etc., may be, and often are, the cause of nuisance in connection with the production of REFUSE MATTERS of an objectionable nature, which, useful in their proper place, are liable, when stored or dealt with in private habitations, to become a source of injury to the health of the community. The subject was reported on by me to your Vestry in 1878, under the heading of Filth Removal. In 18801 brought the subject before the Society of Medical Officers of Health, who referred it to a Committee, of which I was appointed the chairman. The report of the Committee embraced consideration of the best modes of dealing with animal and vegetable trade refuse, e.g., from slaughter houses, 135 fishmongers', poulterers' and greengrocers' shops, etc., with a view to its collection, removal, and ultimate disposal, by utilization or destruction. It also treated of house refuse, stable refuse, and cowshed refuse. The Society forwarded the report to the (late) Metropolitan Board of Works, the Vestries and District Boards, etc. It was also circulated largely among Members of Parliament; the Society sharing my view that the subject could not be effectually dealt with save by legislation. For some years I had been directing attention to the question, especially as it bore upon the nuisance arising in the conduct of the business of the marine-store keeper (rag and bone dealer), and ultimately (in 1883) your Vestry resolved to apply to the Metropolitan Board of Works to schedule this particular trade as an "offensive business" under the provisions of the Slaughter Houses (Metropolis) Act, 1871. The Board declined to do this, upon the ground that the business was not such as the legislature intended to be dealt with under that Act. The High Court of Justice (Queen's Bench Division), subsequently, in an appeal case, came to a different conclusion, and declared the business of a rag and bone dealer to be ejusdem generis with those scheduled in section 3 of the Act. In November, 1887, a communication was received from the Special Purposes and Sanitary Committee of the Board on CONVEYANCE OF OFFENSIVE SUBSTANCES THROUGH STREETS. The Committee intimated that they were satisfied that "serious nuisance does arise in the collection and conveyance, through streets, of offensive substances, such as fish-offal, blood, kitchen stuff, etc." They admitted, also, that the provisions of the Nuisances Removal Acts and the Metropolis Management Act do not enable the Local Sanitary Authorities to deal effectively with the nuisance, and that additional legislative powers were necessary. But before recommending the Board to take any steps for obtaining an amendment of the law, the 136 Committee thought it well to ascertain the views of the several Vestries, etc. In compliance with the request of your Vestry, I reported fully on the subject,* my principal contention being that the nuisance can be dealt with effectually only by regulation of the trades, by "bye-laws entailing an adequate and a fixed penalty for offences bye laws made by the Board, but the carrying out of which should be entrusted to the Local Sanitary Authorities." Such bye-laws, I said, "with respect to offensive substances of animal origin, should make provision with regard (1) to storage vessels, which should be of metal, impervious, and covered; (2) to removal in iron tank vans, or, better still, in the storage vessels themselves; (3) to time of daily removal; and (4) to measures for disposal of the refuse." 1 added that it was "open to consideration whether the duty of removing all offensive substances should not be imposed upon the Sanitary Authority at the reasonable cost of the producers thereof." Your Vestry approved my report, and forwarded it to the Board (12th December, 1887), together with a letter, in which it was observed that "the success of the Board's Regulations, made under the provisions of the Slaughter Houses (Metropolis) Act, 1874, suggested the course most likely to succeed in preventing nuisance in connection with the storage, the collection and the conveyance of offensive material through streets, viz., by the creation of bye-laws to regulate in these respects the trades, &c., which involve the production of refuse of an offensive character." The Board's existence having been threatened by the introduction of the Local Government Bill in 1888, no legislation was initiated in that session. Indeed, I believe that the Committee made no report on the subject. The materials collected are available for the use of the County Council, * Vide Annual Report for 1887, pp. 176—89 (inclusive). 187 whose attention will probably be given to it in connection with the subject of bye-laws to which I have already referred (vide p. 126). NUISANCE FROM BRICK-BURNING. Every summer complaints are made in regard to stenches, usually observed in the early morning hours, and almost invariably supposed to be due to sewer gas, but which are actually due to brick-burning in localities beyond the limits of the Parish. The reality of the nuisance is not open to question, and the law is strong enough to put a stop to it; but the process is tedious and costly, as was proved in two important actions decided in the course of the year 1885, in respect of nuisance arising from this cause at Streatham and Hampstead respectively. The decisions in these two causes are satisfactory so far as they go, injunctions having been obtained; but although they hold out hope of success in any similar proceedings, few are the persons rich enough, as in the Streatham case, or the local authorities spirited enough, as in the Hampstead case, to incur the expense and worry of litigation. The nuisance, however, being unquestionable, and such as may be prevented by the adoption of a particular method of burning bricks, viz., in kilns as contradistinguished from the "clamp" system, the subject would seem to be a proper one to be dealt with by legislation. The business of a brick maker is an "offensive" one, in very truth, but it cannot be brought within the provisions of the Slaughter Houses (Metropolis) Act, 1874. The London County Council would be the proper authority for introducing such a measure, and probably the Council would take up the question were it encouraged to do so by the several Vestries and District Boards. But it is somewhat difficult to obtain united action by so many different bodies, and it being nobody's business in particular to initiate proceedings which would involve a good 138 deal of trouble, year after year passes by and nothing is done. The Society of Medical Officers of Health did what it could after the trial of the above-mentioned actions, by drawing the attention of the Metropolitan Board of Works to the subject, in a communication to the effect (1) that there are sufficient reasons for regulating the trade of brick-making by bye-laws, as other offensive trades have been regulated with manifest advantage to the public; and (2) that owing to the considerable distance to which the effluvia of brick-burning travel, and to the fact that many of the brickfields contributing to the nuisance are outside the Metropolitan area, legislation should be general, and apply to areas within a specified distance of centres of population. COMMITTEE FOR CARRYING OUT THE NUISANCES REMOVAL ACTS. With the view of accelerating proceedings in cases of nuisance, your Vestry decided, in February, 1885, to appoint the Works, Sanitary, and General Purposes Committee, to be a Committee to "receive notices, take proceedings, and in all respects execute the Nuisances Removal Act for England, 1855, and all Amending Acts." The Committee meet for the purposes of the Acts once a week, and Notices are issued upon the immediate authority of the Committee, who in due course report their proceedings to your Vestry. Summonses continue to be heard by the Justices, in Petty Sessions at the Vestry Hall, who now sit weekly for the transaction of Sanitary business. THE WORK OF THE SANITARY INSPECTORS. Tables VI. and VIa (Appendix) contain a summary of the work of the Sanitary Inspectors during the year ended March 25th, 1889. One-hundred and fifteen summonses were taken out 139 for offences under the Nuisances Removal Acts, against 80, 99 and 51 in the three preceding years. This number is irrespective of 29 summonses under the Sale of Food and Drugs Act, and 12 in cases of obstruction. Orders were made by the Justices in every instance, for giving effect to Notices previously served on the defendant persons; upon whom, as the law at present stands, no penalty can be inflicted, however serious or long-continued the nuisances for which they are responsible. Under the provisions of Section 96 of the Public Health Act, 1875, which does not apply to the Metropolis, the Justices have power by their Order to inflict a penalty, not exceeding five pounds, on the person upon whom the Order is made, together with all costs. The same power should be conferred upon Courts of Summary Jurisdiction in London* At present the Justices can punish for contempt of Court only, viz., by a penalty not exceeding ten shillings per diem, during continuance of disobedience to their Order. If the Justices had power to inflict a penalty for offences under the Nuisances Removal Acts, disregard of the Local Authority's Notice, which implies continuance of nuisance, with consequent injury to health, to say nothing of the trouble and loss of time to public officers, would be infrequent—always supposing the power were exercised That our cases are proper to be brought before the Justices is obvious from the fact that dismissal of a summons is a rare occurrence. Proceedings were taken in twelve cases for disobedience of the Justices' Orders and penalties were inflicted, in five cases, to the aggregate amount of six guineas : one shilling per day in four cases, and two shillings per day in one case. Proceedings were taken in one case for breach of the Slaughter-House Regulations, a penalty of ten shillings being imposed; the proper amount of the penalty being sixty shillings. * Provision was made for enabling the Justices to inflict a penalty in the Public Health (Metropolis) Bill, 1885, but there was not time to pass the measure, which hitherto has not been re-introduced, but may be during the current Session (vide p. 129). 140 SLAUGHTER-HOUSES (METROPOLIS) ACT, 1874. Section 55 of the Metropolis Buildings Act, 1844, provided for the abolition of Slaughter Houses in London in 1874. These establishments were then numerous, and for the most part unsatisfactory in nearly every respect. Few of them had been built for the purpose—only one in Kensington out of 48. Parliament, upon the report of a Select Committee of the House of Commons, appointed, in 1873, to consider the subject of this and other ''Noxious Businesses," decided that, subject to proper regulations, Slaughter Houses might be allowed to remain, and the above-named Act was passed. In view of probable legislation I had read a paper before the Society of Medical Officers of Health (March 21st, 1874), on "Private Slaughter Houses considered with reference to the report of the Select Committee on Noxious Businessess." In this paper, after describing the unsatisfactory state of the Slaughter Houses, and expressing my preference for the abattoir system, I specified the requirements of a Sanitary Slaughter House; indicated the conditions necessary to be enforced by bye-laws ; foretold that suitable regulations would lead to a large reduction in the number of Slaughter Houses, and insisted on the necessity for a heavy and irreducible penalty for breach of the regulations. The Act was passed; the Metropolitan Board was constituted " Local Authority" for carrying it out, and regulations were framed practically embodying my views. The Regulations, however, made no provision for separation of the lairage from the slaughter house, to prevent the living animals seeing the butcher at his work, nor for an entrance to the slaughter house independent of the house or shop. For both these points your Vestry, at my instance, contended successfully before the justices, and the Local Authority subsequently followed suit. Your Vestry, moreover, insisted upon the provision of a water supply in the lairs. In 1875 I made proposals for amendment of the bye-laws, which were approved by the Society of Medical Officers of Health : but the bye-laws remain now as they were 141 originally framed. They have done much good however, and led to the closing of many of the worst establishments. In 1874 there were some 1,500 Slaughter Houses; in 1888, 732 only. In Kensington 48 were licensed in 1873; in 1874, 31 only. The present number is 22, and no new Slaughter House has been opened since the passing of the Act. The defect of the Act is that it ignores the Sanitary Authorities (Vestries, &c.), whose Medical Officers of Health and Sanitary Inspectors should have been made available for the purposes of inspection and supervision. Such inspection and supervision, however, has been kept up in Kensington with obvious advantage, although your Vestry have no statutory authority, excepting such as is derived from power to oppose the renewal of the annual licence. LICENSED SLAUGHTER-HOUSES. Thirteen of the licensed slaughter-houses are in North Kensington (i.e., the district north of Uxbridge Road), and nine in South Kensington (i.e., the remainder of the parish south of Uxbridge Road). The names of the licensees, and the localities of the premises, are set out in Table XI. (Appendix). The several premises were inspected, in July, by the Works, Sanitary, and General Purposes Committee, who found some of them in a less satisfactory condition than usual, from disregard by the proprietors of certain of the bye-laws, Comparatively little slaughtering is now carried on, and on some of the premises none at all, the licence being kept up apparently with the view of maintaining the value of the premises. It is desirable in the interests of public health that private slaughter-houses should give place to public abattoirs, and that the dead meat trade should be encouraged to the utmost. The several premises are systematically visited by the Sanitary Inspectors, although, as already stated, your Vestry have no statutory right of control over them; the County Council 142 being the local authority under the Act. It is necessary that the Council should be a local authority for the purpose of making regulations, so as to secure uniformity for the whole Metropolis, but the Sanitary Authorities should have concurrent powers to enable them them to enforce the provisions of the regulations. COW SHEDS, DAIRIES, &c. In 1875 I called attention to the Cow Sheds and Dairies in the Metropolis, in a paper read before the Society of Medical Officers of Health, urged the necessity, in the interests of public health, of regulating them by bye-laws, and submitted a draft code, I contended that an Act should be passed, providing for the regulation of Cow Sheds and Dairies ; that the Metropolitan Board of Works should be the Local Authority, to exercise a general supervision, and to make regulations, uniform for the Metropolis ; but that the duty of inspection, etc., should devolve on the Vestries and District Boards of Works. The code, with slight alterations, was adopted and published by the Society as "Model Bye-laws." In 1878 the Board was constituted Local Authority by Section 34 of the Contagious Diseases (Animals) Act; the Privy Council framed the Dairies, Cow Sheds and Milkshops Order in 1879; and Regulations, based upon the code, were made by the Board, under the operation of which as much improvement as could be expected has been effected, seeing that the Board's powers were limited. The Order has proved useful; and soon after its promulgation I was erabled successfully to prosecute a dairyman for carrying on his business while his house was practically a small-pox hospital. One of the regulations provides for a certain amount of cubic or "air space" for each animal. Long before it existed I Lad successfully contended for 800 feet. The Justices adopted my view, with the result that, in the parishes and districts comprised in the Kensington Division, that amount became a standard allowance which has been enforced, although the regulations 143 require only 600 feet tinder certain circumstances. There has been considerable reduction in the number of (low Sheds in the Metropolis, from 1,044 in 1880 to 720 in 1888. In 1878 the number in Kensington was 26; now there are just 12, viz., 8 in North Kensington and 4 in South Kensington. The names of the licensees and the localities of the licensed premises are set out in Table XII. (Appendix). The premises were visited by the Works, Sanitary and General Purposes Committee in July, and found in a satisfactory condition They are licensed for the keeping of 188 cows, but contained 84 only at the time of inspection. In 1885 a new Dairies Order was issued, which enabled the Local Authority to frame more stringent regulations, especially for the prevention of contamination of milk, and spread of infectious disease through the agency of milk, a subject, to which I have already referred, at page 27. The defect in legislation, as in the cognate case of the Slaughter Houses Act, is that no attempt was made to utilise the services of the Medical Officers of Health and the Sanitary Inspectors, the Sanitary Authorities (Vestries, &c.) being ignored. BAKEHOUSES. Under the provisions of the Bakehouses Regulation Act, 1863, the Sanitary Authorities (Vestries, &c.) were responsible for the inspection, &c. of bakehouses. In January, 1879, the supervision of these establishments was transferred to the Factory Inspectors by the Factory and Workshop Act, 1878. The Inspectors, few in number, could not perform the duty, and in the result the bakehouses fell into a state more or less unsatisfactory, depending on the degree of attention bestowed upon them—without statutory authority—by sanitary officials. In some parishes no inspection at all was made, and at last it was seen to be necessary (the Chief Factory Inspector himself being witness) to reverse the legislation of 1878, and to retransfer the control of bakehouses to the Sanitary Authorities, 144 which was done by the Factory and Workshop Amendment. Act, 1883. In my annual report for 1881,1 called attention to the failure of the Act of 1878, and urged the restoration of the status quo ante 1879. At the same time I pointed out the necessity for 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, and 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. These views were adopted by your Vestry in 1882, and in January, 1883, they were communicated to the other Vestries and District Boards. (The subject had been previously taken up and dropped by the St. Pancras Vestry.) The Society of Medical Officers of Health forwarded to the Home Secretary a memorial which I had drafted, in which the grounds for placing the Bakehouses under the Sanitary Authorities were set out. The Operative Bakers' and Confectioners' Union addressed the Government on the subject, in a memorial which stated that "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." And subsequently the President of the Local Government Board received a deputation from the Union, which stated that "the unsatisfactory condition of bakehouses seriously affected the wholesome character of bread, and injuriously affected the health of the operatives.'' The President observed, in reply, that the Government proposed, by legislation, to prevent the construction of underground bakehouses for the future, but that he could not then hold out any promise as to inspection. In the last days ofthe session (1883), however, the Factory and Workshop Amendment Act was passed, by which your Vestry are constituted " local authority," so far as relates to cleanliness, ventilation, overcrowding, and other sanitary conditions of bakehouses—with power to enforce sections 3, 33, 145 34, and 35 of the Factory and Workshop Act, 1878. The President's attention was drawn by me to the imperfect character of the provisions of the Bill qua bakehouses, but there was no time to get it amended. There has been no fresh legislation on the subject since. The Society of Medical Officers of Health subsequently prepared" Suggestions for Regulations with respect to Bakehouses," for the guidance of local authorities. These suggestions were adopted by your Vestry, and communicated to every bakehouse proprietor. The number of bakehouses in Kensington is 149, viz., 82 in North Kensington, and 67 in South Kensington. REFUSE MATTERS. The prevention of nuisance from accumulations of offensive matters, coming under the general description Refuse, is a matter of no little difficulty. The difficulty, common to all parts of the Metropolis, is not likely to be surmounted without legislative action. The subject, in relation to certain important parts of it, was very fully dealt with in my Annual Report for 1887 (at pages 153 and 176), in connection with a report by the Law and Parliamentary Committee, and in my observations on a communication received by your Vestry, November, 1887, from the Metropolitan Board of Works, under the heading" Conveyance of Offensive Substances through Streets." A copy of this report was sent to every member of the London County Council, which is the proper and only body able to deal effectively with the subject. (A summary of my observations in that report will be found at page 136 ante.) HOUSE REFUSE. The collection of ashes, and miscellaneous refuse from nearly 22,000 inhabited houses spread over an area of 2,200 acres, and to the extent of 40,700 loads in a single year, is no l 146 light task. That it is on the whole satisfactorily performed may be inferred from the comparative fewness of complaints, which were numerous when the work was in the hands of contractors. Few as the complaints now are, a not inconsiderable proportion of them results from the neglect of domestic servants to allow the refuse to be removed when the periodical call is made. Nuisance, in the sanitary sense, need not arise even from a full dustbin : when it occurs it is due to improper use of the receptacle by the deposit therein of animal and vegetable matters, of which it may be said that the former has an appreciable value, and should be utilized, while the latter admits of being burned, after drying, on the kitchen fire. A notification to this effect was left at every house in the Parish in 1873, and again in 1883. The work of dust collection has been systematized by division of the parish into districts, and provision has been made for inspection of dustbins and oversight of the "dusting gangs." A call is now made at every house once a week, and further improvement is scarcely possible until the objectionable practice of refuse-harbourage shall have given place to the only rational system of daily, or, at any rate, frequent collection from moveable receptacles, to be provided either by the Sanitary Authority or by the householder. Desirous of dealing with this nuisance in an effective way, your Vestry, in November, 1887, requested the late Metropolitan Board of Works to include in any suitable Bill thereafter promoted by them in Parliament, clauses to confer power enabling Sanitary Authorities to abolish dust-bins, and to enforce provision in lieu thereof, of approved moveable receptacles, in order that a more frequent and accelerated collection of dust might be made. The Board referred the subject to the Works, Sanitary and General Purposes Committee, who addressed a communication to the Vestries and District Boards of Works, intimating that a representation had been made to the Board" as to the 147 desirability of an amendment of the law" in the direction indicated, and stating that" before considering as to any recommendation to the Board " they desired to learn the views of the Sanitary Authorities upon the subject, and inviting suggestions. At the meeting of the Board held August 3rd, 1888, the Committee presented their report, as follows :— "Your Committee have considered the letter referred by the Board on the 25th November last from the Vestry of Kensington, representing the desirability of an amendment of the law so as to enable Vestries and District Boards to enforce the abolition of dust-bins in such districts as may be deemed expedient, and the substitution, in lieu thereof, of approved moveable receptacles ; asking the Board to take such steps in the matter as may appear desirable, and transmitting copy of a report by the Wharves and Plant Committee of the Vestry on the subject. Your Committee have given careful attention to this matter, and have now to report that in their opinion it is not desirable to promote the suggested legislation. Your Committee recommend the Board to adopt that view, and to inform the Vestry of Kensington accordingly." Amendments proposing (1) that the report be referred back for further consideration, (2) that your "Vestry be furnished with a copy of the replies received from the Vestries, etc., on the subject, and (3) that a copy of the report be sent to all of the Vestries, etc., were successively moved and rejected. The report of the Committee was approved, the mover of it remarking that the local Boards had already sufficient power to deal with the matter themselves—a statement which would seem to be borne out by the statement of another member, that the Poplar District Board had in use many thousand pails, and that the system appeared to work well. Nothing can well be more objectionable than the system of dust-harbourage in what may be called the statutory brick receptacles, and it would be satisfactory were Parliament to confer upon the Sanitary Authorities the powers your Vestry desire to obtain. Meanwhile, I am not aware of any reason why the excellent suggestions of the Wharves and Plant Committee, upon which your Vestry's application to the Board was based, should not be carried out, L 2 148 by giving the pail-system an extensive trial in selected districts; seeing that, if successful, it would abolish a serious nuisance by securing a frequent and accelerated collection of the offensive refuse. The subject is important, and it may be expected to receive attention from the London County Council. A constantly increasing difficulty is experienced in finding convenient, i.e., accessible, "shoots" for house refuse, to the deposit of which within their boundaries the Sanitary Authorities of contiguous districts naturally object. The refuse, moreover, has little value now that building operations are being prosecuted upon so limited a scale in, or within easy distance of, the Parish, and other districts being able to supply the brickmakers' wants. Your Yestry obtained, in July, a site at Purfleet, on the river, which it was hoped would lead to a solution of all our difficulties. From causes into which it is not my province to enter, no use has hitherto been made of this property. STABLE REFUSE. "Notice" has been given ''for the periodical removal of manure and other refuse matter," under the provisions of Section 53 of the Sanitary Act, 1866, which prescribes a penalty of twenty shillings a day for default; and yet one of the most frequent causes of complaint by parishioners, and the most common of recurring nuisances, arises from the neglect of this obligation. The difficulty generally originates with the coachman, who will not give the refuse away, while the farmer will not pay for it. At certain seasons there is difficulty in getting the receptacles cleared, the farmers being too busy to collect the refuse, which has value for manurial and other purposes. The quantity made in this large Parish, with its 177 mews, is great, and of an aggregate value sufficient, probably, to pay for collection and removal. I am of opinion that your 149 Vestry should undertake the work of collection and removal, as the law allows, "with the sanction of the owner." The necessary sanction would be obtainable, probably, in the great majority of cases, were it understood that the requirements of the law would be enforced. The statutory" notice " requires manure to be removed'' every alternate day but twice a week in summer, and once a week in winter, would probably suffice for practical requirements, were tho manure stored in properly constructed receptacles above ground. TRADE REFUSE, In a special report dated March 13, 1885, on Sanitary, Nuisances Removal, and other cognate Acts, made in connection with an enquiry referred to the Law and Parliamentary Committee (April 9, 1884), I stated that your Vestry " have power, and indeed are required, when called upon, to remove the refuse of any trade, etc., upon the application and at the cost of the owner or occupier of any house, etc.," and I added that "the section (of the Act referred to) would apply in the case of trades which lead to the production of ' refuse' of an offensive character."* It is eminently desirable that the Sanitary Authority should undertake the removal of such " refuse " matters, of animal and vegetable origin, as may become, if kept too long on the premises, injurious to health; and in the interests of public health, moreover, the producer of trade refuse of an offensive sort should be compelled to employ the services of the Sanitary Authority for its removal. But, at present, it is exactly the offensive refuse that the Sanitary Authority are not called upon * This subject, cursorily referred to at page 136, was fully dealt with in my Annual Beport for 1887 (pp. 176-189), and in the Report on Sanitary Nuisances Removal and other cognate Acts above-mentioned. Copies of these documents have been forwarded to every member of the London County Council. The subject is well deserving of immediate attention. 150 or expected to remove—viz., that produced by butchers, fishmongers, fried fish dealers, poulterers, &c., who pay substantial sums for the removal of their refuse, which is effected, not seldom, in a manner calculated to give rise to nuisance. DISINFECTION. During the year ending March 25th, 1889, a largo number of infected articles, clothing, bedding, &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 16 tons 3f cwts., their number 9,413, and the cost of the process £313 15s. l0d. Two hundred and eighty-seven rooms in 245 houses were disinfected with sulphurous acid by your Vestry's officer, no charge being made in the majority of instances. Many rooms were disinfected by the contractor, as well as numerous parcels of clothing, bedding, etc., at the cost of the owners. NECESSARY ACCOMMODATION. There are only fourteen public urinals in the Parish—a very inadequate number—and no public water closets, except at the rear of the Vestry Hall. Section 88, Metropolis Management Act, enables the Vestries and District Boards to "provide and maintain urinals, water-closets, and like conveniences, for both sexes, in situations were they deem such accommodation to be required but your Vestry's efforts to provide this necessary accommodation for the male sex have frequently been thwarted by local opposition. A proposition to erect "chalets" as a commercial speculation has been long under consideration, and one has been erected in Norfolk Terrace, Westbourne Grove West. Accommodation, it may be added, is provided at about 170 public-houses—not of a very 151 satisfactory sort in many instances; but better than none at all, and much improved as the result of proceedings directed to be taken by your Vestry. The County Council has recently (May, 1889) signified to the Vestries and District Boards its opinion of the necessity for chalet accommodation for men and women, or the construction of places giving such accommodation below the level of the ground, in the manner which has proved successful in the City and elsewhere; moved thereto by the" many cases of physical injury coming to the knowledge" of the Medical Profession, which are" traceable to the want of proper accommodation of this nature in London." PUBLIC BATHS AND WASH-HOUSES. The Baths and Wash-houses, at the junction of Lancaster and Silchester Roads, Notting Hill, were opened in April, and have been well supported. For the majority of parishioners the site will not be found sufficiently central for bathing; and obviously it is too remote for washing purposes. The same objections would apply to any single site in the Parish. Much good might be effected by the provision of buildings, on a modest scale, in several localities, to which the poor could resort for the purpose of washing clothing. The question of public wash-houses might with advantage be separated from that of public baths. PUBLIC MORTUARY. The Mortuary in the Parish Churchyard, at the flank of the Town Hall, was opened in July, 1883. In the first year 37 bodies were deposited; in the second year 77; in the third year 100 ; in the fourth year 97 ; in the fifth year 109 ; and in the sixth year 128. 152 The bodies removed to the Mortuary in 1888-9 were admitted upon application as follows :— 1. At the request of relatives of the deceased 21 2. At the request of Undertakers (bodies principally of parishioners removed from hospitals) 32 3. At the request of the Coroner (Inquest cases)— Cases of sudden death 33 Cases of violent death 17 — 50 4. Brought in by the Police Found dead 16 Accident cases 3 Suicide 1 — 20 5. Deaths due to infectious disease 5 128 In 52 of the above cases post-mortem examinations were made by authority. The Mortuary comprises two chambers, for infectious and non-infectious bodies respectively, separated by" a place provided for post-mortem examinations," which is highly convenient, and much appreciated by medical practitioners. This "place" is designed" for the reception of dead bodies for and during 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; the cost of such 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 Coroner now occasionally permits the removal of bodies for this purpose—at your Vestry's charge. 153 Too little use by far is made of the Mortuary, and especially as a depository for the dead bodies of persons who have died from infectious disease. Medical men can secure the removal of the body in such cases by Justice's Order (Sanitary Act, 1.866, sec. 27), but only if persons live or sleep in the room where the body is retained. A body in such a state as to endanger the health of the inmates of the same house or room, may in like manner be removed to the Mortuary. The Royal Commission on the Housing of the Working Classes recommended provision of additional mortuaries in London. What, however, is more required, at present, is power to compel removal of the dead to existing mortuaries, when removal is necessary. The Commissioners recognized this fact by the further recommendation that "in the event of a death from infectious disease the body should forthwith be removed to a mortuary in cases where it would otherwise be retained in a room used as a dwelling by others." They thought it desirable, moreover, " that in any case where the body lies in a room which is used by other persons, it should, in the same manner, be removed." (Report, p. 31.) The London County Council thinks it desirable to provide a Morgue for the unidentified dead , and no doubt it would be a useful institution ; especially should provision be made for preserving the bodies unchanged in appearance whilst awaiting identification. CORONER'S COURT. It is now the usual practice to provide a Court for the Coroner in connection with the Public Mortuary, so as to obviate the scandal of holding inquests at public-houses. This step seemed to me to be unnecessary when plans for the Mortuary were under consideration, there being rooms at the Vestry Hall suitable for the purpose. My anticipation that a 154 room could and would be provided for the Coroner's use in that building not having been realized, your Vestry fitted up a room, in January, at the Town Hall, where in the year ended 31st December, 1888, 66 inquests were held out of a total of 139. The bulk of the remaining 73 inquests were held at public-houses; so that the object your Vestry had in view in providing the accommodation has been but partially realized. When inquests are held at public houses the post-mortem examination of the body is necessarily made in the house where death took place, at which too commonly proper accommodation is totally wanting. Communications have recently passed between the Coroner and your Vestry with regard to the use of the Court, and of the Mortuary, which it is hoped may issue in a more adequate use of those valuable institutions. REGULATIONS FOR HOUSES LET IN LODGINGS. The Sanitary Act, 1866 (sec. 35), enables the Nuisance Authority, with the consent of a Secretary of State, to make Regulations " for houses, or parts of houses, let in lodgings or occupied by members of more than one family." The Authority may by its regulations fix the number of persons who may occupy a house. They may register the house, and inspect it to see that it is kept in a cleanly and wholesome condition. They may enforce the provision of privy accommodation, water supply, etc., and provide for the cleansing and ventilation of the common passages and staircases, and for the cleansing and lime-whiting of the premises at stated times. In all but a very few districts in the Metropolis this useful enactment was ignored for years. In 1874, further powers were conferred under the Sanitary Law Amendment Act, enabling regulations, framed under the first-named Act,to extend to ventilation of rooms, paving and drainage of premises, separation of the sexes, and notices to be given? and precautions to be taken in case of any dangerously 155 infectious disease occurring in a registered house. The same Act conferred power on the Local Government Board to declare the enactment to be in force in any district. The sections, nevertheless, remained practically a dead letter in most of the metropolitan districts, the Board not exercising its power. I brought the subject to the notice of your vestry in 1878, when the Sanitary department had been reorganised and the staff enlarged; and in April, 1879, I was requested to make an enquiry as to the working of the Acts in places where they had been put into operation. Meanwhile, 1 had introduced the subject at the Society of Medical Officers of Health, which resolved (1) That the Acts are practicable, (2) That they should be put in operation in London and other large towns, (3) That a uniform code of regulations for the Metropolis was desirable, and (4) That the Society should undertake the framing of such a code. The Council of the Society, to which the matter was referred, requested me to draft a code. This draft code, with slight alterations, was adopted by the Society, and in May, 1879, the regulations were published" for the guidance of Urban Sanitary Authorities." Your Vestry, finding that the Acts were carried out in very few places, decided that it was not expedient, at the time (July, 1879) to proceed any further in the matter. In a Presidential Address to the Society of Medical Officers of Health, delivered in October, 1883, I drew attention to the Acts, and to the desirability of their being put in force This address was printed and widely circulated by the Society. In November your Vestry resolved, unanimously, to take steps for carrying out the provisions of the Acts, and at once set to work to frame regulations. In the following month, December, 1883, the Local Government Board, exercising the power conferred by section 47 of the Sanitary Law Amendment Act, 1874, declared the enactment contained in section 35 of the Sanitary Act, 1866, to be in force in every district of the Metropolis, the Authority of which had not previously made application to the Board for powers to enable it to make regulations. Early in 1884 your Vestry made regulations, which, after modifications 156 suggested by the Board, were confirmed by the President in January, 1885, and are now in force. Under these regulations about 2,000 houses have been placed upon the register, and the process of registration is still in progress. The announcement of intention to register houses proved distasteful to many" landlords," some of whom, complying with your Vestry's invitation, "stated in writing reasons why the house should not be registered;'' but almost without exception the " reason " stated amounted to no more than an "objection" to registration—based usually on a mistaken supposition that by registration the "registered house" would become a" common lodging-house," subject to police inspection, and be stigmatized in a manner likely to diminish its letting value. It is hardly necessary to say that these evils are purely imaginary. The registeris a quasi-private document: no intimation of registration is given excepting to the parties immediately interested; to wit the "owner," the "keeper" (i.e., the occupier; but in the case of a tenement-house the "owner" is ''keeper," also), and the lodgers. So far from registration injuring property, I believe it will come to be regarded as a guarantee that the house is in good sanitary condition, when time shall have permitted the carrying out of your Vestry's Instructions for the guidance of the Sanitary Inspectors in regard to the sanitary arrangements of registered houses, which require them to see: — 1. That all cisterns are periodically cleansed and properly covered ; 2. That all waste-pipes from sinks, cisterns, baths, &c., be disconnected and empty themselves over, or, preferably, near surface gratings, and outside the house where practicable ; 3. That the drains under all such gratings be efficiently trapped ; 4. That the paving of yards be laid to a fall towards such gratings, with the joints of such paving grouted or pointed in Portland cement or other impervious material; 157 5. That all drains be trapped from the sewer, outside the wall of the house next the sewer. Note.—Where convenient or practicable an intercepting chamber with a closefitting cover and an air-tight pipe should he recommended. 6. That all house drains are air-tight; Note.—Where there is reason for believing that any house drain is imperfect, notice must, if necessary, be given to the Surveyor, who willprovide workmen for opening it up for examination. 7. That all special soil pipes be air-tight at the joints, and carried, full diameter, above the roof, at a safe distance from windows and chimney tops; 8. That all rain-water pipes used as soil pipes be air-tight at the joints ; Note.—The use of "combined soil and rain-water pipes" if a bad arrangement, and should be discountenanced. These Instructions, adopted February 11th, 1885. were by your Vestry, on February 10th, 1886, directed to be observed " in respect to all other houses wherein, on examination, sanitary improvements are found to be necessary." HOUSING OF THE WORKING CLASSES. In connection with the subject of registration of houses let in lodgings, a full summary of the Report of Her Majesty's Commissioners for enquiring into the Housing of the Working Classes, was given in my Annual Report for 1884-5 (page 184). The report itself did scant justice to the work of the sanitary authorities, which, though carried on under pressure of many difficulties, has had the effect of making London the cleanest, best paved, best drained, best lighted, safest and healthiest of great cities. The existing system of local government may not be perfect, but under it much good work has been done, work that is not likely to be surpassed under any change in the form of local government. 158 The labours of the Commission have hitherto borne little fruit. The Prime Minister, Lord Salisbury, brought in a Public Health (Metropolis) Bill in the Session of 1885, which, as a measure for consolidating, with some few useful amendments, existing scattered statutes, fourteen in number—all bearing more or less on the question under considerationwould have proved useful to Sanitary Authorities and sanitary officials alike. But there was not time to pass the Bill. Your Vestry having requested Lord Salisbury to reintroduce the Bill in 1887, his lordship expressed his fear that the chances of any such measure becoming law are at present very remote. As already stated (page 130), the County Council have appointed a Housing of the Working Classes Committee, and have shewn in other ways, e.g., by putting Cross's Acts into operation again (vide page 131), their interest in this subject. To what extent they will be enabled to solve the tremendous difficulties by which it is encompassed, time only can determine. UNHEALTHY HOUSES. By section 13 of the Housing of the Working Classes (England) Bill, 1885, a measure introduced by Lord Salisbury with a view to give effect to recommendations of the Royal Commission, it was proposed to enact that, in any contract for letting an unfurnished house for human habitation, there should be implied a condition that the house was in all respects reasonably fit for habitation; and that in the event of a breach of such condition, any inmate of such house who suffered any loss by injury to health or otherwise, in consequence, should be entitled to recover damages from the person responsible for such breach. The section was in accord with my proposal (in 1884) that " there should be an implied warranty when a house is let, that it is in a proper sauitary condition ; that it is fit to live in which I hoped would " before long be established as a principle of English law." Unfortunately, the section was altered in 159 Committee so as to become of little value for practical purposes. The "condition," however, is implied by existing law in the letting of a furnished house, and a good practical application of it has lately been published in the report of an action (Charsley v. Jones) brought to recover damages for breach of an agreement to let a furnished dwelling house at Ryde. Owing to the alleged defective system of drainage, and contaminated condition of a well, in connection with the house, several members of the plaintiff's family got typhoid fever, and so the plaintiff and his family had to quit the house and find apartments elsewhere. The learned Judge (Mr. Justice Manisty), in summing up to the (Special) Jury, said that " the law in the case of a furnished house was that there was an implied undertaking that the house was fit for human habitation. The question was whether the typhoid fever was due to the house not being in a reasonably habitable condition owing to the water or the drains. It seemed that the defendant honestly believed that the house was in a fit state of habitation; but that was not the question. The date when the family went to Ryde was important, as in typhoid fever there was a period of incubation." The learned Judge then went carefully through the evidence, and said, as regarded the damages, if they thought the house was not fit for human habitation, the plaintiff was entitled to a verdict for the rent and such other expenses as he was put to. The Jury returned a verdict for the plaintiff, with £70 damages. THE METROPOLITAN SEWAGE QUESTION. In my Annual Reports for 1885 and 1886, I referred, under the heading, "Metropolitan Main Drainage," to the steps taken by the late Metropolitan Board of Works to clarify and deodorize the Sewage of the Metropolis before its discharge into the River, well-founded complaints having been made with regard to the condition of the river resulting from the introduction of enormous volumes of crude sewage. 160 For the purpose of clarification, or precipitation of the solid matters, lime and green vitriol were employed, supplemented by the addition of manganate of soda and sulphuric acid to the effluent when necessary. These last-named materials, however, were alleged to be unnecessary when the river water and the sewage were cool, and the latter much diluted by rainfall. But their addition, it was stated, purified and deodorized the effluent to such an extent as to render its discharge into the river unobjectionable at all states of the tide, a statement very generally traversed. I mentioned also that the Board, in order to prevent nuisance within the Metropolis arising from the discharge of offensive gases from the sewer ventilators, were applying the manganate and acid, at numerous stations, to the sewage as it flows through the main sewers. It was hoped that this plan would ensure the arrival of the sewage at the outfalls in a deodorized condition, and thus assist in the production of a satisfactory effluent. The object the Board had was to avoid the necessity for costly land filtration of the effluent, recommended by the Royal Commission on Metropolitan Sewage Discharge, with a view to ensure the removal of all odour and the possibility of ''secondary fermentation." The Board, in giving effect to the views of their scientific advisers, incurred a large expenditure for works of construction, and in the carrying out of the system adopted. SIR HENRY ROSCOE'S REPORTS. Deferring, however, to the objections made to the system above described, the Board, in 1887, retained the services of Sir Henry Roscoe, as consulting chemist, and scientific adviser in this matter, and they ultimately consented to the request by Sanitary Authorities—your Vestry among the number—to make that gentleman's reports public. These reports were five in number. The first, dated 16th May, 1887, dealt with "The Deodorization of Sewage in the Metropolitan Sewers," the second and third, dated August 7th and December 9th, 1887, 161 with "The Deodorization of Sewage at the Outfalls." The fourth report, dated March 3rd, 1888, treated of the deodorization of sewer emanations by the use of sulphurous acid applied at numerous stations within the Metropolitan area; while the fifth was a further report on deodorization of sewer emanations, and on sewer ventilation. In my last Annual Report I summarised the contents of all of these reports (p. 231—240). The reports had been referred by your Vestry to the Works, Sanitary and General Purposes Committee for consideration. The Committee reported on the subject to the effect a) "That having regard to the statement that 'the effects of the chemicals used are imperceptible,' they doubt the propriety of continuing the attempted deodorization of the sewage, as recommended by Sir H. Roscoe, at a cost of £40,000 per annum; especially as it is stated that this outlay will not prevent a foul condition of the river occurring during the summer months, in drought or hot weather, and as it had been previously stated by Sir H. Roscoe that such an expenditure is not justifiable. (b) "That as Sir H. Eoscoe is 'convinced that sooner or later the recommendations of the Royal Commission on Metropolitan Sewage Discharge will have to be adopted, and that the Sewage, whether previeusly clarified or not, must either be filtered through land or discharged into the Estuary at a point not higher than the Sea Reach,' it would appear that the Board are proceeding upon erroneous lines in dealing with the Sewage at the Outfalls, and hence the great expenditure being incurred will have been practically thrown away. (c) "That the methods of deodorizing the emanations from Sewers, at an annual cost of £11 or £12 for each station where it is applied, appear to be practically unsuccessful, and therefore might as well be discontinued. (d) "That the best-known method of dealing with Sewer emanations is by admitting air freely into the Sewers, to oxidize and dilute the emanations, and by favouring the escape of foul air by free openings in the roads, and by pipe ventilators carried above the houses," M 162 The Report of the Committee was adopted by your Vestry, as also was their recommendation "That the system of pipe ventilation be carried out in this parish where necessary and practicable, as heretofore, and that all obstructions to the ventilation of the sewers be removed by frequent removal of the mud from the air openings in the gratings on the road level." The latter recommendation arose out of a favourable notice by Sir Henry Roscoe of a method of ventilating sewers recommended by Mr. Parker, late Surveyor to the Poplar District Board of Works, and in use for many years past; viz., "by carrying a shaft from the sewer to the side of the road, and connecting to it a vertical pipe attached to the head of which is fixed a 'cowl.'" The Flushing Inspector of the Metropolitan Board's Sewers in the district, " spoke well in favour of the system;" and I must say for myself that, upon hearing Mr. Parker describe his system, some years ago, and looking at his drawings, the Medical Officer of Health for the district, moreover, testifying to the good results obtained, I formed the opinion that the method was likely to afford a solution to the difficulty, based, as I understand it to be, upon the principle of flooding the sewers with fresh air so as to dilute, oxidize, and favour the escape of the foul emanations from the sewage. Sir Henry Roscoe, in December, 1888, presented a further report to the Board dealing with The Deodobization of Sewage at the Outfalls, setting out the proceedings taken in 1888. From this document we learn that Deodorization was commenced at both outfalls—Crossness and Barking—May 7th, by the addition of three grains of bleaching powder to the gallon of effluent sewage, and continued until the stock of that material in hand (839 tons) was exhausted. After May 27th, at the Northern Outfall, and June 17th at the Southern Outfall, manganate of soda, in the same proportion, was used until July 11th, when the condition of the river was much improved by a heavy rainfall ; 163 the temperature, moreover, being low : 1,178 tons of the manganate had been used. Deodorization was resumed July 16th, and continued until October 13th, 893 tons having been used. About 52 million gallons of crude but deodorized sewage was discharged at the two stations on the flood tide daily. The value of the chemicals used in 1888 was £24,357, as compared with £42,467 in 1887, a saving of £18,110, part of which was due to cheapening of the manganate. The amount expended in 1887, moreover, was less by £38,600 than in 1886. Thus the expenditure in 1888, as compared with the expenditure in 1886, shows a reduction of £56,700 in the item of chemicals, without apparent deterioration of the river. The manganate of soda was found to be not less effective in its action than when sulphuric acid is added, as was done in 1887. Sir Henry Roscoe states that it is only by oxidation that putrescent sewage, which contains little or no oxygen, can be purified. One gallon of pure river water contains nearly four times as much oxygen as that supplied by three grains of manganate of soda. A much larger quantity would not suffice to convert the whole of the fcecal matters into harmless forms. The oxygen in the manganate is quickly consumed in removing the putrescent odour of the sewage, and in preparing for a process of natural oxidation by the further supply, by the river, of free oxygen, of which the deodorized sewage contains none. The chemicals then, as used, can effect little improvement in the river. I mprovement is to be sought in some process of effluent aeration. This matter requires further experiment. The purification of the river is chiefly effected by living organisms, requiring free oxygen for their growth, which produce the changes ascribed to animal life. Vegetable organisms (algæ, etc.), always present in river water, evolve oxygen during their life, and are potent instruments in the natural purification of the river. Both forms of life act together in ridding the water of dead organic matter —soluble and insoluble—thereby bringing it into a healthy conditiou. The summer rainfall of 1888 was greater, and the temperature lower, than in 1885-6-7; influences favouring the m 2 164 purity of the river. There was in the water more oxygen and less chlorine—evidence of a better condition of the water. Sir Henry Roscoe reiterates the opinion expressed in his former reports, "that the use of chemicals of any kind must be considered as a temporary measure," and that" any reasonable outlay on them will not prevent a foul condition of the river," in a dry summer or during hot weather. He is not responsible for the scheme of the Board for chemical precipitation. If this can be advantageously adopted, and the sludge be carried to sea, he still thinks" that the sewage, whether previously clarified or not,, must either be filtered through land (as recommended by the Royal Commission) or discharged into the estuary at a point not higher than the Sea Reach." The Chemical Examination of the Foreshores and Mud Deposits of the River Thames and its Estuary, forms the subject of a further and final report by Sir Henry Roscoe, dated March 4th, 1889, and is the outcome of a resolution by the Board, approving of the recommendation of Sir Henry Roscoe, "that an examination should be made of the condition of the Thames deposits from Barking down the river to the mouth, including the whcle of the estuary." It appeared desirable, in view of the proposal to carry the sludge out to sea, and of questions which may arise thereon, to be in possession of scientific data as to the condition of the foreshores. The examination was of a twofold character, chemical and microscopical, the latter part being conducted by Mr. Dibdin, the Chemist to the Board. The mud was collected at points where, in consequence of the sot of the tides, sewage-sludge would, in the Engineer's opinion, be most likely deposited on the foreshores and banks; and from Clacton, Walton-on the-Naze, and H arwich, as positions which, in the judgment of competent persons, were those where sewage-sludge would be found if it were discharged at sea, and should it then reach the shore. The investigation was made in September and October last. The samples divide themselves into two classes : (1) those 165 collected on the foreshores of the river proper, from Barking and Crossness down to Southend on the north, and Jenkin Sands on the south; (2) those on the estuary, from Shoeburyness to Harwich on the north, and from Warden Point to Margate on the south, including two sandbanks known as "Little Sunk" and "Gunfleet." The Royal Commission of 1884 stated a conclusion "that foul mud, partly composed of sewage, accumulates at Erith and elsewhere," a conclusion borne out by the well-known appearance of black patches of offensive matter in the river, derived from sewage-sludge, which are at times raised to the surface, as a result of putrefaction and the evolution of gases, which, becoming entangled with the material, cause it to float. Analyses of 59 samples of the mud and deposits collected from the foreshore of "sections of the river of considerable length" were made, the average composition of which indicates that a gradual diminution occurs in the impurity of such deposits from the outfalls downwards. The river for the purpose of the inquiry was divided into four sections, viz. :— (1) Halfway Reach to Erith Roads inclusive ; (2) Long Reach to Gravesend Reach ; (3) Ovens Flat to Blyth Sand ; (4) Chapman Lighthouse to Southend inclusive. The reliability of four different means adopted for ascertaining the existence of sewage impurity in the deposits is considered in detail. The conclusion obtained from a comparison of all the numbers given in the tables, taken together, is stated to be of distinct value for obtaining a general view of the relative chemical condition of the foreshores ; and a Table has been constructed to show the average relative amount of the organic impurity in the various sections of the river (and of the estuary). Taking the total values or average impurity of Section 1 as 100, that of Section 2 is 90, that of Section 3 is 49, that of Section 4 is 16—there being a total percentage loss of impurity in passing from the Outfalls to Southend of 84 per cent. The presence of manganese in samples taken in Section 1, and in that Section only, is cited as a further proof that Sewage imputities exist in the river deposits—the manganese being derived from the manganate of soda 166 which is added to deodorize the sewage before being discharged into the river at the Outfalls. The conclusions arrived at from chemical examinations are, in the main, borne out by the microscopical evidence obtained by Mr. Dibdin. Thus, for example, no muscular fibre or spiral vessels, indicating animal matter, appear beyond Gravesend, although vegetable fibre and hairs were traced as far as Southend. The percentage of particles of flint, indicating road detritus, is higher in Section 1 than in any of the other three. From Southend to Harwich there were very few fibres of any kind, but at that town they were again met with, and sewage pollution was evident. On the north shore, from Yantlet Flat to Margate, nothing of a sewage character was met with beyond occasional woollen and cotton fibres. Samples taken from the two sand banks ("Gunfleet" and "Little Sunk") showed, under the microscope, no signs of sewage pollution. A large amount of detailed information is set out in Tabular Appendices to both of the Reports upou which the conclusions in the body of the Reports have been founded. It will be remembered that Sir Henry Roscoe's engagement with the Metropolitan Board of Works was for a limited period, which expired on the 25th March last, before which date the Board itself came to a premature end. The County Council, while hoping to enable to avail themselves, in the future, of Sir Henry Roscoe's services, did not think it necessary to renew his appointment upon their own accession to the responsible position occupied by the Board in relation to the sewage question ; so that the investigations have, for the present at least, come to a close. Sir Henry Roscoe's reports, meanwhile, are on record, and they undoubtedly embody a great mass of valuable scientific information, which will be of service in any future inquiry. It remains to be seen what will be the effect upon the river of the costly scheme of subsiding reservoirs, and of the deodorization of the sewage, to which the Council no doubt will give a fair trial, although the old Board 167 is exclusively responsible for the experiment; an experiment on a vast scale, made, it may be said, in defiance of the recommendations of the Royal Commission, generally opposed by scientific chemists and condemned by their own chosen adviser, Sir Henry Roscoe himself. [Addendum.—In May, 1889, Sir Henry Roscoe published a paper "On the Metropolitan Sewage Question," in which he summarized the conclusions of the Royal Commission of 1882; the proceedings of the late Metropolitan Board of Works in regard to the treatment of the Sewage, in opposition to the recommendations of the Commission ; the views of the Chemists consulted by the Board; and his own reports of which, in my Annual Reports for 1887, and (the present one for) 1888, I submit abstracts. The paper is very brief, 24 pp. only, and is well deserving of consideration by all concerned in metropolitan sanitary administration. Primarily, it has been prepared for the use of members of the County Council, whose Main Drainage Committee, it is understood, are proceeding upon the lines of the late Board, in carrying out a discredited system which, if I am correctly informed, will involve an outlay in the present year for disinfectants alone of £100,000, or four times as much as was expended in 1888, under the direction of Sir Henry Roscoe. After "A criticism of the system proposed by the Metropolitan Board" (page 15), Sir Henry Roscoe concludes by stating his opinion that" the proposal of the late Board for the disposal of the sewage is based on false principles." " (1") As regards the addition of lime and iron in the proportions recommended. " (2) As regards the addition of manganate of soda to the effluent, after precipitation, in the quantities suggesled. '. (3) As regards the formation of underground settling tanks at Barking and Crossness. " (4) As regards pumping the sludge into tank steamers and sending it out to sea." 168 The suggestion he makes is that "the Main Drainage Committee should appoint an engineer and a chemist of position, to report to them on the whole question of the treatment and disposal of the sewage as a basis for future action."] WATER SUPPLY. Cutting-off Powers of the Companies.—Regulations authorized by the Water Act of 1852 were framed by the Companies in 1872, consequent on the passing of the Water Act, 1871. The "Metropolitan Authority" (Metropolitan Board of Works) declined any responsibility in regard to the regulations—which were allowed by the Board of Trade—disapproving of the provisions with respect to fittings, which they considered would entail an unduly heavy outlay on the consumers. I have always contended, but as yet without success, that the Sanitary Authority should have co-ordinate power with the Companies to enforce certain of the regulations which appear to have been framed in the interests of Public Health ; especially Regulation 14, which enables the Companies to cut off all connexions of waste-pipes of cisterns with drains; the Companies, for the most part, regarding this Regulation simply as a provision for preventing waste. Your Vestry, upon my recommendation, applied to the Local Government Board to obtain legislative power to enable the Sanitary Authority to enforce the regulation; but without result, although the application—which was endorsed by many of tho Yestries and District Boards—arose out of a recommendation by the Board's Medical Officer, that such severance should be made, when it was thought that Asiatic cholera might be imported, and although his advice was in harmony with the views of the (late) Water Examiner. The Companies possess, under section 74 of the Waterworks Clauses Act, 1847, power to cut off the domestic water supply if the rate is not paid. Such a power cannot be safely entrusted to any commercial body, having regard to the importance of the water supply in relation to the public health. 169 In 1885, a striking exercise of this power by one of the Companies in Kensington, in depriving the people (80 in number) occupying a Mews, led to communications being made to the Local Government Board and to the Sanitary Authorities, which, by drawing public attention pointedly to the subject, contributed to bring about a partial remedy by legislation. I had for some years previously contended that the power should be taken from the Companies; that they should be left to their remedy like other traders, the rate being treated as a debt to be recovered—if they did not enforce the right of prepayment—every facility being given to them for the purpose. The Royal Commission on the Housing of the "Working Classes in their report (1885) recommended that the Companies be deprived of the summary power to cut-off the water supply. Your Yestry supported a Bill brought in by Lord Camperdown (1885) intended to settle the question. It was thought that the Companies had had their own way too much in moulding the Bill in Committee of the Lords, and it was thrown out in the Commons. In 1887 a very useful measure, Water Companies (Regulation of Powers) Act, was passed (your Vestry petitioned the House of Commons in favour) which, as respects houses, the water rate of which is paid by the landlord, precludes the Companies from cutting off the supply (for which poor people pay in their rent), but gives them very ample powers to enforce payment of their claims. Professor Frankland's Report.—The report on the water supply of the Metropolis prepared for the RegistrarGeneral by Professor Frankland, is published, as usual, in the Annual Summary. It sets out the results obtained in monthly examination of the water supplied by the eight Companies, three of which—Grand Junction, West Middlesex, and Chelsea —supply Kensington. The results obtained in a similar periodical examinations of the water supplied by the Colne Valley Water Company and by the Tottenham Local Board of Health, are included for the purpose of comparison. The high quality 170 which the river water has now exhibited for several years past, was maintained in 1888. The monthly variation in the temperature of the water is very great (viz., from 37°.4 Fahr. in February to 65°.3 in June = 27°.9), that of the Kent Company's deep well water being 2°.7 only, viz., from 53°.6 in February to 56°.3 in August This water thus remains cool and refreshing in summer and is less likely to become frozen in the servicepipes in winter. The river water is soft by comparison with the deep well water, which owes its hardness to the much larger proportion of mineral substances which it contains and which compose the great bulk of the "solid matters." The hardness of the water, sufficiently great to materially diminish its value for washing, steam, and industrial purposes generally, is almost entirely due to the presence of bi-carhonate of lime in solution ; this bi-carbonate of lime can be readily removed by treating the water with lime, as is so successfully done by the Colne Valley Company; by which the hardness of that Company's water is reduced to from one-fourth to one-fifth of its original amountin 1888 from 30°.2 to 7°.5; the hardness of the Thames water being 20O-0. This mode of softening is by far the most economical, for it entails only about one-eightieth of the expense which devolves upon the private consumer in the shape of additional soap required for washing purposes. The small proportion of organic material which the solid matters contain, is of the greatest importance in connection with the use of the water for drinking purposes; as it may be of the most objectionable character on account of its origin—such as the drainage from manured land, the effluents from sewage works, or even raw sewage itself. The animal matter may at times be accompanied by zymotic poisons dangerous to health—although the chances of such substances reaching the consumer are reduced by filtration and by the exclusion of flood waters from the reservoirs. During the greater part of the year the water contained only a very moderate amount of organic matter; but the amount was exceptionally high in the months of March, November, and December. The water sent out by the West 171 Middlesex Company was conspicuous by a higher maximum and a greater average of organic impurity. Every sample of river water was clear and bright when drawn from the mains, a fact highly creditable to the Companies as evidence of the extreme care taken in filtration. The Water Examiner's Report—I am indebted to the courtesy of Major-General A. de C. Scott, R.E., the Water Examiner, for an early copy of his Annual Report for 1888, from which most of the following particulars are taken. General Scott's duties as Water Examiner are multifarious and important. He makes monthly inspections of the several Metropolitan waterworks, filter beds, reservoirs, &c., examines the quality of the water, both at the intakes and after filtration at the works, and reports, monthly, the results of such inspections and examinations to the Local Government Board. Upon him rests the responsibility of seeing that the requirements of Section 4 of the Metropolis Water 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, according to the late Sir F. Bolton (the first Water Examiner, appointed under the Act of 1871) upon :— 1. A sufficient area of properly constructed filter beds, constantly cleaned, 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. A limit to the rapidity of filtration has been generally adopted. It is represented by the passage of about 540 gallons 172 through each square yard of the upper surface area of the filter in 24 hours, or 2½ gallons through each square foot of surface per hour. Water passed through well-constructed filters at a rate not exceeding this becomes under ordinary conditions bright and clear. Effectual filtration is greatly facilitated by previous subsidence. The average rate of filtration, per square foot of filtering area, in gallons per hour, by the several local companies, in 1888, was as follows:—West Middlesex, 1.33 ; Grand Junction, 1.80; Chelsea, 1.75. The requirements of the Act in this respect, therefore, are fully carried out. The filteiing basins are lined with brickwork or concrete, and contain layers of sand, and fine and coarse gravel arranged in descending order. The water passes vertically downwards, and is collected by pipe and brick drains laid on the floors of the basins, and led by conduits to the well of the pumpingengine. The thickness of the filtering media ranges from eight feet in the case of the Chelsea Company to three feet in that of the Grand Junction Company. The thickness of the upper layer of sand, which is the most effective of the layers, varies from two feet to four feet six inches. The filter beds are formed as follows :— West Middlesex.—Harwich sand, 2ft. 3in.; Barnes sand, 1ft.; gravel screened to different sizes, and arranged in layere, 2ft. 3in. Total thickness, 5½ft. Grand Junction.—Harwich sand, 2ft. 6in.; Hoggin, 6in.; fine gravel, 9in.; coarse gravel, 9in.; boulders, 1ft. Total thickness, 5½ft. Another and more modern kind of filter is used by this Company, made up of sand, 2ft., line gravel, 9in., pipe drains, 3in. Total 3ft. Chelsea.—Thames sand, 4ft. 6in.; shells, &c., 3in.; gravel, 3ft. 3in. Total thickness, 8ft. Sand is the efficient agent in filtration as practised, and this, it may be added, varies in quality. In the Water Examiner's Report for 1886, the West Middlesex Company was 173 referred to as prominent in "respect of the uniformity in the quality of its water this Company using," to an appreciable extent sand from Harwich which is remarkably fine and uniform in grain." The sand becomes clogged in course of time, and then the upper layer is scraped off and removed. Renewals of sand should take place periodically as the layer becomes reduced below an assigned minimum. But filtration avails little if the water is allowed, as frequently happens, to be fouled in the cisterns; whether through the uncleanly condition of those receptacles or by the connection of them with drains through the medium of wastepipes. The attention of householders cannot be too frequently drawn to the necessity for the abolition of waste-pipes and the periodical cleansing of cisterns for storing potable water. Cisterns, moreover, should be properly covered so as to exclude light and dirt; and so placed that the water may be kept cool in summer, without being in danger of freezing in winter. When "constant supply" is given, a screw-down draw-off tap should be affixed to the rising main or service pipe, so that drinking and cooking water may be drawn therefrom, fresh and uucontaminated, without the intervention of cisterns, which are required for washing, flushing, baths, and similar purposes. A stop-valve should be fixed outside the premises to prevent damage to the house in case of pipes burst by frost or other causes. The quantity of water for domestic purposes supplied by the Grand Junction, the West Middlesex, and the Chelsea Companies respectively, last year averaged 26.8, 22.5, and 27'3 gallons daily per head of the population, and 241, 169, and 215 gallons per house. The "intake" of the Chelsea Company is at West Molesey, the intakes of the other Companies being at Hampton. The Grand Junction supply is supplemented from sand and gravel beds at Hampton, the Company having a complete system of 174 ground collection of water on about 20 acres of land, and beingable, during the time of flood, to raise large quantities of water that has passed through the natural beds of gravel and sand, which are characteristic of the neighbourhood. The freshets and floods in the rivers were of average character in 1888, and no special difficulties as regards filtration of the water supply presented themselves. The results were on the whole satisfactory, and generally speaking the filters were maintained in a satisfactory condition. Turbid water is very 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. Turbid water must of necessity be sometimes admitted, and filters are then overtaxed. The fact that the impurity of the water in the river is so largely increased during periods of flood, renders it of great importance that there should be sufficient provision cf subsidence and storage reservoirs to enable the necessary daily supplies to be delivered during such periods, while keeping the intakes closed. The position of the several Companies varies in this respect very considerably. The following statement shows the number of days' supply, represented by the capacity of the reservoirs for unfiltered water, behnging to each of the local Companies:—Chelsea, 14; West Middlesex, 8 ; Grand Junction, 4. But the Grand Junction Company's resource during floods, of pumping from the gravel beds adjoining the Thames, is practically equivalent to an addition to their provision of storage reservoirs. For sake of comparison it may be added that the East London Company has capacity for 18 days' supply. The same Company is conspicuous by its advance in work for improving the water supply of its district in other respects. Dr. Percy Frankland's biological experiments by the process known as gelatine-plate cultivation, from which it appeared that in 1887 the average reduct on in the number of 175 micro-organisms present in the unfiltered water of the Thames, effected before delivery to the consumers, amounted to 96.7 per cent., have come to an end, that gentleman having left London. Constant Supply.-—I have no means of ascertaining to what extent constant supply has been extended to houses in this parish, but the following facts with refeience to the several districts may be acceptable :— The West Middlesex Company was giving constant supply at the end of 1888 to 23,877 houses, out of a total of 71,095 ; the increase during the year was 621. The Grand Junction Company was giving constant supply to 42,988 houses out of a total of 55,093; the increase during the year was 1,407. The system has been extended to North Kensington. The Chelsea Company was giving constant supply to 6,507 houses (increase during the past year 546), out of a total of 34,806. This Company is the only one of the eight Metropolitan Water Companies which has given no notice of its intention to substitute a constant for an intermittent supply under the provisions of the Act of 1871. Judging from the few applications made for constant supply, there appears to be little desire on the part of the public authorities, or private individuals, in any of the districts, for the continuous service; but all new estates and new lines of streets are being so supplied voluntarily. By way of comparison it may be mentioned that the East London Waterworks Company now gives constant supply to 155,000, out of a total of 163,358 houses supplied. The increase during the year was 3,116. The percentage of house supplies on the constant system in each local Company's district, Dec. 31st, 1888, was, Chelsea, 19 per cent. ; West Middlesex, 34 per cent.; and Grand Junction, 78 per cent. In the East London District the percentage is as high as 95. But considerable advance was made during the past year in London as a whole, in extending the constant supply ; 416,082 out of the total number of 746,319 houses supplied, or 56 per cent., being now on constant service, an increase of 13,158 during the year. 176 The Act prescribes three modes by which a constant supply of water may be obtained : (1) Any Company may propose to give it; (2) the Metropolitan Authority (County Council) may call upon a Company to provide it; and (3) failing the above, and under certain conditions, the Local Government Board may require it. In general the constant supply has been voluntarily given by the Companies. Neither the Metropolitan Authority in the past (the Metropolitan Board of Works), nor the Local Government Board, nor the Board of Trade, whose powers are now executed by the Local Government Board, having called upon the Companies to provide it. The ground alleged by the (late) Metropolitan Authority for their failure to call upon the Companies to provide constant supply was that the Companies had made the regulations so stringent as to constitute a heavy and unnecessary burden on the owners and occupiers of houses. It is nevertheless the fact that the Companies having taken the initiative, 56 per cent. of the houses in the Metropolis now have the constant supply, and the system is being extended daily. It remains to be seen whether the County Council will persist in the negative policy adopted by their predecessors. Subsequent to the passing of the Act of 1871, the Water Companies have incurred a considerable expenditure, amounting altogether to £4,438,180; for the improvement of the water supply, both in quantity and quality, by extending the storage capacity of their reservoirs, and increasing their areas of filtration; as well as by providing for the requirements of constant supply; by the construction of high service reservoirs for filtered water; the laying of mains, and the addition of powerful machinery to their works. These measures have tended to improve the supply of water to the Metropolis. The total expenditure of the Companies on works, improvements, &c., to the end of 1888, amounted to £14,413,179, of which £272,746 was expended during the past year. 177 GAS. The subjoined Tables, based on the quarterly reports of the Chief Gas Examiner, summarize the principal results (averages) of the daily testings, at the Ladbroke Grove Station, of the " common gas," manufactured by the Gas Light and Coke Company at their Kensal Green Works. 1. With respect to illuminating power. The maximum, minimum, and average illuminating power, in standard sperm candles, the statutory standard being 1(3 candles, was as follows:— Maximum. Minimum. Average. Quarter ended March 31st 17.8 16.0 16.7 Quarter ended June 30th 22.2 15.8 17.7 Quarter ended September 30th 19.2 17.7 18.0 Quarter ended December 31st 17.1 16.1 16.5 Averages, whole year 19.3 16.4 17.2 It appears from these results that the average illuminating power of the gas at the Station was higher than the Parliamentary standard. On one occasion only was the minimum lighting power lower than the Parliamentary standard, viz. 15.8 on May 24th. In the Annual Report of the late Metropolitan Board of Works for 1884, it was stated—as the result of testing with a portable photometer—that there are parts of London the inhabitants of which do not always get their gas of the quality which it was thought had been secured to them by Act of Parliament; the gas hiving been frequently found to be inferior in lighting power to the prescribed standard, sometimes by as much as one candle, There is no way of preventing this, the companies in default being subject to no forfeiture or penalty, as they are when the gas is shown to be defective at the regular testing places- The above facts point to the necessity for an N 178 alteration of the law. The gas referees, it was stated, approve of the testing of the gas by means of a portable photometer; and the Metropolitan Board advised the Board of Trade that statutory power should be obtained for that mode of testing, so that the companies may be liable to forfeitures for gas which the portable photometer shows to be defective in lighting power. The Board also suggested the expediency of an alteration in the standard of light prescribed by the statutes. The statutory standard is obtained by burning a sperm candle of six to the pound, at the rate of 120 grains an hour; and the gas is required to be of such lighting power as to produce, when consumed at the rate of five cubic feet an hour, a light equal to that produced by sixteen such candles. A Committee, appointed by the Board of Trade, reported adversely to the continuance of the use of the sperm candle as a standard, it having been proved that, in spite of precautions taken to secure uniformity in the manufacture of the candles, there remained considerable variation in their lighting power. In the Reports of the Board for 1885 and 1886, no reference was made to the important matters dealt with in the above paragraph, but in the Report for 1887, the subject was again dealt with, and we were informed that in the interval a long series of careful and complete experiments had been made by the Officers of the Board, under the Board's authority, with the result that the Pentane air-gas standard, as devised by Mr. A. Vernon Hareourt, one of the gas referees, appeared to possess, in a higher degree than any other, the merits of simplicity, accuracy, and reliability. These subjects doubtless will receive attention from the County Council 2. As regards purity. The gas was free from sulphuretted hydrogen throughout the year; and the quarterly average quantity of other sulphur compounds present in the gas was considerably less than the quantity permitted, the maximum moreover not having been attained on any occasion. 179 Grains of sulphur per 100 cubic feet of gas; the Parliamentary limit being 17 grains in 100 cubic feet during the months from April to October, and 22 grains from October to April. Maximum. Minimum. Average. Quarter ended March 31st 12.1 7.3 8.8 Quarter ended June 80th 14.8 7.0 9.4 Quarter ended September 30th 11.5 8.7 9.8 Quarter ended December 31st 12.6 8.1 10.7 Averages, whole year 12.7 7.8 9.7 Ammonia, a valuable residual product of gas manufacture, was present in the gas more or less frequently throughout the year, but only in slight quantities. On no occasion was the limit fixed by the Acts of Parliaments—viz., four grains in 100 feet of gas—exceeded. The Chief Gas Examiner being independent of the Company, it is satisfactory to note that his reports on the daily testing of the gas are so favourable. Conclusion.—It only remains for me, in bringing this Report to an end, to offer my thanks to all who have contributed by their assistance to whatever success may have attended the work of my department during the past year. I have had occasion in previous reports to refer to the cooperation of the Board of Guardians. It would be impossible to over-value the services rendered by them in past years, through their officers, in measures for preventing the spread of dangerous infectious diseases—viz., by securing the speedy removal of the sick. The sub-district Registrars, Messrs. Barnes and Hume, and the Vaccination Officer, Mr. Shattock, have, as usual, readily complied with my applications for information on subjects connected with their several departments. N 2 180 The Sanitary Inspectors have discharged their onerous, and in some respects perilous, duties with zeal, intelligence, and success. To Mr. Rudman, the Sanitary Clerk, I am much indebted, among other things, for assistance rendered in passing this Report through the press. The Assistant Clerk has performed his duties to my entire satisfaction. But above all, my thanks are due to your Vestry for continuance of confidence which, now for eighteen years, has enabled me to carry out, with pleasure and satisfaction, the duties of my office, and to superintend the work of a Department the importance of which, I believe, is now generally recognized. I am, Gentlemen, Your obedient servant, T. ORME DUDFIELD, Medical Officer of Health. Offices : Town Hall, Kensington, W., July, 1889. APPENDIX. Note.—The forms for Tables I.—VI. were arranged by the Society of Medical Officers of Health, with the object of securing uniformity in Statistical Returns. (Vide page 95.) 183 TABLE I. Shewing Population, Inhabited Houses, Marriages, Births, and Deaths, in 1888, and ten preceding years. The Year. Estimated Population.* No. of Inhabited Houses.† Marriages. Registered Births. Deaths. Total all Ages.‡ Under One Year. Under Five Years. In Public Institutions § 1888 177,000 21,600 1,497 3,776 2825 604 1,077 590 1887 175,000 21,566 1,561 3,941 2,872 680 1,129 608 1886 173,500 21,500 1,605 4,149 2,756 636 1,029 604 1885 171,900 21,420 1,180 4,032 2,768 653 1,085 561 1884 169,520 21,290 1,498 4,394 2,638 678 1,020 439 1883 167,561 21,030 1,616 4,230 2,615 601 982 483 1882 161,880 20,908 1,474 4,327 2,691 635 1,114 403 1881 163,299 20,666 1,461 4,400 2,726 644 1,067 437 1880 161,385 20,700 1,483 4,605 2,884 719 1,219 369 1879 158,231 20,240 1,428 4,790 2,992 722 1,218 424 1878 154,217 19,719 1,331 4,607 3,120 823 1,429 410 Average of 10 yrs, 1878-87. 165,949 20,903 1,493 4,347 2,806 679 1,129 473 Population in 1861, 70,108 ; 1871, 120,234; 1881, 163,151. Average Number of Persons to each house at Census : in 1871, 7.6 ; in 1881, 8.1 Area of Parish, 2,190 acres. Number of Persons to an acre (1888), 81. *For statistical purposes the population is estimated to the middle of the year, on the basis of the rate of increase ruling between the two preceding inter-censal periods, checked by the known number of inhabited houses, and by the average number of persons per house, as ascertained at the preceding Census. † Mean of numbers on rate books in April and October yearly. ‡ Inclusive of the deaths of parishioners at public institutions outside the parish, but exclusive of the deaths of non-parishioners at public institutions within the parish. § Viz.: At the Parish Infirmary, the Brompton Hospital, and outlying public institutions, including the Asylums Board Hospitals. TABLE II. Shewing the Annual Birth Kate and Death Rate ; Death Rates of Children, and Proportion of Deaths in Public Institutions in a Thousand Deaths, for the year 1888 and ten preceding years. The Year. Birth Rate per 1,000 of the Population Death Rate per 1,000 of the Population. Deaths of Children under 1 year; per 1,000 of Registered Births. Deaths of Children under 1 year : per 1,000 of Total Deaths. Deaths of Children under 5 years; per 1,000 of Total Deaths. Deaths in Public Institutions ; per 1,000 of Total Deaths. 1838 21.3 15.9 160 214 381 208* 1887 22.5 16.4 172 237 393 212 1886 23.9 15.9 154 230 373 219 1885 23.4 16.1 161 236 392 202 1884 25.8 15.1 156 261 392 166 1883 25.2 15.5 143 229 375 184 1882 26.1 16.2 146 236 413 149 1881 26.9 16.6 146 236 391 160 1880 28.5 17.8 156 249 422 128 1879 30.2 18.8 150 241 407 133 1878 29.8 202 178 263 458 132 Average of 10 years, 1878—1887. 26.2 16.8 156 241 401 168 *Includes Deaths of Parishioners at outlying Public Institutions, but excludes deaths of non.parishioners at Brompton Consumption Hospital and Marylebone Infirmary, Notting Hill. In the years 1878-83 the deaths at Brompton Consumption Hospital are included as compensation for an unknown number of deaths of Parishioners at outlying Public Institutions. 184 TABLE III. Deaths registered from all causes in the year 1888. (Exclusive of the Deaths of Non-Parishioners at Public Institutions within the Parish, but inclusive of the Deaths of Parishioners at Public Institutions without the Parish) CAUSES OF DEATH. AGES. Total under Years of Age. GrandTotal All Ages sub-districts. 0 to 1. 1 to 5. 5 to 15. 1 15 to 25. 25 to 35. 35 to 45. " 45 to 55. 55 to 65. 65 to 75. 75 to 85. 85 and Kensington Town Brampton (classes). I. SPECIFIC FEBRILE or ZYMOTIC DISEASES 134 224 47 10 14 10 6 6 7 6 1 358 465 399 66 II. PARASITIC DISEASES 2 .. .. .. .. .. .. .. .. .. .. 2 2 2 .. III. DIETETIC DISEASES .. .. .. .. 2 5 6 3 1 .. .. .. 17 14 3 IV. CONSTITUTIONAL DISEASES 56 67 26 34 81 91 82 60 50 18 4 123 569 443 126 V. DEVELOPMENTAL DISEASES 69 .. .. .. .. .. .. 2 11 50 23 69 155 118 37 VI. LOCAL DISEASES 219 176 59 39 66 81 133 199 243 160 26 395 1401 1106 295 VII. DEATHS FROM VIOLENCE 10 6 5 5 6 9 6 6 8 3 .. 16 64 53 11 VIII. DEATHS FROM ILL-DEFINED AND NOT SPECIFIED CAUSES 114 ... 3 5 5 4 6 5 3 4 3 114 152 115 37 604 473 140 93 174 200 239 281 323 241 57 1077 2825 2250 575 I. SPECIFIC FEBRILE or ZYMOTIC DISEASES. 1.iasmatic Diseeases. Smallpox Vaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Unvaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... No Statement ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 22 94 7 1 ... ... ... ... ... ... ... J16 124 113 11 Scarlet Fever 1 13 9 2 1 ... ... ... ... ... ... 14 26 23 3 Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping-Cough 46 54 ... ... ... ... ... ... ... ... ... 100 100 80 20 Diphtheria 4 52 29 ... 2 2 ... ... ... ... ... 56 89 87 2 Enteric or Typhold Fever ... 2 2 4 6 4 2 1 ... ... ... 2 21 17 4 Other Miasmatic Diseases 2 1 ... ... ... ... ... ... ... ... ... 3 3 3 ... 2.—Diarrheal Diseases. Simple Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diarrhoea, Dysentery 47 5 ... ... 1 ... 1 ... 2 2 ... 52 58 45 13 3. —Malarial Diseases. Remittent Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Zoogenous Diseases. Cowpox, and effects of Vaccination ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases(e.g.,Hydrophobia Glanders, Slenic ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5.—Venereal Diseases. Syphilis 11 1 ... ... ... ... ... ... 1 ... ... 12 13 10 3 Gonorrhoea, Stricture of the Urethra ... ... ... ... ... ... ... ... 1 ... ... ... 1 1 ... 6.- Septic Diseases. Erysipelas 1 ... ... ... ... 1 2 2 1 4 1 1 12 5 7 Pyæmia,Septicæmia ... 1 ... ... ... 1 1 2 2 ... ... 1 7 6 1 Puerperal Fever ... ... ... 3 4 2 ... ... ... ... ... ... 9 7 2 II.PARASITIC DISEASES. 134 224 47 10 14 10 6 6 7 6 1 358 465 399 66 Thrush and other Vegetable Parasitic Diseases 2 ... ... ... ... ... ... ... ... ... ... 2 2 2 ... Worms,Hydatids,and other Animal Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... III. DIETETIC DISEASES. 2 ... ... ... ... ... ... ... ... ... ... 2 2 2 ... Want ol Breast Milk—Starvation .. ... ... ... ... ... ... 1 2 ... ... ... ... 3 3 ... Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chronic Alcoholism ... ... ... ... 1 3 4 1 1 ... ... ... 10 9 1 Delirium Tremens ... ... ... ... 1 2 1 ... ... ... ... ... 4 2 2 IV. CONSTITUTIONAL DISEASES ... ... ... ... 2 5 6 3 1 ... ... ... 17 14 3 Rheumatic Fever,Rheumatism of the Heart ... ... 6 ... 1 4 ... 1 1 ... ... ... 13 9 4 Rheumatism ... ... ... ... ... ... ... ... 1 1 ... ... 2 2 ... Gout ... ... ... ... ... 1 2 1 5 ... ... ... 9 5 4 Rickets 2 3 ... ... ... ... ... ... ... ... ... 5 5 3 2 Cancer,Malignant Disease 1 ... ... 2 2 12 30 28 33 11 2 1 121 92 29 Tabes Mesenterica 15 12 ... ... ... ... ... ... ... ... ... 27 27 25 2 Tubercular Meningitis,Hydrocephalus 19 26 5 1 ... ... ... ... ... ... ... 45 51 41 10 Phthisis ... 1 8 26 72 70 45 26 6 4 1 1 259 202 57 Other forms of Tuberculosis,Scrofula 19 25 7 4 4 1 2 1 ... ... ... 44 63 52 11 Purpura Hæmorrhagic Diathesis ... ... ... 1 ... ... ... ... ... 1 ... ... 2 1 1 Anæmia,Chlorosis,Leucocythæmia ... ... ... ... ... 1 ... ... ... ... ... ... 1 1 ... Glycosuria, Diabetes Mellitus ... ... ... ... 2 1 3 2 4 1 1 ... 14 9 5 Other Constitutional Diseases ... ... ... ... .... 1 ... 1 ... ... ... ::: 2 1 1 V.DEVELOPMENTAL DISEASES 56 67 26 34 81 91 82 60 50 18 4 123 569 443 126 Premature Birth 55 ... ... ... ... ... ... ... ... ... ... 55 55 40 15 Atelectasis 3 ... ... ... ... ... ... ... ... ... ... 3 3 3 ... Congenitalo Malformation 11 ... ... ... ... ... ... ... ... ... ... 11 11 6 5 Old Age ... ... ... ... ... ... ... 2 11 50 23 ... 86 69 17 VI. LOCAL DISEASES. 69 ... ... ... ... ... ... 2 11 50 23 69 155 118 37 1.Diseases of Nervous System. Inflammation of Brain of Membranes 2 5 5 1 2 1 2 3 2 ... 1 7 24 18 6 Applexy,Softening of Brain Hemiplegia Brain Paralysis ... 1 ... 1 6 5 16 27 45 39 7 1 147 111 36 Insanity General Par lysis of the Insane ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 ... Epilepsy ... ... 1 3 1 3 1 3 1 2 ... ... 15 12 3 Convulsions 47 7 ... ... ... ... ... ... ... ... ... 54 54 45 9 Laryngismus Stridulus (Span of Glottis) 2 2 1 ... ... ... ... ... ... ... ... 4 5 3 2 Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... ... 1 ... 2 3 3 2 1 ... ... 12 9 3 Other Diseases of Nervous System 3 2 5 2 4 2 5 9 12 7 1 5 52 44 8 2.-Diseass or Organs of Special Sense. (e.g., of Ear, Eye, Nose) 1 ... ... ... 1 ... ... ... ... ... . ... 1 2 1 1 3.—Diseases of Circulatory System. Pericarditis 1 ... ... ... ... ... ... ... ... ... ... 1 1 ... 1 Acute Endocarditis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Valvular Diseases of Heart ... ... 1 2 1 2 7 7 3 1 ... ... 24 13 11 Other Diseases of Heart ... 3 5 9 10 18 20 29 39 23 3 3 159 127 32 Aneurism ... ... ... ... ... ... 1 ... 1 ... ... ... 2 1 1 Embolism Thrombosis 1 ... ... ... 2 ... ... ... 2 1 ... 1 6 3 3 Other Diseases of Blood Vessels ... ... ... ... ... ... 1 1 ... 1 ... ... 4 2 2 4.—Diseases or Respiratory Organs. Laryngitis 1 10 4 ... ... ... ... 1 ... ... ... 11 16 14 2 Croap 2 20 5 ... ... ... ... ... ... ... ... 22 27 26 1 Emphysema Asthma ... ... ... ... ... 1 3 4 1 ... ... ... 9 7 2 Bronchitis 90 78 3 2 1 8 21 50 69 56 10 168 388 328 60 Pneumonia 20 30 11 3 9 13 17 10 12 7 ... 50 132 107 25 Pleurisy 1 1 ... ... 1 3 1 4 2 2 ... 2 15 7 8 Other Diseases of Respiratory System 9 2 1 ... 3 2 2 5 7 3 1 11 35 28 7 5.-Diseases of Digestive System. Dentition 13 6 ... ... ... ... .. ... ... ... ... 19 19 15 4 Sore Throat, Quinsey ... 1 4 ... 1 ... ... ... ... ... ... 1 6 6 ... Diseases of the Stomach 1 1 ... ... ... 3 1 1 1 1 ... 2 9 4 5 Enteritis 9 3 2 1 3 ... ... 1 ... 1 ... 12 21 19 2 Obstructive Diseases of Intestine 1 1 2 1 2 ... 2 5 4 3 ... 2 21 13 8 Peritonitis 4 ... 3 3 2 2 1 3 1 1 ... 4 20 12 8 Ascites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver ... ... ... 1 2 4 11 4 2 ... ... ... 24 16 8 Jaundice, and other Diseases of Liver 7 1 ... ... 4 3 2 7 5 2 ... 8 31 25 6 Other Diseases of Digestive System ... . ... 2 ... 1 ... ... 1 2 ... ... ... 6 5 1 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) ... ... ... ... ... ... ... ... ... ... ... ... . ... ... ... 7.—Diseases of Glandlike Organs of Uncertain Use. (e.g.,Bronchocele,Addison Disease) ... 1 ... ... ... ... 2 ... 1 ... 1 1 5 4 1 8.—Diseases of Urinary System. Nephritis 1 1 1 1 ... 2 ... 3 3 ... 1 2 13 12 1 Briht's Disease Albuminuria ... ... ... 1 4 2 7 6 11 3 ... ... 34 27 7 Diseases of Bladder or of Prostate ... ... ... ... 1 ... ... 3 7 4 ... ... 15 13 2 Other Diseases of the Urinary System 1 ... 1 2 ... 1 3 4 3 ... ... 1 15 8 7 9.-Diseases of Reproductive System a. Of Ornant of Generation. Male organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Female Organs ... ... ... 1 ... 1 2 2 ... 1 ... ... 7 4 3 B.of Parturition Abortion iscarriage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal C 'onvulsions ... ... ... ... 2 ... ... ... ... ... ... ... 2 ... 2 Placenta Prtevia, Flooding ... ... ... 1 ... ... ... ... ... ... ... ... 1 1 ... Other Accidents of Childbirth ... ... ... 3 1 3 ... ... ... ... ... ... 7 5 2 10.—Diseaseh of Bones and Joints. Caries Necrosis ... ... 2 ... 1 ... 2 1 2 ... ... ... 8 6 2 Arthritis,Ostitis Periostitis 1 ... ... ... ... ... ... 1 1 1 ... 1 4 3 1 Other Diseases of Bones and Joints ... ... ... ... ... ... ... ... ... ... ... ... ... .. ... 11.Diseases of Integumentary System Carbuncle Phlegmon ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 1 Other Diseases of Integumentary System 1 ... ... ... ... ... 1 ... : ... ... 1 2 1 1 DEATHS FROM VIOLENCE 219 176 59 39 66 81 133 199 243 160 26 395 1,401 1,106 295 1.—Accident or Negligence. Fractures and Contusions . 1 3 5 2 2 4 3 3 6 3 ... 4 32 28 4 Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... Burn,Scald ... 3 ... 1 ... ... ... 1 i ... ... 3 6 5 1 Poison . ... ... ... ... ... 3 ... ... ... ... ... ... 3 2 1 Drowing 1 ... ... ... ... ... ... ... ... ... ... 1 2 2 ... Suffocation 7 ... ... ... ... ... 1 1 ... ... ... 7 9 8 1 Otherwise ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2.—Homicide Manslaughter ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... Murder 1 ... ... ... ... ... ... ... ... ... ... 1 1 1 ... 3.- Suicide. Gunshot Wounds ... ... ... 1 1 ... ... ... ... ... ... ... 2 ... 2 Cut,Stab ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... 1 Poison ... ... ... l 1 1 ... 1 ... ... ... ... 4 8 1 Drowning ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 ... Hanging ... ... ... ... ... ... ... ... 1 ... ... ... 1 1 ... Otherwise ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Execution. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... VIII. DEATHS FROM ILL-DEFINED AND NOT SPECIFIED CAUSES. 10 6 5 5 6 9 6 6 8 3 ... 16 64 53 11 Dropsy 1 ... ... ... ... ... ... 1 ... ... ... 1 2 2 ... Debility, Atrophy, Inanition 99 ... 1 ... ... ... ... ... ... ... ... 99 100 79 21 Mortification 1 ... ... ... ... ... ... ... ... 2 1 1 4 3 1 Tumour ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Abscess 2 ... ... 1 ... ... ... ... ... ... ... 2 3 2 1 Hæmorrhage ... ... ... ... 1 ... ... ... 1 ... ... ... 2 2 ... Sudden Death(Cause not ascertained) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Causes not pecified or Ill-defined 11 ... 2 4 4 4 6 4 2 2 2 11 41 27 14 114 ... 3 5 5 4 6 5 3 4 3 114 152 115 37 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. 85 and upwards. Total Under Five ears of Age. Grand total All Ages. Kensington Town Brompton. AGES. sub-districts. 187 TABLE IV. Shewing the number of Deaths at all ages in 1888 from certain groups of Diseases, and proportions to 1,000 of Population, and to 1,000 Deaths from all causes; also the number of Deaths of Infants under one year of age from other groups of Diseases, and proportions to 1,000 Births and to 1,000 Deaths from all causes under one year. Division I. (Adults). Total Deaths. Deaths per 1,000 of Population at all ages. Deaths per 1.000 of Total Deaths, at all ages. 1. Principal Zymotic Diseases 420 2.3 148 2. Pulmonary Diseases 622 3.5 220 3. Principal Tubercular Diseases 354 2-0 125 Division II. (Infants under One Year). Total Deaths. Deaths per 1,000 of Births. Deaths per 1,000 of Total Deaths, under one year. 4. Wasting Diseases 154 40 255 5. Convulsive Diseases 79 21 130 NOTES. 1. Includes Small-pox, Measles, Scarlet Fever, Diphtheria, Whooping-cough, Typhus Fever, Enteric (or Typhoid) Fever, Simple Continued Fever and Diarrhoea. Fifty-six of the deaths occurred in Hospitals outside the Parish. 3. Includes Phthisis, Scrofula, Tuberculosis, Rickets, and Tabes. 4. Includes Debility, Atrophy, Inanition, 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). 188 TABLE V. Shewing the Number of Deaths from the Principal Zymotic Diseases in the ten years 1878-87 and in the year 1888. Diseases. 1878. 1879. 1880. 1881. 1882. 1883. 1884. 1885. 1886. 1887. Annual Average of ten years 1878-87. Proportion of Deaths to 1,000 Deaths in ten years 1878-87. 1888. Proportion of Deaths to 1,000 Deaths in 1888. Small Pox 24 24 11 55 0 1 26 25 0 1 16.7 5.9 - - Measles 53 60 75 67 77 39 32 111 56 108 67.8 24.2 124 43.9 Scarlet Fever 77 51 105 38 62 28 18 7 11 44 44.1 15.7 26 9.2 Diphtheria 20 26 22 8 25 24 17 22 30 40 23.4 8.2 89 31.5 Whooping. Cough 185 93 95 85 119 44 81 98 82 86 96.8 34.5 100 35.4 Typhus Fever 3 1 4 2 1 2 0 0 0 0 1.3 0.4 - - Enteric Fever 26 14 24 22 25 30 26 12 11 11 20.1 7.2 21 7.4 Simple Continued Fever 4 8 5 5 6 3 4 0 0 2 3.7 1.3 2 0.7 Diarrhoea 181 71 128 101 61 80 110 86 90 124 103.2 36.9 58 20.5 TOTALS. Kensington 573 348 469 383 376 251 314 361 280 416 377.1 134.3 420 148.6 London 14734 12256 13681 13811 13553 10801 13629 11261 11121 12684 12753 152.7 10803 137.0 England & Wales 84676 62020 82537 58239 69734 58972 71762 57726 62859 64676 67314 128.2 50684 99.2 189 Table VI Inspectors' Report of the Sanitary Work completed in the year 1888-9. Sanitary Districts* [o. of Complaints received during the year. No. of Houses, Premises, &c., inspected. No of Re-inspections of Houses, Premises, &c. Results of Inspection. House Drains. Water Closets. Dust Bins. Water Supply. Miscellaneous. Notices issued for Sanitary Amendments of Houses and Premises. Houses, Premises, &c., Cleansed, Repaired, Whitewashed, &o. Houses Disinfected after illness of an Infectious character. Repaired, Cleansed, Trapped, &e. [ Ventilated. Repaired, &c. Supplied with Water. New Provided. I New Provided. Repaired, Covered &c. Cisterns (new) erected. j 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. f 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. 40 1499 1395 578 100 58 80 80 63 92 6 26 36 4 81 27 59 373 50 ... 36 6 8 43 N.E. 65 703 961 513 42 122 54 156 125 60 ... 4 12 ... 50 2 44 549 11 1 46 2 5 33 Centrl 50 1525 2432 532 216 45 44 148 22 122 24 30 41 6 15 49 73 303 20 ... 23 2 7 23 South 281 2508 2174 683 479 36 138 111 74 153 1 1 59 6 146 42 112 728 324 38 44 2 2 16 Totals 436 6235 6962 2306 837 261 316 495 284 427 31 61 148 16 292 120 288 1953 405 39 149 12 22 115 * The North-Bast and North-West Districts lie north of the centre of Uxbridge Road, to the Bast and West of Ladbroke Grove and Ladbroke Grove Road respectively (North Kensington): the Central and South Districts are south of Uxbridge Road (South Kensington.) § 288 Houses were registered in 1888. The total number on the Register, in March, in round figures, was 1,800. † The actual complaints of neglect, made by letter, were 27. ‡ Exclusive of proceedings, in 29 cases, under the Food and Drugs Adulteration Act, all of the Inspectors being Inspectors under the Act; and in 12 cases of " obstructions," on and over the public ways, but inclusive of 12 cases of disobedience of the Justices' orders. 190 TABLE VIa. Summary of Monthly Returns of Work, &c., done by the Sanitary Inspectors, in the year 1888-9. Date of Report. Houses Inspected. Mews Inspected. Slaughter Houses Inspected. Cowsheds Inspected. Bakehouses Inspected. Offensive Trades Inspected. Sanitary Notices Issued. Removal ot Dust, Ashes, &c., Letters of Bequest received and attended to. Date of Report. District. District. District. District. District. District. District. District. N.W. N.E. c. s. N.W. N.E. c. s. N.W. N.E. c. s. N.W NE. c. s. N w. N E. c. s. N.W. N E c. s. N.W N.E. c. s. N.W. NE. c. s. 1888, Ap.21 118 20 108 150 90 103 75 197 8 4 8 8 8 1 3 11 10 1 8 3 19 10 17 8 9 6 15 25 42 45 31 56 Ap. 21,1888 „ May 19 104 31 116 181 105 33 110 223 12 ... 6 8 6 ... 5 12 19 ... 15 6 7 ... 15 14 39 12 16 28 60 76 36 77 May 19 „ „ Jane 16 72 37 87 178 82 49 62 156 13 ... 3 8 6 ... 3 11 11 ... 5 3 21 ... 14 5 10 19 29 37 53 70 35 104 June 16 ,, ,, July 14 81 32 167 263 73 56 81 200 8 2 6 9 6 ... 5 12 6 ... 14 5 23 2 22 10 70 34 66 104 24 41 26 65 July 14 „ „ Aug. 11 149 133 125 145 106 59 51 157 33 16 12 8 18 9 4 9 31 24 6 4 20 8 9 6 76 114 50 65 22 30 17 54 Aug. 11 „ ,, Sept. 8 86 88 53 180 57 32 36 142 8 4 2 6 1 2 2 4 4 28 4 10 10 ... 12 7 31 75 16 71 11 23 12 23 Sept. 8 „ „ Oct. 6 153 26 179 244 95 36 65 183 8 7 8 9 6 1 3 4 17 39 3 4 23 2 16 5 66 26 74 93 9 15 14 31 Oct. 6 „ „ Nov. 3 142 80 130 201 109 48 62 158 8 7 3 8 7 2 4 4 12 16 6 3 20 ... 11 7 61 27 20 48 21 23 16 25 Nov. 3 ,, „ Dec. 1 125 50 102 229 106 41 55 176 10 3 5 8 7 3 4 16 22 4 3 22 2 8 9 48 33 40 57 11 16 19 25 Dec. 1 „ „ „ *9 123 36 70 167 82 53 59 176 8 6 2 8 3 1 3 8 3 20 6 1 23 1 19 5 25 35 50 19 15 37 14 39 „ 29 „ 1889Jan.26 116 63 129 187 102 30 57 162 5 5 5 7 8 2 3 8 27 9 3 2 29 15 4 28 44 54 38 33 66 29 95 Jan.26,1889 „ Feb. 23 100 54 119 189 100 42 70 195 9 2 6 8 7 ... 4 8 ... 10 9 20 22 4 21 15 52 47 43 52 40 54 40 75 Feb. 23 „ „ Mar. 23 130 53 140 194 80 56 70 177 8 6 7 8 8 1 5 8 7 25 11 22 7 5 10 11 63 41 59 46 32 63 14 59 Mar. .23 „ Totals 1499 703 1525 2508 1187 638 853 2302 138 62 73 103 91 19 47 103 163 194 94 86 246 35 189 106 578 513 532 683 373 549 303 728 Totals. 191 TABLE VII. Shewing the Death Rate per 1,000 persons living: the Annual Rate per 1,000 from the principal Diseases of the Zymotic Class; and the proportion of Deaths from these Diseases to total Deaths, in Kensington and in. all London, in 1888, and in ten preceding years. The Year. Deaths per 1,000 living. Total Deaths from seven principal Zymotic Diseases, Kensington. Annual rate of Mortality per 1,000 living, from seven principal Zymotic Diseases. Proportion of Deaths to 1,000 Deaths, from seven principal Zymotic Diseases. The Year. Kensington. London. Kensington. London. Kensington. London. 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 17.8 22.2 469 2.9 3.7 162 170 1880 1881 16.6 21.2 383 2.3 3.6 140 172 1881 1882 16.2 21.4 376 2.2 3.5 140 163 1882 1883 15.5 20.4 251 1.5 2.7 96 134 1883 1884 15.1 20.3 314 1.8 2.7 119 164 1884 1885 16.1 19.7 361 2.1 2.7 130 140 1885 1886 15.9 19.9 280 1.6 2.7 101 135 1886 1887 16.4 21.1 416 2.4 3.0 144 154 1887 AVERAGES OF TEN YEARS, 1878-87. 16.8 21.1 377 2.2 3.2 133 155 AVERAGES OF TEN YEARS, 1878-87. 1888. 159 18.5 420 2.3 25 148 137 1888. 192 TABLE VIII. Comparative Analysis of the Mortality in all London, and in Kensington, in 1888. LOCALITY. Annual Death Rate per 1,000 living, from all causes. Annual Death Bate per 1,000 living, from seven 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 seven principal Zymotic diseases. From Violence. Registered upon information of Coroners. (Inquests.) Registered at Public Institutions.* Uncertified London 18.5 2.5 14 6 24.3 23.2 13.7 3 7 7.4 22.5 1.0 Kensington 15.9 23 16.0 21.4 29.8 14.8 2.3 5.8 21.2 0.4 * Viz— Parish Infirmary, Brompton Consumption Hospital, so far as relates to Deaths of Parishioners therein, and outlyi Public Institutions, i.e., General and Special Hospitals, etc. TABLE IX. Showing the Localities in which fatal cases of some of the Principal Zymotic Diseases occurred in 1838. KENSINGTON TOWN REGISTRATION SUB-DISTRICT. Locality. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhoea. Total. Locality. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhoea. Total. Enteric. Simple Continued. Enteric. Simple Continued. Acklam Road 1 ... 2 1 1 5 Ledbury Mews ... ... 3 ... ... ... ... 3 Adair Road 1 ... ... 1 ... ... ... 2 Little Charles Street ... ... 1 ... ... ... 1 2 All Saints' Road ... ... 1 2 1 ... 1 5 Lionel Mews ... ... 3 ... ... ... ... 3 Appleford Road 3 ... ... 3 ... ... ... 6 Lower Notting Hill Terrace.. ... ... 1 ... ... ... ... 1 Archer Street ... 1 ... 2 ... ... ... 3 Manchester Road 1 ... 1 1 ... ... ... 3 Bangor Street 2 ... ... ... 2 ... ... 4 Murchison Road ... ... 1 ... ... ... 1 2 Bevington Road 1 ... 2 3 ... ... ... 6 Norfolk Road ... ... 1 ... ... ... ... 1 Blechynden Street 3 ... ... 2 2 ... ... 7 Observatory Gardens ... ... 1 ... ... ... ... 1 Bolton Road ... 2 1 2 ... ... 1 6 Oxford Gardens 1 ... 1 ... ... ... ... 2 Buckingham Terrace 2 ... 1 2 ... ... ... 5 Peel Street 2 ... 1 ... 3 ... ... 6 Campden Hill Road ... 1 1 ... ... ... ... 2 Pembridge Place ... 1 ... ... ... ... ... 1 Chapel Road ... 1 ... ... ... ... ... 1 Portland Road 2 ... ... 1 1 ... 1 5 Chepstow Place and Mews ... 1 ... ... ... 1 ... 2 Portobello Road 5 1 2 4 1 ... 4 17 Chepstow Villas ... 1 3 ... ... ... ... 4 Queen's Gate Terrace ... ... ... ... 1 ... ... 1 Chesterton Road 2 ... 2 2 ... ... ... 6 Rackham Street 2 ... 2 ... ... ... ... 4 Clarendon Road ... ... 1 ... 1 ... 1 3 Eaymede Street ... ... 1 ... ... ... ... 1 Colville Gardens ... ... ... ... 1 ... ... 1 St. Ann's Road 2 1 ... ... 1 4 Colville square ... ... 1 ... ... ... ... 1 ,, Clement'u Road 4 ... ... 2 ... ... ... 6 Convent garden 1 ... ... ... ... ... 1 2 „ Ervan's 1 ... ... ... ... ... ... 6 Cornwall Road ... ... 1 1 ... ... 1 3 George's , 1 ... 2 ... ... ... ... 3 Crescent Street 3 1 ... ... ... ... 1 5 ,, Katherine's 5 1 2 ... ... ... ... 3 Dunworth Mews 1 ... 1 1 ... ... ... 3 ,, Lawrence ,, ... 2 ... ... ... ... 1 7 Edenham Street ... ... 1 3 ... ... 2 6 Silchester Terrace ... ... 2 ... ... ... ... 2 Faraday Road 2 ... 3 1 ... ... ... 6 Southam Street 4 1 3 2 ... ... ... 2 Gloucester Road 2 ... ... 1 1 ... ... 4 Stoneleigh Street ... ... 1 ... ... ... ... 10 Golborne Road 1 ... 2 1 ... ... ... 4 Swinbrook Road 2 ... ... 3 ... ... 1 6 Golborne Terrace 1 ... 1 1 ... ... ... 3 Talbot Grove ... 1 ... ... ... ... ... 1 Gordon Place ... ... ... ... 1 ... ... 1 Tavistock Road ... ... 1 ... ... ... ... 1 Harrow Road ... ... ... ... 1 ... ... 1 Telford Road 1 ... 3 ... ... ... ... 1 Hazlewood Crescent 2 ... 1 ... ... ... ... 3 Thomas Mews ... 1 1 1 ... ... ... 4 Heathfield Street ... ... 1 ... ... ... ... 1 Thorpe Mews ... ... 1 1 ... ... ... 3 Hesketh Place 2 ... 1 ... ... ... ... 3 Tobin Street 1 ... 1 1 ... ... ... 2 High Street, Notting Hill ... 1 ... 1 1 ... 1 4 Treverton Street 2 ... 1 1 ... ... 1 5 Horbury Crescent ... ... ... ... ... ... ... 1 Virginia Place ... ... 2 ... ... ... 1 3 Inkerman Terrace ... 1 ... ... ... ... ... 1 Walmer Road, &c. 5 1 1 1 ... ... 3 11 James Street 2 ... ... 1 ... ... ... 3 Warwick Road ... 1 1 ... ... ... ... 2 Johnson Street 1 ... ... ... 1 ... ... 2 Western & Victoria Dwellings ... ... 1 2 ... ... ... 3 Kensington Park Road ... ... 1 ... ... ... 1 2 Wheatstone Road 3 ... 11 1 ... ... 1 16 Ladbroke Grove Road ... ... 2 ... ... ... ... 2 William Street, Notting Dale ... ... ... 3 ... ... ... 3 Lancaster Road 2 ... 2 1 ... ... ... 5 Wornington Road 8 2 3 5 1 ... 2 21 BROMPTON SUB-DISTRICT. Astwood Mews ... ... ... 2 ... ... ... 2 Knaresborough Place ... ... 1 ... ... ... ... 1 Catkcart Road ... ... ... ... 1 ... ... 1 Marloes Road ... 1 ... ... ... ... ... 1 Childs Place, &c. ... ... ... ... ... ... 3 3 Montpelier Place ... ... ... ... 1 ... ... 1 Collingham Place 2 ... ... ... ... ... ... 2 North Street, &c., St. Mark's 1 ... ... 1 ... ... 1 3 Cromwell Road ... ... 1 ... ... ... ... 1 Bedcliffe Road ... ... ... ... 1 ... ... 1 Emperor's Gate ... ... ... ... 1 ... ... 1 Shaftesbury Road ... 1 ... ... ... ... ... 1 Hooper's Court ... ... ... 3 ... ... 1 4 Sussex Place 2 ... ... ... ... ... ... 2 Ifield Road ... ... ... 3 ... ... 3 6 Yeoman's Row 1 ... ... 4 ... ... 1 6 195 TABLE X. Return respecting the Vaccination of Children whose births were Registered in 1887.* Date. Registration Sub-Districts comprised in Vaccination Officer1 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 entered in the Vaccination Register, on account (as shewn by Eeport Book), of Column 11. Postponement by Medical Certificate. Removal to District the Vaccination Officer of which has been duly apprised. Removal to places unknown or which cannot be reached, and cases not having been found. Cases still under proceedings by summons and otherwise. Column 10 Successfully vaccinated. Insusceptible of Successful vaccination. Had Small-pox. Column 13, Dead, Unvaccinated. 1887. 1 2 3 4 5 6 8 9 10 1st January Kensington Town 3214 2633 10 ... 317 31 5 215 3 to Brompton 714 670 4 ... 47 2 ... 21 ... 31st December Total 3958 3303 14 ... 364 33 5 236 3 *The Return for 1888 is not yet complete. 196 TABLE XI. LICENSED SLAUGHTER-HOUSES. SOUTH OF UXBRIDGE ROAD. LOCALITY. LICENSEE. 6, Church Street, Kensington . Mr. Blott 11, Peel Place, Silver Street . ,, Osborne 25, Silver Street „ Wright 183, Brompton Road . „ Joyce 60, Kensington High Street . ,, Evans 15, High Street, Notting Hill „ Short 133, ditto ditto ,, Candy 20, Addison Terrace, ditto ,, Austin 35, Earl's Court Eoad Mrs. Matson NORTH OF UXBRIDGE ROAD. 13, Archer Mews Mr. Grantham 195, Clarendon Road . „ Thorn 10, Edenham Mews . „ Goddard 2, Ledbury Mews ,, Sansom Lonsdale Mews „ Grove 10, Prince's Yard „ Coles Clarendon Mews „ Colley 41, Princes Place ,, Grant 23, Norfolk Terrace . ,, Borthwick 61, Silchester Road ,, Crawforth 235, Walmer Road „ Van 4, Royal Crescent Mews ,, Brooker 8, Ditto ditto , ,, Down 197 TABLE XII. LICENSED COWSHEDS. SOUTH OF UXBEIDGE ROAD. LOCALITY. LICENSEE. Newland Terrace (rear of) Mr. Tisdall Addison Cottage, Lome Gardens. „ Glenie Campden Street (Yard in) ,, Lunn Redfield Lane, Earl's Court. ,, Cross NORTH OF UXBEIDGE EOAD. 5, Ledbury Mews Mr. Liddiard 187, Walmer Road . ,, Arnsby 235, Walmer Road . ,, Van 27, Tobin Street ,, Copperwheat 47, Tobin Street ,, Burton 23, Bramley Road ,, Tame 41, St. Mark's Road . ,, Hickox Portobello Road (rear of 209) . Aylesbury Dairy Company