KEN 1 THE ANNUAL REPORT on the HEALTH, SANITARY CONDITION, &c., &c., of the Parish of St. Mary Abbotts, KENSINGTON, FOR THE YEAR 1893, BY T. ORME DUDFIELD, M.D., Medical Officer of Health. PRINTED BY SAMUEL SIDDERS, 17, BALL STREET, KENSINGTON HIGH STREET, W. 1894. THE ANNUAL REPORT ON THE HEALTH, SANITARY CONDITION, &c., &c., of the Parish of St. Mary Abbotts, KENSINGTON, FOR THE YEAR 1893, by T. ORME DUDFIELD, M.D., Medical Officer of Health. PRINTED BY SAMUEL SIDDERS 17, BALL STREET, KENSINGTON HIGH STREET, W, 1894. TABLE OF CONTENTS. page THE Census of 1891 1 Registration District and Sub-Districts ok Kensington 2 Wards, Area of; and Inhabited Housesand Population of, in 1881 and 1891 3 „ Rateable Value and Population of; Inter-censal Increase in 3 Population, 1801-1893; Rateable Value, 1823-189.5 3 ,, Inhabited Houses, and Rateable Value; Increase of since 1856, and since 1871 4 ,, Inhabited Houses, etc., in 1893 5 ,, of the Parish, and of the Sub-Districts, at different Age-periods (1891) 6 Marriages and Marriage Rate 7 Births and Birth-Rate 7 ,, of Illegitimate Children 8 „ Annual Number of, and Births of Males and Females, and Birth-Rate, 1883-1892 8 Deaths and Death-Rate 9 Infantile Mortality 9 ,, ,, Amongst Illegitimate Children 10 Senile Mortality 10 Death-Rate at different Age-periods 10 Death-Rate and Mean Temperature ; Monthly Table of 11 ,, ,, in London, and in England and Wales 12 ,, ,, in Large Provincial Towns 14 ,, ,, in Indian, Colonial, and Foreign Cities 14 Mortal Statistics, etc., 1893; Summary of 15 Death, Assigned Causes of 22 Zymotic Diseases, "Seven Principa;" General Remarks on the 22 ,, ,, ,, ,, Number of deaths from, in 1893 23 ,, „ ,, ,, Death-rate from ; in Kensington ; in London and other large Towns ; and in England and Wales 24 ,, ,, „ ,, Monthly returns of Deaths from, in Kensington 24 iv. Death, Assigned Causes of—continued. page Zymotic Diseases: Small-Pox, in Kensington and in London 25 ,, Endemic of, at North Kensington 26 ,, Difficulty in diagnosis of 36 Measles, in Kensington and in London 41 ,, Should it be made Notifiable ? 42 Scarlet Fever, in Kensington and in London 43 ,, Tables shewing Notifications ; Admissions to Hospitals, and Deaths, in Kensington and in London; and Cases in Hospitals at end of thirteen consecutive four-weekly periods, 1892-1893 44 ,, Illustrative Examples of; Shewing how the Disease is spread by Exposure of the Sick 46 ,, Statistical Returns of Cases of; recorded in Kensington, 1883-1893 (Tables) 48 Diphtheria 51 ,, Decrease in Case-mortality of 51 „ In London 52 ,, Statistical Table of Cases in Kensington, in 1893 S3 Whooi'INC.-Cough, in Kensington and in London 54 Fever, in Kensington and in London 55 Diarrhœa, in Kensington and in London 55 Cholera; Precautions taken against 56 ,, Local Government Board's Action with reference to 56 Influenza 59 Table shewing Number of Deaths from, in Kensington and in London, in thirteen four-weekly periods 60 Venereal Diseases 61 Septic Diseases: Puerperal Fever 61 Parasitic Diseases 63 Dietetic Diseases 63 ,, ,, Alcoholism 63 Constitutional Diseases 63 ,, ,, Cancer 64 ,, „ Tubercular 65 Developmental Diseases 67 Local Diseases 67 ,, Nervous System, Diseases of 67 ,, Circulatory System ,, 68 „ Respiratory ,, ,, 69 ,, Digestive ,, „ 70 „ Urinary „ „ 70 ,, Reproductive „ ,, 70 V. Death, Assigned Causes of—continued. page Violent Deaths 71 Ill-defined and not Specified Causes of Death 71 Causes of Death in 1893 : Summary of Table III. (Appendix) 72 Public Institutions, Deaths at 73 ,, ,, ,, Parish Infirmary and Workhouse 73 „ ,, „ Consumption Hospital, Brompton 75 ,, „ ,, Marylebone Infirmary, Notting Hill 75 ,, ,, ,, St. Joseph's House ,, ,, 75 ,, ,, ,, Outlying Hospitals, etc. 75 Uncertified Deaths. The position and duties of Coroners and their their Officers in relation to 77 „ „ Report of Select Committee upon 80 Inquests: 80 „ Deaths from Violence; Accident; Suicide; Homicide 81 ,, Why so many become necessary 82 Meteorology 83 Vaccination: Return of Vaccination Officer for 1892 84 ,, Interim Report of the Royal Commission on 85 ,, Animal; Calf Lymph 88 Metropolitan Asylums Board: The Work and Proceedings of the 89 ,, ,, ,, Annual Report of the Chairman 90 ,, ,, ,, Expenditure of the 95 ,, ,, ,, Statistical Committee, Annual Report of the 96 ,, ,, ,, Admissions to Hospitals of the 102 ,, ,, ,, Ambulance Service of the 104 ,, ,, ,, ,, „ Origin of the 105 ,, ,, ,, ,, Land Service; Stations 106 ,, „ ,, „ River Service 107 ,, „ ,, ,, Committee, Annual Report of the 107 ,, Western Hospital: Report of Medical Superintendent 113 Hospital Accommodation for the Infectious Sick: The Needs of the Metropolis in respect of 117 ,, „ For Fever : Steps taken by the Asylums Board to increase the amount of 121 vi. page Hospital Accommodation—continued. ,, ,, For Fever: The Difficulties of the Asylums Board in respect of sites for Hospitals 123 ,, „ Conference of Sanitary Authorities on 127 ,, „ Fountain Hospital: Description of 128 „ „ North-Eastern Hospital 130 ,, ,, Small-Pox 131 Hospital Construction, Principles of 134 Increased Facilities for the Removal to Hospital of the Infectious Sick 135 Danger to Public Health in connection with Removal of the Sick 137 Table showing Admissions (Quarterly and Total) of Patients to the Hospitals, from each Parish and Union, in 1893, and Population of Districts, in 1891 138 Notification' of Infectious Diseases, Compulsory 140 ,, in London, 1890-93: Number of Cases Notified 140 „ „ ,, Corrected Table of cases of, in 1893 141 ,, Cases notified, in Kensington and in London, in 1893: Arranged in Thirteen four-weekly periods 142 ,, Duplicate: Subject of Complaint 143 ,, ,, Table showing number of cases of, in 1893 146 ,, Delay in 147 ,, The School Board for London and 148 „ Payment of Fees lor Certificates of 149 Compulsory Removal of the Infectious Sick to Hospital ; Need for Amendment of the Law with respect to the 149 Sanitary Legislation ; Progress in 151 Royal Commission (1881-2) on Hospital Accommodation for Infectious Diseases ; Recommendations of the 152 Public Health (London) Act, 1891 ; Bye-laws, etc. 153 Public Health (London) Bill, 1893 ; Introduced and Withdrawn 154 Factory and Workshop Acts 155 Workshops, etc. : Women Inspectors of, Appointed 156 Women Inspectors ; Report on the work of the 157 ,, ,, Table of Inspecting Work done by the 159 ,, ,, Desirability of Investing them with the Status of Sanitary Inspectors 160 ,, ,, Duties of, under the Public Health (London) Act, 1891 162 ,, ,, Labour Commission; Minority Report of on 163 vii. page Factory and Workshop Bill (1894); Introduced 163 Sanitary Inspectors, The Work and Districts of the 164 Sanitary Department, Official Staff of the 165 Legal Proceedings: Fish Offal, Nuisance in Removal of 166 ,, ,, Unsound Fish, Exposure for Sale of 167 ,, „ Unsound Meat, Sale of 167 ,, ,, Exposure in Public Vehicles of the Infectious Sick 168 „ „ Neglect to Notify cases of Infectious Disease 168 ,, ,, Jurisdiction of Justices in regard to, confirmed 170 Infected Dead Bodies in Churches 171 Offensive Businesses 172 ,, ,, Fat Extractor 172 ,, ,, Marine Store Dealer 172 ,, ,, Brickmaker 173 Slaughter-Houses, The Licensed 174 ,, ,, Report on by the Sanitary Committee 174 „ ,, Reduction in the number of the 175 Cow-Houses, The Licensed 176 ,, Reduction in the number of the 176 Dairies Order of 1885 177 Bakehouses; Regulation of 179 ,, ,, Proposals of the County Council with reference to 179 „ ,, Medical Officer reports with reference to 181 ,, ,, Proceedings in 188183 with reference to 181 „ ,, Legislation in 1891 with reference to 87 ,, ,, County Council to apply for power to make bye-laws for 188 Refuse Matter ; Nuisance arising in Removal of 189 House Refuse ; The Work of Collection and Removal of 189 „ ,, Daily Collection of, from Moveable Receptacles: A Desideratum 190 ,, ,, Shoots for; Difficulty of finding 191 Trade Refuse ; The Law on the subject of the Removal of 192 viii. page Stable Refuse 193 ,, ,, Nuisance from Non-removal of, largely dependent on the use of Improper Receptacles 194 ,, ,, Sunken Dung-pits 194 ,, ,, ,, Use of now made Illegal 195 ,, ,, Difficulty in obtaining Removal of 196 ,, ,, Sanitary Committee recommend the Vestry to undertake the collection and removal of 197 Housing of the Working Classes 198 ,, The Boundary Street (Bethnal Green) and other Schemes : Proceedings of the County Council with reference to 198 ,, Municipal Common Lodging-houses 199 ,, Overcrowding: Migration as a remedy for 200 ,, The James Street (Kensington) Scheme 203 ,, Houses closed by Justice's Order 203 ,, Royal Crescent Mews : Houses in, closed by Justice's Order 204 ,, Bye-laws for Houses let in Lodgings, &c. 205 Common Lodging Houses, in Kensington; List of 206 ,, ,, ,, Control of, transferred to County Council 207 Vagrants and the Spread of Infectious Disease : Conference of Sanitary Authorities at the County Hall 209 Glanders or Farcy in the Metropolis 210 Rabies in the Metropolis 211 Public Mortuary ; Particulars with reference to Bodies admitted into the 211 „ „ Royal Commission of 1882; Views of, with reference to 212 Coroner's Court ; Inquests held at the 213 „ ,, Duties of theCounty Council, and the Sanitary Authority, with reference to provision of 213 Disinfection in 1893-94 214 ,, Duties of the Sanitary Authority with reference to 215 ,, The cost of 217 ,, Shelters for persons unhoused during process of 218 ix. page Public Baths and Washhouses ; Separate Washhouses a Desideratum 219 Public Sanitary Conveniences 220 Drainage Map of the Parish 22 Elementary Schools ; Sanitation of 223 Hygienic Carriage-ways and Pavements 225 Obstructive Buildings 227 Smoke Consumption 227 Grand Junction Canal 228 Metropolitan Sewage-Disposal 229 Sewer Emanations : Bacterial Studies 30 Water Supply ; Metropolitan; Report of the Royal Commission on the 231 ,, ,, Dr. Frankland's Report on the 32 ,, ,, Bacterioscopic Examination of the 234 ,, ,, Water Examiner's Report on the 237 ,, ,, Constant Service System 237 ,, ,, Storage Reservoirs 238 ,, ,, Filtration of the 238 ,, ,, Deterioration of the, in Dirty Cisterns 238 ,, ,, Cutting-off Powers of the Companies 239 ,, ,, ,, Report on, by the Sanitary Committee 240 ,, ,, Regulations; Proposed Amendment of the 242 ,, ,, ,, Action of County Council with reference to 242 ,, ,, ,, Views of Medical Officer ,, 244 Gas ; Results of Examinations for Ascertaining the Illuminating Power and the Purity of the 246 ,, Variation in the Illuminating Power of the 248 ,, Portable Photometer ; Proposal to acquire power to test with 248 ,, Standard for Ascertaining Illuminating power of; A Desideratum 248 Conclusion 250 [appendix—tables. ] X. APPENDIX. STATISTICAL AND OTHER TABLES. page Table I. Estimated Population, in 1893, and Ten previous years, 1883-92 : Number of Inhabited Houses, and of Marriages, Births, Deaths, &c. 252 „ II. Birth-rate and Death-rate ; Death-rates of Children ; Deaths in Public Institutions, in 1893, and in 1883-92 253 ,, III. Deaths Registered from all Causes, 1893 254-5 (For Summary of Table III., see Page 72) „ 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 256 ,, V. Deaths in 1893, and in 1883-92, from the Seven Principal Diseases of the Zymotic class—in the Parish; in the Metropolis; and in England and Wales 257 VI. Summary of Inspectors' Reports of Sanitary Work completed, in the year 1893-94 258 „ VII. Death-rates, General and Zymotic, in Kensington, and London ; and Proportion of Deaths from Zymotic Diseases, to Total Deaths, in 1893, and in 1883-92 259 ,, VIII. Comparative Analysis of the Mortality, in London and Kensington, in 1893 ; Percentages 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 ; and of Inquest cases ; and of Deaths at Public Institutions, to Total Deaths 260 ,, IX. Localities where fatal cases of the more important of the Zymotic Diseases occurred in 1893 261.2 ,, IXa. Streets, &c., in which cases of Infectious Disease were notified, in 1893, under the Provisions of Section 55 of the Public Health (London) Act, 1891 263.4 ,, X. Vaccination Officers's Annual Return for 1892 265 ,, XI. Slaughter-houses, Licensed: and names of Licensees 266 ,, XII. Cowsheds ,, ,, ,, 267 THIRTY-EIGHTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, Being for the Year 1893. To the Vestry of the Parish of St. Mary Abbotts, Kensington. Gentlemen, The vital and mortal statistics in the present report have been compiled, as usual, for the fifty-two weeks of the Registration year, which in 1893 terminated on the 30th December. In other respects, the report is for the official year ended March 25th, 1894. In the report for 1891 I gave my reasons for believing that the population of the parish, as enumerated at the Census in April, 1891, during the currency of the Easter holidays and the Parliamentary vacation, was considerably below the true normal number. At the same time, I stated that I had felt it to be my duty to adopt the official figures for statistical purposes, a course which involved the recasting of all calculations of birth and death-rates, &c., for each of the preceding ten years. I need not repeat here the grounds for my opinion as to the deficiencies of the Census figures: it will suffice to refer to the report for 1891 in which they are set out with all needful detail 2 REGISTRATION DISTRICT AND SUB-DISTRICTS. "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 comprises, according to the Registrar-General, an area of 2,190 acres. Registration Sub-Districts.—For registration purposes the Parish is unequally divided into two sub-districts, respectively named "Kensington Town," (hereinafter, for brevity, designated "Town,") and "Brompton." The Town sub-district comprises an area of 1497 acres, the area of Brompton being 693 acres. The Town sub-district still includes some open spaces, as Holland Park and Notting-Barn 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 practically covered. The West London or Brompton Cemetery, Government property, is in this sub-district; the Kensal Green Cemetery, in private ownership, is 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 as I believe 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 well-built, and obviously intended for occupation by the lower middle classes: many 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, 3 WARDS. KENSINGTON is, for some local purposes, divided into Wards. The subjoined Table shows the acreage of the Wards, their population, as enumerated, and the number of inhabited houses in each, in 1881 and 1891:— Name of Ward. Area in Statute acres. Inhabited 1881. Houses 1891. Increase in 10 years. Population. Increase in 10 years. Decrease 1881. 1891. St. Mary Abbotts 846 6,573 7,535 962 48,831 50,823 1,992 Holy Trinity, Brompton 439 3,936 4,440 504 26,746 28,379 1,633 Sc. John, Nottinghill, & St. James, Norland 905 9.594 10,109 515 87.574 87,106 — 468 2,190 20,103 22,084 1,981 163,151 166,308 3,625 468 RATEABLE VALUE AND POPULATION. The rateable Value of Property in the several Wards, at ten-year intervals, between 1851 and 1891, was as follows:— Ward. 1851. 1861. 1871. 188l. 1891. £ £ £ £ £ St. Mary Abbotts 68,000 129,958 323.992 619,512 834,875 Holy Trinity, Brompton 61,000 119,302 246,716 459,000 536,492 St. John, Notting-hill, & St. James, Norland 99.500 155,428 365,012 501,704 510,082 †131,394 £228,500 404,688 935,720 1,580,216 2,012,843 The increase in rateable value between 1851 and 1861, was 77 per cent.; between 1861 and 1871,130 percent.; between 1871 and 1881, 69 per cent.; and between 1881 and 1891,26 per cent. The subjoined figures illustrate the developement 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 1891 166,308 2,037,221 (April) 1893 1893 167,000 †These figures represent the value of the hereditaments of public companies. 4 Kensington is still in process of developement by building, but at a very slow rate compared with past years— 1861-70, for instance. The following Table, brought up to date exhibits the growth of the Parish since the Metropolis Local Management Act came into operation, in 1856:— 1856. 1893. Increase in 37 years. Number of Inhabited Houses 7,600 22,050 14,450 Population 57,000 167,000 110,000 Rateable Value of Property £,308,000 £2,037,221 £1,729,221 The increase in all respects within the last twenty-two years, the period over which my official experience extends, is not inconsiderable, as the subjoined figures show:— 1871. 1893. Increase in 22 years. Number of Inhabited Houses 15.735 22,050 6,315 Population 121,000 167,000 46,000 Rateable Value £935,720 £2,037,221 £1,101,501 From the foregoing figures we learn that the population in 1893 was nearly twenty times as large as in the first year of the century, and that the rateable value of property in 1893 was nearly 27 times as great as in 1823, the first year in respect of which I possess information. In the last 37 years, since the Metropolis Local Management Act of 1855 brought your Vestry into existence, the rateable value has increased nearly seven-fold: the mere increase in the last 22 years being more than treble the total in 1856 ; since which date the population and the number of inhabited houses have increased nearly three-fold. The rateable value of the parish is exceeded by that of the Cities of London, Liverpool and Manchester only, and by that of only ten of the larger counties with their towns thrown in. The population of Kensington is to that of London as 1 to 26; the rateable value as 1 to 16.5, 5 POPULATION, INHABITED HOUSES, &c. The population of Kensington which in 1871, my first year of office, was 120,299, increased to 163,151 in 1881, and to 166,308 in 1891. The inhabited houses which numbered 15,735 in 1871, and 20,103 in 1881, were 22,002 in 1891. The falling-off in the rate of increase of population between 1881 and 1891, as compared with the two previous decennial periods, is remarkable. It is noteworthy, however, that there was an increase of about 1900 in the number of inhabited houses between 1881 and 1891, which might reasonably have been taken as an indication of a population-increase of not less than 15,000, whereas the enumerated increase but little exceeded the fifth of that number. As already intimated, I feel bound to accept the Census figures for statistical purposes, and I therefore assume—both for the ten years 1881-91, and as an estimate for the current decennium commencing in 1891—an annual increase of 300 persons only, notwithstanding thatthe average yearly excess of births over deaths in the ten years, 1881-91 was 1356: this assumption therefore involves an annual loss of over 1,000 by migration duringthe ten years, 1881-91. On this basis it is assumed that the population at the middle of 1893 numbered 167,000, and that there was a loss to the Parish of 445 persons in the year by migration. The density of the population was 76.2 persons per acre, the number of persons to a house being 7.57 (against 8.08 in 1881) and the inhabited houses being 22,050. The estimated population of the Town sub-district was 118,900, that of Brompton being 48,100. The males numbered 65,950 : the females were 101,050, and therefore upwards of 35,000 in excess; the excess in 1871 having been 22,000 only. The increase in this excess between 1881 and 1891 was 2664, or only 493 less than the enumerated increase of population in the ten years (3170) a remarkable and inexplicable fact, seeing that the male births (20,464) exceeded the female births (19,794) by 670 in the ten completed years 1881-90. 6 The following Table shows the relative Number of Persons of each Sex at the Census of 1891, 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 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 100,591 7466 14194 24216 21147 13520 9420 5774 3367 1278 202 7 100,591 Females. Males 65,717 7394 12962 12947 10759 8695 6337 3822 2046 666 86 2 65,717 Males. Excess of Females 34,874 72 1231 11269 10388 4825 3083 1952 1321 612 116 5 34,874 Excess of Females. Total of both sexes 166,308 14860 27157 37163 31906 22215 15757 9596 5413 1944 288 9 166,308 Total of 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 69,384 5976 11192 15483 13330 9172 6592 4060 2450 969 154 6 69,384 Females. Males 49,367 5905 10287 9540 7815 6377 4696 2741 1472 470 63 1 49,367 Males- Excess of Females 20,017 71 905 5943 5515 2795 1896 1319 978 99 91 5 20,017 Excess of Females. Total of both sexes 118,751 11881 21479 25023 21145 15549 11288 6801 3922 1439 217 7 118,751 Total of 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 31,207 1490 3002 8733 7817 4348 2828 1714 917 309 48 1 31,207 Females. Males 16,350 1489 2676 3407 2944 2318 1641 108l 574 196 23 1 16,350 Males. Excess of Females 14,857 1 326 5326 4873 2030 1187 633 343 113 25 — 14,857 Excess of Females. Total of both sexes 47,557 2979 5678 12140 10761 6666 4469 2795 1491 505 71 2 47,557 Total of both sexes ***The death-rate at the different age-periods will be found at page 10. 7 MARRIAGES AND MARRIAGE-RATE. The marriages in 1893 were 1,540, against 1,511, 1,569 and 1,584 in the preceding three years respectively. Of these there were celebrated : By the Church (73'9 per cent. of total marriages) 1138 At Roman Catholic Places of Worship 120 At other Nonconformist Places of Worship 56 At the Superintendent-Registrar's Office 226 Total 1,540 The marriage-rate, i.e. persons married to 1000 inhabitants, was 18.4, compared with 18.2, 18.9 and 19.0 in the preceding three years respectively. The marriage-rate in England and Wales was 14.7 per 1,000* as compared with 15.15, 15.5, and 15.4 in the preceding three years. The rate in London, was 17.2 compared with 17.4 in 1892, 17.7 in 1891, 17.6 in 1890, 17.1 in 1889, 16.9 in 1888, and 16.8 in 1887 ; the latter being the lowest rate ever recorded. BIRTHS AND BIRTH-RATE. The births registered in the 52 weeks of the registration year 1893, were 3,661 : males, 1,893, and females, 1,768; the numbers in the Town and Brompton sub-districts respectively, being 2,993 and 668. They were 57 fewer than in 1892 (viz., 3,718 : Town 3,071 ; Brompton 732), and 380 fewer than in 1872, when the population (127,400) was 39,600 less than in 1893. The Kensington birth-rate, which is considerably below that of London as a whole (31.0 in 1893) has been declining since 1868, when it was 33.1 per 1,000. In 1893 it was 21.9 per 1,000, and 21 below the deccenial average (24.0). The rate was 25.2 in the Town sub-district and 13.9 in Brompton There was one birth to 45.6 inhabitants, and 107 births of males to 100 of females. The birth-rate in England and Wales in 1893 was 30.8 per 1,000, and slightly higher than that in 1892 ; but it was 3.4 per *The rate in the four quarters successively was 10.9, 15.9, 15.6, and 16.3. 8 cent. below the average in the ten years 1888-92. The births of illegitimate children in Kensington in 1893 were 179 (2 fewer than in 1892), viz., males 101, and females 78. Of these births 167 were registered in the Town subdistrict, which includes the Parish workhouse, at which institution there were 129 births, males 72, females 57 (including five of still-born male children), of which 88 were illegitimate In the Parish generally, the illegitimate births formed 4.9 per cent. of total births, as against 5*8, 5'4, and 4.9 per cent. in the preceding three years respectively. The subjoined Tables show (1) the quarterly number of births of males and females in each of the sub-districts in 1893, and (2) the annual number of births, &c., in the decennium 1883-92. Kensington Town Total. Brompton Total. Grand Total. Males. Females. Males. Females. 1st Quarter 429 388 817 91 72 163 980 2nd „ 332 383 715 88 79 167 882 3rd „ 388 352 740 87 77 164 904 4th 381 340 721 97 77 174 895 Totals 1530 1463 2993 363 305 668 3661 The Year. Population. Total Births. Males. Females. Birth-rate per 1000. 1883 163,860 4,230 2,162 2,068 25.8 1884 164,180 4,394 2,246 2,148 .26.8 1885 164,500 4,032 2,049 1,983 24.5 1886 164,820 4,149 2,137 2,012 25.2 1887 165,140 3,941 2,016 1,925 23.9 1888 165,450 3,776 1,914 1,862 22.8 1889 165,760 3,69S 1,846 1,852 22.3 1890 166,080 3,864 1,919 1,945 23.3 1891 166,400 3,847 1,935 1,912 23.1 1892 166,700 3,718 1,867 1,851 22.3 Totals 39,649 20,091 19,558 Average 24.0 Excess of male births in the ten years. 533 9 DEATHS AND DEATH-RATE. The deaths registered in 1893, inclusive of 312 deaths of parishioners at outlying public institutions, &c., but exclusive of deaths of non-parishioners at public institutions within the Parish, were 2,916, and were 110 above the corrected decennial average (2,806). Of these deaths 2,305 belong to the Town sub-district, and 611 to Brompton. The death-rate, which in the preceding three years had been 17.8, 18.4 and 17'2 respectively was 17'5 per 1,000, being 0.7 above the decennial average, 16.8 : it was 3.8 below the rate in the Metropolis as a whole (21.3), this being 0.9 above the decennial average (20.4:). The rate in the Town sub-district was 19"4, that in Brompton being 12.7; against 19.0 and 13.1 respectively in 1892. The rate in the male sex was 20.0, that in the female sex being 15.2 ; against 20.9 and 14.9, in 1892. In the Parish, as a whole, there was one death to 57'3 persons living, the proportion in 1892 having been one to 57.8. The deaths of males were 1,378, out of a total of 65,950 persons of that sex, or one in 47'8 ; against one in 47.7 in 1892. Of 101,050 females 1,538 died, or one in 65.7; against one in 66.4 in 1892. The deaths in the first and fourth or colder quarters (1,611) exceeded those in the second and third or warmer quarters (1,305) by 306. In the preceding three years consecutively, the difference in favour of the warmer quarters was 293, 288 and 358. Infantile Mortality.—The deaths of children under 5 bear a high ratio fo total deaths. In 1893 these deaths were 965 (againsit 1,095, 968, and 972 in the preceding three years) the corrected decennial average being 1,040. These 965 deaths were equivalent to 33T per cent. on total deaths, and to 26.5 per cent. on births registered: the equivalent percentages for the whole Metropolis were 38.4 and 26.5. The deaths under one year were 625, against 651, 633, and 587 in the preceding three years, the corrected decennial average being 10 These 625 deaths were equivalent to 21.4 per cent. on total deaths, and to 17.0 per cent. on births registered: the equivalent percentages for the whole Metropolis were 23.8 and 16.4, and for England and Wales 25.5 and 15.9. The deaths of illegitimate children under five years of age, 118, 119, and 119, in the preceding three years respectively, were 100 in 1893 (males 56, and females 44), of which 90 were registered in the Town sub-district, and were equal to 55.9 per cent. on births registered as illegitimate. Of these 100 children, 15 only outlived their first year; ten died in the second and 5 in the third year of life. The causes of death as registered, were atrophy, &c., 26 ; premature birth, 8 ; tubercular diseases 5 ; zymotic diseases 18 (viz., diarrhoea 13, whooping-cough 2 ; scarlet fever 1; diphtheria 1; and measles 1); syphilis 6 ; lung diseases 16 ; convulsions 7 ; diseases of the digestive organs 8 ; violence 2 (burns 1, suffocation 1) ; meningitis 2 ; septicoemia and cellulitis one each. Senile Mortality.—At sixty years of age and upwards there were 859 deaths, against 826, 957, and 880, in the preceding three years ; they were equivalent to 29.5 per cent. on total deaths, the equivalent percentage in London as a whole, being 23.8. The death-rate per 1000 persons living at different ageperiods in 1893, 1892, and 1891, was as follows:— (Population, 1893.) 1893. 1892. 1891. Under 5 years of age 14,922 64.6 65.4 65.1 Five and under 15 27,271 5.0 3.1 3.6 Fifteen „ „ 25 37,319 2.1 2.3 3.2 Twenty-five „ 35 32,040 5.3 5.4 5.8 Thirty-five „ 45 22,308 11.1 11.1 10.8 Forty-five „ 55 15,823 18.6 17.0 21.0 Fifty-five „ 65 9,636 33.5 35.5 36.8 Sixty-five „ 75 5,437 66.6 68.1 76.4 Seventy-five „ 85 1,952 117.8 130.6 139.9 Eighty-five & upwards 298 248.3 279.4 289.5 11 The subjoined Table shews the quarterly number of deaths of parishioners, males and females, in each of the sub-districts:— Kensington Town sub-district. Total. Brompton sub-district. Grand Total. Total. Whole Parish. Males. Females. Males. Females. 1st Quarter 285 306 591 70 98 168 759 2nd „ 226 257 483 68 71 139 622 3 rd „ 298 261 559 52 72 124 683 4th „ 308 364 672 71 109 180 852 1,117 1,188 2,305 261 350 611 2,916 The Births were, Males, 1893 The Deaths were, Males, 1378 Females, 1768 Females, 1538 Total Births, 3661 Total Deaths, 2916 2916 Deaths 745 Excess of Births over Deaths. The subjoined Table shews 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. 1893 Decennial Average. Above or below Decennial Average. 1893 10 years 1883-92. Jan. 28 23.2 22.2 + 1.0 34.2 37.9 –3.7 Feb. 25 14.2 18.4 –4.2 42.0 39.5 + 2.5 March 25 17.0 18.7 –17 45.0 38.9 + 6.1 April 22 16.4 17.6 –1.2 49.6 44.8 + 4.8 May 20 13.9 16.5 –2.6 570 50.1 + 6.9 June 17 14.3 16.1 –1.8 60.3 57.3 + 3.0 July 15 169 15.1 +1.8 63.2 61.3 +1.9 August 12 17.3 16.0 +1.3 63.1 61.8 + 1.3 Sept. 9 14.4 14.3 +0.1 64.1 59.8 + 4.5 Oct. 7 16 3 12.6 +3.7 54.7 55.1 –0.4 Nov. 4 147 15.0 —0.3 50.4 47.5 + 2.9 Dec. 2 207 15.7 +5.0 40.4 43.2 –2.8 Dec. 30 27.6 17.7 +9.9 41.6 38.0 + 3.6 Averages, whole year 17.5 16.8 51.1 48.9 12 DEATH.RATES IN LONDON, ENGLAND AND WALES, AND FOREIGN CITIES. Before entering upon details with respect to the causes of death in Kensington, I may mention, by way of comparison with our local mortality.rates, that the death.rate in England and Wales in 1893 was 19.2 per 1000, corresponding with the mean rate in the ten years 1883.92. The rate in London, as already stated, was 21.3 per 1000, and was 0.9 above the decennial average, 20.4. The subjoined table shews the annual death.rate per 1000 persons living, in each of the last eleven years, in Kensington, in London, and in England and Wales:– 1893. 1892. 1891. 1890. 1889. 1888. 1887. 1886. 1885. 1884. 1883. Kensington 17.5 17.2 18.4 17.8 14.6 17.1 17.4 16.7 16.8 16.1 16.0 London 21.3 20.6 21.4 21.4 18.4 19.3 20.3 20.6 20.4 20.9 20.8 W. Districts .19.7 20.0 20.8 20.5 18.1 19.3 19.9 19.8 19.9 19.7 19.8 North ,, 20.2 19.4 20.0 19.6 16.9 17.7 18.9 18.9 19.3 19.6 19.4 Central ,, 25.7 23.9 26.5 24.8 20.9 22.7 23.5 23.4 22.9 23.8 23.3 East ,, 24.9 23.5 24.0 25.1 21.2 22.7 23.3 23.9 23.0 23.4 24.4 South ,, 19.5 19.0 19.8 19.6 177 18.1 19.4 19.9 19.1 20.2 19.8 England am Wales . 19.2 19.0 20.2 19.5 l8.2 18.1 19.1 19.5 19.2 19.7 19.6 The Registrar.General in his Annual Summary has a table shewing diminution or excess of deaths in 1893, compared with annual deaths in 1883.92, corrected for increase of population. From this we learn that there was a diminution in the number of deaths from small.pox (97), measles (1,053), typhus (16), whooping.cough (443), simple fever (36), phthisis and other tubercular diseases (917), diseases of nervous system (498) andhomicide(17),the total diminution being 3,077,against 14,720, 3,762, 4,712 and 4,453 in the preceding four years. On the other hand there was an excess under several heads, viz., scarlet fever (449), influenza (970), diphtheria (1,985), enteric fever (10), diarrhceal diseases (391), cancer (374), premature birth (365), diseases of circulatory system (403) 13 diseases of respiratory system (662), diseases of urinary system (170), childbirth and puerperal fever (173), accident (249), suicide (40), and "all other causes" (825). The diminution being deducted from the excess, a balance of excess and diminution shows a net excess or loss of 3,989 lives in the year, compared with 719 in 1892, 4,147 in 1891, and 1,546 in 1890, and contrasted with a net diminution of 13,224 in 1889. This point may be made clearer by the statement that " had the death-rate in 1893 been only equal to the average rate in the preceding decennium, 3,989 fewer persons would have died in London than was actually the case." The RegistrarGeneral adds that "among the headings distinguished in the table contributory to (the above-mentioned) excess, are again diphtheria, cancer, premature birth, and diseases of the circulatory and urinary systems, which have, for several successive years, shown an increased mortality. Besides these, in 1893 there was a considerable excess in the mortality from scarlet fever, influenza, diarrhceal diseases, diseases of the respiratory system, childbirth and puerperal fever and accident. The excess under diphtheria was no less than 1985, the total deaths from this disease having been 3,265. The deaths under the heading influenza showed an excess of 970, against an excess in the preceding year of 1945." Greater London.—The death-rate in "Greater London," which is co-extensive with the Metropolitan and City Police Districts, the population in 1893 numbering 5,849,707, was 19.7 per 1000, the rate in the preceding three years having been successively, 201, 19.8 and 19.3, and the average for the three years 19'7. The deaths properly belonging to the Outer Ring, as distinguished from Inner or Registration London, were equivalent to a rate of only 15.4 per 1000, the rate in the Inner Ring, as already shewn, having been 21.3. The death-rate from the principal zymotic diseases in Inner London, was 3.08 per 14 1000; in the Outer Ring 2.25 only; the rate for Greater London, as a whole, being 2.86 per 1000. Compared with the average rates in the preceding three years, these rates show an increase of 16 per cent, in Greater London, of 18 per cent, in Inner London, and of 11 per cent, in the Outer Ring. Other Large Towns.—The death-rate in thirty-two Cities and Boroughs next in importance to London, and having a population exceeding six millions, was 21.8; ranging from 16.3 in Croydon, 17.2 in Huddersfield, 17.4 in Halifax, 18.2 in Derby and Portsmouth, and 18.4 in Brighton, 24.1 in Bolton, 24.9 in Manchester, 26.4 in Preston, and 27.3 in Liverpool, without correction for differences between one town and another in regard to the age and sex-distribution of their respective populations. The death-rates of Edinburgh, Glasgow, and Dublin, were 19.8, 23.4, and 27.0 respectively. Indian, Colonial and Foreign Cities.—In 33 European, American and Australian cities with an aggregate population of about twenty millions, the mean rate of mortality was 23.2 per 1000, and exceeded by l.8 the mean rate in the 33 largest English towns (London included) having a population exceeding ten millions. The lowest rates were 15.7 in Sydney, 16.3 in Brisbane, 17.5 in Christiania, 17.9 in San Francisco, 18.6 in Amsterdam and 18.7 in Cincinnati; ranging upwards to 23.9 in New York, 24.0 in Boston, 28.1 in New Orleans, 30.6 in St. Petersburg, and 35.9 in Moscow. The rate in Paris was 21.8, in Berlin 21.0, in Rome 22.3, and in Vienna 24.0 Among the Indian Cities the highest death-rate was in Madras, viz., 40.9, the rates in Bombay and Calcutta being 28.1, and 25.9 respectively. In Alexandria and Cairo the death-rates were 36.3, and 50.9 respectively; these high rates being mainly attributable to excessive mortality from diarrhceal diseases, 15 SUMMARY OF MORTAL STATISTICS, &c. The year 1893, considered from the point of view of the death-rate, was, like the preceding three years, below the average of healthiness, the rate, 17.5, having been 0.7 above the decennial average (16.8). There were considerable fluctuations in the rate at different periods of the year, for whereas the rate was considerably below the decennial average in the five four-weekly periods between January 29th and June 17th, it was more or less considerably above the average in seven of the remaining four-weekly periods, as shown in the Table at page 11. The deaths in the first half of the year were 1,381, the death-rate 16.5 per 1,000; the deaths in the second half of the year being 1,535 (excess. 154) and the death-rate 184. In like manner there was a considerable excess of mortality from the principal diseases of the zymotic class in the second half of the year, viz., 149; so many as 245 persons having died from these causes, as compared with 96 in the first half period. The total deaths from these diseases (341) were 7 in excess of the corrected decennial average. The most fatal disease was diarrhœa (98 deaths), diphtheria coming next with 83 deaths, and being followed by whooping-cough, 65 deaths, and scarlet fever, 51 deaths. The relative proportion of these several diseases to their decennial averages may be seen in the Table at page 23. The mortality from the diseases of the respiratory organs was excessive both at the beginning and at the end of the year, the deaths from these causes having been in the first four weeks 124, and in the last four weeks 93: total in eight weeks 217, or nearly onethird of the recorded deaths from these causes during the year (671). The deaths from influenza were 93, compared with 155 in 1892. In neither year was the total mortality from chest diseases abnormally high as it was in 1890, when influenza for the first time, in recent years, became a serious factor in the bills of mortality. The highest monthly deathrate in 1893 (=27.6 per 1,000) was recorded in the last four 16 weeks of the year, the lowest (=13.9) in the four weeks ended May 20th. The mean temperature of the air (51.1 Fahr.) was 1.9° above the means in the preceding fifty-three years. The death-rate in the first four weeks of the year ended January 28th, the highest save one in 1893, was 23.2 per 1,000 of the estimated population, and l.0 above the decennial average (22.2). It was 3.9 below the rate in the Metropolis as a whole (27.1) this being 1.2 above the decennial average (25.9). The deaths from the principal diseases of the zymotic class were ten in number, and twelve below the corrected decennial average; viz., diphtheria 5, scarlet fever and whooping-cough 2 each, and enteric fever 1. The mortality from the diseases of the respiratory organs was greater than in any other month: the deaths from these causes were 124, including bronchitis 84, and puenmonia 22. The deaths of children under five years of age were 57, including 39 under one year. The deaths at sixty years of age and upwards were 119, the highest number recorded in 1893, and corresponding with the number recorded in the last four weeks of the year. The mean temperature of the air was 34.2° Fahr. and 3.7 below the means in the corresponding weeks in the preceding ten years (37.9). In the second four-weekly period of the year (5th-8th weeks, January 29th to February 25th) the death-rate fell (from 23.2) to 14.2, and was 4.2 below the average (18.4). It was 5.3 below the Metropolitan rate (19.5), this however being 2.5 below the average (22.0). The deaths from the principal zymotic diseases were again ten, and nine below the corrected average number; viz., three each from scarlet fever and diphtheria, and two each from whooping-cough and diarrhoea. There were six deaths from influenza in Kensington and 96 in London. The diseases of the respiratory organs were fatal to 47 persons only, a reduction of 77 compared with the previous month: 32 of these deaths were due to bronchitis and seven to pneumonia. The deaths of children under five years fell (from 57) 17 to 51, including 37 under one year. The deaths at 60 and upwards were 78, or 41 fewer than in the previous four weeks. The mean temperature, 42.0, was 2.5 above the average (39.5). In the third period (9th-12th weeks, February 26th to March 25th) the death-rate rose (from l4.2) to 17.0, but was 1.7 below the average (18.7). It was 2.9 below the Metropolitan rate (19.9) this being 2.3 below the average (22.2). The deaths from the principal zymotic diseases were 14, and 6 below the average; viz., diphtheria 6, scarlet fever 4, whooping-cough 3, and small-pox 1. There were 8 deaths from influenza in Kensington, and 162 in London. The deaths from diseases of the respiratory organs further fell (from 47) to 41, including 27 from bronchitis and 12 from pneumonia. The deaths of children under five rose (from 51) to 70, including 40 under one year. The deaths at 60 and upwards further fell (from 78) to 56. The mean temperature was 45.0, and 64 above the average (38.9). In the fourth period (13th-16th weeks, March 26th to April 22nd) the death-rate fell (from 17.0) to 16.4, and was 1.2 below the average (17.6). It was 4.3 below the Metropolitan rate (20.7) this being 0.5 below the average (21.2). The deaths from the principal zymotic diseases were 4, and 18 below the average; viz., scarlet fever 1, measles 2, and diarrhoea 1. The deaths from influenza were 13 in Kensington,and 180 in London. The deaths from the diseases of the respiratory organs rose (from 41) to 59, including bronchitis 38 and pneumonia 12. The deaths of children under five fell (from 70) to 48, including 37 under one year. The deaths at 60 and upwards rose (from 56) to 71. The mean temperature was 49.6, and 4.8 above the average (44.8). In the fifth period (I7th-20th weeks, April 23rd to May 20th) the death-rate further fell (from 16.4) to 13.9 (the lowest 18 rate recorded in 1893) and was 2.6 below the average (16.5). It was 4.6 below the Metropolitan rate (18.5) this being 15 below the average (20.0). The deaths from the principal zymotic diseases were 19, and 8 below the average; viz., scarlet fever 6, diphtheria and diarrhcea 4 each, whooping-cough 3, small-pox and enteric fever one each. The deaths from influenza fell to 10 in Kensington and to 125 in London. The deaths from the diseases of the respiratory organs fell (from 59) to 38, including bronchitis 14 and pneumonia 21. The deaths of children under five were 45 (the lowest number recorded in 1893) including 30 under one year. The deaths at 60 and upwards fell (from 71) to 59. The mean temperature was 57.0, and 6.9 above the average (50.1). In the sixth period (21st-24th weeks, May 21st to June 17th) the death-rate rose (from 13.9) to 14.3, but was 1.8 below the average (16.1). It was 3.8 below the Metropolitan rate (18.1) this being 0.3 below the average (18.4). The deaths from the principal zymotic diseases were 21, and 9 below the average; viz., diphtheria 7, diarrhœa 6, whooping-cough 4, scarlet fever 2, small-pox and measles 1 each. There was only one death from influenza in Kensington, but 72 in London. The deaths from the diseases of the respiratory organs were 30, including bronchitis 12 and pneumonia 10. The deaths of children under five rose (from 45) to 59, including 41 under one year. The deaths at 60 and upwards fell (from 59) to 52. The mean temperature was 60.3, and 3.0 above the average (57.3). In the seventh period (25th-28th weeks, June 18th to July loth) the death-rate further rose (from 14.3) to 16.9, and was T8 above the average (15.1). It was 5p6 below the Metropolitan rate (22.5) this being 4.2 above the average (18.3). The deaths from the principal zymotic diseases were 42, and 2 above the average; viz., diarrhœa 19, whooping-cough 9, 19 diphtheria 9, scarlet fever 4, and small-pox 1. There were also two deaths from simple cholera. Influenza caused 4 deaths in Kensington, and 49 in the metropolis as a whole. The deaths from the diseases of the respiratory organs were 34, including bronchitis 9 and pneumonia 16. The deaths of children under five rose (from 59) to 97, including 76 under one year. The deaths at 60 and upwards were 35, this being the lowest number recorded in 1893. The temperature was 63.2, and 1.9 above the average (61.3). In the eighth period (29th-32nd weeks, July 16th to August 12th) the death-rate further rose (from 16 9) to 17.3, and was 1.3 above the average (16.0). It was 3.7 below the Metropolitan rate (21.0) this being 0-4 above the average (20.6). The deaths from the principal zymotic diseases were 50 (the highest number recorded in 1893) and 5 above the average viz., diarrhoea 28 (the highest monthly number), diphtheria 9, whooping-cough 7, scarlet fever 3, enteric fever 2, and measles 1. The deaths from influenza fell to 2 in Kensington and to 23 in London. There was one death from simple cholera. The deaths from the diseases of the respiratory organs were 31, including bronchitis 14 and pneumonia 12. The deaths of children under five further rose (from 97) to 110, including 76 under one year. The deaths at 60 and upwards rose (from 35) to 53. The temperature was 63.1, and 1.3 above the average (61.8). In the ninth period (33rd-36th weeks, August 13th to September 9th) the death-rate fell (from 17.3) to 14 4, but was 0.1 above the average (14.3). It was 5.9 below the Metropolitan rate (20.3) this being 2.3 above the average (18.0). The deaths from the principal zymotic diseases were 33, and 1 above the average; viz., diarrhœa 15, scarlet fever 8, whoopingcough 6, and diphtheria 4. There was one death from simple cholera, The deaths from the diseases of the respiratory 20 organs were 22 (the lowest monthly number recorded in 1893) including bronchitis 12 and pneumonia 5. The deaths of children under five fell (from 110) to 70, including 49 under one year. The deaths at 60 and upwards were 41. The temperature was 64.3, and 4.5 above the average (59.8). In the tenth period (37th-40th weeks, September 10th to October 7th) the death-rate rose (from 14.4) to 16.3, and was 3.7 above the average (12.6). It was 2.3 below the Metropolitan rate (18.6) this being 2.0 above the average (16.6). The deaths from the principal zymotic diseases were 34, and 15 above the average, viz., diarrhœa 11, whooping-cough 10 (the highest monthly number in 1893) scarlet fever 6 (also the highest monthly number) diphtheria 6, and enteric fever 1. The deaths from the diseases of the respiratory organs were 27, including bronchitis 17 and pneumonia 5. The deaths of children under five years were 74, including 48 under one year. The deaths at 60 and upwards were 47. The temperature was 54.7, and 0.4 below the average (55.1). In the eleventh period (41st-44th weeks, October 8th to November 4th) the death-rate fell (from 16.3) to 14.7, and was 0.3 below the average (15.0). It was 4T below the metropolitan rate (18.8) this being 0.1 below the average (18.9). The deaths from the principal zymotic diseases were 43, and 25 above the average; viz., diphtheria 16 (the highest monthly number in 1893) diarrhoea 9, whooping-cough 6, scarlet fever and enteric fever 4 each, measles 3, and small-pox 1. The deaths from the diseases of the respiratory organs rose (from 27) to 40, including bronchitis 22 and pneumonia 8. The deaths of children under five were 76, including 38 under one year. The deaths at 60 and upwards were 45. The temperature was 50.4, and 2.9 above the average (47.5.) In the twelfth period (45th-48th weeks, November 5th to December 2nd) the death-rate rose (from 14.7) to 20.7, and 21 was 50 above the average (15.7). It was 4.2 below the Metropolitan rate (24.9) this being 49 above the average (20.0). The deaths from the principal zymotic diseases were 22, and 2 above the average; viz., enteric fever 5 (this being the highest monthly number in 1893) whooping-cough 5, diphtheria 4, scarlet fever and measles 3 each, small-pox and diarrhoea 1 each. In these four weeks there were 10 deaths from influenza in Kensington and 152 in all London. The deaths from the diseases of the respiratory organs further rose (from 40) to 70, including bronchitis 43 and pneumonia 17. The deaths of children under five were 84, iucluding 44 under one year. The deaths at 60 and upwards rose (from 45) to 84. The temperature, 40.4, was 2.8 below the average (43.2). In the thirteenth and last four-weekly period of the year (49th—52nd weeks, December 3rd to 30th) the death-rate further rose (from 20.7) to 27.6 (the highest rate in 1893) and was 9.9 above the average (17.7). It was also 0.2 above the Metropolitan rate (27.4) this being 5.5 above the average (21.9). The deaths from all causes in Kensington (355) were no fewer than 125 in excess of the corrected decennial average, and were 84 in excess of the births registered. The deaths from the principal diseases of the zymotic class rose (from 22) to 39, and were 19 above the average; viz., diphtheria 10, measles 8 (the highest monthly number in 1893) whoopingcough 8, scarlet fever 5, small-pox and enteric fever 3 each, and diarrhoea 2. Influenza was the cause of 35 deaths, the number in the metropolis as a whole being 546. The deaths from diseases of the respiratory organs further rose (fiom 70) to 93 (the second highest number recorded in 1893, the highest number, 124, having been recorded in January) including bronchitis 69, and pneumonia 12. The deaths of children under five were 126 (the highest monthly number in 1893) including 66 under one year. The deaths at 60 and upwards, 119, were the same as in the first four weeks of the yearThe temperature, 41.6, was 3.6 above the average (38.0). 22 ASSIGNED CAUSES OF DEATH. Class I.—Specific Febrile or Zymotic Diseases.*— 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 "Diarrhœal") include the diseases which the RegistrarGeneral describes as "the seven principal diseases of the zymotic class," grouping as he does, under the generic term "Fever," the three distinct fevers,named "Typhus," "Enteric,. and "Simple Continued." These zymotic diseases have a special interest for sanitarians, being of a more or less preventable character ; the absence or the prevalence of certain of them therefore, 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 illustrations, founded on our own local experience within the last few years. Thus, Afeasles was very prevalent in 1888 and 1890, the deaths being considerably above the average. In 1889 and 1891, on the other hand, the deaths from measles were greatly below the average: * but the lowered mortality, regarded as evidence of the diminished prevalence of the disease, was the natural consequence of an excessive prevalence and fatality in the preceding years. In saying this, I 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 measures, to check the spread of infection. Again, the number of deaths from ]Yhooping-cough in 1889 was the lowest on record; it is not surprising to find, therefore, that in the immediately preceding and succeeding years this disease was fatal above the average : the large total of 185 deaths in 1878, moreover, followed the then minimum return of 34 in the previous year. Diarrhaa may be cited as an illustration of quite another kind. The mortality from this disease amongst * The classification of the causes of death in the Weekly Returns and Annual Summary of the Registrar-General, was considerably modified in 1882. The list of causes, in its new form, is an abbreviation of the more detailed list used in the Annual Reports of Births, Deaths and Marriages in England. Table III. in my reports prior to 1882, was framed upon the lines of the abridged list of the causes in the Annual Summary, and was the basis of some of the other Tables. It being desirable that Table III. should accord with the new list used in the Annual Report, the Society of Medical Officers of Health revised certain Tables framed, at my instance, for uniformity, in 1872, and settled the lorms of Tables I—V as they appear in the Appendix. 23 infants was excessive in 1887; the mortality in 1888 was much below the average : but the diminished mortality in 1888 had no relation to the excessive mortality in 1887. The conditions were altogether different: the summer of 1888 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 1887. 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 01 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 had both been below the decennial average in Kensington. In 1893 general rate was (as in London also) slightly above the average; the zymotic rate was 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. The subjoined Table shews the number of deaths from the principal zymotic diseases in 1893, together with the decennial average, etc. Disease. Sub-district*. In Hospitals. Total. Decennial Average. Town Brompton. Town Brompton. Uncorrected. Corrected for increase of Population. Small-pox 3 ... 6 ... 9 5.3 5.3 Measles 15 l 1 l 18 76.2 77.0 Scarlet Fever 9 l 37 4 51 24.0 24.2 Diphtheria 24 7 41 11 83 42.7 43.1 Whooping-cough 55 9 1 ... 65 75.7 77.0 Typhus Fever ... ... ... ... ... 0.2 0.2 Enteric Fever 7 3 7 ... 17 18.4 18.5 SimpleContd.Fever ... ... ... ... ... 1.4 1.4 Diarrhœa 80 16 2 ... 98 86.5 87.3 193 37 95 16 341 330.4 334.0 24 It thus appears that the deaths from these diseases were seven above the corrected decennial average. They were 8 more than in 1892; and as usual the deaths in the Brompton sub-district (53) were fewer in proportion to population than those in the Town sub-district (288). The total deaths were equivalent to 117 per 1,000 deaths from all causes in Kensington (Metropolis 144), and to a rate of 2.0 per 1000 persons living (Metropolis, 31); the decennial average being 2.0 in Kensington, and 2.8 in London. In England and Wales the deaths from these diseases were 129 in each 1000 deaths, and the rate was 2.47 per 1000 persons living, the decennial average being about 2.4 per 1000. In the 32 Cities and Boroughs grouped by the Registrar-General with the Metropolis, the zymotic death-rate averaged 3.12 per 1000 living, ranging from 1.24 at Huddersfield and 1.65 at Bristol, to 4.65 at Bolton and 6.01 at Salford. The subjoined Table shews the distribution of deaths in Kensington from the principal diseases of the zymotic class, registered in thirteen four-weekly periods corresponding with my monthly reports :— Report for Four Weeks ended. Small-pox. Measles. Scarlet Fever. Diphtheria. Whooping-cough. Enteric Fever. Diarrhœa. Total. January 28 ... ... 2 5 2 1 10 February 25 ... ... 3 3 2 ... 2 10 March 25 1 ... 4 6 3 ... 14 April 22 ... 2 1 ... ... ... 1 4 May 20 1 ... 6 4 3 1 4 19 June 17 1 1 2 7 4 ... 6 21 July 15 1 ... 4 9 9 ... l9 42 August 12 ... 1 3 9 7 2 28 50 September 9 ... ... 8 4 6 ... 15 33 October 7 ... ... 6 6 10 1 11 34 November 4 1 3 4 16 6 4 9 43 December 2 1 3 3 4 5 5 22 December 30 3 8 5 10 8 3 2 39 Totals 9 18 51 83 65 17 98 341 25 SMALL-POX. Ninety-six cases of small-pox were notified during the year, 79 of them in North Kensington and 17 in South Kensington, Uxbridge Road being the dividing line: 84 of the cases were removed to hospitals. The deaths were nine in number, and four above the corrected decennial average; six of them occurred in hospitals to which the deceased persons had been removed from the Town sub-district. The three deaths "at home" were all in the same sub-district; but two of them occurred south of Uxbridge Road. The deaths from this cause in the preceding three years had been 2, 1, and 3, successively. In London 206 deaths were registered, the decennial average corrected for increase of population being 304. During the preceding seven years the total deaths from this cause aggregated 95 only, the annual number of deaths being 24, 9, 9, 0, 4, 8, and 41, in the several years successively. The mean annual mortality in the decennium 1883-92 was 0.07 per 1000 persons living, and lower than in any previous decennium: the rate in 1893 was 0.05. The notifications in 1893, corrected for dual returns, were 2813. Small-pox in Kensington.—The cases of small-pox notified in ten successive four-weekly periods, from the beginning of the year to October 7th, were 0, 5, 1, 3, 8, 2, 3, 2, 0, and 1; or 25 in all. These cases call for little remark. Of the cases recorded in the second period, one occurred at the Casual Ward, North Kensington; the other four were in the family of a dentist at Campden Hill, three out of the four cases, and the death of the head of the family, being the result of failure on the part of the medical man in attendance to recognise the variolous nature of the first case. Some account of this outbreak was given in my last annual report (page 27). In the third period five cases occurred at the Marylebone Infirmary, but these are not included in our statistics, having been notified to the Medical Officer of Health for Marylebone 26 as the Act directs. All of them were, I believe, removed to hospital, and the disease did not spread to any person in Kensington. In the fourth period two cases occurred at common lodging-houses in North Kensington, but happily the disease did not spread. I had communicated with the keepers of the several common lodging-houses in January, calling their attention to the fact that small-pox had for some time past been spread in London mainly through the agency of casual wards, shelters, and common lodging-houses, and urging them to make a careful inspection, night and morning, of the people seeking accommodation at their respective establishments, and to obtain medical advice in case any lodger should develope a rash or suffer from described symptoms of illness. The remaining cases in the parish up to October were of no particular interest. They occurred singly in houses. In London generally small-pox was declining, Kensington was supposed to be free from the disease, and all danger of an epidemic appeared to be at an end. Small-pox at North Kensington.—The supposed freedom of Kensington from small-pox towards the close of 1893 to which reference is made above proved delusive, for suddenly and unexpectedly I became aware, in the latter days of October, of an outbreak in the north-east part of the parish—to wit, at the north end of Portobello Road, and in adjacent streets—which had been smouldering for a month before the first notification was received. This outbreak, which involved a large number of cases and five deaths, was, in many respects, a remarkable one. For its elucidation it will be necessary to give the particulars of some of the earlier cases, which had a common origin in a girl who, as it turned out, had contracted the disease from (and at the residence of) relatives in the adjoining parish of Paddington. This case was that of :— Maud K., aged 12, daughter of a purveyor of bread, milk, &c., who carried on his business at No. 412, Portobello-road, and also distributed 27 milk from door to door in the neighbourhood. The girl appears to have fallen ill on or about September 22nd; having been at a Board School up to Wednesday, 20th. On Wednesday, 27th (but how long before I do not know) she had spots on her face, and a medical man, whom I will call Mr. Blank, was called in. He continued to attend her for about a fortnight. The mother, for a reason which will appear later, suspecting that the illness was small-pox, persuaded the girl, and obtained her consent (" for father's sake ") to go to hospital, and got her ready to go before the doctor saw her. But Mr. Blank having pronounced the disease to be chicken-pox only, the girl, unhappily, remained at home. By the 8th October (Sunday), she had recovered sufficiently to take part in carrying on the business of the shop, although her face was covered with scabs. It is alleged, moreover, that, even before this date, she had been visited by her young friends of both sexes from adjoining houses, some of whom, as we shall see, were in due course attacked by the disease. Case 2 was that of James K., aged 48, the father of Maud, who fell ill on or about Thursday, October 12th. On the 16th there was a copious eruption on the face, which Mr. Blank, who was called in, said was that of chicken-pox. The patient was seen by him daily until Saturday, October 21st. Another doctor saw the patient late in the evening of Sunday, 22nd. The patient was then dying, and he died shortly after midnight, as certified by the second doctor, of " confluent small-pox." This second doctor saw the girl Maud also, and considering her to be still infective with small-pox, he notified both cases. Maud was removed to hospital on Monday 23rd; her father's dead body was disinfected, coffined, and removed to the public mortuary the same day.* The girl, it may be mentioned, had been medically treated in the parlour, behind and communicating with the shop, in which the family lived and three other children slept. The deceased man lay ill and died in the slip room at the rear. During his and Maud's illness, the conduct of the business fell on Mrs. K, who also acted as nurse. The unfortunate man had been an ardent opponent of vaccination ; but Mr. Shattock, the Vaccination Officer, informed me that, in March, 1882, he had received a medical certificate of the The undertaker concerned in the burial of James K. contracted small-pox, in the parish of Marylebone, at a date which leaves no doubt that the dead body of James K. was the source of the infection which was transmitted to another person in the same house. 28 successful vaccination of Maud, signed by a medical man, now deceased, whose certificates he always viewed with more or less suspicion. The girl's arm, however, exhibited no marks, and her mother subsequently admitted that the vaccination had not "taken." Her father had often boasted that he was unvaccinated: whether he was so appears to be doubtful; but humanly speaking his fatal illness was the result of his child's unprotected state. The remaining children of the family had been successfully vaccinated by the Public Vaccinator, and notwithstanding the intensity of the infection to which for a whole month they had been exposed, one and all escaped. But to resume:— Case 3.—Mary J., aged 27, a married woman, ironer by occupation, was removed from No. 414, Portobello Road (top floor) to the Parish Infirmary, with febrile symptoms thought to be of a rheumatic nature, on Wednesday, October 18th. Next day spots appeared on the face. On the 20th the eruption of small-pox was recognized, and the patient was removed to Hospital forthwith. On Saturday, 21st, I received the notification certificate. The house in Portobello Road was visited the same day with negative results, the residents stating that 110 one was ill. This statement, as the two next cases show, was untrue. Case 4.—Alfred H., aged 10, No. 414, Portobello Road (back basement room) fell ill Monday, October 9th, and was taken to the Dispensary, at Mary Place, on the nth. There was nothing characteristic in the symptoms. The boy was seen again on the 14th, and now, there being spots on the face which excited the medical officer's suspicion, a colleague was consulted and expressed the opinion that the disease was chicken-pox. The boy, therefore, was sent home. The mother, however, being anxious to learn what really was the matter with the boy, took him to St. Mary's Hospital on Monday, October 16th. Here again the eruption at first excited suspicion, and the mother was directed to bring the child again next day, with the result that, after further examination, the doctor came to the conclusion that the disease was chicken-pox. This boy, who had been one of Maud K.'s visitors at No. 412, was seen at home by the District Medical Officer on Monday, October 23rd, small-pox was then recognized and he was removed to hospital forthwith. Case 5. — Caroline H., aged 10 (unvaccinated) also of 414, Portobello Road (first floor) appears to have fallen ill on or about Wednesday, October 18th. She was seen by the District Medical Officer on Monday, 29 October 23rd, was found to be suffering from small-pox, and was removed to hospital forthwith. This girl also had been one of Maud K.'s visitors. Case 6.—Francis P., aged 40, a painter in regular Work, of No. 4x2, Portobello Road (first floor) had ailed and stayed at home Monday and Tuesday, October 16th and 17th. On Wednesday, 18th, spots appeared on his face. Neverthelesss he went to his work, as usual, continuing thereat until mid-day Monday, October 23rd. I saw him on the afternoon of that day, recognized small-pox, and he was removed to hospital the 24th. Case 7.—Emma W., aged 25, married, of No, 416, Portobello Road (first floor) sister to Caroline H. (Case 5) ailed sometime before the middle of October. Shortly afterwards a few spots appeared in different parts ol the body, for which she consulted her doctor who did not recognize small-pox and therefore did not notify the case. When I saw this person, on Monday, October 23rd, she was convalescent; I formed the opinion, nevertheless, from the history, and from what remained of the rash, that she had had small-pox but was no longer infective. This view was endorsed by the District Medical Officer, and its accuracy was proved by the occurrence of the following case :— Case 8.—Joseph W., aged 35, employed at Gas Works, husband of Emma W. (Case 7) fell ill soon after I saw him on Monday, October 23rd. He was seen on the 30th by the doctor who had attended his wife, notified as having small-pox, and was removed to hospital on Tuesday, 31st. Case 9.—Jane L., aged 21, married (doubtful if vaccinated—no scars), of 34, Treverton Street, who had been confined September 20th, visited her mother from time to time, at James K.'s house, No. 412, Portobello Road, whilst James K. and his daughter Maud were lying ill of small-pox. She fell ill with small-pox, the rash appearing on or about Wednesday, 25th. She was seen by the District Medical Officer on the 28th, and removed to hospital on Monday, 30th. The infant of five weeks hiving been at once vaccinated, was removed with the mother, and did not contract the disease. Case 10.—Martha L., aged 2, daughter of Jane L. (Case 9) was sent to her grandmother, at No. 412, Portobello Road, after her mother's removal to hospital. She sickened with small-pox almost immediately, having probably contracted the disease at the same house. The case was notified, and the patient was removed to hospital 011 Saturday, November 4th. This child was successfully vaccinated on November 1st, not having been previously vaccinated. The vaccination, though too late to save her from the disease, mitigated the severity of the attack. For convenience, I subjoin, in tabular form, a list of the 65 cases reported during the currency of the endemic. 30 CASES OF SMALL-POX AT NORTH KENSINGTON, SEPTEMBER 22ND TO DECEMBER 5TH, 1893. Patient's Name. Age. Occupation of Patient or Parent. Address. Approximate date of illness. Date of Notification Date of Removal to Hospital 1 Maud K.* 12 Daughter of a Milk Purveyor 412, Portobello Road Sept. 22nd Oct. 22nd Oct. 23rd 2 \ James K.‡§ 48 Milk Purveyor 412, ,, Oct. 12th Oct. 22nd Died at Home. 3 Mary, T.** 2 7 Wife of a plasterer 414, ,, Oct. 18th Oct. 20th Oct. 20th 4 Alfred H.† 10 Son of a labourer 414, ,, Oct. 9th Oct. 23rd Oct. 23rd 5 Caroline H.* 10 Daughter of a labourer 414, ,, Oct. 18th Oct. 23rd Oct. 23rd 6 Francis P. † 40 Painter 412, ,, Oct. 16th Oct. 23rd Oct. 24th 7 Emma W.† 25 Wife of a labourer 416, ,, Oct. ? Not notified ... 8 Joseph W.† 35 Labourer 416, ,, Oct. 26th Oct. 31st Nov. 1st 9 JaneL.‡ 21 Wife of a labourer 34, Treverton Street Oct. 25th Oct. 28th Oct. 30th 10 Martha L.* 2 Daughter of a labourer 412, Portobello Road Oct. 31st Nov. 4th Nov. 4th 11 Annie S.* 4 Daughter of a labourer 406, Portobello Road Oct. 30th Nov. 3rd Nov. 3rd 12 Edwin D.† 40 Labourer 404, ,, Oct. 30th Nov. 3rd Nov. 3rd 13 Lizzie B.* 6 Daughter of a coal-porter 130, Wornington Road Oct. 30th Nov. 3rd Nov. 3rd 14 Eliza W.* 33 Wife of a labourer 405, Portobello Road Oct. 31st Nov. 4th Nov. 4th 15 Alice P.† 19 Dressmaker 406, ,, Oct. 31st Nov. 4th Nov. 4th 16 Frederick C.† 20 Labourer 18, Lionel Mews Oct. 31st Nov. 4th Nov. 4th i7 Charles L.† 29 Labourer 169, Wornington Road Oct. 31st Nov. 4th Nov. 4th 18 Dulce C.* 8 Daughter of a labourer 1711 ,, Oct. 31st Nov. 4th Nov. 4th 19 Agnes B.# 4ms. Daughter of a sweet-stuff shop proprietor 23, Bosworth Road Oct. 31st Nov. 4th Nov. 4th 20 Mary S. 16 Daughter of a labourer 161, Southam Street Oct. 31st Nov. 4th Nov. 5th 21 John E.‡ 20 Schoolmaster's assistant 141, Wornington Road Oct. 31st Nov. 4th Nov. 4th 22 Maud F.* 16 Domestic servant 27, Chesterton Road Nov. 4th Notified at Ealing 23 f Edward Y.* 112 Son of a painter 175, Wornington Road Nov. 1st Nov. 5th Nov. 5th 24 Emily Y.† 20 Wife of a painter 175' ,, Nov. 1st Nov. 5th Nov. 5th 25 Ambrose C.† 32 Carpenter 3, Queen Anne's Terrace Nov. 1st Nov. 5th Nov. 5th 26 William A.† 23 Furniture Dealer 408, Portobello Road Nov. 1st Nov. 5th Nov. 5th 27 LucyJ.† 41 Wife of a labourer 408, ,, Oct. 31st Nov. 5th Nov. 5th 28 Frederick K.† 20 Carman 408, ,, Nov. 1st Nov. 4th Nov. 4th 29 George B.‡ 35 Purifier at gas factory 394, ,, Nov. 2nd Nov. 5th Nov. 5th 30 Alfred C.† 15 Labourer 23, Bomore Road Nov. 2nd Nov. 6th Nov. 6th 31 31 Samuel S.* 13 Son of a carpenter 152, Wornington Road Nov. 3rd Nov. 6th Nov. 7th 32 Arthur G.† 17 Van guard 407, Portobello Road Nov. 4th Nov. 7th Nov. 7th 33 Charles B.† 38 Platelayer 173, Wornington Road Nov. 4th Nov. 8th Nov. 8th 34 George C.* 24 Labourer 149, Nov. 4th Nov. 8th Nov. 8th 35 V\ illiam D.* 12 Son of labourer 404, Portobello Road Nov. 4th Nov. 8th Nov. 8th 36 Michael R.* 14 Son of a charwoman 134, Southam Street Nov. 5th Nov. 8th Nov. 9th 37 Alfred S.‡ 35 Labourer 429, Portobello Road Nov. 6th Nov. 9th Nov. 9th 38 John E.† 32 Painter 36 Bosworth Road Nov, 7th Nov. l0th Nov. nth 39 Thomas G.† 21 Porter 407, Portobello Road Nov. 7th Nov. 11th Nov. 12th 40 Walter S. *§ 7 ms. Son of a labourer 406, Nov. 10th Nov. 15th Nov. 15th 41 Angelina B.† 9 Daughter of a general dealer 23, Bosworth Road Nov. 10th Nov. 17th Nov. 17th 42 Frances B.† 5 Daughter of a general dealer 23, Bosworth Road Nov. 10th Nov. 17th Nov. 17th 43 Alice C.† 18 Daughter of a Nurse woman 116, Southam Street Nov. 16th Nov. 20th Nov. 20th 44 Thomas H.* 10 ms. Son of a labourer 417, Portobello Road Nov. 17th Nov. 20th Nov. 20th 45 Agnes T.† 32 Wife of a coach trimmer 82, Wornington Road Nov. 17 th Nov. 21st Nov. 21st 46 William P.† 23 Coal porter 43, Southam Street Nov, 20th Nov. 23rd Nov. 23rd 47 Ellen M.‡ 39 Wife of a furniture dealer 391, Portobello Road Nov. 17th Nov. 24th Nov. 24th 48 Napoleon F.* 9 Son of a coachman 53, Prince's Road Nov. 22nd Nov. 25th Nov. 27th 49 JohnC.† 19 Labourer 59, Treverton Street Nov. 1st Not notified ... 5° Susan C.† 39 Wife of a painter 59, Treverton Street Nov. 21st Nov. 26th Nov. 25th 51 Joseph H.* 17 Bootmaker 3, Telford Road Nov. 22nd Nov. 25th Nov. 26th 52 Charles K.* 7 Son of a baker 18, Golborne Road Nov. 20th Nov. 27th Nov. 28th 53 Emily W.*§ 27 Wife of a horsekeeper 6, Branstone Street Nov. 20th Nov. 27th Nov. 27th 54 Charles W.† 29 Labourer 9, Bolton Road Nov. 20th Nov. 28th Nov. 28th 55 Ada H.‡ 15 Orphan 108, Ladbroke Grove Rd. Nov. 19th Nov. 28th Nov. 28th 56 Luke G.† 40 Milkman 13, Golden Mews Nov. 4th Not notified ... 57 Emily G.‡ 31 Wife of a Milkman 13, Golden Mews Nov. 18th Dec. 6th Dec, 7th 58 Edward G.*§ 3 Son of a Milkman 13, Golden Mews Dec. 3rd Dec. 6th Dec. 7th 59 Bertie G.*§ 3 ms. Sor. of a Milkman 13, Golden Mews Dec. 4th Dec. 6th Dec. 7th 60 William G.* 3 ms. Son of a Milkman 13, Golden Mews Dec. 4th Dec. 6th Dec. 7th 61 John C.* 13 Son of a nursewoman 116, Southam Street Dec. 3rd Dec. 6th Dec. 7th 62 Henry T.† 4i Painter 42, Southam Street Dec. 4th. Dec. 6th Dec. 7th 63 Philip K.* 12 Son of a Baker 18, Golborne Road Dec. 5th Dec. 7th Dec. 8th 64 Emma R. * 26 Wife of a painter 33, Bramley Road Dec. 4th Dec. 8th Dec. 8th 65 Richard F.† 7 Son of a coachman 53, Prince's Road Dec. 4th Dec. 9th Dec. 9th *Unvaccinated, (27) † Vaccinated, (30) ‡ Vaccination doubtful, (8) ** Revaccinated, (1) § Dead, (5) On January 20th, 1894, four cases of Small-pox were discovered at No. 18, Golborne Road, whence cases 52 and 63 had been removed. These cases, which originated in December, were four unvaccinated children whose illness had been concealed. They raise the total number of sufferers to 69, of whom 31 were unvaccinated. 32 Consideration of the facts stated in the foregoing histories,—regard being had to the contiguity of the houses; to the relationship of some of the people; the close intimacy of all of them; and the fact that the several families were customers at James K.'s shop—left no doubt in my mind that the cases numbered 2 to 10 contracted the disease, directly or indirectly, from Maud K. (case 1). That many of the remaining cases, (Nos. 11 to 65), were infected at the shop, or by contact with the inmates of the three Portobello Road houses, is at the least highly probable. In a considerable number of instances the mode of transmission of infection was clearly made out, and was described in the histories given in my eleventh and twelfth monthly reports, for the two four-weekly periods ended respectively, November 4th and December 2nd. One group of cases which came to my knowledge towards the close of the endemic, is too interesting to be omitted here, the first of five sufferers having contracted the disease from the K. family (cases 1 and 2). The facts, as reported in my eleventh monthly report, were as follows:— Cases 56 to 60.—Luke G., aged 40, is a milkman. He had assisted James K. (case 2) who died of confluent small-pox, at 412, Portobello Road, October 23rd. When James K.'s business was stopped, Luke G. obtained milk and served the various customers on the usual round. He felt unwell 011 or about November 4th, and spots having appeared on his face, etc., he saw a doctor on the 8th. The doctor, who saw the patient once only, did not recognise small-pox. The man continued at his work uninterruptedly. On or about the 18th November, Emily G., aged 31 (case 57) Luke's wife, began to ail with the same symptoms, followed by a rash ; but she did not see a doctor. On December 7th, three of their children (cases 58, 59, and 60) were notified as suffering from small-pox, two of them being twins aged 3 months, the other being three years old. With the mother, who was still infective, they were removed the same day to hospital, where the twins died and the boy scarcely escaped with his life. All of these children were unvaccinated. There were three other children in the family who had been vaccinated in infancy, and escaped. With respect to these five cases, it would seem impossible that the father and mother should not have suspected the 33 nature of their illness, and I have little doubt but that they did so. Luke G., however, failed to tell the doctor that he had been exposed to the infection of small-pox. Had he done so, the nature of his illness would have become apparent : he would have been isolated in hospital, and his wife and the three children probably would have escaped. The endemic then, so far at least as the Kensington cases were concerned, having originated with Maud K, the question that naturally arose was, How and where did she contract the disease ? This question I was able to answer confidently, by stating that it was at the residence of her uncle, a Mr R., No. 60, Barnsdale Road, in the parish of Paddington. At this house—as I subsequently learned, from information courteously supplied by Dr. B., the medical attendant of the several families living there—a febrile disease, attended with a rash, had existed for some weeks prior to the date of Maud K.'s illness ; but without, for a considerable time, exciting suspicion of small-pox. The earliest sufferers were children of Mrs. W. (first floor) the first of whom fell ill at about the middle of August; the appearance of the spots having been preceded by febrile and other symptoms resembling the premonitory symptoms of small-pox. The source of infection was not known. On or about September 4th, one of the children of Mr. H. (top floor) fell ill with similar symptoms, and another child subsequently. Mr. H. himself fell ill soon afterwards, and Dr. B. was called in, on September 14th. Meanwhile, Maud K.'s Aunt (Mrs. R.) who, with her husband and two young children occupied the only remaining (or basement) floor, had fallen ill, on September 7th, with symptoms, local and constitutional, like those of the other cases. Later, her three-months old baby was attacked. Dr. B. saw this child on September 25th. Satisfied that she had small-pox, and confirmed in his suspicion that the previous illnesses had been modified cases of the same disease, he notified the case to the Medical Officer of Health on the 26th. The child, who had not been C 34 Vaccinated, and whose rash does not appear to have been typical, was removed on September 27th. On arriving at the Riverside Wharf, for embarkation on the Ambulance Steamer, the patient was examined by the Medical Officer in charge; no case being sent to the Ship Hospital till the certifying practitioner's diagnosis is confirmed. This gentleman, having formed the opinion that the disease was chicken-pox, vaccinated the child and sent her home again. The vaccination did not "take." The father, Mr. R., had fallen ill a day or two after the baby, a copious eruption having come out, apparently, on the 27th. On this day the house was visited by the Assistant Medical Officer of Health, who, seeing the father's condition, wrote to Dr. B. urging him to notify the case as one of smallpox. But the child having been sent home as not suffering from this disease; the doctor, reasonably assuming that the father and child had the same disease, whatever it might be, declined to notify the case unless the Medical Officer of Health himself should confirm the diagnosis. The Medical Officer, being unwell, requested a medical friend to see the patients. This gentleman—not knowing the history of the previous cases, and seeing that the rash was vesicular, the temperature, moreover, being at the time normal—came to the conclusion that the disease, in father and child, was chicken-pox; an opinion which corresponded with that of the Medical Officer at the Wharf, as regarded the baby. Dr. B. a few days later reported that the father's rash had become pustular; whereupon, on October 2nd, the Assistant Medical Officer of Health, and the consultant, vvent to the house; but in the absence of Mrs. R. they were refused admittance by the landlady. Having heard of the illnesses in this family, and of the connection with the family of James K., I asked Dr. B. to allow me to see his patients, and with him I saw them on Friday, October 27th, a full month after the appearance of the rash. Mrs. R. was not at home. The baby was convalescent, but the marks of the rash, not very distinctive however, were still visible. 35 The father's skin was deeply stained with the remains of a great number of undoubted small-pox pustules. Considering the case to be still infective, I advised Dr. B. to notify it to the Medical Officer of Health. He did so forthwith, and the patient, on Saturday, October 28th, was removed to hospital, where he was detained for about three weeks. Ultimately it became admitted on all hands that the baby's illness had been small-pox (caught from the mother probably) of a singularly mild description, having regard to the fact that she had not been vaccinated; and that Dr. B.'s opinion was correct that the other cases in the house were also small-pox, highly modified by vaccination. This child's comparative insusceptibility to small-pox was not a little remarkable. It has been said that her vaccination, done at the Wharf, did not "take"; a subsequent operation, by a Public Vaccinator, was equally unsuccessful, but a third operation, I was informed, proved successful. I return from this digression to state that Maud K. had been accustomed to visit her relatives at the house in Paddington, from whom, beyond doubt, she contracted the disease, which she transmitted with fatal effect to her father and others. But to resume:—In my eleventh monthly report (dated November 16th) I gave a sketch-plan of the streets, showing the houses in which the first forty cases had occurred —as well as certain houses in Paddington and Chelsea (Kensal District) where there had been cases some of which undoubtedly belonged to the same outbreak. At that date 22 cases had occurred in Portobello Road, viz., four at No. 412 (where the outbreak began) three at No. 414, two at 416 (these nine cases being intimately connected) three at No. 408, three at 406, two at No. 404, one at 394; all of these houses being on the East side of the street. On the West side there had been four cases, viz., one at No. 429, two at No. 407, and one at No. 405; the last two houses being near to Lionel Mews, where, at No. 18, there had been one case. 36 In Wornington Road there had been nine Kensington cases, viz., two on the East side, one each at No. 152 and No. 130; and seven on the West side, viz., two at No. 175 and one each at Nos. 173, 171, 169, 149, and 141. There was one case at No. 3, Queen Anne's Terrace, and one case at No. 34, Treverton Street, the latter belonging to the No. 412, Portobello Road group. All of the above cases were shown on the plan. The remaining cases, six in number, in as many houses, occurred at Nos. 23 and 36, Bosworth Road, Nos. 134 and 161, Southam Street, No. 23, Bomore Road and No. 27 Chesterton Road. The last mentioned patient sickened at Ealing, six days after leaving the parish. All of these cases, forty in number, (except secondary cases in the same houses) had become infected before the death of James K., and the removal to hospital of Maud K. (cases 2 and 1) a fact that may be taken as an indication of the large share this family had in the spread of the disease Some of the cases were very mild, and the "sufferers" were able to go about, and did so, the most flagrant instances being those of Francis P., and the children Angelina and Frances B. (cases 6, 41, and 42). Many of the later cases (41 to 65) dealt with in my twelfth report (dated December 11th) were more scattered, several fresh streets having become invaded. The last of these cases was notified in the week ended on December 9th. Between that date and the end of the year four other cases were notified, but it is doubtful whether either of them had any connection with the Portobello Road outbreak. Inability to Diagnose Small-Pox.—One of the commonest causes of the spread of small-pox is the inability of many medical practitioners to recognise the malady which they are rarely (and may never have been) called upon to treat, and which is sometimes so singularly modified by vaccination as to almost lose the characteristics of disease after a very brief interval from the date of invasion, Some 37 illustrations of this kind have already been given. The following case is also in point. Case 49.—John C., aged 19, fell ill about November 1st with the usual premonilory symptoms of small-pox, and subsequently a few spots appeared on his face. He was attended by a doctor who did not recognise the disease, but evidently, after a time, had his suspicions aroused, as he consulted another doctor who expressed his opinion that the disease was small-pox. The case was not notified. On 21st November, the patient's mother (case 50) was attacked with small-pox and removed to hospital. In the following group of cases the source of infection was discovered, outside the parish, in an illness which was not even suspected by the medical practitioner to be small-pox : Case 43.—Alice C., aged 18, was removed to hospital November 20th. Her brother John C., aged 13 (case 61) contracted the disease from her and was removed December 7th. Upon inquiry it was ascertained that Alice C., is engaged to Charles P., who lives at Willesden, and is employed at Paddington Railway Station. This man had left his work ill, on the 30th October, with symptoms which were undoubtedly premonitory of smallpox. A rash subsequently appeared on his face and body. A doctor said he had "blood poisoning," but did not recognise small-pox and the case was not notified. The patient remained at home for about eight days, and then returned to his work whilst infective. Alice C. had visited him on November 5th, 7th, 8th ; and it was probably on the first of these occasions that she became infected. (It may be mentioned in passing that Charles P.'s young brother, aged 5, also contracted the disease and that William B., who lives at Paddington, and works on the railway, visited Charles P. during his illness and so contracted small-pox.) Arthur G., aged 17 (case 32) works with Charles P., and it is suspected that both patients, and also Thomas G. (case 39) brother to Arthur G., contracted infection from the same undiscovered source. Subsequently, Emily W., aged 27, of 6, Branstone Street, and her brother-in-law Charles W., aged 29, of 9, Bolton Road (cases 53 and 54) contracted small-pox and were removed to hospital on the 27th and 28th November respectively. The woman had lain ill for some days without medical attendance. The case coming to Inspector Pettit's knowledge, November 27th, he took a doctor to see her, and upon his certificate removed her forthwith. She died of hæmorrhagic small-pox on November 29th. The histories of these two cases suggested a common source of infection which was found at 407, Portobello Road, whence cases 32 and 39 had been removed, and where the two sufferers had been accustomed to visit the mother of the female patient. 38 The following cases are not without interest: Case 44.—Thomas H., aged 10 months, of 417, Portobello Road, Was taken charge of during the day by Mrs. P., at No. 416, in the same street. Mrs. P.'s daughter (case 15) was attacked with small-pox, and removed to hospital November 4th. From her, Thomas H. caught the disease, and was removed from his own home November 20th. Case 45.—Agnes T., aged 32, of 82, Wornington Road, had a child taken ill with scarlet fever. The child was treated at home. Anxious to preserve the other children, she sent them to her mother at 21, Southam Street, in Paddington parish. Here, one of the children contracted small-pox. Desirous of seeing the child before removal to hospital, the mother ran round, kissed the little one, and so contracted the disease. She was removed to hospital November 21st. The following case illustrates a danger to which working people may, unwittingly, be exposed. Case 62.—Henry T., aged 41, of 42 Southam Street, had been working at his trade of a painter, at a house in Kensal Road (Paddington) whence four cases of small-pox had been removed to hospital in November. He there contracted the disease and was removed to hospital, December 7th. vaccination.— The condition of the several patients as regards vaccination is shown in the list of cases at page 30. Many of the sufferers (27 out of 65) had never been vaccinated; 30 had been vaccinated; the state as to vaccination in 8 cases was doubtful: one patient only had been re-vaccinated. The deaths were five in number, and all of them occurred amongst the unvaccinated cases; unless it be assumed that, contrary to his own assertion, James K (case 2) had been vaccinated in infancy. Precautionary Measures Adopted.—Every possible precaution was adopted with the object of stamping-out the disease. Thus, in view of the gravity of the outbreak I had felt it my duty at the outset to communicate with every medical practitioner at North Kensington, suggesting care in isolation of any febrile case presenting symptoms premonitory of smallpox—to be followed by immediate application to the Asylums Board for removal of any patient in whom the disease should 39 declare itself—and requesting co-operation in measures for limiting the extension of the endemic. I also communicated with the head teachers of public elementary schools, pointing out that modified small-pox is frequently a mild disease, sometimes scarcely affecting the general health after the first day or two, so that children who had had such an attack might possibly be found at school : I described the symptoms of the malady, and the appearance of the rash, and requested to be informed of any suspicious case that might come under notice. I wrote likewise to the Medical Officers of Health of the adjoining parishes of Paddington and Chelsea, to put them on the alert. Every case was duly reported, day by day, to the Vaccination Officer ; and the Clerk to the Guardians was informed that the outbreak justified, and even demanded, special vaccination arrangements, including house-to-house visitation with a view to re-vaccina tion of adults. At an interview with this gentleman, I pointed to the necessity for the relief of persons who had been advised to temporarily discontinue their usual avocations with a view to prevent the spread of infection, or who had become destitute through the illness of the bread-winner. The Guardians, at their meeting on the 2nd November, after consideration of their Clerk's report, referred the whole matter to a Committee for enquiry ; meantime directing the Relieving Officers to accept a written intimation in regard to cases in which relief appeared to me to be necessary, instead of requiring an application to be made at the Relief Office from the head or other member of the family, which might be the means of bringing infected persons into contact with other people at the waiting rooms. Large posters, moreover, were printed, indicating, for the guidance of the public, the Guardians' ordinary and special arrangements in respect to vaccination ; and the District Medical Officers were instructed to revaccinate persons living in infected houses. The special arrangements included a weekly evening sitting by the Public Vaccinator to afford facilities for vaccination, and the revaccina- 40 ¬tion of persons occupied during the daytime; and lastly, a houseto-house visitation of a large part of the district was carried out, by the Vaccination Officer and five assistants, which led to the discovery of many unvaccinated persons, and was the means of promoting revaccination on a considerable scale. The effect of the measures taken was that, by the middle of December, the endemic was at an end—a result largely due to the energy exhibited by Inspector Pettit in searching out cases, and obtaining their removal to hospital, which was done with great rapidity. Only four of the sufferers were treated throughout at home, viz., James K. (case 2) and three other persons, the nature of whose illnesses was not recognised and whose cases (numbered 7, 49, and 56) were not notified. Certain incidents connected with the outbreak are worthy of mention, the first and most important being the prosecution of the doctor who had attended cases 1 and 2, for failure to notify the illness as the law directs. The magistrate believing that this gentleman, strange as it may appear, was really ignorant of the nature of the disease he was called upon to treat, dismissed the summons. Particulars of the proceedings in this case will be found in another part of the report. A woman was prosecuted for exposing two of her sick children, both in her shop and by allowing them to play in the streets. She was without excuse another of her children being in the hospital for small-pox at the time of the exposure. She did not, moreover, deny that she knew that the two children were suffering from the same disease. The sudden increase in the number of small-pox cases which the Asylums Board were called upon to admit to their hospitals at the end of October, consequent on this outbreak, and there being "foci of infection in almost every quarter of the Metropolis," led the Committee for the small-pox hospitals to close the "lower" hospital at Gore Farm, against scarlet fever convalescents, and to prepare the "upper" hospital for 41 the reception of small-pox patients. I ventured at the time to deprecate the haste with which the Committee, almost in the spirit of panic, had acted, giving reasons for the belief that the imagined emergency did not exist, and having regard to the serious demands of scarlet fever upon the Managers' resources. It soon became apparent that the course adopted by the Committee was entirely unnecessary. MEASLES. Measles was the cause of 18 deaths in 1893 (16 in the Town sub-district, and 2 in Brompton), the decennial average corrected for increase of population being 77. All but one of the deaths occurred under five years of age, four of them in the first year of life. This low mortality is accounted for by the fact that Measles had been epidemic in 1892, the deaths in that year having been 109, and 35 above the corrected average. Measles in London.—The deaths from measles in London were 1,661 and 1,053 below the corrected decenial average. The death-rate was 0.39 per 1,000 population, the rate in the preceding decennium having been 0.63. In 1890 the deaths from measles were 3,291, and 664 above the average; in 1891 only 1,807, and 871 below the average; in 1892 the deaths were 3,393, being 791 above the average, and 1,732 more than in 1893. The mortality was in excess in six out of the ten years 1883-92. It is to be regretted that 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 as inevitable as teething, they naturally enough rather like to have all of the children ill at one time and get the trouble over. It must be allowed, 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, 42 moreover, in which the poor live in London—two or more families usually 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, of the lungs &c., which are, as a rule, the immediate causes of death. I entertain no doubt that many lives might be saved were it practicable to isolate the little sufferers in hospital, especially such as live in overcrowded homes, tainted with foul air, and under conditions which preclude the care so necessary in the nursing and management of measles. But no provision of hospital accommodation for cases of this disease has been made. Should Measles be made Notieiable?—Measles is not one of the diseases required to be notified to the Medical Officer of Health under the provisions of the Public Health (London) Act, 1891; and, as I endeavoured to show in my report for 1891 (pp. 97—106) it remains to be proved that any great advantage would accrue from its addition to the list,unlesshospitals should be provided for the reception of the sufferers who cannot be properly treated at home, and these are very many. It is the fact, however, that the disease is often spread through the agency of schools: it might probably be held, therefore, that the duration of an epidemic would be shortened by the closure of schools, which are not seldom deprived of a large proportion of their pupils by an outbreak. And, in fact, an epidemic is sometimes, as in 1890, brought to an end on the occurrence of the long holidays. With a view to prevent the spread of measles through the agency of public elementary schools, I addressed a letter, at the commencement of the epidemic in that year, to the Superintendent of Visitors of the Chelsea Division, pointing out the desirability of an effort being m ide to exclude from the schools all children from houses where the disease exists. The School Board do not allow children living in infected houses to attend their schools, a fact probably unknown to many parents. I suggested, 43 fore, that a circular letter should be sent to the parents of pupils for their information; but this course was not adopted. Such a communication, if systematically made at the beginning of an epidemic of any infectious disorder, would probably be the means of saving many lives: it would certainly have the effect of checking the spread of measles in the only practicable way short of closing schools. SCARLET FEVER. Scarlet fever, which had been the cause of 28, 26, 16, and 36 deaths of parishioners in the preceding four years consecutively, proved fatal to 51 persons in 1893, or 27 more than the corrected decennial average. Five only of the deaths belong to the Brompton sub-district. Forty-one deaths took place at public institutions without the parish, to which 568 cases were removed, and 12 at the homes of the deceased. The case-mortality was 3.1 per cent. in home-cases and 7'2 per cent. in hospital-cases. The cases notified were 957, compared with 375, 323, and 715, in the preceding three years respectively, viz., 570 in North Kensington, i.e., North of the Uxbridge Road, and 387 in South Kensington. Scarlet Fever in London.—The deaths from scarlet fever in London as a whole were 1,596, and 449 more than the corrected decennial average number. Nine hundred and twentyone of the deaths, or 58 per cent., occurred in public hospitals or infirmaries. The total deaths corresponded to an annual rate of 0.37 per 1000 population, this being 0.10 in excess of the decennial average. The notifications, after correction for duplicate returns, were 36,901, and 9,805 more than in 1892. The case-mortality was about 4 3 per cent., the rate in 1892 having been 4.2. The following table shows the progress of the epidemic, both in the parish and in the metropolis as a whole, as evidenced by the number of the cases and the deaths recorded in the thirteen successive periods covered by my four-weekly reports, 44 Scarlet Fever in 1893.* Report for four weeks ended No. of Notifications Kensington London. No. of eases adrritte to hospitals Kensington London, 1 No of Deaths Kensington London, No. of cases in hospitals at the end of the period Jan. 28 45 1717 37 922 2 128 2688 Feb. 25 60 1601 38 907 3 94 2293 March 25 38 1428 26 808 4 83 1971 April 22 34 1559 18 894 1 91 2037 May 20 56 2149 42 1255 6 90 2345 June 17 84 2799 51 1168 2 118 2681 July 15 84 3772 55 1365 4 136 2924 August 12 110 3927 67 1331 3 142 2885 Sept. 9 67 3502 46 1338 8 147 2883 Oct. 7 113 4966 56 1249 6 139 2801 Nov. 4 117 4811 74 1481 4 150 2906 Dec. 2 88 3473 49 1542 3 160 3183 Dec. 30 61 2215 29 1148 5 118 2988 957 37919 588 15408 51 1596 For the sake of comparison, I subjoin the corresponding Table for 1892, taken from my report for that year. Scarlet Fever in 1892* Report for four weeks ended No. of Notifications Kensington London. No. of cases admitted to hospitals Kensington London. No. of Deaths Kensington London No. of cases in hospital at the end of the period Jan. 30 28 863 22 412 4 48 1329 Feb. 27 23 776 14 386 2 55 1198 March 26 19 895 12 485 — 39 1226 April 23 41 1491 20 670 2 67 1400 May 21 51 1761 24 835 4 77 1677 June 18 39 1788 22 837 2 85 1945 July 16 70 2404 44 1239 3 93 2488 August 13 74 2690 53 1486 2 98 3088 Sept. 10 59 2773 50 1609 4 133 3339 Oct. 8 98 3959 63 1500 2 123 3628 Nov. 5 85 3755 59 1859 4 127 4067 Dec. 3 82 2789 43 1412 4 124 3882 Dec. 31 49 1968 30 1051 3 105 3254 718 27912 456 1378I 36 1174 *The figures in the tables are uncorrected for duplicate notifications and errors in diagnosis. The notifications are taken from the weekly returns of the Asylums Board. The admissions to, and the numbers in the hospitals, and the deaths in London, are taken from the weekly returns of the Registrar-General. 45 On comparison of these tables we learn, that the notifications in 1893 exceeded those in 1892, by 239 in Kensington, and by about 10,000 in London; and that the cases admitted into the hospitals in 1893 were also in excess—by 132 in Kensington, and by more than 1,600 in London. The deaths, moreover, in 1893 were also in excess—by 15 in Kensington, and by 422 in the metropolis as a whole, compared with the corresponding totals in 1892. The tables further show that in both years the notifications were fewest at the beginning of the year, and that the maxima wereattaini>d in the 37th-44th weeks, September 10th to December 1st. In 1892 scarlet fever began to assume large proportions in the period dealt with in my fourth four-weekly report, beginning March27th; in 1893 in the fifth four-weekly period, beginning April 23rd. In the first quarter of 1892, however, the disease was not epidemic, whereas in the first sixteen weeks of 1893 there was a continuance only, of the decline in the epidemic prevalence which had set in in the previous November, and which ended in April, when a severe recrudescence commenced. In 1892 the notifications in London in the last fourweekly period were 1,968; in the corresponding weeks in 1893 the number was 2,215. In both years the hospital accommodation at the disposal of the Asylums Board proved inadequate to the requirements of the Metropolis. More so in 1893, however, than in 1892; for whereas on November 5th, 1892, there were so many as 4,067 persons in hospital at one time, the highest number for whom accommodation was found at any one time in 1893, did not exceed 3,183. But, as I pointed out in my ninth four-weekly report (September 11th) the number of cases in hospital furnished no true indication of the state of the epidemic; for, the accommodation being totally inadequate, all the hospitals were continuously full, and not a day had passed for many weeks but patients had to be refused admission, from this parish and others, for want 46 of room* The Gore Farm Convalescent Small-pox Hospital was utilized during part of the year for scarlet fever convalescents; in November, however, in anticipation of a smallpox epidemic, which did not ensue, it was hurriedly closed, disinfected, and prepared for its more, legitimate use. How Disease is Spread.—Several cases occurred in the parish during the year illustrating modes of spread of scarlet fever. In the first instance, two children of a coachman living in a South Kensington Mews having died of the disease, in hospital, the man's employer informed me that he had reason for believing that other children living in the same mews, had had scarlet fever and had not been isolated—in fact, had been constantly playing in the mews with other children. I visited the houseandfound two children whowere "peeling" afterscarlet fever, the mother however averring that this symptom was due to the children having simultaneously plunged both their hands into hot water! These children had not only been in the mews, as alleged, but they had also been attending school. The parents professed ignorance of the nature of the illness—said, in fact, that the children had not been ill: no doctor had been called in. But their story was inconsistent, as the mother also said that they thought the complaint was measles, although she admitted that both of the children had suffered from this disease in 1892. There was evidence, moreover, that the mother had told at least two persons that her children had "the fever"—the one being their schoolmistress, who thereupon excluded them from school; the other a milk-carrier, who thereupon ceased to leave milk at the house, and removed *As an illustration of the extent to which the hospital accommodation fell short in the last eight months of 1893, it may be mentioned that the admissions during that period were equal to only 38 per cent. of the notified cases of scarlet fever, whereas during the first four months of the year, when the accommodation sufficed for current needs, the admissions were equal to 55 per cent. of the notifications 47 his own children from the school in question. It is satisfactory to know that these children did not infect the two children who had died, their illness having preceded that of the offending children. Proceedings were taken against the father for the offence of exposing his children in a public place, and he was fined in the sum of £1 and costs. In another instance the illness of a child from scarlet fever, in a small street at Notting Hill, having been notified, the Inspector visited the house with a view to obtain removal. He was taunted for not having interfered vvith other cases in the street (where several were known to have occurred) and one of the neighbours let out that children living at a particular house were "peeling" and going about as usual. The Inspector at once visited the said house, and found two children " peeling." I saw the children myself on the following day, and there could be no doubt that both had scarlet fever, although the mother pretended ignorance, whilst not denying that they had been unwell, with a red rash, etc. No medical man had been called in. It appeared that the younger boy had fallen ill first; subsequently, an elder brother being attacked, he was taken by his grandmother to an empty house in another parish, where she was employed as caretaker. The second child's illness was mild, and in a few days he resumed his attendance at a large Board school. It was impossible in this instance to prove guilty knowledge on the part of the parents, and therefore no proceedings were taken. A third and most glaring case of wilful self-exposure came to light in July. The man had been expressly warned of the nature of his illness, but he persisted in going about as usual whilst "peeling"; and although specially enjoined not to go to a private house where his mother was acting as caretaker, during the absence of the family, it was discovered that he went there daily. This man was a ciub patient, but not being entitled to the doctor's attendance at home, he went again and again to the doctor's residence in another 48 parish. The doctor did not notify the case: had he done so the patient would have been visited and either removed to hospital or isolated at home. Proceedings were taken against the patient for the exposure and against the doctor for not notifying the case. Both were convicted, and fines to the amount of twenty shillings and forty shillings respectively were inflicted. In yet another instance, a man went about the parish for many days whilst "peeling." It was said that he had presented himself in the out-patient room of a general hospital; but, as in the cases mentioned above, he took no steps to obtain medical assistance at home, and pretended ignorance of the nature of his illness. He was ultimately removed to hospital—under threat of prosecution for the offence he had committed—as well as a child from the same house whom he had infected. In another case, which turned out to be scarlet fever, the patient, who had been discharged from a country convalescent hospital evidently because of the suspicious character of the symptoms, travelled to London in a public conveyance—only to be removed forthwith to a general hospital, whence she was immediately transferred to a fever hospital. STATISTICAL RETURNSSCARLET FEVER. 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 objects being to form "as correct an estimate as possible of the accommodation to be provided in future " for cases of this disease. At the request of your Vestry, I drew up the desired information, in the form of the subjoined Tables, which are self-explanatory, and have been bought up to date. It need hardly be added that the Board now obtain necessary information, through the Medical Officers of Health under the notification provisions of the Public Health (London) Act 1891: the Tables, nevertheless, still possess interest. 49 Statistics of Scarlet Fever in Kensington in 1893 and Ten Previous Years. The Year. No. of Recorded Cases. Total Number of Recorded Cases. 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 1893 389 568 957 59 10 41 51* 24 76 5.3† 1596* 1892 259 456 715 64 9 27 36 25 75 5.0 1174 1891 117 206 323 61 3 13 16 19 81 4.9 589 1890 161 214 375 57 6 20 26 23 77 6.9 875 1889 86 166 252 66 8 20 28 29 71 11.1 778 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 9.0 1444 1883 141 90 231 40 22 6 28 79 21 12.0 1989 D *The corrected decennial average number of deaths from Scarlet Fever in Kensington (1883-92) was 24, and in London 1147. †The case-mortality in Kensington patients treated at home in 1893, was 3.1 per cent., and in patients treated in hospital, 7.2 per cent. 50 Scarlet Fever Cases Recorded in Kensington in 1893, and in Ten Previous Years, in Thirteen Four-Weekly Periods. The Year. Weeks. 1-4 Weeks. 5-8 Weeks. 912 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. 1893 45 60 38 34 56 84 84 110 67 113 [ 117 88 61 957 1892 28 23 20 34 51 39 73 74 59 97 85 82 50 715 1891 38 47 18 24 23 23 13 27 17 31 23 22 17 323 1890 10 32 17 23 24 15 12 19 24 42 71 49 38» 375 1889 16 4 6 8 14 17 14 26 19 25 29 41 33 252 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 Average 1883-92 20.7 21.2 13.4 14.6 18.9 18.6 19.9 20.5 21 0 38.5 36.6 33.9 24.8 303‡ * Return comprises five weeks, ‡ Without correction for increase in population. Compulsory Notification has been in operation since the end of October, 1889. 51 DIPHTHERIA. In 1888, and 1889, diphtheria was epidemic in Kensington, especially in the northern parts of the parish: the deaths, 89 and 111 in the two years respectively, were 65 and 79 above the corrected decennial average. In 1890 the deaths were 35 only, and 6 below the corrected average. In 1891 the deaths further fell to 28, and were 12 below the corrected average. In 1892 the deaths were 31, and 12 below the average. Last year the deaths were 83, and 40 above the average. Sixty-five of the deaths belong to the Town sub-district, and eighteen to Brompton. The deaths in the Brompton sub district in the preceding five years had been 2, 5, 6, 4, and 4, respectively. Twenty-nine of the deaths in 1893 took place at home and 54 in hospitals—most of them in the North-Western and the Western Fever Hospitals. The ages at death were: under five years, 47 (including five in the first year of life) ; between five and fifteen, 25; between fifteen and twenty-five, 3; between twenty-five and thirty-five, 3 ; between thirty-five and fiftyfive, 4 : one death occurred at the age of seventy-seven. The cases recorded as diphtheria were 353, viz., 158 north, and 195 south of Uxbridge Road, i.e., in the Parliamentary Divisions of North and South Kensington respectively. One hundred and ninety-one of the sufferers were removed to hospital; 87 from North Kensington and 104 from South Kensington. The sufferers comprised 146 males and 207 females: 96 of them were under five years of age; 133 between five and twelve years (the usual public elementary school age) 42 between twelve and twentyone, and 82 upwards of twenty-one. One hundred and forty of the children had been in attendance at schools, 64 in North Kensington, and 76 in South Kensington. The casemortality in hospital-treated cases was 28 3 per cent. in home-treated cases 17.9 per cent. The total case-mortality, 61.8 per cent in 1888, and 45.3 per cent. in 1889, fell in 1890 (notification being then in practice) to 16 8 per cent., and in 1891 to 15.4 per cent. In 1892 it was 17.5 per cent., and last 52 year it was 23.5 per cent. The reduction in the rate of mortality from the rates prevailing in 1888-89 is too great to be accounted for on the assumption of diminished malignancy in the type of the disease, and was more probably due to the inclusion among the home-treated adult cases notified, of a considerable number of cases of non-specific throat disease. It is to be remembered, however, that in 1888, and during the greater part of 1889, diphtheria was not notified, so that non-fatal cases to a considerable number may have occurred without my knowledge. Diphtheria in London.—The deaths from diphtheria in London in 1893 were 3,265; 1,984 above the corrected decennial average and 0 76 per 1000 of the population: they were also 1,380 more than in 1892, a year characterised by the then highest death-rate on record from this disease. The quarterly numbers of deaths in 1893 were 639, 677, 860, and 1,089. The Registrar-General, referr ing to the increased mortality from this disease in recent years, states that a part of it, but only a small part, may be attributed, with much probability, to a number of deaths which would formerly have been referred to croup being now ascribed to diphtheria ; for, concurrently with the increase under diphtheria, there has been a constant diminution in the number of deaths from croup. If, however, the deaths from diphtheria and croup be taken together, they amounted in 1893, to 3,482, while the average number in the preceding decennium, corrected for increase of population, did not exceed 1861. Diphtheria, which was formerly mainly a rural disease, shows an ever-increasing tendency to become an urban disease. Fortunately, the hospitals of the Asylums Board are available for the reception of sufferers from it, but the accommodation is at present quite inadequate to the demand. The following table sets out some particulars with regard to diphtheria in Kensington, in 1893, 53 PARTICULARS WITH REFERENCE TO DIPHTHERIA IN KENSINGTON, IN 1893. Set out in Report for Four weeks ended. Total Cases Notified. Cases Notified in North Kensington.* Cases Notified in South Kensington.* Cases removed to Hospital from Deaths in North Kensington. South Kensington. North Kensington. South Kensington. January 28 9 6 3 4 1 5 ... February 25 16 7 9 3 4 1 2 March 25 15 7 8 5 6 4 3 April 22 9 4 5 4 2 ... ... May 20 26 16 10 7 3 3 1 June 17 22 15 7 7 6 3 4 July 15 35 14 21 5 14 1 8 August 12 44 13 31 6 17 3 6 September 9 26 9 17 7 7 3 1 October 7 "27 10 17 6 7 2 4 November 4 55 25 30 19 17 8 7 December 2 39 18 21 8 11 4 ... December 30 30 14 16 6 9 4 6 353 158 195 87 104 41 42 * North Kensington and South Kensington, are the districts to the North and the South of the centre of the Uxbridge Road, respectively. The population of the two districts is about equal. 54 WHOOPING-COUGH. Whooping-cough was the cause of 65 deaths, 12 below the corrected decennial average: nine of them were registered in the Brompton sub-district: all but four were of children under under five years of age, including 26 under one year. Nineteen of the deaths were registered in the first half of the year and forty-six in the latter half-period. Reference has been made to the carelessness of parents among the poorer classes in regard to the spread of measles in their families. The observation is, perhaps, even more generally applicable in regard to whooping-cough, the seriousness 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 inevitable and do not regard as being dangerous. Often enough, the fatal event comes as a surprise, being due commonly to some intercurrent disease—of the respirator}' organs, or of the nervous system : few deaths are registered from whoopingcough alone. These complications cannot always be prevented ; but the occurrence of bronchitis or pneumonia, for instance, is not seldom due 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. Whooping Cough in London. — The deaths in London from whooping-cough in 1893, were 2,330, and 443 below the corrected decennial average: they were in the proportion of 0.54 per 1,000 living, the average proportion in the preceding decennium having been 0.65. 55 FEVER. There was no death from Typhus or from Simple Continued Fever in 1893. Enteric Fever was the cause of 17 deaths, compared with 15, 24, and 15, in the preceding three years respectively, the corrected decennial average being 19. Fourteen of the deaths belong to the Town sub-district (seven of them having taken place in hospitals to which 39 cases were removed) and three to the Brompton sub-district. Ninety-seven cases were notified, 52 in North Kensington and 45 in South Kensington, compared with 84, 95, and 58, in the preceding three years. Fever in London.—There were 5 deaths from typhus in London and 21 from simple and ill-defined fever, the decennial averages being 21 and 58 respectively. The deaths from enteric fever were 693 (257 more than in 1892) and 10 above the corrected decennial average. DIARRHŒA. Diarrhoea was the cause of 98 deaths (11 above the corrected decennial average) 82 in the Town sub-district, and 10 in Brompton. Eighty-nine of the deaths were of children under five, including 76 under one year. The deaths from diarrhceal diseases in London generally, were 3,446 (356 above the corrected decennial average) including 2,567 of infants in the first year of life, and 511 of children between one and five. The question why diarrhoea is so prevalent, and so fatal, to infants, in hot summers, has been long under consideration by the medical department of the Local Government Board. A " provisional or working hypothesis" has been formulated, which assumes the existence of a form of germ-life in the earth—especially where this is sewage-tainted or otherwise polluted—which germ, developing activity when a certain temperature is attained, and rising into the air, finds admission with food into the system, and, multiplying there, generates a poison which is the immediate cause of the disease. 56 CHOLERA. Cholera having re-appeared in various parts of the continent (as well as at Mecca) the Local Government Board issued a circular to Sanitary Authorities in the Metropolis, dated 22nd June, calling attention to their circular letter of the 25th August, 1892, in which, " in view of the severe outbreak of cholera" which was then occurring in Hamburgh, they reminded Sanitary Authorities of "the responsibilities and duties devolving upon them, in connexion with the organisation of measures of precaution against the possible introduction of the disease into London." With this circular there was sent a "Memorandum" by the Board's Medical Officer, mainly historical, in which it was pointed out that, " whereas a considerable portion of the summer of 1892 was taken up with the diffusion of cholera across the Continent of Europe, the disease only reaching ports in the North Sea and British Channel in the month of August, recrudescence of the disease (in 1893) along the coastline of Western Europe, may well occur at a date which would involve danger to this country during a longer term of our summer and autumn season than was the case in 1892." The memorandum further set out the places where cholera was then prevalent—mainly in France, the ports of which, on the west coast, were at the time regarded and treated as infected places, all vessels coming from them being carefully overhauled by the Port Sanitary Authority at Gravesend. The Medical Officer, in conclusion, stated that it was " important that the Sanitary Authorities of England and Wales should be prepared, in advance, to prevent extension of any cholera that may be imported into their districts," a duty which " devolves especially on the Authorities of those districts into which cases of imported cholera are most likely to make their way." The Local Government Board subsequently, in August, called " attention to the powers vested in them to issue Epidemic Regulations imposing upon Sanitary Authorities the duty 57 of making arrangements for the prevention and treatment of cholera." "Those arrangements (they stated) would comprise the appointment of Committees for the purpose of carrying out the Regulations, the division of the sanitary district into special areas, the appointment of medical visitors for the visitation of the poorer houses, and the detection of cholera and diarrhoea, the supply of medical attendance and nursing, and of medicine and disinfectants, and the provision of dispensaries, and of such additional hospitals and places of refuge as might be necessary for the several parishes and districts ; the hospitals being provided for the reception of those cholera patients who could not be properly treated in their own homes, and the places of lodgment for those persons, not actually sick, whom it might be right to keep under observation, or to accommodate, while their homes were either under disinfection, or were devoted to sick persons who could not properly be removed." The Board, moreover, "in view of the possible recurrence of cholera, during the (then) approaching summer and autumn, in continental ports with which this country is in rapid and close communication," thought it right that the Sanitary Authority "should take into their early consideration the question of their readiness to meet any emergency that might arise." They, therefore, requested to be informed how far the preliminary action taken in 1892, or since decided on by the Sanitary Authority, might be regarded as enabling them, without undue delay, to perform the duties which would devolve on them in the event of the Board finding it necessary to issue Regulations of the kind referred to. Shortly after the issue of the circular letter, cases of cholera occurred at some of the eastern ports, notably Grimsby and Hull, and several persons died of the disease. The assistance of the medical staff of the Local Government Board was freely rendered to the Sanitary Authorities of the affected places, and everything that could be done to prevent the spread of the disease was done. The indications happily pointed to the probability that the measures taken would, as was the case in 1892, protect the country generally, and the metropolis in particular, from an epidemic of this terrible disease; and although here and there, at inland places, 58 ¬ing London itself, isolated cases of choleraic disease occurred, some of which proved fatal, there was nothing approaching to a serious outbreak. It was open to question indeed, whether all, if the majority, of the cases were cases of Asiatic Cholera. The disease did not spread; the occurrence of the illnesses could not be connected with any known importation of cholera to the respective localities, and the balance of probability favoured the assumption that the several cases might have been virulent examples of English Cholera. One such case occurred in this parish, the sufferer being a sweep, aged 28, who died after a brief illness. The cause of death as certified was choleraic diarrhœa. The case stood alone, no other person in the house having shown any symptoms of a like character. It was a reassuring feature in regard to the public health of the Metropolis, and of our own parish, that the mortality from diarrhœal diseases at the time, was below the corrected decennial average. A measure of alarm doubtless existed, but, on the whole, it was felt that the Health Authorities, central and local, were on the alert ; so that there was, manifestly, a calmer state of feeling on the subject than in 1892, when the public were suddenly awakened to the probability of an invasion of the disease which was causing havoc so near to our own shores as Hamburgh. The position was one of watchful expectancy, and of calm preparation for any emergency, tempered by a reasonable hope that the energetic measures taken by the several Port Sanitary Authorities (at their own proper cost!) and by the Medical Officer of the Local Government Board and his able staff, would suffice to detect imported cases, and to deal with them on the spot, so as to protect the country generally from this dreaded scourge. Provision, I may add, had been made for the establishment of three ambulance stations in this parish, viz., at the Parish Infirmary, the Workhouse at Mary Place, and St. Marylebone Infirmary, Notting Hill, at which institutions, moreover, about 150 or 160 beds could have been made available for the sick at a few hours' notice Happily no occasion arose for testing the adequacy of these preparations. 59 INFLUENZA. For the fourth successive year, Influenza was prevalent in the Metropolis and in many other parts of the Kingdom. The deaths attributed directly to this cause in London, were 1,526, compared with 2,336 in 1891, 650 in 1890, and 2,264 in 1892. The deaths, therefore, in the four years, were 6,676 ; compared with a total of 63 in the preceding ten years, 1880-89. There was no week in 1893 in which no death from influenza was registered in London. The deaths in the four quarters successively, were 356, 354, 84, and 732. In the last four weeks of the year 546 deaths were registered from this cause. Manydeaths, moreover, attributed to pneumonia were probably due to influenza. The mortality from this disease which attained its maximum in London, in 1891, did not attain its maximum in Kensington until 1892, when 155 deaths, including 106 in January, were registered ; the deaths in the preceding three years successively having been 39,113, and 115. In 1893 the deaths attributed directly to influenza were 93 (75 in the Town sub-district and 18 in Brompton) 21, 22, 3, and 47, in the four quarters respectively. Thirtyfive of the deaths were registered in the last four weeks of the year, wherein the total mortality (355) was by far the highest recorded in 1893, the next highest number of deaths (298) having been recorded in the first four-weekly period ended January 28th. It is somewhat remarkable that the deaths from diseases of the respiratory organs should have been 31 fewer in December than in January, seeing that the parish was free from influenza in the last named month. In January the deaths from chest-diseases were 124: in December 93 only. In London as a whole the deaths from chest-diseases in the first three weeks of December were 809 in excess of the corrected average: in the last week of the year the deaths from these causes were 104 below the average. As already stated, 546 deaths were registered during these four weeks as primarily due to influenza. 60 Table showing the number of Deaths from the principal Diseases of the Zymotic Class in Kensington, and in London, in 1893, Arranged in four-weekly periods. Date of Report. For Four Weeks ended. Weeks of the Year KENSINGTON. LONDON, Weeks of the Year, Date of Report. For Four Weeks ended Small-pox. Scarlet Fever, Diphtheria. Enteric Fever. Diarrhoea. Typhus & other Continued Fevers. Measles. Whooping-cough. Cholera. Total. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Diarrhoea. Typhus & other Continued Fevers. Measles. Whooping-cough. Cholera. Total. January 28, 1893 1-4 ... 2 5 1 ... ... ... 2 ... 10 3 128 198 32 57 1 149 123 ... 691 1-4 January 28, 1893 February 25 ,, 5-8 ... 3 3 ... 2 ... ... 2 ... 10 10 94 216 29 65 1 63 162 ... 640 5-8 February 25, ,, March 25 ,, 9-12 1 4 6 ... ... ... ... 3 ... 14 20 83 189 35 75 ... 75 185 1 663 9-12 March 25, ,, April 22 ,, 13-16 ... 1 ... ... 1 ... 2 ... ... 4 19 91 165 26 52 2 121 223 ... 699 13-16 April 22, „ May 20 ,, 17-20 1 6 4 1 4 ... ... 3 1 20 34 90 223 32 83 2 112 173 1 750 17-20 May 20, „ June 17 ,, 21-24 1 2 7 ... 6 ... 1 4 ... 21 38 118 193 29 224 4 147 149 8 910 21-24 June 17, „ July 15 „ 25-28 1 4 9 ... 19 ... ... 9 2 44 27 136 237 61 890 2 197 213 39 1802 25-28 July 15, „ August 12 ,, 29-32 ... 3 9 2 28 ... 1 7 1 51 23 142 265 59 760 4 174 207 17 1651 29-32 August 12, ,, September 9 ,, 33-36 ... 8 4 ... 15 ... ... 6 1 34 8 147 240 78 644 1 139 167 52 1476 33-36 September 9, „ October 7 ,, 37-40 ... 6 6 1 11 ... ... 10 ... 34 6 139 323 57 353 1 56 172 11 1118 37-40 October 7, ,, November 4 ,, 41-44 1 4 16 4 9 ... 3 6 ... 43 5 150 341 74 134 3 91 115 4 917 41-44 November 4, „ December 2 ,, 45-48 1 3 4 5 1 ... 3 5 ... 22 6 160 358 86 55 3 160 174 ... 1002 45-48 December 2, ,, December 30 ,, 49-52 3 5 10 3 2 ... 8 8 ... 39 7 118 316 95 56 2 177 267 ... 1038 49-52 December 30, ,, Totals ... 9 51 83 17 98 ... 18 65 5 346 206 1596 3234 693 3448 26 1661 2330 133 13357 ... Totals. Note.—The above Table, designed to show the relative degree of prevalence at different periods of the year of the specified diseases, has been compiled from my thirteen four-weekly reports. 61 Other Diseases of the Zymotic Class. — Thus far I have dealt with the " seven principal diseases of the zymotic class," comprising, with Cholera and Influenza, all of those Maladies which in Table III. (Appendix), go to make up Orders 1 and 2 (Miasmatic and Diarrhoeal Diseases), of class 1 in the Registrar-General's classification, viz., " Specific Febrile or Zymotic Diseases." Still dealing with this important Class, it appears that no deaths were registered from Malarial Diseases, comprised in Order 3, viz., Remittent Fever and Ague ; nor from Zoogenous Diseases, in Order 4, viz., Cow-pox and Effects of Vaccination, and " Other Diseases," viz., Hydrophobia, Glanders, Splenic Fever. Order 5, Venereal Diseases, includes Syphilis, Gonorrhoea, and Stricture of the Urethra. Syphilis was the registered cause of 28 deaths, against 14, 13, and 10, in the preceding three years respectively. Twenty-five of these deaths occurred in the Town sub-district: 20 of them were of children under one year of age. If the truth were known, 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, Pyoemia, Septicœmia and Puerperal Fever: the total deaths registered were 32, against 24,18, and 23, in the preceding three years respectively. Erysipelas was the cause of 17 deaths,* against 8 and 11 in the preceding three years respectively; eleven of them in the Town sub-district. Two of the deaths were of children under one year of age. Pyœmia and Septicaemia were the causes of 5 deaths, all of them in the Town sub-district. There had been 6, 5, and 4 deaths from these causes in the preceding three years respectively. * The notified cases were 273, many of them being of traumatic origin, unimportant in character, and such as the framers of the Act could scarcely have intended to be notified, 62 Puerperal Fever was the registered cause of 10 deaths, (against 10, 5 and 8 in the preceding three years respectively) eight of them in the Town sub-district. Three of the deaths were of women between fifteen and twenty-five years of age; four between twenty-five and thirty-five, and three between thirty-five and forty-five. In addition to these 10 deaths, other 7 (five of them in the Town sub-district) were registered as having occurred in " childbirth," against 14, 10, and 8, in the preceding three years respectively. Puerperal fever is a communicable disease depending upon " blood poisoning," whereas other causes of death connected with childbirth, are, so to say, accidental e.g., hemorrhage ("flooding"). The deaths registered as having been caused by diseases and accidents associated with parturition (17) were equal to about 4 6 per 1,000 live births, against 6.2, 4.0, and 4.3 per 1,000 in the preceding three years respectively. The notifications of puerperal fever were nine only, ten deaths having been registered from this cause. Two of the notified cases, of which one proved fatal, occurred in the practice of two midwives (the one being pupil of the other) concerned with the patients of a lying-in hospital. The infection in the second case was to all appearance conveyed by the midwife. Bearing in mind the disastrous series of cases of this disease upon which I reported in 1883, when a verdict of manslaughter was returned by a Coroner's jury against a midwife, under circumstances set out in my fourth and sixth reports for that year, I have ever since felt it my duty to warn nurses, and all other women concerned with these painful cases, of the responsibility they incur by attending parturient women until after a period of three or four weeks, and without disinfection of their persons, clothing, &c. This course was adopted in respect of the cases notified in 1893, with satisfactory results, there having been no spread of the disease. 63 Class II.—Parasitic Diseases. Includes Thrush and Other Vegetable Parasitic Diseases, from which there were four deaths ; and Worms, Hydatids, and Other Animal Parasitic Diseases, there having been no deaths from any of these causes. Class III.—Dietetic Diseases Were the causes of 24 deaths, seventeen of them in the Town sub-district. To Want of Breast Milk, Starvation, three deaths were classified ; to Scurvy, none. Delirium Tremens was the cause of three deaths, against 6, 4, and 7, in the preceding three years respectively; Chronic Alcoholism of 18 deaths, against 8, 13, and 7. Of these 21 deaths, 15 occurred 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 misuse 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 truly be said, is accountable for a large part 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 of many premature deaths: it fills our prisons and workhouses, our asylums and hospitals, our cemeteries—and our National Exchequer ! Class IV.—Constitutional Diseases. This important Class comprises the causes of 504 deaths (=17'3 per cent. of total deaths), including 80 of children under the age of five years : 391 of the deaths were registered in the Town sub-district, and 113 in Brompton. 64 Rheumatic Fever and Rheumatism of the Heart caused 15 deaths, all of them in the Town sub-district ; Rheumatism, 6 deaths. In fatal cases of rheumatic fever, the immediate cause of death, not infrequently, 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 connection 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 complication. Gout was the cause of 7 deaths, 6 of them in the Town sub-district, and Rickets of 4. Cancer, Malignant Disease, was accountable for 140 deaths ; 105 in the Town sub-district and 35 in Brompton. Cancer is on the increase in the country generally : possibly, however, some portion of the apparent increase in deaths classified to this cause may be due to more accurate diagnosis. The deaths in Kensington in the preceding ten years, were 128, 117, 119,128, 117, 121, 138,125,127, and 129, 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 being 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 disease, moreover, being for the most part one of later life. Thus 116 of the deaths took place at ages above forty-five, and 18 between thirty-five and forty-five. It is proper to mention that in Table III. (Appendix) the deaths attributed 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, 65 Anœmia and Leucocythemia were the causes of 7 deaths Glycosuria, Diabetes Mellitus, of 15 deaths. The remaining diseases in this Class belong to the group designated— TUBERCULAR, and they are among 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 overcrowding in ill-constructed, unventilated and sewage-tainted houses ; and, in a word, by whatever is inimical to the maintenance of a typical condition of health. The cases that occur amongst the well-to-do 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, and like them depending for its origin on its own special " bacillus " : we are encouraged to believe, therefore, that a remedy will ultimately be found for this scourge of the human race. Tubercular diseases were the registered causes of 307 deaths in 1893 (against 369, 343, and 293, in the preceding three years respectively) : viz., 240 in the Town sub-district, and 67 in Brompton ; 74 of the deaths being those of children under five years of age. The numbers in the four quarters of the year respectively, were 82, 71, 77, and 77 ; or 159 in the winter, E 66 and 148 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 in other parts of the body than the lungs, e.g. brain, bowels, &c. Such deaths have been classified in Table III. with those ascribed to " Other forms of Tuberculosis, Scrofula;" the total being 46 (of which 22 occurred under five years of age) including 12 registered in the Brompton subdistrict. Tabes Mesenterica, popularly known as " consumption of the bowels," was the cause of 20 deaths (including 3 in Brompton) 19 of them under five years of age, and 16 under one year. Tubercular Meningitis and Hydrocephalus (water on the brain) were the causes of 42 deaths (3 of them in Brompton) 30 under, five years of age Phthisis, popularly known as " decline " or " consumption," was the cause of 199 deaths : 3 under five years of age, 4 between five and fifteen, and 185 between fifteen and sixty-five ; viz., 36, 46, 51, 42, and 10, in the five decades consecutively: 7 deaths were registered at ages over sixty-five. The quarterly numbers were 55, 36, 53, and 55. Of the total, 150 belong to the Town sub-district and 49 to Brompton. The deaths from tubercular diseases were, proportionately, not so numerous in Brompton as in the Town sub-district. It is probable that the mortality ascribed to tubercular diseases does not comprise all 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 the medical certificates of the causes of death ; but all such associated diseases have been disregarded in the preparation of Table III. ; for when phthisis is returned, the death is classified to that heading, it being assumed that the tubercular diathesis was underlying the other disease, and was, in fact, the primary cause of death. 67 Class V.—Developmental Diseases. In this Class the total deaths were 175; viz., 138 in the Town sub-district, and 37 in Brompton. Premature Birth was the assigned cause of 71 deaths, 18 of them in the Brompton sub-district ; Atelectasis of 7, all of them in the Town sub-district ; and Congenital Malformation of 5. Old Age was the registered cause of 92 deaths, all but one of them at ages over sixty-five : between sixty-five and seventyfive there were 15 deaths so classified; 48 between seventyfive and eighty-five, and 28 at eighty-five and upwards. Class VI.—Local Diseases. The diseases in this Class, comprising eleven Orders named after the systems or organs to which the diseases relate, were accountable for 1,481 deaths, or 50.8 per cent, of the deaths from all causes: 1,157 were registered in the Town sub-district, and 324 in Brompton : 374 were of children under five years of age. These totals tally pretty closely with those recorded in 1892, but they are considerably below the numbers recorded in 1891, when the deaths from local diseases were 1,690. The deaths from the disease comprised in the several orders were as follows :— 1. Nervous System.—Diseases of the nervous system were the registered causes of 305 deaths (against 321, 327, and 293, in the preceding three years respectively) viz., 231 in the Town sub-district, and 74 in Brompton : 91 of the deaths were of children under five years of age, and 170 occurred at ages over 45. The quarterly numbers were 84, 69, 70, and 82. The fatal diseases were Inflammation of Brain or Membranes,47 deaths; Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis, 138 deaths (101 in the Town sub-district, 37 in Brompton); Insanity, General Paralysis of the Insane, 12, all in the Town sub-district; Epilepsy, 14; Convulsions, 52 (all under five, and 47 under one year) ; laryngismus 68 Stridulus (spasm of glottis), 5 ; Disease of the Spinal Cord, Paraplegia, Paralysis Agitans, 8 ; Other Diseases of Nervous System, 29. convulsions as a cause of death is frequently associated, in medical certificates, with definite diseases, and with " teething." The convulsions being a symptom only, such deaths are classified to the primary 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 sometimes assigned as the cause of the death of children " found dead in bed." In the absence of other apparent cause of death, in such cases, the preexistence of spasm of the glottis may have been inferred ; but it is quite possible, to say the least of it, that the children had been suffocated—a remark still more applicable to the 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 guessedat 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. Diseases ok the Organs of Special Sense (eg., of Ear, Eye, Nose), are comprised in this Order. Five deaths were registered from these causes. 3. Circulatory System.—The deaths due to diseases of the organs of circulation, heart and blood vessels, were 219, against 220, 198, and 173, in the preceding three years respectively: 150 were registered in the Town sub-district, and 69 in Brompton. The quarterly numbers were 65, 58,46, and 50. To specified forms of disease, 56 deaths were ascribed, viz. Pericarditis, 5 ; Acute Endocarditis, 4 ; Valvular Diseases of the Heart, 47. Aneurism was the cause of 8 deaths, 69 and Embolism, Thrombosis, of 8. Other Diseases of the Heart caused 144 deaths, and Other Diseases of Blood Vessels, 3 deaths. 4. Respiratory System.—The deaths from diseases of the chest, Phthisis being excluded, were 671 (against 745, 853, and 704, in the preceding three years respectively), and 23 per cent. of total deaths. Of these deaths 560 were registered in the Town sub-district, and 111 in Brompton. The deaths in the first and fourth or colder quarters, were 228 and 221 (— 449) those in the second and third or warmer quarters, being 134 and 88 (=222. The deaths under five years of age were 210, or 31.3 per cent. (against 35.3, 32.1 and 34.6 per cent. in the preceding three years respectively), and at fifty-five and upwards 285, or 42.5 per cent. of the whole number (against 41.2, 44.3, and 43.3 per cent. in the preceding three years respectively). These diseases are thus seen to be most fatal at the extremes of life. The prevalence of them moreover, 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. There was good reason for believing that the epidemic of Influenza was largely responsible for the fatality of this order of diseases in 1891 : the same remark did not appear to apply, or not to the same extent, with regard to the deaths from diseases of the respiratory organs in 1892 : it is even less applicable to the mortality in 1893. The fatal diseases were Laryngitis, 6 deaths ; Croup (transferred in the new classification from " miasmatic " diseases), 9* ; Emphysema, Asthma, 17 ; Bronchitis, 402 ; Pneumonia, 163; Pleurisy, 33 ; and Other Diseases of the Respiratory System, 41. Bronchitis and Pneumonia, therefore, were accountable for 565 deaths (including 177 under five years of age) of which 82 were registered in Brompton. * Fifteen cases of membranous croup were notified. 70 5. Digestive System.—The diseases of the various organs concerned in digestion, were the causes of 182 deaths, 66 of them under five years of age ; 141 in the Town subdistrict and 41 in Brompton. In the new classification, Dentition is included in this Order: it was the cause of 12 deaths under five, 7 of them under one year. Diseases of the Stomach caused 21 deaths ; Enteritis, 48 ; Obstructive Diseases of Intestine, 25 ; Peritonitis, 19 ; Ascites, 1. Cirrhosis of Liver caused 22 deaths ; Jaundice and Other Diseases of Liver, 27 (including three under one year); and Other Diseases of Digestive System, 7 deaths. 6. Diseases of Lymphatic System (e.g., of Lymphatics, and of Spleen).—No death was ascribed to these causes. 7. Diseases of Gland-like Organs of Uncertain Use.—(e.g. Bronchocele, Addison's Disease)—Two deaths. 8. Diseases of Urinary Organs.—Of the 68 deaths ascribed to these causes, 48 were registered in the Town subdistrict and 20 in Brompton. The diseases were, Nephritis, 11 deaths ; Bright's Disease (Albuminuria), 32/ Diseases of Bladder or of Prostate, 7 ; and Other Diseases of Urinary System, 18 deaths. 9. Diseases of Reproductive System.—(a) Of Organs of Generation—Male Organs, no death; Female Organs, 11 deaths ; (b) Of Parturition, 7 deaths, viz., Miscarriage, 3 ; Puerperal Convulsions, 1 death, and Other Accidents of Childbirth, 3 deaths. 10. Diseases of Bones and Joints.—Five deaths; Caries, Necrosis, 2 ; Arthritis, 2 ; Other Disease, 1. 11. Diseases of Integumentary System.—Six deaths. 71 Class VII.—Deaths from Violence. Seventy-eight deaths, including 21 under five years of age, and 14 under one year, are distributed over the four Orders comprised in this Class : 22 of them belong to the Brompton sub-district. 1. Accident or Negligence.—Total deaths, 61, including 14 in Brompton, and 21 under five years of age ; viz., from Fractures and Contusions, 35 ; Burn, Scald, 8 ; Poison, 2 ; Drowning, 3 ; Suffocation, of infants " overlaid," 13, all under one year. Twelve of the deaths from suffocation were registered in the Town sub-district.. 2. Homicide.—Manslaughter, one death. 3. Suicide.—Total deaths, 16,including 8 in Brompton ; viz., by Cut, Stab, 4 ; Poison, 5 ; Gun-shot Wounds, 3 ; Drowning, 2 ; Hanging, 1 ; Otherwise, 1. Class VIII.—Deaths from Ill-Defined and not Specified Causes. This Class includes the causes of 150 deaths ; 118 under five years of age, and 106 under one year : 127 and 23 in the Town and Brompton sub-districts respectively. The causes named are ; Debility, Atrophy, Inanition, 115 deaths (all but 12 under one year); Dropsy, 2; Mortification, 2; Abscess, 3; Tumour, 5 ; and Hemorrhage, 1. To " Causes not Specified or Ill-defined," 22 deaths were ascribed. The Causes of death from the various diseases above set out are summarised in the following table :— 72 Summary of Table III. (Appendix) showing the number of deaths from the diseases in the Classes and Orders. CLASS I. SPECIFIC FEBRILE OR ZYMOTIC DISEASES No. of Deaths. Order 1. Miasmatic Diseases 336 2. Diarrhoeal ,, 103 3. Malarial „ ... 4. Zoogenous ,, ... 5. Venereal ,, 29 6. Septic ,, 32 500 II. PARASITIC DISEASES 4 III. DIETETIC DISEASES 24 IV. CONSTITUTIONAL DISEASES 504 V. DEVELOPMENTAL DISEASES 175 VI. LOCAL DISEASES— 1. Diseases of Nervous system 305 2. Diseases of Organs of Special Sense 5 3. Diseases of Circulatory System 219 4. Diseases of Respiratory System 671 5. Diseases of Digestive System 182 6. Diseases of Lymphatic System — 7. Diseases of Glandlike Organs of uncertain use 2 8. Diseases of Urinary System 68 9. Diseases of Reproductive System — a. Diseases of Organs of Generation . . 11 b. Diseases of Parturition 7 0. Diseases of Locomotive system 5 11. Diseases of Integumentary System .. 6 1481 VII. VIOLENCE— 1. Accident or Negligence 61 2. Battle ... 3. Homicide 1 4. Suicide 16 5. Execution ... 78 VIII. ILL-DEFINED AND NOT SPECIFIED CAUSES ... 150 Total ... 2916 73 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 remark. 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-parishioners at the Marylebone Infirmary, Notting Hill (456) and at the Brompton Consumption Hospital (131) 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 (423) at the Brompton Consumption Hospital (5) and at outlying institutions, &c., (312) were 740, or 25.4 per cent. on total deaths, the percentage proportion of deaths in public institutions in the Metropolis generally, being 26.9. The Registrar-General in his Annual Summary states that " About one in every eight deaths occurred in a Workhouse or Infirmary, one in 42 in a Metropolitan Asylum Hospital, one in 10 in some other hospital, and one in 56 in a public lunatic or imbecile asylum." The increase in the number of deaths in public institutions has been great and continuous for some years past. The Parish Infirmary and Workhouse.—I am indebted to Dr. H. Percy Potter, Medical Superintendent of the Infirmary and Medical Officer to the Workhouse, for the statistics of mortality at these important institutions. The deaths in 1893, were 423, compared with 394, 523, and 433, in the preceding three years, and were equal to 14 5 per cent. on total deaths. The quarterly numbers were 109, 92, 98, and 124: 74 201 deaths therefore occurred in the first half of the year, and 222 in the latter half. The deaths included 215 of males and 208 of females. The ages at death were : under one year, 84 (against 45, 71, and 77, in the preceding three years respectively) : between one and sixty 195 (against 179, 214, and 199, in the preceding three years), and at sixty and upwards, 144 (against 170, 238, and 157, in the preceding three years). Summary of Causes of Death. DISEASES. Under 1 year. Between 1 year and 60 At 60 and upwards. Total. Nervous System, (including Apoplexy and Epilepsy) 1 27 17 45 Convulsions 6 .. ... 6 Circulatory System, Diseases of ... 12 16 28 Respiratory System, Diseases of 17 51 47 115 Digestive System, Diseases of 8 6 14 28 Urinary System, Diseases of ... 9 6 15 Tubercular (including Phthisis and Marasmus) 30 60 1 91 Gout ... 1 2 3 Cancer ... 9 12 21 Syphilis 11 6 ... 17 Lymphadenoma ... 1 ... 1 Scarlet Fever ... 1 ... 1 Measles 1 1 ... 2 Whooping Cough 3 ... ... 3 Influenza ... 4 2 6 Erysipelas ... 2 6 8 Carbuncle ... ... 1 1 Premature Birth 6 ... ... 6 Senile Decay ... ... 15 15 Abscess, Gangrene, Pernicious Anæmia (2 each) ... 2 4 6 Joint Disease, Stomatitis, Addison's Disease, Delirium Tremens, Alcoholism 1 each) 1 3 1 5 84 195 144 423 Four inquests were held : verdicts of death from " natural causes " were returned in three of the cases, and a verdict of death from heart disease in the fourth case. 75 The Infirmary has been enlarged recently, by the addition of extensive buildings fronting upon Marloes Road, and is now, probably, second to none in accommodation, or otherwise, among the Poor Law Infirmaries of the Metropolis. 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 Wing " having been established on the farther side of the Fulham Road, in the parish of Chelsea), were 136 ; males 77, and females 59. Five of the deaths were of parishioners, and are included in Table III. (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, 456 deaths of nonparishioners were registered, all of which are excluded from Table III. St. Joseph's House, Portobello Road.—The deaths at this quasi-public institution, with a few exceptions of parishioners, are not included in Table III. (Appendix). They were 27 in number; males, 7 ; females, 20. Some of the deceased had previously resided in Ireland, some in London, and the remainder in the provinces and abroad. Outlying Public Institutions.—The deaths of parishioners at public institutions, &c. outside the parish, which, in the preceding three years, had been 211, 247, and 236, respectively, were no fewer than 312 in 1893. In Table III. (Appendix) all of these deaths are included. The deaths occurred in the following institutions, viz.:— 76 St. Mary's Hospital 58 City of London Chest Hospital 1 St. George's Hospital 40 Royal Hospital, Waterloo Road 1 University College Hospital 8 St. Saviour's Hospital 1 West London Hospital 7 Cancer Hospital, Fulham Road 1 Middlesex Hospital 6 General Lying-in Hospital 1 King's College Hospital 5 Cheyne Hospital 1 St. Bartholomew's Hospital 3 Hospital for Epilepsy, Portland Terrace 1 Charing Cross Hospital 2 Westminster Hospital 2 St. Camilo's Hospital 1 St. Thomas's Hospital 1 Private Hospital, Weymouth Street 1 North-West London Hospital 3 St. Elizabeth's Home 2 Brompton Hospital (South Wing) 7 St. Peter's Home, Kilburn 1 Western Hospital 44 Friedenheim House of Peace 1 North-Western Hospital 26 St. Luke's House, Osnaburgh Street 1 South-Western Hospital 5 Northern Hospital 3 St. Pœlagio's Creche 1 London Fever Hospital 3 Fulham Infirmary 1 Hospital Ship "Atlas" 5 Wormwood Scrubbs Prison 2 " Fountain" Fever Hospital 2 H.M. Prison. Holloway 1 " Red Cross " Ambulance Steamer 1 Offices of Society for Prevention of Cruelty to Children 1 Queen Charlotte's Hospital 6 Hospital for Women, Chelsea 5 Caterham Asylum 7 Children's Hospital,Great Ormonde Street 4 Darenth Asylum 6 Cane Hill Asylum 5 Children's (Victoria) Hospital 3 Han well Asylum 4 Convent Hospital 2 Leavesden Asylum 4 Bethlem Hospital 2 Banstead Asylum 3 Homoeopathic Hospital 2 Colney Hatch Asylum 1 French Hospital 1 Ilford Asylum 1 German Hospital 1 Hoxton House Asylum 1 German Lying-in Hospital 1 312 Home Hospital, Fitzroy Square 1 North London Consumption Hospital 1 The deaths of six parishioners, in addition to the above, were recorded as follows : three males, by drowning, two in the Thames, at Hammersmith and Wandsworth, and one in the Grand Junction Canal at Haddington ; a male and a female, from accidental injuries, whilst being conveyed to St. George's and St. Mary's Hospitals respectively ; and a male, who died suddenly, in Praed Street, Paddington. Deaths from diseases of the zymotic class, occurred at public institutions without the parish, as follows: Western (Asylums Board) Hospital 43 (scarlet fever 25, diphtheria 17, and enteric fever 1); North-Western Hospital, 25 (diphtheria 18, and scarlet fever 7); St. George's Hospital, 9 (diphtheria 7, enteric fever 1, and measles 1); Hospital Ship " Atlas," 5 (small-pox); St. Mary's Hospital 4, 77 (diphtheria); London Fever Hospital 3 (scarlet fever 2, and diphtheria 1); Northern Hospital 3 (scarlet fever 2, and diphtheria 1); South-Western Hospital 3 (diphtheria 2, and enteric fever 1); King's College Hospital 3 (enteric fever)-, Children's Hospital, Great Ormonde Street, 2 (diphtheria); The " Fountain" Fever Hospital 1 (scarlet fever)-, University College Hospital 1 (diphtheria); Victoria Hospital for Children 1 (diarrhoea) ; Fulham Infirmary 1 (measles); and on board the "Red Cross" Ambulance Steamer 1 (small-pox). UNCERTIFED DEATHS. Four deaths, of 1 male and 3 females (against 5, 8, and 14, in the preceding three years respectively) were returned as not having been certified, either by a registered medical practitioner or by a Coroner. The ages at death were 5 minutes, 2 months, 9 years, and 32 years : the causes of death were premature birth and heart disease in the first and last mentioned cases, " natural causes " being returned in the other two cases. The several deaths were duly reported to the Coroner who did not deem it necessary to hold inquests. The attention of the Metropolitan Sanitary Authorities was called, in 1887, to the subject of uncertified deaths by the Vestry of St. James's, 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 were meant," as I observed in my report for that year, " that the Medical Officer 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." The Vestry stated that " at present (i.e. 1887) 3 to 4 per cent. of the total deaths are not certified at all." Upon this I may observe that the proportion of deaths not certified, either by registered 78 medical practitioners or by coroners, has steadily declined of late years. It was 4.7 in 1879. The percentage varies widely in different parts of the Kingdom. In 1893 it was 0.9 percent in London ; 0.13 in Kensington ; 2.7 in England and Wales as a whole ; ranging upwards to 5.4 in North 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 attendance cannot be obtained. In such cases the suggested duty would be impossible of performance by the Medical Officer of Health. 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, practically, all deaths returned as " uncertified " are referred to the Coroner, and registration takes place only after the Coroner's decision that inquisition is unnecessary. The preliminary inquiry by the Coroner's officer is not satisfactory ; and it is probable that in many of the cases in which inquests would be held under existing circumstances, an inquiry by an expert—e.g., a Medical Officer of Health—would save the time of the Coroner, and of persons liable to serve as jurymen, as well as some expense to the county, if his decision that an inquest was unnecessary were accepted. In these circumstances,the Medical Officer would become,practically,the "Coroner's Officer," as indeed the St. James's Vestry proposed. If suitably remunerated for the task, he might reasonably be authorized to inquire, in the first instance, into the causes of uncertified deaths, and to certify in proper cases ; referring those from violence, or otherwise involving suspicion of foul play,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 cases of deaths registered as " not certified," in which,after reference to the Coroner inquest is not held,it cannot be doubted that an inquiry and report by a Medical Officer of Health would be more satisfactory than that by a Coroner's 79 Officer. Presumably, the deaths " not certified " in lone and mountainous districts, are not even referred to a Coroner. In some of the manufacturing towns there is much so-called " 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 persons who had been duly attended in their last illness by a registered practitioner. I have long held the opinion that when death ensues in the case of persons attended by unregistered practitioners, an inquiry should be held : the dread of inquisition would tend to limit irregular " medical " 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 the Society passed a resolution to the effect:— " 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. Of all the unsatisfactory arrangements connected with uncertified deaths, it was felt that the least defensible is that which makes the Coroner's Officer tie facto judge, in a doubtful case, whether an inquest should be held, and the Society, at my instance, adopted the following resolution on the subject :— * The percentage of uncertified deaths to total deaths in 1893, in the thirty-two large provincial towns, was 2.4 per cent. It was 4.3 in Halifax, 4.5 in West Ham, and 4.9 in Birmingham. 80 ' 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 preliminary enquiry should be made by an expert. The subject of uncertified deaths was considered last Session by a Select Committee of the House of Commons appointed, on March 27th, 1893, "to inquire into the sufficiency of the existing law as to the disposal of the dead, for securing an accurate Record of the Causes of Death in all cases, and especially for detecting them when death may have been due to Poison, Violence, or Criminal Neglect." The recommendations of the Committee were summed up in ten paragraphs, of which it is only necessary to cite the first two, as follows :— (1) " That in no case should a death be registered without production of a cate of the cause of death signed by a registered medical practitioner, or by a Coroner after inquest." (2) "That in each sanitary district a registered medical practitioner should be appointed as public medical certifier of the cause of death in cases in which a certificate from a medical practitioner in attendance is not forthcoming. ' No Parliamentary action has been taken, hitherto, to give effect to the recommendations of the Committee. INQUESTS. Two hundred and ten inquests were held on parishioners 133 in the Town sub-district,41 in Brompton, and 36 at places beyond the Parish, mostly at Public Institutions (hospitals) to which the deceased had been removed for treatment: twenty-five of these cases belong to the Town sub-district, and 11 to Brompton. The subjects of inquest were: males 124 and females 86. The ages at death were : under five years 74, including 51 under one year; between 5 and 60 81 years, 93 : at 60 and upwards, 43. The cause of death is stated to have been ascertained by post-mortem examination in 128 cases. Ten of the subjects of inquisition were illegitimate infants. The Deaths from Violence were 78, of which 24 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 fatal diseases may be classified as follows : Diseases of the brain and nervous system (including convulsions, 5) 24 Diseases of the circulatory and respiratory systems 68 Other visceral diseases 7 Tubercular diseases, including phthisis 8 " Syncope" 2 Debility 9 Zymotic diseases (diarrhoea, 2 ; measles, and whooping-cough, 1 each) 4 Other causes 10 132 The Causes of death may be classified as follows :— Deaths caused by disease – 132 Deaths caused by violence— Accidental 61 Suicidal 16 Homicidal 1 — 78 Total 210 82 The violent deaths were classified as follows : Accident, 61, viz:— By suffocation ; of infants under one year (in bed) 13 By burn, scald 8 By drowning 3 By poison 2 By fractures and contusions 35, viz.— By vehicles 8 By falls under various circumstances 20 By injuries, otherwise 7 Suicide, 16, viz.— By hanging 1 By cut, stab 4 By poison 5 By pistol-shot 3 By drowning 2 Otherwise 1 Homicide (Manslaughter) 1 The Suicidal Deaths (eight of which belong to the Brompton sub district), comprised 9 of males and 7 of females. Among the deaths described as " sudden," and in other cases of persons " found dead," &c., there were, as usual, many that were ascertained to have been caused by curable visceral diseases, so that there must have been culpable neglect of the deceased, in that medical attendance had not been procured, although the illnesses, doubtless, extended over many days, and could scarcely have failed 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, which is the primary object of inquisition, seems scarcely to satisfy the requirements of justice; considering that the death of 83 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, have, on several occasions, been found guilty of manslaughter. The inquests on Kensington parishioners were in the proportion of 7'2 per cent. of total deaths: the rate in the Metropolis was 8.1 per cent.: in England and Wales it was 5.8 per cent.; the relative percentages in the preceding year having been 6.6, 6.8, and 5.7. The reported deaths from different forms of violence were equal to 27 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. These deaths were equivalent to 0.47 per 1000 population in Kensington, 0.80 in the metropolis, and 0 63 in England and Wales. METEOROLOGY. The mean temperature of the air at Greenwich in 1893, was 51.1° Fahrenheit: 2.5 above the average of 122 years, and 1.9 above the average of 52 years. The means in the four quarters respectively were 40.9, 57.0, 61.9, and 44.6. The highest reading by day (95.l) was registered in the week ended August 19th, and the lowest reading by night (13.9) in the week ended January 7th. The mean of the highest weekly readings of the thermometer in the four quarters respectively (49 3, 65 9, 73 6, and 55.0) was recorded in the weeks ended April 1st, June 17th, August 19th, and October 84 21st; and of the lowest readings by night (25.5, 453, 53.8, and 40.3) in the weeks ended January 7th, April 15th, September 23rd, November llth, and December 30th. The hottest week was that which ended August 19th (mean temperature 73 6) and the coldest week that which ended January 7th (mean temperature 25.5). August was the hottest month (mean temperature 65.5). January was the coldest month (mean temperature 35.4). June exhibited the greatest range in temperature, viz., 537; from 91'0 to 37.3; and November the smallest range, viz., 32.6; from 60.0 to 27.4. Rain fell on 154 days, the total amount registered in the year being 20.13 inches, and 4.98 inches less than the average of 78 years. Most rain fell in October (4T6 inches), and least in April (012). The means of the readings of the barometer were 29 815 inches; the means of April 29 990, and of February 29.542, being the highest and lowest, respectively. The relative proportion of wind was, North, 75; East, 83; South, 107 ; and West, 100. VACCINATION. Table X. (Appendix) is a return respecting vaccination in 1892—the return for 1893 is not yet complete—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 8.7 percent. on the total number of births—against 5.4, 5.9, 6.0, 6.5, 6.7, and 8 0, in the preceding six years respectively— "from removal of children to places, out of the Parish, unknown, or which cannot be reached, and cases not having been found." In England and Wales, we were told a few years back, on the authority of the then Medical Officer of the Local Government Board, "that 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; 85 so that the infant population was made up of "19 vaccinated to each unvaccinated individual," The proportion of vaccinated children now is doubtless smaller, and certainly the proportion of unvaccinated persons in this parish, as the above figures testify, is increasing year by year. Summonses were taken out in 29 instances for neglect to have children vaccinated. In 28 of these cases the law was complied with; in the remaining case a fine of twenty shillings and costs was imposed. Of the 3,001 successful vaccinations, 1,710 (about 57 per cent.) were performed at the Public Stations and the Parish Infirmary. The revaccinations at these placeswere 313. 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 ought not to be necessary to say anything; but the pertinacity with which some misguided persons still decry the most beneficent of medical discoveries shows no signs of abatement; and as their teaching is calculated to prejudice the general public against the wise compulsion authorised by law, it was well that the Government resolved, a few years back, to appoint a Royal Commission to inquire and report on the subject. It is a matter for regret that in 1892, at a time when small-pox threatened to assume an epidemic form, the Commissioners should have taken a retrograde step, which is not unlikely to be attended with disastrous results, by encouraging disobedience to the law in respect of vaccination, for in a fifth Interim Report, a recommendation was made which, if carried into effect, would be tantamount to an abrogation of compulsory vaccination. At present, every parent or person having the custody of an unvaccinated child, who, after certain proceedings, disobeys the order of a Justice directing the child to be vaccinated within a certain time, is liable to a penalty not exceeding twenty shillings. And upon proof of continued disobedience, after such order made, the said parent 86 or person may be fined again and again, and even sent to prison in default of payment of the penalty. The Commissioners report, with respect to this state of things, that, in their opinion, "the imposition of repeated penalties in respect of the non-vaccination of the same child should no longer be possible, and should cease to be inflicted altogether." They state that they arrived at this conclusion "quite independently of the question whether vaccination should continue to be compulsorily enforced," and add that, whatever the conclusion they may have to submit on this part of their inquiry, and even if it should ultimately appear that they are not able all to agree in the same conclusion, they have no difficulty in agreeing upon the recommendation that repeated penalties should not be inflicted. In other words, exemption from the operation of compulsory vaccination law (and incidentally the power to spread disease, deformity, and death among the community), should.be purchasable at the cost of one pound sterling—to be paid doubtless by anti-vaccinating societies! The Select Committee of 1871 had dealt with this question, and their recommendation, viz., that there should be no repetition of prosecution after two penalties, or one full penalty, found expression in a clause passed in the House of Commons but which the Lords struck out. It does not follow that the recommendation of the Commission will be carried out, but the effect of such a recommendation having been made has already proved mischievous, not merely or chiefly by giving encouragement to persons already predisposed to disobey the law, but also by inciting Boards of Guardians to give instructions to their Vaccination Officers not to prosecute offenders. Whatever the ultimate decision of Parliament on this question, it must surely be felt that the recommendation of the Commission was ill-timed, and, should small-pox become epidemic, may well prove disastrous. There is only one consolation in view of this contingency, viz., that people who reject the boon 87 of vaccination when they have no fear of small-pox, very commonly hasten to secure its protection when the disease is prevalent. This applies most, perhaps, in the case of the well-informed among the so-called "anti-vaccinators," the brunt of the epidemic usually falling on the poor and ignorant. The opponents of vaccination are wont to cite the experience of one large non-vaccinating town which has succeeded, more or less, during many years, in warding off an epidemic, although local outbreaks, from imported cases, have occurred from time to time, despite the fact that the disease has caused great anxiety for many months past. But even in the case of Leicester, the town referred to, such immunity from small-pox as it has enjoyed, has been largely secured by vaccination. The Sanitary Authority of that town has been diligent, not only in searching out, and isolating in hospital, every case of small-pox (even at the risk, as in 1893, of spreading scarlet fever by refusing admission to hospital of cases of the disease), but also by quarantining and compensating the persons exposed to infection. Moreover, the doctors, the nurses, and the other members of the hospital staff (and even, it is alleged, the members of the Sanitary or Hospital Committee themselves) are protected by vaccination and re-vaccination. It can hardly be doubted, however that a time will come when all the admirable precautions taken at Leicester will prove unavailing, and that its rulers will have cause to regret their disregard of Jenner's beneficent discovery, which, with a minimum of risk, and this avoidable by the use of calf-lymph, has conferred incalculable benefits on every civilized community in the world, and this just in proportion to the efficiency with which the operation is carried out. Lamentable as is the decision of the Commission, it is the more surprising, if it be true, as alleged, that whilst much evidence had been heard on the antivaccinators' side against vaccination-administration, the adminstrators themselves had not been heard when the 88 decision was arrived at. It would seem indeed, that the majority yielded to the minority, and accepted a compromise on the matter which, in the best interests of the community, does not properly admit of compromise. Animal Vaccination: Calf-Lymph.—An objection to "arm-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 the late Medical Officer to the Local Government Board stated, that he "could not 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 is to be desired that the Board should make arrangements for affording to parents the option of having their children vaccinated with calf-lymph at the public vaccination stations. But so far from doing this, the Board actually discourage calf-vaccination and almost penalise its performance. Nevertheless, the Guardians in this Parish have persisted during some years in giving the option referred to, having made arrangements for a supply of fresh calflymph weekly, on the days appointed for vaccination, at the trifling cost of about £12 per annum. Stations, moreover, public and private, have been established in London, at which persons can be vaccinated direct from the calf, and supplies of calf-lymph can be obtained. Direct vaccination is highly successful at the Government stations, an average of 988 vesicles resulting from 1000 insertions of calf-lymph. "This rate of success." it has been observed on the highest authority, "is nowise to be had when the lymph (human or animal) is used in any preserved condition." 89 THE METROPOLITAN ASYLUMS BOARD. The work of the Asylums Board has of late years assumed increased importance to Sanitary Authorities, by reason of the legislation which has conferred power on the Managers to fulfil, for the entire Metropolis, the functions which under the provisions of the Sanitary Act, 1866 (now incorporated in the Public Health Act, 1891) devolved upon the forty-three Vestries and District Boards. The Board are nowthe Central Authority for providing hospital accommodation and an Ambulance Service, by land and water, for the infectious sick; by warrant of law, as they previously had been in fact, for it is well-known that legislation has, during many years, followed in the steps of the Managers' practice in regard to all that concerns the removal of the sick and their admission to hospital. As will be shown later on, the Ambulance arrangements leave nothing to desire; the accommodation, for the sick moreover, was always sufficient until within a comparatively recent date, but the increased and increasing disposition of the public to make use of the hospitals, which dates from the scarlet fever epidemic of 1887, together with the enlarged demands on the resources of the Managers consequent on compulsory notification, have given rise to difficulties to which reference has frequently been made in my reports. The work of the Board is summarised in three reports, issued annually, by the Chairman (Sir E. H. Galsworthy), by the Statistical Committee, and by the Ambulance Committee. As usual, I submit the substance of these interesting and important documents, which, dealing essentially with the same subjects, necessarily overlap more or less. In the subjoined abstract of their contents, I have endeavoured as far as practicable to avoid repetition. 90 The Annual Report of the Chairman.—Sir E. H. Galsworthy commences his report, which is for the official year ended March 25th, 1894, by stating that the fears entertained in the Spring of 1893, that the accommodation in the Fever Hospitals of the Managers would again prove insufficient to meet the usual autumnal increase of scarlet fever, were but too well founded ; so that, for the second time in the history of the Board, the Managers were compelled, for some months, to limit the admission of patients to the vacancies caused by discharges and deaths. The task of coping with this seasonal increase of fever was even more difficult in the period under review than in the preceding twelve months, inasmuch as the accommodation at the Managers' disposal was decreased, during 1893, to the extent of 1,000 beds,* by the demolition of certain temporary buildings, by the reduction in the number of beds at some of the hospitals, under medical advice, and by the inability to make use of the Upper Hospital at Gore Farm, in consequence of its being required for small-pox. Fever Hospital Accommodation.—The decrease above referred to, was to some extent met, but not until towards the end of the year, by the erection of the Fountain (temporary) Hospital at Tooting Graveney, for 400 patients. It has been computed that,had sufficient accommodation existed when scarlet fever was at the maximum, as many as 6,000 patients, or almost double the actual number, would not improbably have been under treatment at one and the same time. It is satisfactory to learn that the scheme propounded by the General Purposes Committee, in January, 1893 (and of which I gave an account in my last annual report), whereby it was proposed to largely increase the Fever Hospital accommodation, is now in a fair way to realisation; and that by the erection of "acute hospitals," on sites already secured, and of one or more convalescent hospitals on a site or sites yet to be acquired. "there will, at no distant date, exist accommodation for about 5,500 beds in the Fever Hospitals of the * There are here and there in the several reports slight discrepancies in figures which are left as found. Thus in regard to the loss of beds referred to in the Chairman's report, the Ambulance Committee more precisely give the exact number as 1,179. 91 Board"—a number which will probably prove inadequate if the above computation is correct, viz.: that 6,000 beds could have been filled with scarlet fever patients alone, in 1893 ; seeing that what is called "Fever Hospital accommodation" includes provision of beds for enteric fever and diphtheria, and for isolation purposes also. Reference is made to the hospital—to be called the Brook Hospital— —for about 500 fever and diphtheria patients, about to be erected at Shooter's Hill, at an estimated cost of some £200,000; and it is stated that architects have been invited to send in competitive plans for the erection of permanent hospitals, affording accommodation for another 1,000 patients (500 in each hospital) on the sites at Tooting Graveney and Hither Green, to be called respectively the Fountain Hospital and the Park Hospital. The Chairman concludes this portion of his report with an account of the alterations and additions in present contemplation at the existing Fever Hospitals, and which will provide considerably increased accommodation at five of these institutions. Smallpox Hospital Accommodation.—Reference is made to the outbreak of small-pox in the early part of the year, which although fortunately it did not attain serious proportions, yet, owing to the "Castalia," being in dock for extensive repairs, necessitated the re-opening, for small-pox patients, of the Gore Farm (Upper) Hospital, which in 1892 had been temporarily appropriated to scarlet fever convalescents. Profiting by past experience, and recognising the necessity of being prepared to deal promptly with any future epidemic, the Managers have, during the twelve months, not only increased the accommodation at their disposal from 1,100 to 1,198 beds, by the erection of additional pavilions at the Gore Farm Hospital, but they have also recently applied to the Local Government Board for their assent to the purchase of 218 acres of land between Long Reach and Dartford, as a site for a new hospital for acute cases of small-pox. The retention of the Hospital Ships in readiness for emergency, and the provision of accommodation for convalescents at Gore Farm, as parts of a system enabling the Managers to convey every case of small-pox out of London, immediately on application for removal, is justified "as an insurance against small-pox," and is defended on grounds of true economy. 92 Diphtheria Hospital Accommodation.—Even more imperative than the want of more accommodation for scarlet fever and smallpox, is "the want of further provision for cases of diphtheria," the lack of accommodation for patients suffering from this disease having been felt more or less during the whole year. The majority of the cases for which beds were required, were ultimately received, but disastrous delays were not infrequent, and delay in the removal of diphtheria patients is "infinitely more serious than in the case of scarlet fever." The Managers intend the provision of additional beds for this disease at the new Fever Hospitals, but the Chairman questions whether the proposed accommodation will prove adequate, having regard to the progressive increase in this disease which the Metropolis continues to experience; the notified cases, which were 5,907 in 1891, and 7,781 in 1892, having increased to 13,026 in 1893. Cholera.—On the subject' of Cholera the Chairman states that the Cholera Committee of the Board, "recognizing, as they were bound to do, the possibility of the appearance of the disease in London in an epidemic form, did not hesitate to exercise the powers previously conferred upon them by the Local Government Board," by perfecting their arrangements for hospital accommodation and transport of the sick, upon the same lines as in preceding years. An account of these arrangements is given in a report by the physician whose services, as "Cholera Superintendent," were retained by the Managers. Ambulance Department.—The work accomplished by the Ambulance Committee is summarised by the Chairman, who refers to the difficulties experienced at the Chief Offices of the Board, in the selection of cases for removal, during the time admission to the hospitals had to be limited, day by day, to the vacancies occurring by discharges and deaths. It is proposed to establish a new ambulance station at Hampstead, near the North-Western Hospital, and provision, it is stated, will have to be made for one or more additional ambulance stations, in the district south of the Thames, concurrently with the establishment of the Brook, the Park, and the Fountain permanent hospitals. 93 Statistics, etc.—The Chairman summarises the admissions to the several hospitals, showing that 20,318 cases of infectious disease were admitted during 1893, and that the deaths numbered 2,057. The notifications of infectious diseases in London during the same period, were 67,485, made up of 56,425 cases of diseases admissible to the Board's Hospitals, and of 11,060 cases of diseases not admissible. The cases admitted, equal to 36 per cent. of the notifications, would have been far more numerous had the Managers been in a position to receive all applicants seeing that during the first four months of the year, when all applicants, were admitted, 55 per cent. of the cases notified were received into the Board's Hospitals. Statistical and other information is given with respect to Hospitals for Imbeciles,* and matters generally pertaining to the Managers' duties in connection with lunatics. The work done by the Board in connection with the Training Ship, "Exmouth,"* also comes in for notice, and a return is given of the various Institutions and Establishments under the Board's control, with financial, statistical, and general information in regard thereto. Financial.—A statement is given of receipts and expenditure for the twelve months ended on the 30th September, 1893. The liabilities on loans at that date amounted to £1,003,190 15s. 4d., showing an increase of £49,651 13s. 4d. during the year. The net expenditure under all heads during the same period (£644,044 10s. 10d.) exceeded that of the preceding year by £94,202 3s. 11d. The amount expended by the Board in provision of permanent and temporary Fever Hospitals, at present furnishing 3,454 beds, appears to have been about £757,000. The amount expended in providing * It would be beyond the scope of this report to enter into details with respect to these Institutions, but it may be stated that the three Asylnms, at Leavesden, Caterham, and Darenth, provide accommodation for 5.097 imbeciles of both sexes, provision, moreover, being made, at Darenth, of Schools for 1,000 imbecile children. The total expenditure on "Capital" Account to Michaelmas, 1883, on these establishments, was £740,503 19s. 5d. The Training Ship, "Exmouth," which has furnished many recruits to Her Majesty's service, provides accommodation for 600 boys; the expenditure on "Capital" Account to the same date being £27,922 18s. 8d, 94 1,498 beds for small-pox patients has been, in round figures, £184,000.* The total sum expended in carrying on this department of the Board's work, during the year under review, was £285,653 1s. 1d., viz.: Maintenance Account £52,093 11s. 3d., and Common Charges Account £233,559 9s. 10d. Referring to the excess of expenditure last year, the Chairman observes that it cannot "be a matter for surprise if regard be had to the fact that the Board .... now receives one out of every two cases of fever, and almost every case of small-pox, which occurs in the metropolis; that year by year the Managers are admitting into their hospitals a greater percentage of the total number of infectious cases (notified) .... and that as the population of the Metropolis is increasing in density, it becomes more and more necessary, in the interests of the population as a whole, to make proper and sufficient provision for the prompt isolation of those of its inhabitants who may be stricken with infectious disorders." Some consolation is offered in the forecast that it is "most improbable" that the expenditure of the Board will continue to increase in anything like the ratio that it has done during the last few years, "for it is only reasonable to infer that," when sufficient accommodation shall have been provided " the prompt removal and isolation of cases (of fever and diphtheria) as they occur, should— unless the value of isolation be greatly exaggerated,—be followed by a very appreciable reduction in the number of cases." I subjoin a summary of Statistics, condensed from Tables appended to the Chairman's report, which may give some idea of the magnitude of the work carried on by the Managers under the provisions of the Metropolitan Poor Act, 1867, the scope of which, as regards the provision of accommodation for the reception and treatment of persons suffering from infectious diseases, has been largely extended by subsequent legislation, and notably by the Public Health (London) Act, 1891. * The cost of the three permanent Ambulance Stations which have been erected on parts of the several hospital sites at Homerton, Fulham, and Deptford, was close on £40,000. The expenditure in respect of the purchase of the sites, and the construction thereon of piers and other buildings, of the three wharves at Blackwall, Rotherhilhe, and Wandsworth, was about ,£42,500. 95 METROPOLITAN ASYLUMS BOARD STATISTICS. The Accommodation provided by the Managers at their several Institutions, on 25th March, 1894, was as follows :— For Imbeciles, at three Asylums, and at Darenth Schools 6,097 For Fever and Diphtheria patients, at eight hospitals 3,454 For Small-pox patients, at the Hospital Ships and Gore Farm 1,498 For boys on the training ship "Exmouch" 600 Grand Total 11,649 The Expenditure of the Board for the year ended September 30th, 1893, was £644,014 10s. 10d., made up as follows:— On the three Imbecile Asylums and the Schools ('•maintenance," and "common charges," accounts) £145,301 18 6 On Small-pox and Fever Hospitals 285,653 1 1 On Notification of Disease 5,277 16 6 On the Ambulance Stations, Land Service 17,868 12 7 On River Ambulance Service 7,492 9 3 On Cholera, Precautionary Measures 250 0 0 On Telephones 790 9 5 On Training Ships for Boys 20.295 12 11 On Chief Offices 15,781 3 8 On Legal Expenses 613 10 9 On Loans, Instalment repayments 45,643 6 8 On Loans, Interest 37,155 12 10 On Superannuation Allowances 1,012 4 9 533,138 18 11 Balances against Parishes and Unions at the commencement of the year 60,905 11 11 Total Expenditure £644,044 10 10 The "Maintenance Account" totals up 121,649 18 6 The "Common Charges Account" totals up 461,489 0 5 £583,138 18 11 The Daily Average of Patients, &c., in the several Institutions in the year ended September 30th, 1893, was 9,964 The total number of days' maintenance was 3,627,004 The daily average cost of maintenance per head, was 10 28/64d. 96 Annual Report of the Statistical Committee.— In the year 1888 the Asylums Board constituted a new Committee, designated statistical, to which the Annual Reports of the Medical Superintendents of the several hospitals, etc., are referred, these reports being now published in a separate volume instead of being scattered here and there in the minutes of the proceedings of the Managers as formerly. The report of the Committee itself is one of much interest and considerable utility. A series of maps of London accompanying the report, show, in a very concentrated form, most of the thoroughfares, and the outlines of the Sanitary Districts, and also indicate by " spots" the localities in which cases of infectious diseases occurred during the year. By charts and tables, many matters are clearly set out, and altogether very complete information is now collated and placed permanently on record in the very considerable volume now issued annually. The annual report of the Ambulance Committee is included in this volume, thus constituting it a complete statement of the work done in the various departments, in discharge of the multifarious duties which, by successive Acts of the Legislature, have been devolved upon the Board. With this introduction i pass on to give a brief abstract of some of the principal matters ably treated in the Committee's report. The Committee commence their report by stating that they have "again to record a considerable increase in the number of fever and small-pox patients admitted to the Managers' Hospitals." In the seven years 1887-93, "the total annual admissions (of small-pox and fever cases) have been 6,596, 5,219, 5,777, 8,361, 7,873, 16,624, and 21,129 respectively." "Whether the very high figures of the past two years were entirely due to the effects of compulsory notification, and the increased popularity of the Managers' Hospitals, or whether there was not a somewhat greater prevalence of scarlet fever, diphtheria, and small-pox amongst an increased population." the Committee say they " have not, owing to the comparatively recent establishment of 97 compulsory notification in London, sufficient evidence to prove." But from whatever cause or causes the increased demands on the Managers' Hospitals may have arisen, the Committee "cannot but regret that the insufficiency of the accommodation provided should have been such as to compel the Managers at so early a period of the year as the 13th May, to warn the various local sanitary authorities that the accommodation at the Managers' disposal would shortly be exhausted, and that those authorities would be called upon to make provision for their own infectious sick. In a few weeks the Managers' worst anticipations were realized, and from about the middle of June to near the end of the year, the removal of large numbers of patients was deferred from day to day/' and many urgent cases were not removed at all. " To this pass the Managers had been brought, not through any failure to recognise sufficiently early the immensely increased responsibilities cast upon them, by the sudden removal, by the legislature, of all restrictions on the admission of patients to their hospitals, but by the almost insuperable difficulties encountered by the Managers in obtaining proper sites for the erection of additional hospitals." The Committee deal fully with the "difficulties of providing additional hospital accommodation," recount the steps the Managers have taken, since October, 1890, to procure sites, and furnish particulars with respect to the North-Eastern (temporary) Hospital, for 500 patients, erected at Tottenham, at a cost of £54,500, and of the Fountain (temporary; Hospital, for 400 patients, at Tooting Graveney, erected at a cost of £117,000. Permanent hospitals, it is stated, are to be erected adjoining this latter hospital, and also at Hither Green, Lewisham, and at Shooter's Hill. The Committee lament the loss of the Grangewood Estate at Norwood, to the acquisition of which the Local Government Board refused their sanction. This loss, they say, " involves serious consequences," as the South side of London presents special features which render it apparently impossible to find another site in anything like so convenient a position." Reference is made to the additional difficulties the Managers have had to contend with, owing to the increase in small-pox, which compelled them to close the Upper Hospital, at Gore Farm, Darenth, against the reception of scarlet fever convalescents, on the 6th March. On the 12th March, small-pox g 98 patients were admitted to this hospital. On the 28th June, scarlet fever convalescents were admitted to the Lower Hospital. It is mentioned as an " interesting contribution to the controversy as to the aerial convection of small-pox," that " no single instance occurred of infection being transferred from one hospital to the other." On the subject of hospital reconstruction, attention is called to the temporary character of the hospitals at Hampstead, Fulham, and Deptford, which, hastily constructed of wood and iron to meet emergencies, "have given indications that they will not for long remain in a condition fit for the reception of patients, notwithstanding extensive repairs," and will have to be replaced by brick structures. Diphtheria Accommodation.—Since October, 1888, the Managers have admitted diphtheria patients to their hospitals, and the annual admissions, during the last five years, 1889-93, were 722, 949, 1,312, 2,009, and 2,848, respectively. In 1893, many patients whose removal was desired, had to be denied admission for want of accommodation. At the end of the year the beds set apart for this disease numbered 252, only, distributed as follows:—Eastern Hospital, 48 beds; North-Western Hospital, 88 beds; Western Hospital, 36 beds; South-Western Hospital, 52 beds, and South-Eastern Hospital, 28 beds. It is proposed to extend considerably the present insufficient accommodation for this disease. Cases of Mistaken Diagnosis.—In 1893 some 732 patients, or a percentage of 3 9 on the total numbers, were, after admission at the fever hospitals, found to be not suffering from the diseases mentioned in the medical certificates upon which they were removed to hospitals. At the Eastern Hospital as many as 208 such cases, or 7.2 per cent., were received. Eighty-one of the patients admitted to the Hospital Ships, or 33 per cent., were not suffering from small-pox. Staff Illness.—Of 2,484 persons employed at the several hospitals, 130 (or 5.2 per cent.) fell ill with fever, diphtheria, or measles, presumably having contracted disease in the performance of their duties: two of them died. On the Ships, of 307 persons employed, six (or 1.9 per cent.) contracted small-pox, and all recovered. 99 Notification Statistics.—The notifications of scheduled diseases in 1893, as already stated, were 67,485. The Committee give diagrams to show the cases of scarlet fever, enteric fever, diphtheria, and small-pox, which were notified during each week of the four years that compulsory notification has been in operation in London. Fever Statistics.—The year began with 3,548 fever, diphtheria, and other patients in the hospitals. The number under treatment declined until the minimum, 2,199, was reached on the 24th March. After that date the number gradually rose, until it attained 3,224 on the 19th July, remaining at about that figure until the opening, on the 30th October, of the new Fountain Hospital at Tooting, and, subsequently, of certain day rooms at the Northern Hospital, when the number under treatment rose rapidly, until the maximum for the year (3,558) was reached on the 5th December. Of this number, 354 were under treatment at the Western Hospital. The total number of patients under treatment during the year was 22,222, as compared with 18,120 in 1892; an increase therefore of 4,102. The total admissions were 18,674, as compared with 16,276 in 1892 (increase 2,398); 7,809 in 1891; 8,334 in 1890; 5,772 in 1889; 5,152 in 1888 ; and 6,537 in 1887. Up to the latter year, the largest number admitted in any one year had been 2,867, in 1882. The total discharges were 16,975, and the deaths were 1,982, or a total mortality of 10.53 per cent., as compared with 10.55 in 1892. The monthly admissions of all cases were lowest in February and highest in November. A diagram given, shows the monthly admissions of each kind of fever, from the date of opening of the first of the Managers' hospitals in 1872, to the end of 1893, which, by curves relating to scarlet and enteric fevers, clearly indicates the seasonal prevalence of these diseases. The admissions of scarlet fever cases in 1893, were 14,548: males 7,047 and females 7,501—excess of females 454. The mortality, calculated on the admissions, was 6 2 per cent., and equal amongst each sex. The disease is most fatal to children under five, and notably to infants in the first and second years of life. Diphtheria, like scarlet fever, is most fatal to young children ; the maximum mortality (69.9 per cent.) occurs in the first year of life, subsequently falling, with every additional year of life, to the minimum of 36 per cent. amongst persons between 30 and 35 years of age. 100 Enteric Fever is comparatively rare under five years of age: the lowest death-rate is among patients between 5 and 10 years of age; it then increases, with each quinquennium, until it attains a percentage of 27.8, amongst patients between 35 and -10 years of age, and of 29.2, amongst the patients of ages from 40 to 60 and upwards. But the cases admitted of ages above 40 are comparatively tew. By far the largest proportion of the patients are between 5 and 25. Thus of 8,689 patients admitted into the hospitals in the years 1871 to 1893, 1,143 were between 5 and 10 years of age; 2,019 were between 10 and 15; 1,955 were between 15 and 20; and 1,319 were between 20 and 25. The combined mortality at all ages amongst these 8,689 cases, was 17.4 per cent. The male sex is more liable to attack by this disease, but its fatality is greater amongst females, by T3 per cent. Between the ages of 10 and 20, the death-rate is much greater amongst females ; but the case is reversed in all later age-periods Small-pox Statistics.—On January 1st, there were 39 patients remaining under treatment: 91 cases were admitted during this month; 145 in February, 244 in March, 434 in April, and 507 in May. As is usual, the disease then began to be less prevalent, and the admissions declined, from 307 in June, to 209 in July, 93 in August, 71 in September, 72 in October, 122 in November, and 81 in December, making 2,376 during the year. Of the total admissions (2,453, including 77 not suffering from small-pox) 2,441 were admitted at the Hospital Ships, and, of these, 1,552 were subsequently transferred to the Gore Farm Convalescent Hospital. The deaths numbered 189, and all but 6 of them occurred at the ships. Vaccination Statistics are given which show that primary vaccination cicatrices were present in 1,624 of the patients, of whom 42 (about 2 6 per cent.) died. In 252 cases there was "no evidence" as to cicatrices : some of the cases were said to have been vaccinated; in others no statement was made, but the nature of the eruption prevented observation of the marks, if any existed. Of these 252 cases 41 (=17.4 per cent.) died. In 500 patients vaccination cicatrices were absent, and of these 94 (=18.8 per cent.) died. 101 The Committee, in concluding their own report, state that since the opening of the first Institution (the temporary hospital for relapsing fever at Hampstead) in 1870, there have been under the care of the Managers, 97,961 persons, "admitted direct, from homes or parishes and unions," to the Fever Hospitals, of whom 3,270 remained in the various hospitals on the 31st December, 1893. The patients admitted to the Small-pox Hospitals numbered 60,874, of whom 84 remained under treatment at the same date. Grand Total, 158,835. Part II., appended to the Committee's report, comprises the "Reports of the Medical Superintendents of the several Infectious Fever Hospitals for the year 1893." Part III. deals with small-pox, including the report of the Medical Superintendent of the Hospital Ships, and an appendix on va'ccination statistics; a report on the River Ambulance Service by the Medical Officer in charge thereof, together with a history of the small-pox epidemic of 1893, by the same gentleman. The several reports contain a mine of statistical information, which it is impossible to summarise Part V. is the Annual Report of the Ambulance Committee. Part VI. describes the Board's arrangements, made in view of a possible epidemic of cholera, under the direction of a medical adviser appointed for the purpose. Tables appended to the Committee's report show the annual admisssions and deaths of patients at the Managers' hospitals, with the mortality per cent., since the establishment of the first hospital in 1870, together with extracts from the Registrar-General's Annual Summaries showing the annual mortality per 1,000 persons living of the population, from scarlet, typhus, and enteric fevers, and small-pox; and the annual average mortality from scarlet and enteric fevers for certain specified years before and since the establishment of the hospitals. Comparing the mortality from scarlet fever during the 13 years preceding the establishment of the hospitals, with the mortality during the past 13 years, the latter shows a decline of 70 per cent. ; whilst the mortality rates of enteric fever for the three years 1891 to 1893 inclusive, show a decline of 57 per cent., compared with the three years preceding the opening of the hospitals. " The decreasing percentage of the mortality amongst scarlet fever patients treated in the hospitals," it is said, "continues to be a noticeable feature in the fever table." 102 Admissions to Hospitals.—The subjoined Tables show the magnitude and the growth of the work of the Board. The contrast between the large numbers of cases of small-pox dealt with by the Managers in bygone years and the small number admitted to the hospitals in the last seven years is striking. The increase in scarlet fever and other cases admitted to the "fever" hospitals since 1889, compared with previous year, is not less striking. The decrease in small-pox admissions is due to London's immunity from epidemic prevalence of the disease, the increase in the other diseases being largely the result of notification. Table Showing the Admissions and Deaths of Patients and Mortality per cent. at the Managers' SMALLPOX HOSPITALS during each year since the opening of the first Hospital on the 1st December, 1870, together with the Annual Mortality per 1,000 persons living of the Population of the Metropolis from Smallpox; extracted from the Registrar-General's Annual Summaries. YEAR. ADMISSIONS. DEATHS. Mortality per cent. of Patients treated in Managers' Hospitals. Annual Mortality per 1,000 of estimated Population. Smallpox. Other Disease. Total. Smallpox. Other Disease. Total. Smallpox, Smallpox. 1st Dec., 1870, to 3rd Feb., 1871 582 ... 582 97 ... 97 20.81 ... 1871-2 (4th Feb., 1871, to 31st Jan., 1872) 13,139 6 13,145 2,460 ... 2,460 18.95 2.42 1872-3 (year ended 31st Jan., 1873) 2,359 3 2,362 467 1 468 17.84 0.54 1873-4 (year ended 31st Jan., 1874) 174 17 191 35 ... 35 17.02 0.03 1874 (11 months ended 31st Dec.) 112 8 120 10 ... 10 0.02 1875 89 22 111 22 ... 22 0.01 1876 2,134 16 2,150 372 1 373 21.64 0.21 1877 6,516 104 6,620 1,214 4 1,218 17.92 0.71 1878 4,558 1,628 96 4,654 824 9 833 17.99 0.39 1879 60 1,688 273 5 278 15.69 0.12 1880 1,982 50 2,032 8,671 286 2 288 15.95 0.12 1881 8,551 120 1,417 14 1,431 16.61 0.62 1882 1,799 55 1,854 260 3 263 12.96 0.11 1883 598 28 626 93 ... 93 16.06 0.03 1884 6,363 204 6,567 940 3 943 15.98 0.31 1885 6,146 198 6,344 1,052 3 1,055 15.8 0.35 1886 99 33 132 22 2 24 14.28 0.01 1887 56 3 59 3 ... 3 0.00 1888 62 5 67 8 ... 8 0.00 1889 5 ... 5 ... ... ... ... 1890 22 5 27 3 ... 3 o.oo 1891 63 1 64 8 ... 8 o.oo 1892 325 23 348 35 ... 35 11.29 0.01 1893 2,376 118 2,494 180 ... 180 7.57 0.05 Totals 59,738 1,175 60,913 10,081 47 10,128 ... Average annual mortality per 1,000 of estimated population of London during the 22 years (1849 to 1870 inclusive) before the opening of the Managers' Hospitals, extracted from the Registrar-General's Returns 0.27 Avenge annual mortality per 1,000 of estimated population of London during the past 22 years (1872 to 1893 inclusive), extracted from Registrar-General's Returns 0.16 Increase Decrease 0.11 103 Table Showing the Admissions and Deaths of Patients and Mortality per cent, at the FEVER HOSPITALS of the Metropolitan Asylums Board during each Year since 1870, together with the Annual Mortality per 1,000 persons living of the Population of the Metropolis from Scarlet, Typhus, and Enteric Fevers and Diphtheria, extracted from the Registrar-General's Annual Summaries. YEAR. ADMISSIONS. DEATHS. Mortality per cent. of Patients treated in the Managers' Hospitals. Annual Mortality per 1,000 of estimated Population. Scarlet. Diphtheria Typhus. Enteric. Other Diseases. Total. Scarlet. Diphtheria Typhus. Enteric. Other Diseases. Total. Relapsing Fever. Diphtheria Typhus. Enteric. Scarlet. Diphtheria Typhus. Enteric. 1870 (25th Jan. to 15th May) ... ... ... ... 218 218 ... ... ... ... 14 14 12.84 ... ... ... 1.88 0.10 0.15 0.30 (Relapsing Fever.) 1871 ... ... ... ... ... ... ... ... ... ... ... ... Scarlet ... ... ... 0.58 0.11 0.12 0.27 1872 (15 months to 31st Dec., 1872 108 ... 134 279 343 864 11 ... 30 57 70 168 10.78 ... 23.62 21.96 0.28 0.08 0.05 0.24 1873 92 ... 401 381 271 1,145 6 ... 91 56 58 211 6.55 ... 23.15 15.13 0.19 0.09 0.08 0.27 1874 804 ... 536 435 359 2,134 89 ... 106 63 84 342 12.15 ... 19.62 14.87 0.77 0.12 0.09 0.26 1875 1,182 ... 65 299 269 1,815 160 ... 16 78 54 308 13.69 ... 23.35 24.68 1.06 0.17 0.04 0.23 1876 671 ... 139 288 294 1,392 90 ... 28 59 71 248 12.13 ... 19.31 20.34 0.65 0.11 0.04 0.22 1877 479 ... 170 372 186 1,207 54 ... 36 79 33 202 12.1 ... 23.07 22.93 0.44 0.09 0.04 0.25 1878 679 ... 168 484 233 1,564 91 ... 47 100 40 278 14.34 ... 26.25 20.26 0.49 0.15 0.04 0.28 1879 1,469 ... 48 385 196 2,098 211 ... 11 74 39 335 15.27 ... 21.56 19.73 0.72 0.15 0.02 0.23 1880 1,949 ... 28 248 239 2,464 242 ... 6 43 37 328 12.3 ... 20.68 15.63 0.82 0.14 0.02 0.19 1881 1,477 ... 219 415 211 2,322 168 ... 34 86 46 334 11.1 ... 16.95 21.47 0.55 0.17 0.02 0.25 1882 1,850 ... 148 515 354 2,867 189 ... 27 104 60 380 10.37 ... 16.92 20.71 0.52 0.22 0.01 0.25 1883 1,920 ... 45 486 269 2,720 234 ... 11 74 66 385 12.38 ... 21.15 15.64 0.51 0.24 0.01 0.25 1884 1,845 ... 29 493 180 2,547 234 ... 5 98 55 392 12.27 ... 20.00 18 82 0.36 0.24 0.01 0.23 1885 1,353 ... 53 220 229 1,855 130 ... 7 36 46 219 9.47 ... 1217 15.82 0.18 0.23 0.01 0.15 1886 1,780 ... 10 333 74 2,197 151 ... 4 47 22 224 9 04 ... 42.10 14.85 0.17 0.21 0.00 0.15 1887 5,900 ... 35 441 161 6,537 489 ... 4 61 59 613 9.54 ... 11.59 14.59 0.36 0.23 0.00 0.15 1888 4,408 99 1 450 194 5,152 501 46 ... 72 60 679 9.89 59.35 ... 14.64 0.30 0.32 0.00 0.17 1889 4,518 722 23 290 219 5,772 366 275 6 41 48 736 8.85 40.74 31.57 15.15 019 0.39 0.00 0.13 1890 6,537 942 16 498 341 8,334 510 316 5 93 81 1,005 7.86 33.55 25.66 19.68 0.21 0.33 0.00 0.15 1891 5,262 1,312 18 755 462 7,809 357 397 1 106 102 963 6.67 30.63 5.88 14.52 0.14 0.32 0.00 0.13 1892 13,093 2,009 19 430 725 16,276 839 583 2 65 140 1,629 7.28 29.35 9.76 13.20 0.27 0.44 0.00 0.10 1893 14,548 2,848 2 544 732 18,674 901 865 1 110 105 1,982 6.11 30.42 50.00 20.54 0 37 0.76 0.00 0.16 Totals 71,924 7,932 i 2,307 9,041 6,759 97,963 6,023 2,482 478 1,602 1,390 11,975 ... ... ... ... Average Annual Mortality per 1,000 of estimated population of London before the opening of the Managers' Hospitals, extracted from the Registrar-General's Returns Scarlet Fever (only obtainable for 13 years), 1859 to 1871, both inclusive 1.07 ... ... ... Enteric Fever ditto ditto ditto ditto ... ... ... 0.30 Average Annual Mortality per 1,000 of estimated population of London from Scarlet Fever during the past 13 years, and from Enteric Fever during the past 3 years, extracted from the Registrar-General's Returns 0.32 ... ... 0.13 Increase ... ... ... ... Decrease 0.75 ... ... 0.17 Note.—1. From the 1st December, 1870, to the end of September, 1871, Small pox cases only were admitted to the Board's Hospitals. 2 The deaths of Fever patients include all cases dying within 48 hours after admission, and also those deaths due to intercurrent maladies. 3. Diphtheria cases have only been admitted into the Managers' Hospitals since the 23rd October, 1888. 4. The Mortality rates of patients in the Managers' Hospitals are calculated according to the Registrar General's formula. 104 METROPOLITAN AMBULANCE SERVICE. Before submitting an abstract of the annual report of the Ambulance Committee, it may be mentioned that Section 16 of the Poor Law Act, 1879, the provisions of which are now incorporated in the Public Health (London) Act, 1891, conferred on the Metropolitan Asylums Board one of its most valuable powers, that namely, of providing ambulances for the conveyance of the infectious sick to the hospitals of the Managers. Previously to 1879 the Boards of Guardians had removed the sick, under conditions occasionally prejudicial to the public health. The work of removal—whether by land or water—is now effected in an unexceptionable manner. In a former report, I had to observe that this remark was applicable only in the case of patients in course of transit to or from the Managers' hospitals. It was often quite otherwise in respect of private patients, who were but too frequently removed in public vehicles, cabs, &c. The law did not forbid the use of a public vehicle for this purpose, provided that the vehicle was afterwards disinfected. But the driver of a cab was often unaware of the nature 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 public vehicles should never be used for this purpose, and that it would be to the public advantage, were the Asylums Board made the Ambulance Authority for the 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 infectious sick persons. The Managers replied that they were, at that time, " 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 105 Annual Report for 1884, I ventured to express a conviction that the Managers would, in course of time, recognise the desirableness of giving effect to my views. That time arrived in 1888, when the Managers 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." Having communicated their altered views to the Local Government Board, the President of that Board obtained from Parliament the desired powers, in a section of the Poor Law Act, 1889, which, as already mentioned, is now incorporated in the Public Health (London) Act, 1891. This Act (section 70) expressly prohibits the conveyance of any infected person in a public conveyance. It may not be out of place here to remark that the present Ambulance system was first suggested by Dr. James Stevenson, who has recently resigned the appointment of Medical Officer of Health to the Vestry of Paddington. In an able report, dated June, 1877, Dr. Stevenson described the "existing arrangements" in respect of the vehicles in use; and the mode of horsing, housing, and disinfecting them, and of the procedure adopted with reference to the removal of patients above the pauper class. He showed that the said arrangements were improvident, insanitary, and inconvenient. The objections to the then state of affairs having been set out, the policy of establishing an Ambulance Service under the charge of the Hospital Authorities was advocated. Dr. Stevenson's recommendations were:— (1) That neither the Local Authorities nor Boards of Guardians should any longer be expected to provide conveyances for the removal of the infectious sick. 106 (2) That the Managers of Hospitals for the reception of the infectious sick should supply the conveyances, with horses and drivers, necessary for the removal of patients to such hospitals. (3) That a trained nurse should be sent with the carriage every time it is used, to superintend and assist the friends in the removal of patients. (4) That such nurse should be responsible for the charge of the patients whilst under her care, and should ride inside or outside the vehicle as circumstances and the condition of such patients may require. (5) That the carriage itself should be of the most approved construction. The report concluded with an expression of opinion that "economy, uniformity, efficiency, and sanitary requirements will be promoted by the adoption of (the above) recommendations," which, I may add, did not find immediate acceptance. But in 1882 the Asylums Board were converted to Dr. Stevenson's views, the carrying out of which has been attended with great benefit to the people of this Metropolis. Land Service: Ambulance Stations.—The recommendation of the Royal Commission on Infectious Hospitals, in 1882, 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 (the Eastern at Homerton, the South-eastern at Deptford, and the Western at Fulham), under the provisions of the now repealed 16th Section of the Poor Law Act, 1879. It will be seen that the Ambulance Committee recognize the necessity of providing still more stations in connection with the new permanent hospitals shortly to be erected. A small temporary station has been 107 established at the Fountain (temporary) Hospital, Tooting, and it is intended to provide a fourth permanent station at Hampstead in the North-Western District. 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 House, Norfolk Street, Strand, w.C., 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. River Service.—The Managers possess three Ambulance Steamers, Red Cross, Maltese Cross, and Albert Victor, and a steam pinnace, Swallow. A fourth Ambulance Steamer is in course of building, at a cost of nearly .£10,000. This fleet will, I doubt not, be equal to all demands of smallpox should the disease become epidemic again. The patients embark at wharves which the Managers were authorised to provide, by Section 6 of the now repealed Diseases Prevention (Metropolis) Act, 1883, the provisions of which are incorporated in the Public Health (London) Act, 1891. These Wharves are three in number, respectively named North, South, and West. The North-Wharf is at Blackwall, the south-wharf at Rotherhithe, the West-Wharf near Wandsworth Bridge. Here, in the event of a wide-spread epidemic of small-pox, Kensington patients, and patients from other parishes, etc., in the West District, would embark for the voyage to the Hospital Ships. Hitherto, however, this long-completed Wharf has never been brought into use. Annual Report of the Ambulance Committee.—The Committee deal with a variety of matters of general interest in their annual report, in addition to those subjects which usually find a * Telegraphic Address—" Asylums Board, London." Telephone number, 2587. 108 place in their review of the work of the year. Thus they refer, first, to the insufficiency of Fever Hospital Accommodation, stating that "owing to a deficiency of beds (especially for scarlet fever cases) which lasted for several months, the removal of a large number of patients was deferred, from day to day, for so many days that, ultimately, many remained at home until the termination of their illness "—with, I may add, the result of extending the spread of the disease. The Committee further observe that it is" certain that when this state of things became known, in many cases it was considered futile to make any applications at all," and they state that "had sufficient accommodation existed, it is estimated that as many as 6 000 scarlet fever cases would have been under treatment at one time—a number nearly double that which was actually attained." They also say that " the introduction of compulsory notification, and the growing popularity of the Board's hospitals, have increased the demands for admissions to such an extent, that whereas in 1890 the Managers admitted 42 per cent, of the total cases notified in London, in 1892 the percentage had risen to 48, and in the first four months of 1893—when the Managers were able to admit all applicants—to 54 per cent." The notifications of scarlet fever cases in 1893, numbered 36,901, the admission to hospitals being 14,548, or, in round figures, 40 per cent.; but, as already stated, large numbers of patients were refused admission owing to want of room. After referring to the difficulties of obtaining sites for hospitals, the Committee state what has been done to increase accommodation, to the extent of 900 beds, viz., by the establishment of a hospital at Tottenham for about 500 beds, in 1892 ; and of one, at Tooting Graveney, for about 400 beds, in 1893 ; the Board, moreover, at the end of the year, being in possession of vacant land at Tooting, Lewisham, and Shooter's Hill, on which hospitals for about 1,500 patients can be provided. "When hospitals shall have been erected on the sites already purchased, and on the land which must be obtained for one or more Convalescent Hospitals for the Southern Districts," the Committee hope "that sufficient accommodation may exist for all ordinary requirements of the metropolis." For "ordinary requirements" the proposed accommodation will probably suffice; but surely the Managers should recognise the duty of providing for the probable 109 maximum requirements, seeing that the need for hospitals is always most pronounced when infectious disease is epidemic, the liability of any such disease to spread being then greatest. The Committee advert to the reduction of accommodation in existing hospitals, during 1893, as compared with that provided in 1892, which had created some surprise. The accommodation in 1893 was for 3,468 patients only, a decrease therefore of 1,179 beds as compared with the number in 1892; due, as the Committee state in respect of fever hospitals, to the demolition of certain wooden huts; demolition of wards to make way for new administrative buildings, and the reduction of the number of beds in the permanent wards under medical advice. A decrease of 636 beds at Gore Farm (included in the total decrease) arose from the relegation of the Upper Hospital there to its proper use for small-pox cases. "The opening of the Fountain Hospital has reduced the nett loss of beds to 773, and this figure will shortly be further reduced, by the provision of additional beds at the Eastern, the South-Western and the Western Hospitals." The Committee explain the system of selecting patients for admission to the hospitals, necessitated by the insufficiency of accommodation, efforts having been made to secure admission of the most urgent cases. It was the practice, when no bed could be obtained, to require the application "to be renewed from day to day, with a statement of the circumstances appearing to render the case one of urgency, and then each day a selection was made, by the officers employed in the Ambulance Department, of those cases which appeared to be most in need of hospital treatment and isolation." In respect of our own cases, I may mention that the work of removal was much facilitated by the use of the telephone, which led, moreover, to the removal of many cases that would have been left at home, had we been dependent on less rapid means of communication with the offices of the Board. The removal of many of our cases, prior to 1893, had been furthered by the use of the notification certificate, as the "medical certificate" without which the Managers will not remove any patient. In 1893, the Committee, "with a view of facilitating prompt removal, and of avoiding delay in the preliminaries," influenced, moreover, by representations made on behalf 110 of certain Sanitary Authorities (less fortunate than your Vestry) gave "instructions to the Ambulance Nurses to accept, as a medical certificate, a copy of the notification certificate, bearing the official stamp of the Medical Officer of Health, or of the Sanitary Authority, or in some other way showing, on the face of it, evidence that it had been issued by the Sanitary Authority." The Committee observe that the increased work of the Ambulance Service would necessitate the provision of Ambulance Stations, additional to the three already existing, "even with no addition to the number of the Managers' present hospitals. But in view of the establishment of at least three additional hospitals, for acute cases, and of a fourth for convalescing cases," the Committee "think that the time has arrived when it becomes their duty to prepare, and submit to the Board, proposals for the establishment of more Ambulance Stations, in contiguity to some of the new hospitals." Meanwhile, "a temporary shelter for a few ambulances and horses, has been erected adjoining the new Fountain Hospital at Tooting, and this has greatly relieved the work of the South-Eastern Station. The Committee refer to the appointment of a Medical Officer for the River Service, rendered necessary by the outbreak of small-pox which commenced at the end of 1892. All patients are now inspected at the Wharves before embarcation. Persons found to be not suffering from small-pox are sent home again (after being vaccinated) and " Shelters" have been provided, at the South Wharf, for the isolation of doubtful cases pending the clearing up of the diagnosis. The Committee did, and are doing, good service by disseminating among Medical Officers of Health, and others, information bearing on the spread of small-pox, in the form of histories of individual cases, obtained by the Medical Officer, at the South Wharf, in charge of the River Service. Land Service.—The total number of fever patients removed to the Managers' Hospitals in 1893, was 18,496, as compared with 16,118 in 1892; 7,725 in 1891; and 8,235 in 1890. The removals of small pox patients numbered 2,389, as compared with 306 in 1892; 64 in 1891; and 26 in 1890. "The average daily removals of fever 1ll patients in the first six months of the year were 43, and in the last six months 55, as compared with 28.3, and 59.5, respectively, in 1892." The aggregate removals during the year, including the transfer of patients from one hospital to another, numbered 36,976. Of this number 13,266 were effected by the Eastern Station (at Homerton); 11,359 by the Western Station (at Seagrave Road, Fulham); and 12,351 by the South-Eastern Station (at Deptford). The journeys made were 23,434 (in addition to 583 to other places than the Managers' Hospitals), the miles run by horses and vehicles being 245,311. As shewing the pressure of work at busy seasons, it is stated that as many as 62 patients were removed (irrespective of 6 sent for but not removed) in one day in November, by the Eastern Station. In the same month, on a single day, the Western Station removed 41 patients ; the South-Eastem Station 48 patients. The Eastern Station in the week ended 11th November, effected 360 removals (including transfers), 2,501 miles being travelled; the Western Station effected 324 removals in the week ended 4th November, 2,125 miles being travelled; the South-Eastem Station effected 336 removals in the week ended 11th November, 2,243 miles being travelled. Small-pox —The Committee briefly narrate the history of smallpox prevalence in 1893, showing how the disease became spread amongst the settled population of London, as a result of its diffusion amongst tramps and other persons accustomed to use the accommodation afforded in Casual Wards, Shelters, Common Lodging Houses, &c.; many of whom, moreover, were infected by persons of the same class coming into London from places in the provinces where the disease existed in epidemic form. The Committee think it probable that the metropolis "narrowly escaped a severe epidemic of the disease"; but "whether this be so or not, the experience of the year has amply justified the persistence of the Managers, in spite of adverse criticism, in maintaining the River Ambulance Service, and the Hospital Ships, in a complete state of readiness. As a consequence, cases as they were notified were rapidly removed and isolated." Reference is made to the outbreak at North Kensington,* which, traced to infection received in Paddington, commenced at Portobello Road in October, about 70 persons in all being attacked. "The * Vide page 26. 112 action taken by the Medical Officer of Health was prompt; the services of the Vaccination Officer were at once made available: house to house visitations were made, and stringent disinfection measures were enforced, with the result that the outbreak wasrematk ably limited in area and was soon subdued." In the course of the year, 200 patients, who in the opinion of the inspecting Medical Officer at the Wharf were not suffering from small-pox, were returned to their homes. Fever Patients.—At the commencement of 1893, some 3,559 cases of fever, diphtheria, &c., were under treatment in the hospitals, a number greater by 1,718 than at the beginning of 1892. In order to accommodate scarlet fever patients, the accommodation for enteric fever cases was reduced to the lowest point, and, by arrangements made with General Hospitals, 170 cases of this disease were removed to those institutions. Diphtheria.—The cases removed, certified to be suffering from this disease, or from diphtheritic membranous croup, numbered 3,194, but many of these ultimately proved to be not of a diphtheritic character. The Committee observe that, "It is in connection with patients suffering from this disease that an insufficiency of hospital accommodation makes itself most acutely felt. The unavoidable delay sometimes experienced in ascertaining if and where a vacant bed exists, and the deplorable necessity of transporting some patients to a hospital at a considerable distance from their homes, or from the general hospital to which they have in the first instance been taken, cause, it is feared, a great increase both of risk and discomfort to the sufferer, and certainly much dissatisfaction to all concerned." During the year, 590 persons suffering from infectious disorders were conveyed in the Ambulances to other places than the Managers' Hospitals : of these, 26 were stated to have measles, 362 scarlet fever, 72 enteric fever, 58 diphtheria, 53 erysipelas, 14 small-pox, and 8 "other diseases": 270 of these patients were removed to the London Fever Hospital, Liverpool Road, Islington. The charge for the use of an Ambulance is five shillings, and for the service of a nurse halfa-crown. 113 River Service.—The distance run collectively by the three Ambulance Steamers," Red Cross," "Maltese Cross," and "Albert Victor," was 28,341 miles : 10,652 patients and other passengers were conveyed, besides stores, to and from the hospital ships at Long Reach. Cost of the Ambulance Services. —The total payments made during the year on account of the Land Service, were £15,176 19s. 5d., including ,£5,032 for the Western Station at Fulham. The enlargement of this Station has cost ,£1,129 l1s. 3d. additional. The Fountain (temporary) Station cost (on account) ,£500. The payments on account of the River Service were ,£8,505 7s. 10d., viz. :—Ordinary expenditure ,£7,483 17s. 1d, to which must be added payments amounting to ,£1,021 10s. 9d. for overhauling machinery, and repairs of the steamers and repairs to the Wharves. For purposes of account and comparison, the cost of the services of the nurses in charge of the ambulances, who are drawn from the Fever Hospitals or the Hospital Ships, is assumed to be fairly represented by a fixed charge of half-acrown per journey, and in the aggregate these charges amount to ,£2,630 for the past year. WESTERN HOSPITAL: ANNUAL REPORT OF THE MEDICAL SUPERINTENDENT. The Annual Report of the Medical Superintendent of the Western Hospital has a very special interest for us, inasmuch as the bulk of Kensington cases are taken to that institution. It appears that the cases treated during the year 1893 numbered 3,069, including 309 which remained in the hospital at the close of 1892. There were 2,749 admissions; 2,486 discharges, of which 1,511, or 60 per cent., were transferred to Convalescent Hospitals; and 276 deaths leaving 307 cases under treatment at the end of the year. The , total mortality was 9.99 per cent. Of scarlet fever, 2,295 cases were admitted: 2,161 of these were discharged, and 166 died. The deaths include 28 which were due to intercurrent infectious diseases, viz., 26 to diphtheria and 2 to measles. Twenty-one cases died within 48 hours after admission. The diphtheria admissions numbered 256, the discharges 143, and the deaths H 114 94. Of these deaths 42, or 44 per cent., occurred within 48 hours after admission. The total mortality was 38.13 per cent. The enteric fever admissions numbered 56: 47 cases were discharged and 9 died; a mortality of 16.1 percent. Of other diseases 144 cases were admitted: 135 were discharged and 7 died; a mortality of 4.91 per cent. The scarlet fever cases were, on the whole, of a more severe type than in 1892. Postscarlatinal diphtheria was diagnosed in 30 patients, all of whom save 5 died. Four cases in one ward contracted smallpox after admission : the source of the infection could not be traced. The miscellaneous diseases constituted 6.2 per cent. of the total admissions. Three cases certified as scarlet fever, were found to have small-pox ; and of the cases certified to be suffering from diphtheria, 79 were afterwards diagnosed as tonsillitis. During the year 13 members of the staff (including two Assistant Medical Officers) suffered from infectious diseases, viz., 8 from scarlet fever, two from diphtheria, two from enteric fever, and one from small-pox. All recovered— the Medical Officers after very severe attacks of scarlet fever and diphtheria, respectively. The admissions of cases from Kensington included 345 of scarlet fever, 42 of diphtheria, 6 of enteric fever, and 17 of other diseases: total 410. The deaths of Kensington parishioners numbered 42, a mortality of about 10 per cent. The Medical Superintendent concludes his report with a statement of the considerable improvements that have already been carried out at the Western Hospital, to which allusion will be found at page 116, and with a reference to the further accommodation for cases of diphtheria, and for isolation purposes, for which it is proposed to make provision. At Other Hospitals of the Managers, 282 cases were admitted from this parish, viz., at the North-Western Hospital (Hampstead) 206 cases, including scarlet fever 113, diphtheria 87, enteric fever 4, and "other diseases " 2: 115 the deaths were 29 = 14.1 per cent. At the South-Western Hospital (Stockwell) 44 cases were admitted, viz., scarlet fever 27, diphtheria 9, enteric fever 4, "other diseases" 4: the deaths were 5 = 11.3 per cent. At the North-Eastern Hospital (Tottenham) 10 cases of scarlet fever were admitted all of which recovered. At the Fountain (new temporary) Hospital, Tooting, 20 cases of scarlet fever were admitted: two died = 10 per cent. At the Eastern Hospital (Homerton) one case of scarlet fever was admitted and recovered. At the South-Eastern Hospital (Deptford) one non-infectious case was admitted and recovered. At the Northern (Convalescent) Hospital, Winchmore Hill, to which many cases were transferred from the other hospitals, there were four deaths of Kensington parishioners. The grand total of admissions to hospitals of Kensington cases, was 692, including scarlet fever 516, diphtheria 138, enteric fever 14, and "other diseases" 24. The grand total of deaths was 82, or 12.8 per cent, on the admissions. Admissions at the Western Hospital from other parishes, etc.—The Western Hospital is primarily intended for the West District, which comprises, besides Kensington, the parishes of Paddington and Chelsea, and the unions of Fulham, St. George, Hanover Square, and Westminster. The total admissions from these parishes and unions were 1,967 ; those from the parishes and unions in other districts (North, Central, East, and South) being 782. West District Cases Removed to Hospitals in other Districts.—Some 1,445 cases belonging to the parishes and unions in the West District were removed to hospitals outside the district; viz., 893 to the North-Western Hospital; 384 to the South-Western Hospital; 127 to the Fountain Hospital; 28 to the North-Eastern Hospital; 7 to the South-Eastern Hospital, and 6 to the Eastern Hospital. It is to be hoped that when the Western Hospital shall have 116 been enlarged, as proposed, it will be adequate to receive all of the cases from the West District, and that hospital accommodation may be provided for other districts on a scale to render it unnecessary to send patients from those districts to the Western Hospital, which is situated in the parish of Fulham, near to West Brompton Station, and to the west of the Brompton Cemetery. Extension of the Hospital has been provided for on land adjoining the original site, which to the amount of four acres has been secured by the Managers at a cost of nearly £10,000. The Committee for this Hospital submitted, in December, 1893, an elaborate report setting forth their views as to the extent and description of the further accommodation in their opinion necessary, and the Managers authorised them to engage the services of an architect, to be approved by the Board, to prepare plans based upon their recommendations. These include provision of another block, to contain 48 beds, for cases of diphtheria, which has continuously demanded more and more accommodation since the hospitals were made available for the treatment of this disease. Provision will also be made of an isolation block (22 beds) and of 12 beds, in three rooms, for sick-nursing staff, one such room to be attached to adiphtheria ward,a scarlet fever ward,and an enteric fever ward respectively. Anadministrative block will beerected as well as extensive additional accommodation for servants. A new laundry and a boiler house are also to be provided. The extension of the hospital, so far as it had previously been sanctioned by the Board, included the erection of four new pavilions; so that, when the further extensions now sanctioned shall have been made, the establishment will be one of the most important of the Managers' many hospitals. 117 THE NEEDS OF THE METROPOLIS IN RESPECT OF HOSPITAL ACCOMMODATION FOR THE INFECTIOUS SICK. It is an accepted axiom that provision for the isolation of infectious disease should be at the rate of not less than one bed for each thousand of the population. The subject, as regards the Metropolis, was considered by the Royal Commission in 1881-2 and the Commissioners stated in their report (1882) that the then provision of Hospitals should be extended so as to provide 5,100 beds at the least; viz.: 3,000 nominally, for "Fever," and 2,100 for Small-pox. Diphtheria cases were not at that time admissible to the hospitals. The population of London in 1882 was a little under 4,000,000. Consequently, the recommendation of the Commissioners went, to the extent of 1,100 beds, beyond the theoretical requirements of the day. Naturally, however, the Commissioners intended to make provision for a lengthened period in advance. As respects "Fever," nothing happened, prior to 1887, to lead the Managers of the Asylums Board to think that they would be likely to require so many as 3,000 beds, and the only step taken by them towards giving effect to the recommendation of the Commissioners, was the erection of the Northern Convalescent Fever Hospital, at Winchmore Hill, for about 480 patients. In 1887, however, an epidemic of scarlet fever tasked their resources to the utmost. Not only were all the available beds filled, but a large and costly addition of temporary huts had to be run up in the grounds at several of the hospitals; and the "Poplar" hospital, at West Ham, was also brought into requisition. And yet the deaths from scarlet fever (1,443), were 381 below the decennial average. The total number of "fever" patients received into the Managers' Hospitals in that year, including 5,900 suffering from scarlet fever, was 6,537, or nearly 4,000 more than in any previous year: the maximum number under treatment at any one time 118 was 2,600, or about 700 in excess of the normal accommodation. The great increase in the number of persons admitted was largely due to the increased facilities afforded by the Managers—whose new Regulations, issued in that year, permitted of the reception of patients upon the application of any duly qualified medical practitioner—and to an Order of the Local Government Board giving effect to a recommendation I had made in 1875, viz., that the certificate of any duly qualified medical practitioner should be accepted as evidence of the nature of the infectious disease. But the operation of compulsory notification must not be left out of account in any explanation of the growing disposition on the part of the public to make use of the rate-supported hospitals; or, 1 would add, in estimating the probable requirements of the future. How greatly these causes, and the depauperisation, in 1883, of medical relief in the hospitals, which I had been advocating since 1877, operated to popularise the use of these institutions, may be inferred from the fact that the admissions of scarlet fever cases in 1891, when the mortality (589 deaths) was the lowest on record, were no fewer than 5,262, or only about 650 less than in the epidemic year 1887. These numbers were far exceeded in 1892, the admissions having been 13,093, or 7,193 more than in 1887, although the deaths from scarlet fever (1,174) were 269 fewer than in 1887, and 60 below the corrected decennial average. The admissions in 1893, as we have seen, were 15,408. If the demands for scarlet fever only upon the accommodation provided by the Managers were so great, under the circumstances above set out, it may well be asked, What would the requirements be, should the Metropolis be again afflicted with an epidemic like that of 1870, when the deaths from this cause were 6,040 out of a population of 3½ millions? or even like that of 1880, when the deaths were 3,100, out of a population of 3¾ millions ? In the former year there were no hospitals : the epidemic ran its course without check, and 119 I do not expect ever again to see such a terrible death-roll from scarlet fever in London. In 1880 the hospitals were in operation ; the scarlet fever admissions, however, were under 2,000, and less than two-thirds of the number of deaths in London from this cause; whereas in 1893, with a population of 4¼ millions, the admissions were ten times as many as the deaths, 56 per cent, of which took place in the hospitals: the maximum number of patients in hospital at one time, in December, was about 3,200. It is now admitted that the demands of scarlet fever alone, are certain to require for their satisfaction in the future, a number of beds far more than one in the thousand of population, viz., 4,300. A further allowance will have to be made for enteric fever and diphtheria. The average annual number of deaths from enteric fever in the ten years 1883-92, was 683. In 1893 the deaths from this cause were 693, the notifications 3,363, and the admissions to hospital 544. The deaths from this disease in 1893 were fully up to the decennial average; but speaking generally enteric fever is markedly on the decrease in London. Diphtheria, on the other hand, is much more markedly on the increase. The notifications of this disease, which had been 5,907 in 1891, were 8,064 in 1892, and no fewer than 13,026 in 1893: the deaths for some years past, moreover, have exceeded the deaths from scarlet fever. In 1891 they were considerably more than double as many. In 1892, the deaths from this cause were 1,885, the then highest number on record. Last year the deaths were 3,265, or 1,669 more than the deaths from scarlet fever, and 1,984 above the corrected decennial average. The admissions to hospital, moreover, are becoming more numerous: 722, 942, 1,312, and 2,349, in 1889, 1890, 1891, and 1892 respectively, they were 2,848 in 1893; many persons, moreover, having been refused admittance for want of room. It is manifest, therefore, that a considerable number of beds will have to be set aside for these diseases, as well as a small number for typhus and ill-defined forms of fever—the average number of deaths from which in the ten years, 1883-92, was 78—and for isolation purposes. 120 In connection with this subject of Fever Hospital accommodation, reference may be made here to a striking memorandum by the Clerk to the Asylums Board, dated 4th December, 1893, in which, after showing that the existing hospitals contain acommodation of about 3,400 beds, he expresses the opinion that "it would probably-not be a serious exaggeration to say that double the number would not have been an excessive provision for the needs of the past few months." It may be remembered that in 1892* I ventured to say that beds for scarlet fever, "fever," diphtheria, and "isolation" to the number of "not less than 5,000" should be provided by the Managers; and this upon the assumption that certain hospitals would be used interchangeably for fever or smallpox according to the needs of the time. The Clerk to the Board, one year later, deliberately expresses the opinion, which probably is well founded, that a number of beds 650 in excess of my estimate, which was far in advance of the Managers' estimate at the time, and thonght to be excessive, would have been none too many for the requirements of the Metropolis, and the demands of the Sanitary Authorities, had the accommodation been forthcoming during the past year. As regards small-pox the state of affairs presents a more hopeful outlook. There has been no epidemic since 1885, when the deaths in London from this disease were 1,419, and the admissions to the Asylums Board Hospitals 6,146— numbers which pale in presence of the fearful totals of 1871, when the Hospitals received upwards of 13,000 cases, and the deaths in London fell little short of 8,000. In happy contrast with this state of things, the experience of the seven years, 1886-92, may be cited, the total admissions having been only 613 (306 of them in 1892) and the deaths 97. In 1893 the disease again and again threatened to become epidemic but was kept within bounds. Nevertheless the notifications were * Vide No, 10 Report, October 1oth, 1892, page 126. 121 2,813, the admissions to hospital 2,376, and the deaths 206. We might reasonably hope for a continuance of the practical immunity so long enjoyed—provided the vaccination laws were efficiently administered—as a result of compulsory notification, which has worked admirably and was the means of preserving London from an epidemic in 1892 and again in 1893. The practice of taking the sick out of London for isolation and treatment, carried out of late years in accordance with the recommendation I made in 1881, has also been attended with the best results, and still further encourages the belief that London will not again suffer from small-pox as in 1871, or even as in 1881, when the admissions were 8,551, and the deaths 2,367. I expressed the opinion last year that it was probable that the accommodation provided by the Managers for this disease, amounting to 1,100 beds, viz., 300 on the Hospital Ships, and 800 at the Gore Farm, Darenth, would probably suffice. At the same time I urged the provision of an additional Convalescent Hospital, which could be used for " Fever" when not required for Small-pox. Leaving for the moment further consideration of the question of hospital accommodation for small-pox, I proceed to state what the Asylums Board have done since the date of my last report, to supply the needs of the metropolis in respect of accommodation for "Fever" and diphtheria. In January, 1893, the Managers approved generally a report by the General Purposes Committee, which stated that "besides extra Convalescent Accommodation, sites for three additional Acute Fever Hospitals, one in the North and two in the South of London, each with permanent accommodation for not less than 400 patients, should be provided without further delay." The first step taken by the Managers in giving effect to this recommendation was the adoption of a resolution, to the effect that, " subject to the approval of the Local Government Board, the Tooting Lodge Estate " (adjacent to Tooting Bee 122 Common)" be purchased as a site for a Fever Hospital." Opposition was made to the proposal, and the Local Government Board, after a public inquiry, informed the Managers that they could not assent to the proposed purchase. Subsequently, the Board sanctioned the purchase of 31 acres of land at Tooting Graveney, on which the Managers are about to erect the "Fountain" Hospital for about 500 fever patients, having already built on a part of the site a temporary hospital for about 400 patients, some account of which will be found at page 130. The Local Government Board have further sanctioned the purchase of a site at Hither Green, in the Parish of Lewisham, whereon the "Park" Hospital for about 500 patients is to be erected at a cost of some .£200,000, the site, which comprises an area of 20 acres, having cost £23,500. Lastly, the Board have sanctioned the acquisition at a cost of £17,000 of about 31 acres of land at Shooters Hill, Woolwich, on which the "Brook" Hospital for 500 patients is to be erected for the service of the extreme south-eastern part of the Metropolis. The inhabitants of the several localities raised strong opposition to the use of the above mentioned sites for hospital purposes, and it was not until after local public inquiry in each case that the Local Government Board sanctioned their acquisition. The Managers were not so fortunate in their efforts to secure a site at Upper Norwood, for a Convalescent Fever Hospital. Provisional arrangements had been made for the purchase of some 47 acres of land in that locality known as the "Grangewood" Estate; but the Local Government Board, after a public inquiry, declined to sanction the proposed purchase, which had been opposed not only by local residents, but also by the Crystal Palace Company, the London, Brighton and South Coast Railway Company, and the Corporation of the Borough of Croydon. 123 The Difficulties of the Asylums Board.—At the end of May, the hospital accommodation for scarlet fever and diphtheria being exhausted, it became apparent that for some considerable time there would be no beds available other than those set free by discharges and deaths, and therefore wholly incommensurate with the requirements of the Sanitary Authorities. In view of this eventuality the Asylums Board, on the 18th May, addressed a letter to the several Sanitary Authorities, intimating the approaching exhaustion of their resources and giving them notice of the probability that they would shortly be called upon to make provision for the infectious sick of their respective districts. The Managers at the same time forwarded a copy of a communication which they had addressed to the Local Government Board, on the 10th May, " respecting the urgent need of more Infectious Hospitals for the Metropolis, and the difficulty experienced by the Managers in providing suitable sites for such hospitals." This important communication expressed the regret with which the Managers had received the intimation of the Board's decision not to sanction the purchase of the Tooting Bee site, and their feeling that the Board did not "sufficiently realise the gravity of the situation." The Managers referred to the report on the subject of necessary accommodation which they had forwarded to the Board in January 1893, and whilst reminding the Board that the demands on the hospitals during 1892 had been far in excess of any previous experience, they stated their opinion that there was every indication that the pressure would be even greater in 1893, as indeed it proved. The increase in applications for admission to the hospitals in 1892 was attributed "not so much to any exceptional prevalence" of scarlet fever, (for the deaths were 60 below the corrected average number), "as to the operation of compulsory notification," the abolition of the Guardians' power to make people pay for admission, and the "increased knowledge and appreciation of the hospitals." The Managers pertinently * This Report was summarised in my last report, page 107. 124 added that "if this be so, such increase is not likely to be temporary," and they pointed out that since compulsory notification had been in practice, the number of patients received into the hospitals "has rapidly increased and is still rapidly increasing." It was stated that of the scarlet fever cases notified in London in 1890, the Managers received less than 42 per cent.: that the proportion of admissions to notifications rose in 1891 to 46 per cent. and to 48 3 per cent. in 1892, and that the proportion further rose to nearly 55 per cent. during the first four months of 1893, the accommodation at that period being adequate. "It was clear from these figures that the need for extra accommodation was becoming greater and more urgent." The outlook therefore was "most gloomy," having regard to the fact that the cases in the spring are at a minimum, the maximum not being attained until autumn. The minimum in 1893 (1,880) was reached on the 18th March, and was "a number practically double the average minimum of the preceding three years," and 743 more than at the corresponding date in 1892, in which year the maximum (4,001) was reached on the 17th November. It followed, from the statistics given, that the Managers might be required to provide beds in the autumn for 4,832 scarlet fever patients at one time; or, "if the proportion between highest and lowest be taken," on the figures of 1892, for "no less than 6,334." It was pointed out that by great exertions in the time of the most severe pressure, the accommodation in 1892, had been brought upto 4,628 beds. Sincethen not only had diphtheria required a larger provision of accommodation, but "the outbreak of small-pox swept away at one stroke the 836 beds which were available at Gore Farm in the Autumn of 1892;" whilst "certain other wards were not now available owing to building operations and to other causes." The Managers stated that in these circumstances they could not possibly take in more than 3,434 cases of fever of all kinds. The number of fever patients under treatment at the date of the letter was 2,533, " although it was only seven weeks 125 since the tide began to turn, while the number of scarlet fever cases alone which might be expected to require accommodation simultaneously in the autumn, ranged, according to the basis of computation adopted, from 4,800 to 6,300." The Managers stated that they "set out these facts, though they are already known to the Local Government Board," to remind the Board "how urgent is the immediate provision of new hospitals and they insisted that they were justified in expecting from the Board "some indication of their views as to the conditions which should be required in a suitable site" for an infectiousdisease hospital. The Managers' contention was and is that the hospitals should be "as near to the homes of the patients as possible, and therefore as evenly distributed over their district as circumstances will allow." It was their duty simple to see that sites were in themselves suitable, and that in providing for the isolation of the sick the provision they make is the best that is possible. "Working in this view . . . much as they regretted the unwelcomeness of their presence to adjacent owners or occupiers," they contended that "they are not only under no obligation, but they have no right, to give such owners or occupiers a veto or voice in restraining their proceedings, beyond what is afforded by the ordinary processes of law"; and they pointed to the then recent unanimous judgment of the Court of Appeal, " that an owner of land has a right to establish on it a small-pox hospital, and that provided that hospital be properly conducted it is not, in the legal sense, a nuisance," The Managers maintained that "if this be so in the case of small-pox hospitals, d fortiori it is true of fever hospitals, as to which all subsequent experience bears out the conclusion of the Royal Commission of 1882, that 'all evidence goes to show that well-conducted fever hospitals involve no appreciable risk in the neighbourhood." The Managers therefore pressed upon the Board that a small section of the community in a particular locality, is not entitled to claim at the hands of the Board the exercise, in 126 their particular interest, of a veto given to the Board in order that it might be exercised in the interest of the district as a whole. The letter concluded with an assurance that the Managers would endeavour to find other sites, both for acute and convalescent hospitals, and they asked the Board to " give the promptest possible consideration to the proposals (then) before them as to the Tottenham and Hither Green sites, and to the further proposals which it will be the duty of the Managers to lay before them for approval." At the following meeting of the Managers (May 27th), references were made to the " intolerable delays " in respect to matters required to be referred by the Managers to the Local Government Board,and regard being had to the difficulties in which the Managers were placed, by reason of their inability to obtain the necessary sanction for the acquisition of sites for hospitals, it was proposed to "inform the several Sanitary Authorities that, in view of the limited accommodation at their disposal, the Managers would only be able for the present to admit scarlet fever and diphtheria patients when they were provided with an order from the Relieving Officer;" in other words to admit paupers only. The Chairman, however, would not accept this proposal, " inasmuch as it would involve a reversal of the policy of the Board for many years " ; but it was decided that a circular should be sent to the several Medical Officers of Health with a view to their selecting the most necessitous cases for admission to the various hospitals, a course which I did not hesitate to declare impracticable. I felt it my duty to enter fully into this important question of hospital accommodation (in my fifth monthly report, dated May 29th), for the information of your Vestry as one of the Sanitary Authorities who had received an intimation that they might be called upon soon to make provision, locally, for their infectious sick. But I did not 127 advise your Vestry to take this course, being of opinion that it would be impracticable even if it were desirable; for if the Asylums Board were unable to obtain sites, Where, I asked, should forty Vestries, &c., look for sites? It is true that the Sanitary Authorities are not hampered by the necessity of obtaining the sanction of the Local Government Board; and that they have statutory authority to provide hospitals, permanent or temporary, "for the use of the inhabitants of their district (Public Health (London) Act, 1891, Sec. 75); but any attempt to set up a local hospital would be frustrated in the future as similar attempts had been frustrated in the past. Apart from this, and for reasons set out again and again in these reports during the last seventeen years, I was and am entirely opposed to the provision of local hospitals. It only remains to add that the expression of their views by the Managers, as above set out, was not without effect, for soon afterwards theyobtainedthesanction of the Local Government Board to the acquisition of the sites at Lewisham, Woolwich, and Tooting, on which hospitals will be provided with the net result of adding some 2,000 beds to the existing accommodation of the Board. Conference of Sanitary Authorities.—It need hardly be said that the difficulties of the Asylums Board, arising out of the impediments to the acquisition of sites, secured for the Managers the sympathetic consideration of the several Sanitary Authorities, on whose behalf indeed, they were acting. This feeling found expression in June, at a Conference of the Sanitary Authorities convened by the Vestry of St. Marylebone, at which, fully one-half of the said authorities being represented, the following resolution was all but unanimously adopted : " That, in view of the urgent necessity of further provision being made for the rapidly increasing number of persons suffering from Infectious Disease, and the declared inability of the Metropolitan Asylums Board to provide the necessary accommodation, this Conference do appoint a Deputation to wait upon the Local Government Board for the purpose of urging them to facilitate the acquisition of Sites by the Metropolitan Asylums Board, or the provision of suitable Buildings." 128 The President of the Local Government Board received the Deputation on the 21st July. It may reasonably be hoped that the views expressed by such a representative body will not have been made in vain. The matter for regret is that the needs of the Metropolis were not more accurately gauged years ago, so that provision of permanent buildings might have been made after proper deliberation. The Managers are now fully alive to the necessity for a large extension of their hospital system, and I am persuaded that it will not be their fault should London be not provided with adequate and permanent accommodation for the infectious sick within a reasonable time. The Fountain (Temporary) Hospital.—The Asylums Board, whilst endeavouring to make adequate hospital provision of a permanent sort for Fever, &c., were not unmindful of the necessity for securing so-called " temporary " accommodation for the immediate needs of the metropolis. For this purpose they resolved to utilise some ten acres of their new estate at Tooting Graveney, as a site for a temporary hospital, and to give their architect, Mr. Thomas Aldwincle, carte blanche to build with the utmost expedition a hospital for about 400 patients. The commission was executed with surprising rapidity. Clear possession of the land was obtained on the evening of August 22nd, the works were " set out " on the 23rd and commenced on the following day. The buildings were formally inspected by the Managers on the 21st October, and the opening took place on the 31st, ten weeks after the date of commencement. Five firms of contractors were employed on different portions of the buildings ; the daily average number of workers was 1,500, the highest number on any one day being 1,678. An interesting descriptive report of the hospital, with a plan of the several buildings, was prepared by the architect, for the information of the Managers. The final paragraph of this report referred to the extreme costliness of 129 buildings hurried up as these have been, "the ordinary work of at least six months having been compressed into a few weeks." The actual cost, apart from the cost of the site, was about £117,000, or £292 per bed, a sum sufficient, one would have thought, to provide a permanent hospital. It is almost double as compared with the cost of the North Eastern (temporary) Hospital at Tottenham. The new hospital is admirably arranged for administrative and all other purposes. It comprises 16 timber and iron pavilions, (each containing a ward, 144-ft. by 26-ft., for 24 patients) arranged 8 on each side of a central corridor: the administrative block of buildings intersects the corridor at right angles, in the centre, and thus has 8 pavilions on either side of it. Accommodation for the subordinate staff (including 90 nurses) is provided close to the boundaries on three sides of the site. The principal officers are located in the administrative block. The arrangement of the pavilions, and the position of the main staff buildings, were determined by the requirement of the Local Government Board of a space of one hundred feet between the patients' wards and the boundaries, on the three sides of the site near to which there are inhabited houses. The opening of this hospital was not followed by the full measure of expected relief of the Managers' difficulties, the Small-pox Hospitals Committee having felc constrained, in November, to close the "Lower" Hospital at Gore Farm (200 beds) against the reception of scarlet fever convalescents, so that (as I had to report in the same month) the additional beds supplied by the new hospital proved altogether inadequate to the supply of the then pressing needs of the metropolis. We were fortunate in obtaining a larger number of removals than before, but there was still a daily overplus of patients for whom accommodation could not be provided ; and this state of affairs continued until December, when the epidemic had fully entered upon the seasonal period of decline. I 130 North-Eastern Hospital.—It will be remembered that in 1891, the Managers having resolved to acquire the site (at Tottenham) whereon the North-Eastern Hospital now stands, the Local Government Board refused to sanction the purchase. In announcing their decision, the Board stated that they " fully realize that whatever site may be selected by the Managers for hospital purposes, some opposition may be expected." They did not, however, state any ground for their decision, which was due, doubtless, to the fact that they had "received many representations against the erection of a fever hospital on the site in question." Nevertheless, after a very formal local inquiry, they assented to the renewed application by the Managers, made in the middle of 1892, for permission to acquire the site on the terms of the provisional contract entered into in 1891. The hospital was erected forthwith and opened in October 1892. It has proved of the greatest utility. The Board in the first instance restricted the user of the site for hospital purposes to a period of twelve months, but on the representations of the Managers, and after a local inquiry, held before the expiration of the said period, they removed this restriction. The site was subsequently extended by the purchase from the Bethnal Green Guardians of about fourteen acres of adjoining land at a cost of £6,000, and the Managers have decided to add to the existing patients' accommodation, permanent wards for enteric fever, diphtheria, and isolation cases, as well as permanent administrative buildings, staff quarters, and the necessary boundary walls. At the present time enteric fever and diphtheria cases are not received for treatment. It is proposed to utilise part of the Bethnal Green land for the erection of wards for these diseases, the other portion being set apart as a patients' recreation ground. On the completion of the new buildings, moreover, the number of beds for scarlet fever patients will be increased. 131 SMALL-POX HOSPITAL ACCOMMODATION. The Royal Commission in 1882, in one of their " practical recommendations," advised 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 smallpox patients. At the date of my last report the actually existing accommodation fell far short of the lesser of these totals, comprising some 300 beds at the Hospital Ships at Long Reach and 800 beds at the Gore Farm Estate, Darenth, viz., 600 beds for convalescing patients at the Upper Hospital, and 200 beds for acute and relapsed cases in the associated Infirmary known as the Lower Hospital. The administrative block of the Upper Hospital was designed to meet the requirements of 1000 patients, and in June, 1893, the Managers decided to complete this hospital by the addition of 400 beds, in eight pavilions each capable of accommodating 50 patients, together with the necessary staff accommodation, laundry, and also some small wards for isolation purposes. These works, for which a tender at about £27,000 was accepted, are now approaching completion. The Managers subsequently (February 3rd, 1894) adopted a recommendation contained in a report of the Small-pox Hospitals Committee, for acquiring an estate near Long Reach, as a site for a land-hospital for acute cases of small-pox. The Committee's report had been made on a reference by the Board (8th May, 1893) to consider and report, whether " it is possible and desirable to acquire land adjacent to the Small-pox Hospitals, and if so, to what extent and in what mannerand also on a previous instruction to consider, whether it was desirable "to acquire land on the river-side suitable for the erection of a Small-pox Hospital." The Committee in their report, dated 19th January, stated that, even before these references were made to them, they had been devoting their attention to the question how far the small-pox accommodation at the Managers' disposal is adequate to the demands that are likely to be made on it 132 in times of epidemic ? As a result of their consideration of this question, they had no hesitation in advising the Managers to take immediate steps to supplement the existing provision for acute small-pox patients. They anticipate that the Managers may expect, in future epidemics, to have to treat not less than 2,000 cases at one time; whereas, even when the new buildings at Gore Farm are ready, the existing accommodation cannot be put higher than 1,500 beds. Of these 1,500 beds, 1,200 will be at Gore Farm, and available only for convalescents, and slight cases, able to bear a land journey of five miles after transit from their homes to the ships. The number of beds available for acute cases on the "Atlas" and the "Castalia" (which has been restored at a cost of 11,500) is put down at not more than 300 at the outside. It is estimated that if the Managers had 1,000 patients at any time, they would require 300 beds for acute cases: that with 1,500 patients they would need 450 "acute beds," and with 2,000 patients, 600 "acute beds," or twice as many as are at present available. The Committee, therefore, " think that the need for further provision for acute cases is sufficiently established." They also point out that the former provision of 250 beds in London, viz., 50 in each of five hospitals, is gone ; " absorbed long ago by the pressing needs of fever " ; and " even if the beds were again available, the Managers would probably hesitate to use them except under the strongest compulsion." Coming to the question of how the deficiency of accommodation for acute cases can best be provided, the Committee think that, for reasons stated, " additional ships are out of the question." At the same time they say, " it is equally out of the question that the Managers should abandon their connection with the Long Reach," where, not only has £30,000 been sunk " in the purchase of land abreast of the Ships, and in the erection thereat "of various buildings; "but the Long Reach pier affords the only access to Gore Farm," where another 133 ,£115,000 has been spent on convalescent small-pox accommodation. It is held to be "clearly established," therefore. " that any new acute accommodation to be provided, must be provided on shore, and closely adjacent to the existing ships' moorings." The land immediately adjoining, however, is " reclaimed marsh, lying below high-water mark," and, for various reasons assigned, unsuitable. But about half a mile back from the river, " off the marshes, and on to a level terrace of gravel," there is a site " which is in many respects well adapted " for the Managers' purposes, viz., the " Marsh Street Farm " estate, of 218 acres, which can be obtained at a price of £15,000, or somewhat less than £69 per acre. Heie, it " would be possible to erect a hospital, well isolated, well sheltered by trees, and capable of being satisfactorily drained." The Managers resolved to purchase this site, subject to the approval of the Local Government Board, which has been given, subject to certain conditions, which have been accepted by the Managers, one of which involves the purchase of a portion of an adjoining estate, known as "Joyce Green Farm," to the extent of 125 acres and at a cost of £7,500. On this large site of 343 acres considerable additional accommodation will doubtless be provided. I may here mention that with many of my colleagues, I had the privilege, last summer, of inspecting the arrangements made by the Asylums Board for the accommodation of small-pox patients at the Ships and at the Gore Farm Hospital. The cases under treatment on the occasion of the visit, were about 500 ; viz., 200 at the ships and 300 at the land hospitals. The Medical Officers were conveyed to the ships in one of the Ambulance Steamers, and had the opportunity of inspecting the two Wharves where patients are embarked. It is almost needless to say that the arrangements were perfect in all respects, and afforded unqualified satisfaction to the party. 134 PRINCIPLES OF HOSPITAL CONSTRUCTION. At the meeting of the Asylums Board held on the 30th September, 1893, a Local Government Board Inspector, in the course of an address to the Managers, referred to the temporary nature of the buildings of some of the hospitals, and to the fact that some of such buildings were now being replaced by brick structures. He suggested that before any further changes of this nature were made, a ground plan should be prepared in each case, showing the existing buildings, and the outlines of the completed permanent Hospital, and that in order to co-ordinate the action of the several Hospital Committees, and to secure broad lines of uniformity, the Managers should settle some of the fundamental points which should govern the preparation of such schemes. Whereupon the Board resolved :— "That the General Purposes Committee be instructed to consider and report (a) as to the expediency of the'Managers giving directions for the preparation of ground plans, which shall indicate in what manner, and to what extent, it is proposed to replace by permaneut buildings the existing temporary structures at the Board's Fever Hospitals, and (b) as to the advisability of the Board settling certain principles of Hospital construction as a basis for the guidance of the Hospital Committees of Management." This is a wise decision, and it is to be regretted that it was not arrived at long ago. I referred to the subject nearly two years ago, in my tenth monthly report for 1892, when, alluding to the necessity for the provision, of a permanent sort, of hospitals to supply the reasonable maximum requirements of the Metropolis, I remarked that " How this should be done is a subject well worthy of the attention of the Asylums Board, and indeed of the Local Government Board. Among the first questions to be settled " (I added) "would be the number of beds which may properly be placed on a given space, say in pavilions of two storeys each ? and to what extent additional accommodation may properly be 135 provided on the existing sites? as the more economical plan, obviously, would be that of enlarging the existing hospitals." I did not elaborate the subject, for, as I said, " it is one for inquiry by a responsible authority." Such inquiry has yet to be taken in hand. INCREASED FACILITIES FOR THE REMOVAL OF THE INFECTIOUS SICK. Until within the last few years, persons suffering from infectious disease were inadmissible to the Asylums Board Hospitals unless provided with the certificate of a Poor Law Medical Officer, in addition to the order of the Relieving Officer. In 1875, I recommended that the certificate of any registered medical practitioner should be made available for the purpose. The Local Government Board did not fall in with my views then, but twelve years later they issued an Order in conformity therewith. For some time, however, before 1887, the Asylums Board had adopted the practice of accepting the certificate of any properly qualified medical man, as evidence of the nature of the infectious illness, in lieu of the Poor-Law Medical Officer's certificate, with much advantage to the interests of public health. Your Vestry, moreover, authorised the payment of a fee to any medical man who, by giving such certificate, should hasten the removal to hospital of the infectious sick person. Some time after the Infectious Disease (Notification) Act, 1889, came into operation, I began to make use of the notification certificate, as a medical certificate to be handed to the nurse in charge of the ambulance sent to fetch the patient, thus avoiding the necessity of applying to medical men for special certificates—a course which sometimes occasioned delay. In June last year, the Asylums Board gave their official sanction to the use of the notification certificate, having issued a circular letter to the effect that the Ambulance Committee, " with the view of facilitating the prompt removal of patients, 136 and of avoiding every possible delay in the preliminaries, have given instruction to their ambulance nurses to accept, as a medical certificate, a copy of the notification certificate, endorsed by the Sanitary Authority." The Board, it must be allowed, have, during the last few years, manifested the most commendable determination to make their hospitals of the greatest possible use to the community, by removing, one by one, the barriers to free admission. The latest illustration of the fact occurred in December last, when one of the Metropolitan Sanitary Authorities having made request that the Board should not admit from their district, "in times of epidemic," any cases other than those " whose removal is requested " by the said authority, the Managers informed the Vestry in question, that they did "not see their way to restrict the means of application for the removal of patients to the hospitals, from any portion of the metropolis, in the manner suggested ... or to adopt any other method for the selection of cases for admission, than that at present in force." What that method is, in its extremest development, was shown in a Memorandum submitted to the Managers by their Clerk, in November last, from which it appears that, " In order to give to the poor every facility for making their applications for the removal of patients, they are allowed to apply (at the Board's Offices) either personally, or by letter, or by telegram, or by telephone ; or at any one of the several Ambulance Stations, personally or otherwise (in which case the message is telephoned to the Offices as received), or through the Sanitary Officials of their districts, or Relieving Officers; or through any other channel." Here is freedom indeed ! and such as I scarcely dared„to hope for when, in 1877, I began, if I may so speak, the assault upon the doors of the hospitals to secure free admittance-for all classes. It must be manifest that, under the present system, the demands on the Managers' resources will continue to increase; for each added facility for effecting isolation of the sick has increased the 137 number of applicants for admission, and it is now recognized that accommodation will have to be provided, and, in fact, it is in course of being provided, even beyond what was thought to be my extravagant estimate of requirements, in 1892. For in the Memorandum of the Clerk to the Board already quoted, it is stated that " when hospitals shall have been provided (at all the sites acquired) there will exist upwards of 5,500 beds in the fever hospitals my view, in 1892, having been that " provision should be made of not less than 5,000 beds for scarlet fever, ' fever,' and diphtheria, and isolation." DANGER TO THE PUBLIC HEALTH IN CONNECTION WITH THE REMOVAL OF THE SICK. During the outbreak of small-pox referred to at page 26, as on former occasions, the spread of the disease was endangered by the foolish or ignorant conduct of people who congregate around the door of the infected house when the ambulance draws up, making a lane for the passage of the sufferer when carried out by the attendants. Children are, of course, the most frequent offenders. There can be no doubt that this is a public danger. I was minded to write to the Commissioner of Police to ask that the ambulance driver might be authorised to call on a constable to prevent obstructive collection of people near the ambulance. But as the practice referred to prevails in all districts of the Metropolis, I thought it better to communicate with the Asylums Board, and did so, making request that they would endeavour to enlist the aid of the police, for the protection of the public, by making suitable representations to the Commissioner. This was done with the desired effect. STATISTICAL TABLE. Reference to the work of the Asylums Board in 1893 may be fitly concluded by the following Table, showing the number of cases admitted to the Managers' Hospitals from the several Parishes and Unions which, it will be understood, are not conterminous with the sanitary districts :— 138 Table shewing Admissions of Small-Pox, "Fever," and Diphtheria Patients at the Asylums Board Hospitals in 1893, and Population of the several Parishes, and Unions. Parishes, Unions. Small-Pox. Total. Scarlet Fever. Total. Enteric Fever. tal. Diphtheria. Total. Grand Total Small-Pox, Population in 1891. 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Toi 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Fever, and Diphtheria. West District. Kensington 3 14 3 71 91 94 106 163 159 522 1 3 2 11 17 19 29 51 51 150 780 166,308 Fulham 11 22 4 3 46 142 167 160 220 689 10 8 9 8 35 29 23 42 60 154 918 188,877 Paddington 30 9 26 65 77 93 131 122 423 1 4 7 2 14 32 33 20 32 117 619 117,838 Chelsea 7 20 1 12 40 53 68 71 89 281 6 3 2 4 15 17 11 14 15 57 393 96,272 St. George, Hanover Sq. 20 35 7 3 65 81 167 220 198 666 3 2 8 4 17 14 18 22 22 76 824 149,603 V Westminster 3 45 7 55 40 29 41 25 135 4 4 8 4 10 10 5 29 227 3,761 52,752 771,650 North District. Stt. Marylebone 30 95 15 5 145 92 100 38 121 351 2 6 5 11 24 23 45 38 33 139 659 142,381 St. Pancras 12 67 1 9 95 193 214 264 237 908 3 3 4 6 16 47 51 34 43 175 1194 234,437 Hampstead 7 1 1 9 43 60 32 51 186 2 2 0 4 21 18 7 8 54 253 68,425 Islington 34 42 6 5 87 171 255 252 233 911 10 16 12 15 53 34 47 43 50 174 1225 319,433 v Hackney 10 12 22 4 48 138 172 309 258 877 4 10 39 39 92 34 34 40 71 179 1196 4,527 229,531 994,207 rict St. Giles and St. George 20 39 6 65 23 33 38 48 142 2 2 4 3 10 11 7 31 242 39,778 Dist Strand 5 22 3 1 31 20 36 40 26 122 1 2 3 5 20 11 9 45 201 33,405 ntral Holborn 17 34 6 3 60 130 199 225 211 765 5 14 6 6 31 21 37 40 35 133 989 167,000 Ce London, City of 10 17 2 29 22 35 51 4S 156 2 4 6 4 12 7 7 30 221 1,653 51,306 291,489 139 East District. Shoreditch 9 9 8 2 28 94 119 114 109 486 4 12 16 8 40 25 30 35 22 112 616 124,009 [/$$$] Bethnal Green 1 12 40 2 55 66 104 144 138 452 2 3 4 9 18 41 39 31 29 140 665 129,134 Whitechapel 46 53 6 2 107 86 91 167 133 477 1 1 7 9 25 28 34 16 103 696 74,462 St. George-in-the-East.. 25 12 4 1 42 31 46 76 57 210 1 5 6 30 46 25 13 114 372 45,546 Stepney 28 39 5 14 86 105 53 46 90 294 3 3 12 6 24 20 18 31 12 81 00 57,599 Mile End Old Town 11 62 21 7 101 56 84 83 73 296 3 11 5 19 16 19 14 11 60 476 107,565 Poplar 25 43 27 54 149 96 119 104 95 414 5 15 29 16 65 35 36 30 20 121 749 4059 166,697 705,012 South District. /St. Saviour 14 93 35 7 149 111 224 204 212 751 10 5 9 11 35 24 36 54 51 165 1100 195,105 St. Olave 22 107 16 145 67 112 135 136 450 4 8 4 3 19 6 32 25 24 87 701 13f,654 Lambeth 10 60 19 3 92 148 161 225 246 780 11 7 6 6 30 36 49 39 29 153 1055 275,202 Wandsworth & Clapham 6 48 53 8 115 212 308 304 411 1235 20 10 10 18 58 57 66 62 79 264 1672 284,192 Camberwell 31 46 16 6 99 104 130 150 228 612 7 4 9 7 27 14 18 23 28 83 821 235,312 Greenwich 45 96 8 16 165 76 99 131 173 479 2 6 6 10 24 14 19 38 30 101 769 165,417 Woolwich 26 45 11 14 96 74 78 115 91 358 2 2 5 6 15 7 10 6 8 31 500 106,961 Lewisham 6 16 3 25 23 51 80 71 255 1 2 2 1 6 10 6 11 8 35 291 6909 72,533 1,470,376 Port of London 487 1242 369 281 2379 2668 3513 4113 4309 14603 119 153 233 229 734 667 850 848 828 3193 20909 20909 The figures in the above Table have been compiled from the Quarterly Returns of the Asylums Board. In addition to the cases in the Table, 7 cases of typhus were admitted, 2 from Wandsworth and Clapham ; and one each from the City, Fulham, Mile End Old Town, St. Marylebone and Stepney. At the close of the year there were remaining 3,354 cases ; viz., small-pox 84, scarlet fever 2,863, diphtheria 284, enteric fever 105, and "other diseases" 18. 140 COMPULSORY NOTIFICATION OF INFECTIOUS DISEASES. The Table at page 141, shows the number of notifications of the diseases scheduled in section 55 of the Public Health (London) Act, 1891, after correction for duplicate returns, in the entire Metropolis, and in the several sanitary areas comprised therein. The Table at page 142, is designed to show the relative prevalence of the several diseases at different periods of the year, being a summary of the figures set out in my four-weekly reports. In this Table it has been impossible to make the aforementioned correction : the grand total differs to the number of 2,114 notifications. The Kensington notifications were 1,811, viz., in the Town sub-district 1,441, and in the Brompton sub-district 370. The number in 1892 was 1,184. Table IX.A (Appendix) shows the streets, &c., where cases of the scheduled diseases occurred. Owing to the prevalence of scarlet fever and diphtheria, the cases notified in London (67,485) show a great increase upon previous years. The corrected notifications of each of the scheduled diseases during the last four years are set out in the subjoined Table. Total Notifications in London: Year. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Croup. Cholera. Relapsing Fever. Total. 1890 60 '5.330 5,870 2877 35 237 206 4598 550 25 7 29.795 1891 114 H,398 5.907 3372 27 152 221 4764 505 23 39 26,522 1892 423 27,096 7.791 2465 20 147 347 6934 565 54 7 45,849 1893 2813 36,901 13,026 3663 22 205 397 9700 668 86 4 67,485 The Notification Act of 1889 has been adopted by the great majority of provincial Sanitary Authorities, urban and rural. It is time, surely, that the Act should be made compulsory for the whole kingdom, as it has been in London from the first. 141 Corrected Table of Cases of Infectious Disease notified in 1893, under the provisions of the public health (london) act, 1891. Local Authorities in whose Districts the cases were resident. Small-pox.. Scarlet Fever. Typhus J ever. ... Typhoid or Enteric Fever. Continued Fever. Membranous Croup. Diphtheria. Erysipelas. Puerperal Fever. Cholera. Totals. Enumerated Population 1891. Kensington 102 943 1 97 11 15 358 273 9 2 1811 166,308 Battersea 116 1491 2 128 9 35 625 432 19 1 2858 150,458 Bermondsey ... 55 570 1 47 1 23 206 188 5 ... 1096 84,688 Bethnal Green 79 1488 ... 138 4 38 708 426 18 4 2903 129,134 Camberwell ... 143 1854 ... 141 5 25 490 436 23 8 3125 235,312 Chelsea 43 589 ... 76 1 9 227 206 5 1 1157 96,272 Clerkenwell ... 17 731 ... 68 8 25 279 229 1 3 1361 65,885 Fulham 30 706 1 59 5 20 231 156 18 5 1231 91.64C Greenwich 183 1469 ... 115 5 22 469 357 22 ... 2642 165,417 Hackney 65 2505 ... 363 7 44 921 499 18 4 4426 229,531 Hammersmith 17 665 ... 67 4 6 273 183 18 1 1234 97,237 llampstead 14 516 ... 35 3 5 161 78 5 ... 817 68,425 Holborn 30 311 1 41 ... 3 95 95 2 ... 578 33,248 Islington 12 2 2989 1 263 7 38 863 702 40 1 5026 319,433 Lambeth 103 2247 3 159 59 59 770 581 27 30 4038 275,202 Lewisham 26 567 ... 45 ... 6 201 171 8 ... 1024 72,272 Limehouse 80 710 3 115 1 11 229 186 6 ... 1341 57,599 M ai ylebone 179 913 2 94 3 17 384 379 10 2 1983 142,381 Mile End Old Town ... 115 1179 ... 146 ... 9 343 282 5 ... 2079 107,565 Paddington 68 778' 1 67 5 10 279 240 18 ... 1466 117,838 Plumstead 60 765 ... 44 3 21 216 132 10 ... 1251 88,539 Poplar 217 1883 1 390 36 46 1103 566 10 1 4253 166,697 Rotherhithe ... 90 302 ... 29 3 6 100 80 4 ... 614 39,074 Shoreditch 28 1008 1 117 4 30 484 317 10 4 2003 124,009 St. George in-the-East .. 53 485 ... 44 1 6 234 112 5 1 941 45,546 St. George, Hanover Sq. 23 591 ... 68 2 7 116 82 3 2 894 78,362 St. George, Southwark .. 80 594 1 46 2 14 175 144 4 1 1061 59,712 St. Giles 73 238 ... 32 ... 5 73 98 2 ... 521 39,778 St. James, Westminster 52 113 ... 22 3 ... 46 33 3 ... 272 24,993 St. Luke, Middlesex ... 16 361 ... 32 1 10 145 168 2 ...... 735 42,411 St. Margaret and St. \ John, Westminter ) 47 420 ... 41 ... 2 81 84 5 2 682 55,760 St. Martin-in-the-Fields 11 102 ... 6 ... 2 25 9 ... ... 155 14,574 St. Mary, Newington ... 64 1101 ... 66 1 24 454 284 6 1 2001 115,663 St. Olave, Southwark ... 11 117 ... 6 ... 1 31 36 1 ... 203 12,694 St. Pancras ... 120 2589 ... 169 3 21 763 656 24 5 4350 234,437 St. Saviour, Southwark 18 210 ... 21 ... 4 85 54 1 ... 393 27,162 Strand 32 140 ... 11 ... 2 74 22 ... ... 281 25,201 Wandsworth ... 34 1291 1 118 5 37 416 380 '20 2 2304 156,931 Whitechapel ... 99 811 1 62 ... 6 202 216 9 ... 1406 74,462 Woolwich 61 258 ... 28 2 1 26 50 1 2 429 40,848 City of London 27 299 1 27 ] 8 65 76 ... 3 502 38,345 Port of London 10 2 ... 20 ... ... ... 2 ... ... 34 ... Grand Totals 2813 36901 22 3663 205 668 13026 9700 397 86 67481 ... Four cases of " relapsing fever," were also notified. 142 Table showing the Number of Notifications of Infectious Disease, in Kensington, and in London, in 1893, (Uncorrected) Arranged in four-weekly periods. Date of Report. For Four Weeks ended. Weeks of the Year KENSINGTON. LONDON, Small-pox. Scarlet Fever, Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Croup. Cholera. Total, Small-pox. Scarlet Fever. Diphtheria. . Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever Erysipelas. Croupi Cholera. j Total. January 28, 1893 1-4 ... 45 9 6 ... ... 1 17 1 ... 79 86 1717 612 201 1 12 31 599 56 3 3318 February 25 „ 5-8 5 60 17 5 ... 1 ... 12 4 ... 104 159 1601 703 183 1 16 30 531 67 1 3292 March 25 „ 9-12 1 38 16 2 ... ... i 17 1 ... 76 256 1428 649 150 2 9 25 459 49 3027 April 22 ,, 13-16 3 34 9 4 ... ... 2 9 ... ... 61 421 1559 615 149 1 3 23 427 53 3251 May 20 ,, 17-20 8 56 27 4 ... ... ... 19 ... ... 114 528 2149 867 183 2 11 19 579 54 3 4395 June 17 ,, 21-24 2 84 22 4 1 3 1 18 ... ... 135 483 2799 966 194 3 14 27 648 40 3 5177 July 15 „ 25-28 3 84 37 5 ... ... ... 25 2 ... 156 327 3772 1199 397 2 27 35 773 49 9 6590 August 12 ,, 29-32 2 110 46 5 ... ... ... 22 1 ... 186 173 3927 1119 313 4 15 34 807 33 7 6432 September 9 ,, 33-36 67 26 7 ... ... ... 21 1 1 123 107 3502 1153 336 16 27 869 32 23 6065 October 7 ,, 37-40 1 113 27 5 ... ... 1 25 1 1 174 82 4966 1645 362 3 20 27 1163 53 33 8354 November 4 „ 41-44 18 117 58 22 ... 1 2 27 2 ... 247 90 4811 1530 374 1 24 57 1245 55 5 8192 December 2 ,, 45-4S 40 88 40 23 ... 1 1 39 2 ... 234 130 3473 1325 555 4 21 30 1105 80 6723 December 30 ., 49-52 13 61 34 10 ... 2 34 ... 154 91 2215 1068 360 ... 22 48 921 58 4783 Totals 96 957 368 102 1 8 9 285 15 2 1843 2933 37919 13451 3757 24 210 413 10126 679 87 69599 Two cases of Relapsing Fever were notified in addition. 143 DUPLICATE NOTIFICATION. In September, a circular communication was received from the Rotherhithe Vestry, calling attention to the fact that, occasionally, two or more medical men report the same case of infectious disease, each claiming and receiving the statutory fee for so doing. Complaint was made that the Asylums Board "permit the dual, triple, or any numerical notifications " of the same case. It was suggested that the Board might have their attention called to the subject, and " that they be requested to allow a single notification in each case to be sufficient." The ground for this suggestion was, that " dual or triple notification is not fair " to the sanitary district, " as it makes the list "(of notifications) greater than what it really ought to be, so that the return is n<?t a truly correct return of the number of actual cases." It was held, moreover, to be unreasonable to " pay two or three times over for the same thing." The Rotherhithe Vestry therefore requested to be favoured with the views of the several sanitary authorities, " so that united action may be taken to bring the matter to the notice of the Asylums Board." Your Vestry having referred the communication to the Works and Sanitary Committee for consideration, I reported thereon, at the request of the Committee, pointing out in the first instance, that the Asylums Board have no jurisdiction in the matter. It is the local Sanitary Authority that receives the notification certificates and forwards copies of them to the Board, as the Act directs. They also pay the statutory fees for the certificates, and in due course claim repayment thereof from the Board, in conformity with the provisions of section 55 (4) of the Public Health (London) Act, 1891. Unless evidence is forthcoming that the notification has been improperly made, the fee is legally and properly payable to each notifying practitioner, seeing that the Act requires " every medical practitioner attending on, or called in to visit the patient" suffering from an infectious disease, to " send to 144 the medical officer of health of the district a certificate" giving certain specified particulars relating to the case. It occasionally happens that two medical men are called in successively, and manifestly it is the duty of each to notify. Either would be liable to prosecution for neglect to do so, and each is manifestly entitled to the statutory fee. Each case must be judged on its own merits. Should any question arise, it is the Sanitary Authority which has to decide whether the second or the third fee should be paid—if, indeed, they have any discretion in the matter ; for a copy of the certificate must be sent to the Asylums Board, and as the functions of that body are purely ministerial, they will always repay the fees paid and claimed by the Sanitary Authority. Little, if any, of the suggested damage could accrue to the sanitary reputation of a district by the temporary inclusion of duplicate notifications, even if the weekly list were published ; seeing that the average number of duplicate cases, in 1892, was only 30 weekly, for the entire metropolis, the average weekly number of notifications being 910. But there is no such publication. In fact, there is no publication whatever of the notifications, other than the four-weekly list in my reports, excepting in the annual report of the Statistical Committee of the Asylums Board, from which duplicate notifications are excluded. The cases notified in 1892 were 45,849, or 1,487 fewer than the uncorrected total. The dual notifications, therefore, were in round figures, equal to about 3 per cent, of total notifications. In our own parish, the dual notifications were 59 in number, many of them being due to reports received from the Medical Officers of hospitals who are required by the Public Health (London) Act, 1891, to notify the admission of infectious cases to such institutions. The Infectious Disease (Notification) Act, 1889, exempted the medical officers of general hospitals, infirmaries, etc., from the obligation to notify. This exemption being 5 mental to the interests of the public, it was abolished by the Public Health Act. In the parish of Rotherhithe the dual notifications in 1892, appear to have been six only, the uncorrected number of notifications being 347, and the corrected number 341. The Rotherhithe Vestry objected to being called on to " pay two or three times over for the same thing." But the charge is not great, seeing that six notifications, at the maximum fee of half-a-crown, cost no more than fifteen shillings. The fees for 1,487 dual notifications at the maximum ofhalf-acrown for each, would total up .£185 17s. 6dv, a small amount indeed, compared with the benefit accruing to the Metropolis from compulsory notification of cases removed to General Hospitals alone. But of course the charge was not nearly so great, seeing that a considerable proportion of the 1,487 cases were notified by the medical officers of public institutions, the fee payable in each of such cases being one shilling only. These being the facts of the case, it seemed to me that no good would result from any representation on the subject to the Metropolitan Asylums Board, and none was made by your Vestry. The subject nevertheless has interest, and I have prepared a table (page 146), which shows the number of certificates for which, in 1893, the Asylums Board were called upon by the Sanitary Authorities for repayment of fees paid to medical men. In the second figure-column the corrected number of ^notifications is given, duplicate notifications being eliminated. The last column shows the number of duplicate certificates for which the Authorities of the several districts had to pay the statutory fees. The duplicate returns were 2,114, equal to three per cent, on total notifications. The duplicate cases in Rotherhithe appear to have been 11 ; the number in Kensington was 32. 146 Cases of Infectious Disease Notified in 1893 (vide page 145). Name of District. Uncorrected Number of Notifications. Corrected Number of Notifications. Number of Dual Notifications. Kensington 1843 181 r 32 Battersea 2933 2858 75 Bermondsey 1115 1096 19 Bethnal Green 2976 2903 73 Camberwell 3168 3125 43 Chelsea 1200 "57 43 Clerkenwell 1450 1362 88 Fulham 1269 1231 38 Greenwich 2708 2642 66 Hackney 4531 4426 105 Hammersmith 1275 1234 4i Hampstead 847 8*7 30 Holborn 619 580 39 Islington 5187 5026 161 Lambeth 4116 4038 78 Lewisham 1048 1024 24 Limehouse 1367 1341 26 Mile End 2118 2080 38 Newington 2081 2001 80 Paddington 1537 1466 71 Plumstead 1255 i2ji 4 Poplar 4326 4253 73 Rotherhithe 625 614 11 Shoreditch 2114 2003 in St. George in the East. 1008 941 67 St. George Hanover Square 949 894 55 St. George the Martyr 1094 i06l 33 St. Giles', Bloomsbury 559 521 38 St. James, Westminster 294 272 22 St. Luke, Middlesex 784 735 49 St. Martin in the Fields 154 155* ... St. Marylebone 2066 1983 83 St. Olave, Southwark 215 203 12 St. Pancras 4542 435° 192 St. Saviour, Southwark 408 393 15 Strand 289 281 8 Wandsworth 2316 2304 12 Westminster 707 682 25 Whitechapel 1495 1406 89 Woolwich 434 429 5 City of London 542 502 40 Port of London 35 34 1 "The corrected number was one in excess of the uncorrected number. 147 DELAY IN NOTIFICATION. A more serious matter than that of dual notification is the delay on the part of medical practitioners in forwarding certificates which occasionally happens. I do not suggest that this delay is intentional ; but as the Act requires the certificate to be sent " forthwith," i.e., immediately the medical attendant has diagnosed the disease, a sanitary authority would be justified in taking proceedings for the recovery of the statutory penalty in every such case of default. It might be thought harsh to do so, and I would not recommend such a course, excepting in case of repeated neglect, and after caution. But, on the other hand, is it quite fair that the Authority should be called upon to pay for a service which has not been duly rendered, " forthwith," as the Act requires, and which by delay may have been deprived of the greater part, if not all of its value ? For in some instances many days elapse before the certificate is sent, the result being that no steps can be taken to see that the patient is properly isolated so as to prevent the spread of the disease. In my humble opinion, the medical practitioner who neglects to comply with the requirements of the Act in this respect, would have no reasonable cause for complaint were the Sanitary Authority to decline to pay the fee. In any such case, however, it would still be necessary to send a copy of the certificate, when received, to the Asylums Board ; but if the fee were withheld from the certifying practitioner, it would not be charged to the Board. In several instances I have had to apply to the medical practitioner for a certificate of a case of the occurrence of which I was aware, but which I could not report to the Asylums Board, it not having been notified. No service can be said to have been rendered by the practitioner in such a case, and no fee should be paid ; but hitherto in all such cases the fee has been paid, and no proceedings have been taken against the practitioner in default, save in 148 the case to which reference has been made at page 47. Occasionally, I have received a certificate from a medical practitioner who had not been "called in," and was not "attending" the patient, but who, having personal knowledge of the illness, felt it to be his duty to notify the case. In one such case a notification was received 24 hours before the certificate of the practitioner "called in " to and " attending " the sufferer came to hand. Both practitioners had seen the patient, independently, on the same day. The first to notify the illness was a police surgeon who went to the house because a police constable lived there, by whom the case was reported to his superior officer, in conformity with the Order of the Chief Commissioner. This gentleman could not have fulfilled his duty—which, doubtless, involved temporary release of the constable from duty—without seeing the case to ascertain that it was one of infectious disease. The information given was valuable, and the fee was paid ; but, technically, payment might have been refused without infraction of law. THE LONDON SCHOOL BOARD AND NOTIFICATION. In former reports, extending over some seventeen years, I had occasion to refer to the action of the School Board for London, taken at my instance, with the object of preventing the spread of infectious disease through the agency of public elementary schools. The Visitors first, and subsequently the Head Teachers, were instructed to inform the Medical Officer of Health with regard to any children absent from school, when there was reason to suspect that such absence was due to illness of an infectious character. When the Notification Act came into operation, the Board and their Medical Officer manifested a commendable desire to utilize its provisions to the utmost, for preventing the spread of disease through Board Schools. The Public Health Act, 1891, makes provision for 149 information to be given by the Medical Officer of Health to the Head Teachers of all Schools, of the occurrence of any of the infectious diseases named therein, whether in school children themselves, or in houses from which children are attending school. This provision has been duly carried out, by direct communication with the Head Teachers of private schools, and through the Superintendent of Visitors for the Chelsea Division of the London School Board in the case of all public elementary Schools. PAYMENT OF FEES FOR CERTIFICATES. During the year 1893, for notification certificates received by me the sum of £207 Is. 6d. became due to medical practitioners, in amounts varying from one shilling to £6 5s. Od. These amounts having been paid by your Vestry, were recouped by the Asylums Board and charged to the Metropolitan Common Poor Fund. A question having arisen, in 1889, how the accounts could be most conveniently arranged, I proposed that we should prepare a statement of the sums due to the several medical men, and forward to each the amount of his claim, by postal order. This plan—simple and convenient, the amounts due being known, the certificates forming, as it were, a bill of items—was adopted, and has worked satisfactorily. COMPULSORY REMOVAL TO HOSPITAL. An infectious sick person may be compulsorily removed to hospital by a Justice's Order,upon the certificate ofa registered medical practitioner, if he be" without proper lodging or accommodation." But it has been held that the fitness of the lodging or accommodation is to be considered only as it affects the patient himself, and without any reference to the welfare of the other inhabitants of the dwelling-house wherein 150 he may live. The conference of the Sanitary Authorities, convened by your Vestry in 1881, on the subject of Notification of infectious disease, dealt with this question of compulsory removal also, having passed a resolution to the effect that the law, as it stands, is " insufficient for the protection of the public health," and should be " so amended as to empower any Justice to direct the removal to a hospital .... of any person suffering from any dangerous infectious disorder, and being without proper lodging or accommodation, which would enable him to be properly isolated, so as to prevent the spread of disease to other inmates of the same house ; or to be properly treated." My own view that such an alteration of the law is necessary, is just as strong now as when I drafted the above resolution thirteen years ago. I was glad to observe, therefore, that in a Bill to amend the Public Health (London) Act, 1891, introduced by Sir Henry Roscoe and other members in the session of 1893, the subject was proposed to be dealt with in this direction, section 3 of the Bill providing for the following sub-section to be added, and numbered to section sixty-six of the principal Act, viz.:— " (4) A person who is not provided with lodging and accommodation in which proper precautions can be taken to prevent the spreading of the dangerous infectious disease from which such person is suffering, shall be deemed, for the purposes of this Act, to be without proper lodging or accommodation." The state of political affairs, unfortunately, did not allow of the Bill being carried into an Act, and the same cause is operating now as a bar to legislation on the subject. 151 PROGRESS IN SANITARY LEGISLATION. In my Annual Report for 1888, I referred to a SYNOPSIS of various matters, relating to the extension of the duties and powers of the Managers of the Metropolitan Asylums Board, with respect to infectious disease, which were then under the consideration of the Local Government Board. This Synopsis had been prepared by direction of the General Purposes Committee, at the latter end of 1888, and a copy of it was 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 intention to submit to Parliament." The subjects referred to in the Synopsis were— (1) Admission to Hospital of all classes of Infectious Patients. (2) General Conveyance of Infectious Persons to Hospital. (3) Admission of cases of Diphthetia to the Hospitals. (4) Compulsory Notification of Infectious Diseases. (5) Compulsory Removal of the Infectious Sick to Hospital, when without proper lodging or accommodation. (6) Compulsory Purchase of Land. (7) Contracts ivith Sanitary Authorities for the tion and Maintenance in Hospitals of Non-paupers. The objects sought to be attained in respect of (1), (2), (3), (4), and (6) were secured, in 1889, by the Infectious Disease (.Notification) Act, and clauses in the Poor Law Act, which were repealed by the Public Health (London) Act, 1891, in which the provisions are re-enacted. At page 149 I have referred to the question of (5) Compulsory Removal of the Sick, which still awaits settlement. With reference to (7) I have stated, in former Reports, the grounds of my objection to the contract system, which happily is no longer in question, free admission to the hospitals having now been secured by the Public Health (LondonJ Act, 1891. 152 HOSPITALS COMMISSION. In 1881, a Royal Commission was appointed to consider the question of Hospital Accommodation for Infectious Diseases, before which I gave evidence, a summary of which will be found in my Annual Report for 1881 (pages 50—60 inclusive). In my Annual Report for 1882-83 (pages 28—39 inclusive) I dealt with the report of the Commission, reproducing their " Practical Recommendations," which were in accord with the principles, in regard to public health administration in the Metropolis, for which I had long contended. Amongst other principles, most of which first found expression in these Reports, I may refer to (1) Compulsory Notification of cases of infectious disease; (2) Compulsory Removal of the sick to hospital 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 any connection with Poor-Law Relief, or, in other words, abolition of the distinction between Pauper and Non-pauper in respect to the treatment of infectious disease ; (5) Free hospital treatment of persons suffering from infectious disease ; (6) Provision of additional hospitals in London, with skeleton staff of doctors, nurses, and other officers, capable of extension, as necessary, to cope with emergencies ; (7) Provision of hospitals outside London for removable cases of small-pox, and for the reception of convalescents generally ; and (8) Transference of Vaccination arrangements to the Hospital (that is, the Sanitary) Authority. Previous sections of this Report will have shown to how large an extent, either by law or in practice, my views have already been carried out. Parliamentary sanction, I doubt not, will sooner or later be given to those recommendations which are still in advance of public opinion. 153 PUBLIC HEALTH (LONDON) ACT, 1891 ; BYE-LAWS, Etc. The subject of sanitary legislation, which occupied so large a space in my report for 1891, calls for little notice on the present occasion, nothing of importance having been added to the Statutes in the Parliamentary Session of 1893. But since the date of my last report your Vestry's bye laws and those made by the County Conncil, under the provisions of the Act, have been confirmed by the Local Government Board and are now in force. The duty of enforcing the Council's bye-laws devolves upon the Sanitary Authorities. Some of these bye-laws, relating to drainage, have formed the subject of a report by your Vestry's Surveyor, as they deal with matters provided for in your Vestry's, " Rules as to the construction of house drains etc.," which will have to be revised, in order to bring them into conformity with the requirements of the said Bye-laws. Whilst on the subject of bye-laws, I should like to say that it would be to the public advantage were the Council to exercise their power to frame uniform bye-laws with regard to the construction of drains, under the provisions of section 202 of the Metropolis Local Management Act, 1855, for the guidance of Sanitary Authorities throughout the metropolis. The section in question enables the Council, " from time to time," to " make, alter, and repeal bye-laws . . (c) for regulating the dimensions, form, and mode of construction, and the keeping, cleansing, and repairing of the pipes, drains, and other means of communicating with sewers, and the traps and apparatus connected therewith." For thirty-eight years this power has been in abeyance. It would be to the public interest that the question should receive the Council's consideration, and I suggest that the Council be recommended to exercise this power by making the necessary byelaws. 154 PUBLIC HEALTH (LONDON) BILL. A Bill with this title, " to amend and extend the Public Health (London) Act, 1891," was introduced by Sir Henry Roscoe and others in the Session of 1893. The principal sanitary objects of the Bill were (a) to facilitate the regular cleansing of ash-pits, by requiring that they shall be cleansed out and emptied at least once in seven days (sec. 1) ; (6) to prevent the cutting-off of water supply for non-payment of rates, when the rate is payable by the occupier, by making the rate a first charge on the dwelling house, the amount being recoverable from the owner as a debt due from him, after due notice to him to pay, the owner to be entitled to add the amount of the rate to the rent payable to him by the occupier in default (sec. 2); and (c) to provide for the compulsory removal to hospital of a person sick of an infectious disease who is not provided with lodging and accommodation in which proper precautions can be taken to prevent the spreading of the disease (sec. 3). Section 5 was to enable the Local Government Board to limit a time within which a defaulting Sanitary Authority must provide and fit up a Mortuary: the Board's order to be enforceable by writ of Mandamus, the County Council, at the discretion of the Board, to be appointed to provide and fit up the Mortuary. Other provisions of minor importance referred to Milk Supply (sec. 4), Bye-laws providing for air space about buildings (sec. 9), and number and certification of Sanitary Inspectors (sees. 6—7). This useful measure, like so many others, had to be dropped. It will no doubt be revived at some future time, in view of which eventuality it would be well that the Sanitary Authorities should consider what other amendments are desirable, to rectify observed defects, and to supply such additional powers as experience of the working of the Act may have shown to be required. 155 FACTORY AND WORKSHOP ACTS. The duties imposed on your Vestry as Sanitary Authority in relation to factories, workshops, workplaces, &c., both by the Factory and Workshop Acts, 1878 to 1891, and by the Public Health (London) Act, 1891, were fully set out in my report for 1891. From time to time since the latter Act came into operation at the beginning of 1892, I have received from Her Majesty's Superintending Inspector of Workshops complaints of overcrowding of workshops—dressmakers' establishments to wit—in South Kensington. Among the complaints received there were such as follow: " Found 18 women in two rooms on ground floor .... estimated cubic space 2,000 feet " (or 111 feet per person). " Found 25 women in first floor front, estimated cubic space 3,040 feet " (or 122 feet per person). " Found 10 women in one room, estimated cubic space 1,440 feet " (or 144 feet per person). In one room the Sanitary Inspector found 24 women where there was space for 16 only, the workers being cramped even for elbow room. It is almost needless to observe that, apart from the question of ventilation, this air space was altogether inadequate, and it was recognised that a standard of space should be fixed for the guidance of the Inspectors. Your Vestry's regulations for houses " let in lodgings or occupied by members of more than one family " require air space " for each person in a room occupied by day only, or by night only, of not less than 300 cubic feet;" and it seemed not unreasonable that an equal amount should be required in a workplace where at times much gas is consumed, and where more or less of the available room is taken up by furniture, &c. The matter having been considered by the Sanitary Committee, it was resolved, your Vestry subsequently approving, that an air space at the rate of 250 feet per person should be required, three gas burners to be reckoned as equivalent to one person. 156 A good many dressmakers' workshops in South Kensington were visited, in the early part of 1893, by the Sanitary Inspector, who reported that these establishments were so numerous that it would take up much of his time to keep them under such supervision as the Acts require, and, I would add, as in the interests of a numerous and somewhat helpless class of people, they should receive. It was, of course, my duty to see that complaints received from H.M. Superintending Inspector were duly attended to, and it had been my practice to pay immediate attention to complaints (mostly anonymous) received from suppositious work-women. The Sanitary Inspectors, moreover, were instructed to inspect workshops, &c., occasionally, as the exigencies of their more customary work might allow. But feeling all this to be insufficient, and having regard to your Vestry's statutory obligations as set out in the Acts, and to the somewhat delicate nature of the work, I suggested in my sixth report for 1893, the desirability of employing Women Inspectors. This suggestion was well received,and subsequently, upon the recommendation of the Sanitary Committee, your Vestry almost unanimously resolved to appoint two Women Inspectors. In due course two competent ladies were found to undertake the work, and they were authorised to authenticate by their signature such notices as the Sanitary Committee should direct to be issued under the provisions of the Public Health (London) Act, 1891, and alsoto serve written intimations of nuisances in conformity with the requirements of the third section of the same Act. The new departure aroused considerable interest in sanitary circles not confined to the Metropolis. The appointments were made in the first instance for a period of six months, at the conclusion of which period, viz., 25th April in the current year, I submitted a report setting out the results of the experiment as follows :— 157 WOMEN INSPECTORS. " The period for which Miss Rose E. Squire and Miss Lucy Deane, the Inspectors of Workshops, See., where women are employed,were appointed, having expired, I venture to offer a few remarks on the duties these ladies have carried out during the past six months—premising that one of them, Miss Deane, has terminated her connection with the work of the Parish on her appointment by the Home Secretary to the even more important office of Government Inspector of Factories and Workshops. Miss Squire, it will be remembered, was appointed to the district north of Uxbridge Road, Miss Deane taking the South District, which covers the remainder of the Parish south of that road. In the North District the laundries are numerous: in the South District the laundries are few, but the businesses of dressmaker, milliner, and others of like character, are far more numerous than in the North District. It is not to be supposed that nearly all of the business premises that should come under supervision have as yet been discovered and visited; but already Miss Squire has visited, inspected, and registered 239 premises, comprising 169 laundries, 60 dressmakers, and 10 miscellaneous businesses. Miss Deane has visited, inspected, and registered 209 premises, comprising 18 laundries, 175 dressmakers, and 16 miscellaneous businesses. For the purposes of registration, books have been provided with apppropriate columns for the record of particulars, as follows : 1, Register number ; 2, Date of Registration ; 3, Name of Street, &c. ; 4, Name of Occupier; 5, Description of Trade or Business ; 6, Dimensions of (each) work-room, i.e., length, breadth, height, and cubic feet of space ; 7, Number of gas burners ; 8, Maximum number of occupants allowed; 9, Means of ventilation ; 10, Number and position of sanitary conveniences ; 11, Remarks. The Inspectors were provided with pocket books ruled and headed to correspond with the columns in the Register, so as to secure accuracy in making 158 out the lists of trade premises and businesses with all the needful particulars as above set out. The workrooms inspected, measured, and cubed, to date, number 768, viz., 417 in the North District, and 351 in the South District. It will readily be understood, therefore, that considerable time and labour have been expended in obtaining the necessary particulars and placing them on the permanent record. The Inspectors were further provided with books for recording the results of ordinary inspections of registered premises, with ruled and headed columns for showing 1, Date of inspection ; 2, Number of persons found in each workroom ; 3, State of workroom as to warming; 4, Means of heating irons ; 5, Condition of premises ; 6, Condition of sanitary conveniences ; 7, Dustbin, position and condition of; 8, Drinking water supply ; 9, General Remarks. Ruled and headed sheets were provided for the report by the Inspectors of nuisances liable to be dealt with under the Factory and Workshop Acts, 1878 to 1891, and the Public Health (London) Act, 1891, specifying: —1, Number of the case; 2, Registered number of premises ; 3, Premises at which the nuisance exists; 4, Trade or business carried on at the said premises ; 5, Description of complaint, nuisance, &c.; 6, Date when written intimation of the nuisance was served ; 7, Works necessary to be executed, and things to be done, to remove cause of complaint or to abate the nuisance; 8, Time necessary for the abatement of the nuisance; 9, Remarks. Lastly, the Inspectors were furnished with a form of notice to send immediately to the occupiers of premises at which instances of overcrowding were observed. "The supervision of the work of the Inspectors was delegated by the Works and Sanitary Committee to a SubCommittee which meets once in four weeks. The Inspectors attend before the Sub-Committee to submit their ' Complaint Sheets,' and take instructions with respect to each case. The statutory notices which are directed to be issued, are prepared 159 in the clerical department of my office, signed by the Inspectors, and served through the post. For the information of the Sub-Committee, the Inspectors prepare periodically those Statements of work carried out by them, which from time to time appear on your Vestry's Agenda. The following Table comprises the total of work carried out during the period of twenty-four weeks. Description of Work. North Kensington. South Kensington. Total whole Parish. Dressmakers. Laundries. Miscellaneous. Total. Dressmakers. Laundries. Miscellaneous. Total. Houses Visited 152 304 113 569 36s 42 151 538 1107 Workshops Inspected 61 176 .6 253 285 26 26 337 590 ,, Workrooms therein inspected 71 377 56 504 467 61 28 557 1061 ,, Overcrowded 7 2 2 II 45 ... ... 45 56 ,, Insufficiently ventilated 7 2 1 IO 4 ... ... 4 14 „ In a dirty condition 5 80 1 86 25 5 1 31 "7 „ Re-inspected 119 ... 119 38 4 1 43 162 Sanitary arrangements of premises defective ; Cases reported to the Medical Officer of Health ... 57 ... 57 21 5 1 27 84 Notices Issued 1 79 80 61 1 1 63 143 NOTE.— The difference between the number of" Houses visited" and "Workshops inspected," and " re-inspected," represents the number of houses occupied partly or entirely by Dressmakers and others, at which no women workers were found to be employed. " The Sub-Committee, at their meeting held on the 9th April, in calling the attention of the Sanitary Committee to the fact that the tentative appointments of the Inspectors would expire on the 25th April, placed on record their sense of the satisfactory manner in which the Inspectors had performed their duties, and referred to the fact that since they had 160 been in the Vestry's service they had qualified themselves for the office of Sanitary Inspector by obtaining the Certificate of the Sanitary Institute. The Report of the SubCommittee was adopted by the Committee, who, on the 11th April, reported to your Vestry their concurrence with the Sub-Committee 'as to the expediency of renewing the appointment of the Inspectors during the pleasure of the Vestry,'and stated their opinion 'that the discharge of the duties devolving upon them would be materially facilitated were the Inspectors vested with the powers which attach to a Sanitary Inspector.' The Committee accordingly recommended, ' That the appointments of Miss Squire and Miss Deane be continued during the pleasure of the Vestry, and that they be vested with the status of Sanitary Inspectors, subject to the approval of the Local Government Board.' The Committee's Report was referred back on a technical objection, and in a subsequent Report, adopted by your Vestry on the 25th April, the day the six months' term ended, the Committee, whilst fully confirming the previous favourable reference to the satisfactory manner in which the Inspectors had performed their duties, and still holding to ' the expediency of the appointments being renewed for a further period,' did not, ' upon further consideration . . . adhere to that portion of their former recommendation which suggested that the appointments should be continued during the pleasure of the Vestry, and that the Inspectors should be vested with the status of Sanitary Inspectors.' The Committee accordingly recommended, simply, that the appointments ' be continued for a further period of one year.' But prior to the meeting of your Vestry, viz., on the 23rd April, it became my pleasing duty to report to the Committee that Miss Deane had been appointed a Government Inspector of Factories, Workshops, &c., and therefore could not accept re-appointment. The Committee, thereupon, varied their recommendation by naming Miss Squire only, and by 161 ing that it be referred to them ' to take the necessary steps for the appointment of a successor to Miss Deane, with authority to make such appointment subject to confirmation by the Vestry.' " I trust that it will not be thought out of place on my part—as the officer responsible, primarily, for these appointments having been made, and, subsequently, for the control of an entirely new department of your Vestry's sanitary work— to say how cordially 1 concur with the Committee in their favourable appreciation of the manner in which the Inspectors have carried out their duties. I venture to add that it speedily became apparent to me that the position these ladies occupied was a somewhat anomalous one, and that their usefulness would be much enhanced did they possess the status of a Sanitary Inspector. Accordingly—and it being the rule of your Vestry to require of candidates for the office of Sanitary Inspector the possession of the Certificate of the Sanitary Institute—I advised both ladies to take steps to obtain the said certificate, which, after a period of study, followed by examination, they succeeded in doing. The reason for this advice, which was endorsed by the Sub-Committee, was that, before the ' Sanitary Authority ' can lawfully serve notice on the owner or occupier of a workshop to cleanse or purify the same, they must have 'the certificate of a Medical Officer of Health or Sanitary Inspector,' that such cleansing, &c., of the workshop, is ' necessary for the health of the persons employed therein ' (Public Health {London) Act, 1891, Section 25). The Women Inspectors cannot give this certificate, although they are qualified to act as Sanitary Inspectors ; but it must be obvious, I venture to think, that they should be in a position so to do. Notices have been served, by the order of the Sub-Committee, upon the recommendation of the Inspectors, for works of cleansing, etc.; but if it became necessary, in case of objection to the notice on the part of k 162 the owner or occupier of the workshop, or if lie neglected to carry out the requirements of the notice, the Magistrate would be justified in refusing to make an Order, or to inflict the fine attaching to disobedience of a proper notice. To obviate this difficulty it would be necessary for me, or one of the Sanitary Inspectors, to visit every workshop in respect of which a notice was required for works of cleansing, &c., a very undesirable course. The work of the Inspectors is carried out mainly under the above cited 25th Section ; but they have also to take cognizance of Section 2 (1) {g), which includes in the list of nuisances ' liable to be dealt with summarily under the Act,' "' Any factory, workshop, or workplace, which is not a factory subject to the provisions of the Factory and Workshop Act, 1878, relating to cleanliness, ventilation, and overcrowding, and (i.) is not kept in a cleanly state and free from effluvia arising from any drain, privy, earth-closet, watercloset, urinal, or other nuisance ; or (ii.) is not ventilated in such a manner as to render harmless, as far as practicable, any gases, vapours, dust, or other impurities generated in the course of the work carried on therein, that are a nuisance, or injurious, or dangerous to health ; or (iii.) is so overcrowded while work is carried on as to be injurious or dangerous to the health of those employed therein.' " It must be manifest, I think, that the duties the Inspectors are called upon to discharge under this section also, would be facilitated were they ' vested with the status of Sanitary Inspectors.' The question, therefore, whether the recent decision of your Vestry on the subject, may not with advantage be reconsidered at no distant date, is one to which I 163 would respectfully invite attention. I will only add that by Section 107 of the Act cited, the Sanitary Authority are enabled to ' distribute among (the persons appointed as Sanitary Inspectors) the duties to be performed by Sanitary Inspectors'; so that the work of the Women Inspectors, if they were re-appointed as Sanitary Inspectors, could be strictly limited to such duties, and exercised only in regard to such places {e.g., workshops, workplaces, laundries, etc., where women are employed) as your Vestry should see fit to direct. As a minor and final consideration it may be pointed out that, should these ladies be at any time appointed Sanitary Inspectors,as I venture, in agreement with the Sub-Committee, to think they should be, a moiety of the salary attached to the office would be repayable to your Vestry by the London County Council." No action was taken on the above report. It may be here mentioned that in the Minority Report of the LabourCommission,the signatoriesexpress an opinion "that the number of women factory inspectors should be increased, and that local authorities might advantageously be urged by the Local Government Board to follow the example of the Kensington Vestry in appointing Women Sanitary Inspectors, with the special object of enforcing the Sanitary Law in women's workshops "—a duty which, as I have explained above, cannot be efficiently carried out by Inspectors who, like your Vestry's Officers, are not vested with the status of Sanitary Inspectors. New Factory and Workshop Bill.—During the current session, a Bill has been introduced by the Home Secretary, which, inter alia, defines " overcrowding " to mean an allowance of less than 250 cubic feet of space per worker, and includes laundries in the law as to factories and workshops—an amendment of the law which would facilitate the work of Miss Squire, who has in her district some tvvp hundred laundries. 164 THE WORK OF THE SANITARY INSPECTORS. Tables VI. (Appendix) contains a summary of the work of the Sanitary Inspectors during the year ended March 25th, 1894. The work of the Inspectors is conducted under the supervision of the Sanitary Committee, upon which your Vestry have conferred, by resolution, power to carry out the provisions of the Public Health (London) Act, 1891 ; the Housing of the Working Classes Act, 1890; and the Factory and Workshop Acts, 1878 to 1891. The staff having been increased in 1892 by the addition of two Inspectors, it became necessary to re-arrange the sanitary districts, and with the approval of the Committee the Parish was then mapped out into six districts as follows :—All that portion of the Northern Division of the Parliamentary Borough of Kensington, to the north of the City and Hammersmith Railway, to constitute the North District, the remainder of the Northern Division constituting the North-East and the north-west Districts; Ladbroke Grove and part of Ladbroke Grove Road being the dividing line. The central District is, as before, that portion of the Southern Division of the Borough which lies between the centre of Notting Hill High Street, and Uxbridge Road, and the centre of Kensington High Street and Kensington Road. The remainder of the Southern Division constitutes the South-East and the South-West Districts, the dividing line running down Marloes Road and Lexham Gardens to Cromwell Road, crossing that road and then running down Collingham Road, the Boltons, and Gilston Road to Fulham Road. The Inspector for the south-east District takes both sides of Collingham Road, The Boltons, and Gilston Road. The Inspector for the south-west District takes both sides of Marloes Road and the whole of Lexham Gardens. Your Vestry having resolved, in 1893, upon the recommendation of the Sanitary Committee, to appoint an additional Sanitary Inspector to take charge of that portion of 165 the North-West district which comprises, among others, Bangor Street, St. Ann's Road, St. Katherine's Road, Stoneleigh Street, William Street, Crescent Street, and St. Clement's Road, the North-West District was divided accordingly. At the same time a small group of streets, including Bomore Road, Testerton Street, Barandon Street, and Manchester Street, was taken from the North District and tacked on to Division B of the North-West District. The Sanitary Inspecting Staff now comprises seven Inspectors and two Assistant Inspectors, irrespective of the two Women Inspectors of Workshops, &c. The clerical staff comprises a Chief Clerk and three Assistant Clerks. The Disinfector and the Mortuary Keeper complete the list of Officers in the Public Health Department, the cost of which, including the salary of the Medical Officer of Health, is considerably less than one-third of a penny in the pound on the rateable value of the parish. A considerable portion of this, however, viz., half the salaries of five of the Sanitary Inspectors, is repaid to your Vestry by the London County Council, from which body a still larger subvention could be obtained under the provisions of the Local Government Act, 1888, and the Public Health (London) Act, 1891. During the year a large amount of house-to-house inspection was carried out in all parts of the parish by the several inspectors ; and 1897 notices were issued, by order of the Sanitary Committee, involving reconstruction, or trapping and ventilating of drains, amongst other sanitary amendments of the houses dealt with. The written intimations of nuisances served by the Inspectors, under section 3 of the Act, numbered 2724. As a result of these intimations, in a large number of cases, the works necessary for the abatement of nuisances were carried out, by the persons liable, without the service of the statutory notice, which is issued only on the order of the Sanitary Committee. 166 There has been a marked improvement in respect of the attention paid to your Vestry's notices since the Public Health Act of 1891, came into operation. In my last report, for 1892-93 (pp. 128-133), I described under the heading " Sanitary Works and Legal Procedure" the system introduced for giving effect to the provisions, and executing the powers conferred by the Act, and I particularly referred to the diminished frequency with which we had had to invoke the aid of the magistrate—only 36 summonses having been issued in 1892-93 compared with 122 in 1891-92—as a result of the adoption of the plan of sending a courtesy notice to persons in default, calling attention to the serious penalties imposed by the Act and urging, with a view to avoidance of further proceedings, immediate compliance with the requirements of your Vestry. The same success has attended a continuance of the practice in the past year, over 300 of these so-called "final " notices having been sent out, with the result that it became necessary in 35 cases only to have recourse to the police court. Legal Proceedings.—Amjng the cases in which recourse was had to legal proceedings, the following may be cited as of interest:— Removal of Fish Offal.—The offence in this case was the removal of fish offal in an improper receptacle, viz.: the bed of a cart, contrary to the requirement of the bye-law, made by the County Council under the provisions of the Public Health (London) Act, 1891, which deals with the " removal or carriage ... of any . . . offensive or noxious matter or liquid in or through L mdon," and requires " that the carriage or vessel used therefor shall be properly constructed, and covered, so as to prevent the escape of any such matter or liquid, and to prevent any nuisance arising therefrom." A conviction was obtained, a fine of ten shillings and costs being imposed. 167 Unsound Fish.—The Sanitary Inspector for the NorthWest District seized a quantity of herrings which were being sold, at four-a-penny, in the public streets, by a " coster," who admitted that he knew the fish to be bad, and that the seizure was only what he had expected. The fish, which had undergone putrefactive change, were in due course condemned by the magistrate and destroyed. By direction of the Sanitary Committee proceedings were taken against the vendor, for the offence of exposing for sale an article of food which was unwholesome and unfit for the food of man. The offence not admitting of dispute, conviction necessarily followed, but no fine was inflicted. Indeed, the sitting magistrate made the benevolent suggestion, which was acted on, that your Vestry should not apply for the costs incurred by taking out the necessary summons. The defendant, after the fish had been condemned, applied to me for a certificate to enable him to recover the amount paid to the market salesman for them. Had he made this application when he found that he had bought stinking fish—at stinking fish price—instead of exposing the fish for sale, he would have received every assistance. But it was a little too much to expect that the Sanitary Authority should condone a wilful offence by assisting the wrong-doer. A new and valuable provision is contained in the Public Health (London) Act, 1891, Sec. 47 (3), which renders the original vendor of an article of food unfit for the use of man, liable to the fine and imprisonment specified in sub-section (1), " unless he proves that at the time he sold the said article, he did not know, and had no reason to believe, that it was in such a condition." Had the coster sold the bad fish ignorantly, we should have tried to fix responsibility on the market salesman; but whether it would have been possible to'prove guilty knowledge on his part is more than I am able to say. Unsound Meat.—Proceedings were taken against a butcher, in Portobello Road, for the offence of exposing for 168 sale, and selling to a customer, meat which, by reason of putrefactive change, had become unwholesome and unfit for food of man. The defendant having pleaded guilty to the charge, and it appearing to be not an aggravated case, a nominal fine, ten shillings and costs, was inflicted. The prosecution will, I hope, have good effect, if only by bringing it home to butchers that the fact of meat being offered for sale, and sold, at an extremely low price (in this case threepence per pound), cannot be pleaded in extenuation of the offence for which the butcher in question was punished. Exposure of the Infectious Sick in public places, a too common practice, has already received some notice at page 46. In several cases during the past year the exposure was in public vehicles, persons suffering from diphtheria and scarlet fever having, under a variety of circumstances, been removed to hospital, 01* from place to place, in cabs, the numbers of which were unknown, so that the vehicles could not be disinfected, and the subsequent hirers of them undoubtedly were exposed to serious danger. It was not possible to prove that in any of the cases the offending parties had guilty knowledge of the offence they were committing, and no proceedings were taken in this parish. In one case, however, proceedings were taken at a seaside town in respect of an offence which was committed there, and repeated in this parish, a sick child having been conveyed in public vehicles both before and at the end of a railway journey. Failure to Notify Infectious Disease.—A gross case of exposure of children suffering from small pox formed the subject of an inquiry at the police-court. The offender lived in a house from which two cases of the disease had been removed to hospital, in November and December respectively. The house was visited several times by the Sanitary Inspector, who was informed that no one was ill. In January, however, he received an anonymous letter intimating that children 169 living with their parents in the basement were ill. He visited the house immediately and found four children convalescing after mild attacks of small-pox. He also ascertained that the children had been playing in the streets. The children were removed to hospital and their father—who evidently knew what was the matter with them—was prosecuted, not for the offence of exposing them, but for failure to notify the illness to the Medical Officer of Health under the provisions of section 55 (a) of the Public Health (London) Act, 1891. This section requires " the head of the family .... as soon as he becomes aware that the patient is suffering from an infectious disease . . . (to) send notice to the Medical Officer of Health of the District "■—a provision which, doubtless, was inserted for the purpose of meeting cases like this when no medical practitioner is " attending on " or has been " called in to visit the patient." The man was fined forty shillings and costs, all four offences, i.e., in respect of the four children, having been included in one summons in consideration of the defendant's position in life. Failure to Notify by Medical Practitioners.— In two cases it became necessary to take proceedings against medical practitioners. In one instance, alluded to at page 48, a conviction was obtained and a fine of forty shillings was imposed. In a second instance, also alluded to previously, at page 40, the proceedings proved abortive, the case having been dismissed by the Magistrate, without costs, on the ground that the imperfect wording of the section, 55 (2), of the Public Health Act under which the proceedings were instituted, did no enable your Vestry to bring home to the defendant the particular offence with which he was charged. It might have been expected that the defendant, who was represented by counsel, would have pleaded guilty, as advised, and submitted to the small pecuniary fine with which the alleged offence is punishable. But, to the end of the second day of the hearing, his defence was that he was not able to satisfy himself that the iro disease was small-pox—a remarkable admission, seeing that the first case, in an unvaccinated girl of 12, was severe, the eruption being profuse and characteristic, whilst in the second and fatal case, the disease was of the confluent variety, which one would have thought it impossible to confound with any other known disease. The fact that both patients had smallpox was proved up to the hilt, and the Magistrate animadverted on the "lamentable want of judgment and of knowledge" exhibited by the defendant, who, being in doubt, should have consulted someone who might have cleared up the doubt. He suggested, moreover, the desirability of an attempt being made to get the section amended, so that the offence of failure to notify should be established—not on proof of the medical practitioner " becoming aware," but " on it becoming evident " that the patient was " suffering from an infectious disease to which the section applies." In conformity with the'recommendation of the Sanitary Committee, a communication on the subject was addressed to the Local Government Board, setting out the substance of the Magistrate's decision, and endorsing his views on the defects of the section as expressed therein. The wide publicity the case obtained, no doubt, secured in a measure the object the Sanitary Committee had in view in instituting the proceedings, though it may be, as the law stands, somewhat difficult to prove an offence, such as that with which the defendent was charged. The Magistrate commended the course taken by the Sanitary Committee, on public grounds, in bringing the case before the Court. Jurisdiction of Justices.—It may be mentioned that towards the end of the official year 1893-94, your Vestry received a communication from the Clerk to the Kensington Justices, with reference to the question as to the jurisdiction of the County Justices acting within the Districts of the Metropolitan Police Courts, raised some time since, and 171 intimating that decisions in special cases stated from the Kensington Division having recently been given in the High Court of Justice (Queen's Bench Division) in favour of the jurisdiction of the Justices, they would again hold weekly Petty Sessional Courts at the Town Hall Kensington, on and after the 20th January ; whereupon the Vestry Clerk was instructed to " revert to the practice which formerly prevailed, and to bring such summary proceedings as the Vestry may direct, under the Acts which they are called upon to administer, before the County Justices sitting in Petty Sessions at the Town Hall," and this cause has since been adopted. Infected Dead Bodies in Churches.—Reference was made above to the use of cabs for the removal of cases of diphtheria to hospitals. In one such case the child was desperately ill and soon succumbed. The removal had been effected on medical advice, but the parents had not been directed to obtain an ambulance. Guilty knowledge was not imputed to them, and no proceedings were taken against them for the offence. They were desirous of taking the body of the child into a church for performance of the burial service, but the cause of death having became known to the church authorities, not by any communication from the parents, the desired permission was refused. Having been consulted as to the propriety of the course adopted by the said authorities, I had no hesitation in expressing my entire approval. The Sanitary Committee, to whom I reported the facts, also concurred in the propriety of the action taken, and readilyadopted the suggestion that a communication on the subject might, with advantage, be addressed to the beneficed clergy of the parish. This was done, and it is satisfactory to know that the circular letter was well received. The Vicar of Kensington thought the course proposed to be adopted " most wise," and he entertained favourably the suggestion that he might be able with advantage to bring the matter to the attention of the clergy of his rural deanery. The Ven. R. Thornton, D.D., Vicar of St. John's Notting Hill and Archdeacon of Middlesex, also wrote to " approve highly of the judicious circular letter " on the subject. He stated that he was, and would be, " most careful in the matter," as regarded St. John's Church, and would" advise the clergy of the archdeaconry to be equally careful." He made the useful suggestion, which was acted upon, that a similar communication should be sent to the undertakers carrying on their business in the parish. OFFENSIVE BUSINESSES. The only business coming under the statutory description " offensive," other than that of a slaughterer of cattle, carried on in this parish, is that of a FAT EXTRACTOR in Tobin Street, in the Potteries, Notting Dale. The conduct of this business gives rise at all times to more or less local effluvium nuisance, despite improved arrangements, care on the part of the proprietor, and supervision by your Vestry's Inspector, as well as by the Inspector of the London County Council. The premises were inspected by the Sanitary Committee in July, at a time when there was little going on, so that the smell perceived in the neighbourhood was less pronounced than usual. MARINE STORES The business of a marine store dealer is not scheduled in the Public Health (London) Act, 1891, as an offensive business, but it gives rise often to offensive smells; and as it has been held by the Appeal Court to be ejusdem generis with the businesses scheduled in that Act, it would be well should the County Council see fit to add it to the list, as, many years ago, your Vestry at my instance requested the late Metropolitan Board to do, but without success. 173 BRICK BURNING. Your Vestry requested the County Council, in 1889, to add the business of a brick maker to the scheduled list of offensive businesses. The Council, however, thought that the business might be regulated by bve-laws, under the provisions of the Local Government Act, 1888, and Section 23 of the Municipal Corporations Act, 1882; and. under circumstances set out in my Annual Report for 1891 (page 179), the Council made bye-laws accordingly. The Local Government Board did not confirm the bye-laws, being of opinion that the Public Health (London) Act, 1891, section 21, would, when it came into operation, enable Sanitary Authorities to cope with nuisances due to this cause. The nuisance is a serious one causing great annoyance over a very large area. For many years, including the year 1891, it was the cause of numerous complaints in this parish, so surely as the burning season came round. In 1892 not a single complaint was received, a striking fact seeing that, for the first time since I entered upon the duties of my office, no bricks were burned at Wood Lane, Hammersmith, the reputed locality of the nuisance, as it affects Kensington. In 1893, with the resumption of brickmaking, the nuisance from brick-burning recurred and many complaints were received from parishioners in various parts of the parish. The brickmakers were communicated with, and warned that if the nuisance should continue proceedings would be taken to put a stop to it under the provisions of the Act. The nuisance naturally did continue, and in November summonses in the police court were issued under Section 2L of the Public Health (London) Act, 1891, against three of the brickmakers, on account of the nuisance created, and on the ground that they did not adopt " the best practicable means for abating the nuisance, or preventing or counteracting the effluvia." The proceedings at the police court commenced in January, but as the case is still sub judice at the present time (July), I forbear further reference to the subject. 174 It may be mentioned, however, that the Sanitary Authority " may, if they think fit," on the medical or other certificate, necessary to originate proceedings under section 21, " cause to be taken any proceedings in the High Court against any person in respect of the matters alleged in such certificate " (sub-section 3). Proceedings in the High Court ma}' be taken if it should be held that " summary proceedings would afford an inadequate remedy." The power to go to the High Court would be exercised, presumably, when it was considered necessary to apply for an injunction (under section 13). It is further enacted (sub section 4) that " the Sanitary Authority may take proceedings under this (the 21st) section in respect of a manufactory, building, or premises situate without their district " (as Wood Lane is); " so, however, that the summary proceedings shall be had before a court having jurisdiction in the district where the manufactory, building, or premises are situate." If one might venture a forecast, it would be that "summary proceedings" in a Petty Sessional Court under section 21 will not be found to afford an adequate remedy for the nuisance caused by brick-burning, which is not likely to be abated excepting, as in numerous decided cases it has been, by injunction obtained in the High Court. LICENSED SLAUGHTER-HOUSES. Eight of the 15 licensed slaughter-houses are in North Kensington, i.e., the district north of Uxbridge Road, and seven 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 Sanitary Committee, who reported on them as follows :— " The premises, generally, were found in a satisfactory condition as to cleanliness. The requirements of the new bye-laws of the London County Council, the ' Local Authority' with respect to structural arrangements, appear to have been carried out at all of the licensed 175 premises. These bye-laws require, among other things, that the walls of the slaughter-house, including doors and wood-work generally, shall be covered, to the height of at least six feet, with some impermeable material, and that the floor shall be smooth and jointless. It is further required that the grating over the trap of the drain-inlet shall be a fixture. This requirement also appears to have been complied with. But at several of the premises the requirement that a trough shall be provided for supplying wholesome water to the animals in the pens or lairs had not been carried out. Nor did it appear that duplicate sets of covered receptacles for containing blood, offal, garbage, filth, etc., had been provided, as necessary, seeing that these offensive matters are now to be conveyed from the premises in the containing vessels. This matter will henceforth have to be considered with reference to the provisions of the bye-laws of the County Council, which received the sanction of the Local Government Board at the end of June." Some defects in management were observed by the Committee at certain of the licensed premises : the licensees were duly cautioned, and a copy of the report which detailed the defects in question, was by order of the Committee forwarded to the County Council. The licenses of two of the 19 slaughter-houses inspected by the Committee (one in each district) lapsed in October: one was not applied for ; in the other case the business had been discontinued. It may be mentioned that it 1874 there were some 1,500 slaughter-houses in the Metropolis ; in 1893 only 525, and 12 fewer than in 1892. In Kensington 48 were licensed in 1873, the year before the passing of the Slaughter-houses (Metropolis) Act; in 1874 only 31. The present number is 15. No new slaughter-house has been opened in the parish since 1874. The defect of the Act, which was repealed by the Public Health (London) Act, 1891, was that it ignored the Sanitary Authorities (Vestries and District Boards) 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, have been kept up in Kensington, with obvious advantage, although your Vestry had no statutory authority, and no power excepting such as was derived from liberty to oppose the renewal of the annual license. It is proper that the Council should be the " Local Authority " for the purpose of making regulations, so as to secure uniformity for the whole Metropolis ; but I have always contended that the Sanitary Authorities should have concurrent power to enable them to enforce the requirements of the regulations, and this power has practically been conferred by Section 20 (7) of the Public Health (London) Act, 1891. It is to be desired, in the interests of public health, that private slaughter-houses may, at no distant date, give place to public abattoirs. Meanwhile, it is satisfactory to know that comparatively little slaughtering goes on in the parish, the wants of which are mostly provided for by the dead meat trade. In my Annual Report for 1889 I gave a summary of the provisions of the Sale of Horseflesh, &c., Regulation Act, which came into force in September, 1889. Hitherto, no shop has been opened in this Parish for the sale of horseflesh for food of man. LICENSED COW-HOUSES. Five the eight licensed cow-houses are in North Kensington and three in South Kensington. The names oi the licensees, and the localities of the premises, are set out in Table XII. (Appendix). The several premises were inspected in July by the Works and Sanitary Committee, and found to be in a generally satisfactory condition. There were only 53 cows, in all, in the sheds. Not many years ago there were 28 sheds, containing about 500 cows. There has been a considerable reduction in the number of cowsheds in the Metropolis, viz., from 10-14 in 1880 to 489 in 1893, or 56 fewer than in 1892. In Kensington the reduction has been from 23 in 1880 to 8 in 1893, 177 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. The result would appear to be very satisfactory. Many years have elapsed since I have had any reason for connecting the occurrence of infectious disease with the consumption of contaminated milk ; and it is comparatively rare now to see reference to milk as the supposed cause of disease of an infectious nature. But legislation would appear to be necessary for putting a stop to the sale of the milk of cows suffering from tuberculous disease. The defect in legislation qua cowsheds, dairies, &c., as in the cognate case of the repealed Slaughter-houses Act, is that no attempt has been made to utilise the services of the Medical Officers of Health and the Sanitary Inspectors for purposes of inspection and supervision, the Sanitary Authorities being ignored. The County Council, as Local Authority under the Contagious Diseases (Animals) Acts, recognizes the desirability of enlisting the services of Sanitary Officers in aid of their own staff, in connection with dairies, &c., having requested that the Officers in the Public Health Department might be instructed to assist the Council in carrying out their duties under the Dairies Order ; viz., (1) By informing the Council of any unregistered person carrying on the trade of a purveyor of milk, and (2) By reporting the occurrence of any case of dangerous infectious disease in connection with, or upon the premises of any person engaged in the business of a purveyor of milk. Instructions were given accordingly. L 178 REGULATION OF BAKEHOUSES. The Bakehouses, to the number of 136, viz., 75 in North Kensington, i.e., north of Uxbridge Road, and 61 in South Kensington, i.e., the remainder of the parish south of that road, have been regularly inspected, and such action has been taken, in individual cases, as was found necessary for ensuring compliance with the sanitary provisions of the Factory and Workshop Acts, and the Public Health (London) Act, 1891, relating to bakehouses. From time to time references are made in reports of Medical Officers of Health to the insanitary condition of some of the bakehouses in London, which is due in large measure to the fact that, as a rule, the premises where the making of bread, biscuits, confectionery, &c. is carried on, are undergroundand were not originallyconstructed for the use to which they are applied. In the early part of the current session the subject was referred to in the House of Commons, and in May the Local Government Board addressed a letter to the several Sanitary Authorities in the Metropolis, in which attention was drawn to the " powers and duties in this matter " of those bodies. The Board cited the sections of the Public Health (London) Act, 1891, and of the Factory and Workshop Acts, of 1878 and 1883, which impose on the Sanitary Authority the duty of enforcing provisions " with regard to cleanliness, ventilation, and other sanitary conditions, with respect to any bakehouse, which is a workshop, within their district; " the term " bakehouse " meaning " any place in which are baked bread, biscuits, or confectionery, from the baking or selling of which a profit is derived." The Board stated that they " attach much importance to a strict enforcement of the said provisions," and called attention to the means whereby, in a court of summary jurisdiction, they may be enforced, on the prosecution of a local authority, when " any bakehouse is in such a state as to be on sanitary 179 grounds unfit for use or occupation as a bakehouse." The Board, therefore, trusted "that the Sanitary Authority would give such instructions to their officers as would ensure that the bakehouses in their district to which the Act applies, will be systematically inspected by them, and that when the statutory provisions are not complied with, that the facts will be reported to the Sanitary Authority, and that they will cause to be instituted such proceedings as may be necessary for a due enforcement of the law." The attention of the Public Health and Housing Committee of the London County Council having also been drawn to this subject, they instructed the Council's Medical Officer of Health to report "on the sanitary condition of bakehouses in London," and they subsequently submitted a report to the Council, arising out of the Medical Officer's report, in which it was stated that they were satisfied that it is "very desirable that the provisions of the law with reference to bakehouses should be amended." They thought, moreover, that "the central Metropolitan Authority, rather than the local Sanitary Authority, should have charge of the bakehouses of London, and that the Council should be empowered to make regulations which might deal with the following points :— " (I) The position and structure of workshops and workplaces used as bakehouses and of rooms or places used in connection therewith. " (2) The lighting, ventilation (including air-space) cleansing, drainage and water supply of such premises. " (3) The provision and situation of water-closets and urinals in connection with bakehouses. " (4) The prohibition of the use of the bakehouses for other purposes than the preparation of food. " (5) The use of any room adjoining or opening into any bakehouse. " (6) The conduct of the business, and the prevention of the contamination upon the premises of any articles of food prepared in any bakehouse, or of any materials to be used in the preparation of food. " (7) The mode of making application for license to use any premises as a bakehouse." 180 The Committee also considered that— " (a) No premises should be used as bakehouses which are not licensed by the Council, and that a license should be operative for a period of five years, power being however given to the Council to suspend any license for contravention of the regulations. " (b) That all bakehouses which are occupied for the first time after these regulations come into force should, before such bakehouses are occupied, be made to comply with all the regulations. "(c) That bakehouses which are occupied before the by-laws come into force should be exempt for a period of five years from the regulations, as far as these will require structural alterations other than those now required under existing law, but that after this period they should be required to comply with all the regulations." The Committee called attention to the fact that the Home Secretary had introduced a Bill for amending the Factory and Workshop Acts, which seemed to them " to afford an opportunity for amending the law relating to bakehouses." They therefore recommended— "That the Council do endorse the views expressed in this report, and give instructions for a copy of this report, and of the medical officer's report, to be sent to the President of the Local Government Board, with a request that he will take steps to obtain an amendment of the law relating to bakehouses in the manner here proposed." It appearing to me undesirable that the control of the bakehouses should be taken from the Local Authorities and handed over the Central Authority, as had been done in respect of the slaughter-houses and the cow-sheds; but obviously desirable that the central authority should be empowered to make bye-laws for regulating the business of a baker, so as to secure uniformity throughout the metropolis ; and the report of the Committee containing nothing to indicate what had been done by the Sanitary Authorities with a view to obtain such an amendment of the law as would secure proper supervision of bakehouses, 1 thought the opportunity suitable for 181 recalling the history of the question, which I did in my sixth monthly report, for the current year, as follows :— " Prior to 1878 the supervision of London bakehouses was vested in the officers of the ' Local Authority,' under the provisions of the Bakehouse Regulation Act, 1863. For some reason, unknown to me, the Government of the day transferred the duty of supervising these establishments to the factory inspectors under the provisions of the Factory and Workshop Act, 1878. The results were disastrous. The factory inspectors were too few in number to perform the duty imposed upon them ; and, speaking generally, supervision of bakehouses came to an end. In this parish, indeed, the Sanitary Inspectors continued to visit the premises (nearly 500 inspections of 130 bakehouses were made in 1881) and the necessary steps were taken to secure the best sanitation practicable, regard being had to the fact that most of the bakehouses are underground, and that only in exceptional instances had they been constructed for the purposes of the business. Into what an unsatisfactory state the London bakehouses fell when the duties of sanitary officials in regard to them ceased, may be read in the annual report for 1881 of the Chief Inspector of Factories and Workshops, which includes excerpts from a report on some of the East-end bakehouses by an assistant factory inspector. The revelations contained in that report were, doubtless, the efficient cause of the advice tendered to Government by the Chief Factory Inspector, recommending that the duty of enforcing the provisions of the law relating to bakehouses should be transferred from the factory inspectors to the Metropolitan Board of Works. " In my annual report for the same year (1881) I had drawn your Vestry's attention to the subject. The view I took was that, as the Government, in deference to the views of sanitarians, had seen fit (in 1874) to take measures for securing the proper construction and becoming cleanliness of places where an offensive trade (of a slaughterer of cattle) was carried on, it was not too much to hope that, upon proper representations, they might be induced to take measures for the reform of bakehouses. ' The manufacture of bread,' I said, 'as carried on ordinarily by semi-nude men, is open to objection, and this might and should be put an end to, by a law requiring the substitution of machinery for manual labour. Bye-laws should be framed to regulate the construction of bakehouses and flour stores; to provide for cleanliness, by cemented and painted walls, and by impermeable floors furnishing no holes for insects ; and for light ventilation, &c. There should be no drain inlet within the bakehouse, and no other possible source of nuisance within reach of it. To sum up,' I added, 'What really is required, is a proper Bakehouse Regulation Act, providing for the licensing of bakehouses, and conferring on Sanitary Authorities the power, which they should be obliged to exercise, of regulating the trade by Bye-laws, uniform for the Metropolis, dealing with— 182 '(1) The position and construction, including lighting and ventilation of bakehouses ; and ' (2) The periodical cleansing of the premises ; and ' (3) The materials and utensils employed in the manufacture of bread.' " In the following year (1882) your Vestry entered warmly into a movement to secure bakehouse reform, a primary step in that direction being the transference to the Sanitary Authorities of the duty of inspecting and regulating bakehouses. A communication was addressed to those Authorities explaining the views of your Vestry on the subject, as summarised in a report by the Sanitary Committee, which embodied my views, as set out above. The Society of Medical Officers of Health, moreover, resolved, on the recommendation of the council, to memorialise the Home Secretary, ' praying that the powers originally possessed by the Metropolitan Sanitary Authorities under the Bakehouse Regulation Act, 1863, should be restored to those bodies, with power to make bye-laws regulating the structure of bakehouses, periodical cleansing, power of entry at any time, the utensils used in manufacturing bread or pastry, and also such other matters as the Local Authorities may deem necessary.' A memorial was subsequently presented, the terms of which were in close, if not in literal agreement with the subjoined draft which I prepared, showing:— ' 1. That prior to the passing of the Factory and Workshop Act, 1878, the Sanitary Authority in the Metropolis (as elsewhere) was the Local Authority under the Bakehouse Regulation Act, 1863. ' 2. That under the said Bakehouse Regulation Act the Bakehouses in the Metropolis were regularly inspected by the Sanitary Inspectors of the respective Parishes and Districts, and the sanitary provisions of the Act, however imperfect, were duly carried out. ' 3. That on the repeal of the Bakehouse Regulation Act by the Factory and Workshop Act, 1878, the duty of inspecting bakehouses was transferred to the Factory Inspectors. ' 4. That from insufficiency in the number of Inspectors available for the duty, or other cause, official inspection of bakehouses, as a regular and systematic proceeding, has practically ceased since the passing of the Factory and Workshop Act, 1878. ' 5. That as a consequence of such practical cessation of official inspection, the bakehouses have fallen into an insanitary condition, as testified, in respectof some of them, by Assistant Inspector Lakeman (vide Annual Report for 1881 by the Chief Factory Inspector) ; and, generally, by Reports presented to Vestries and District Boards of Works by Medical Officers of Health and Sanitary Inspectors, after inspections made by such officers as a result of the revelations published in the said Annual Report of the Chief Factory Inspector. 183 ' 6. That regular systematic inspection of bakehouses is imperatively necessary for the protection of the interests of public health. ' 7- That such inspection could be best carried out by Sanitary Authorities, who have an ample staff of trained and efficient medical and sanitary officers available for the purpose. ' 8. That the provisions of the Factory and Workshop Act, 1878, are insufficient to secure a proper sanitary condition of bakehouses, regarded as places in which a prime necessary of life, the daily food of man, is prepared. '9. That there is urgent necessity for fresh legislation to secure such proper sanitary condition ; it being desirable, moreover, for the reasons above indicated, that the supervision of bakehouses should be restored to the Sanitary Authorities. ' 10. That in the contemplated legislation provision should be made for— Licensing or Registration of Bakehouses. Power of entry at all times by the Officers of the Local Authority, Power to the Local Authority, being the Sanitary Authority, to enable them to regulate bakehouses, by bye-laws dealing with— (a) the position and the construction, including lighting and ventilation, and periodical cleansing, of bakehouses, and (b) the materials and utensils employed in the manufacture of bread, pastry, &c. ' The Society, therefore, respectfully recommend the introduction of a Govern ment Bill to secure the above objects, being of opinion, moreover, that the principles applicable in respect of bakehouses might be judiciously extended to all other places in which articles of food of man are prepared for sale.' " The Home Secretary was at the same time requested to receive a deputation from the society. In his reply he stated that he was in communication with the Local Government Board on the subject, and that he had referred the suggestions of the Society to that Board, postponing 'for the present the question of receiving the deputation' —which never was received. "The Operative Bakers' and Confectioners' Union were more favoured, for having very properly taken up the question of insanitary bakehouses, in the interests of their personal health and welfare, they obtained an audience from Sir Charles Dilke, President of the Local Government Board, (in the absence of the Home Secretary), the Chief Inspector of Factories being present, to represent their grievances. Mr. Broadhurst, M,P., who introduced the deputation, stated that the main points they wished to bring before the Government were, the desirability of appointing Government Inspectors of Bakehouses, and that the Government should bring in an Act, or a clause in an Act, to provide that for the future no bakehouse should be built underground. Mr. Broadhurst quoted a paragraph in a memorial presented by the deputation, as follows, the facts stated being only too true :— 'At present almost any kitchen or cellar is turned into a bakehonse, often in close proximity to drains, many being even undrained, and totally unfit places for the manufacture of human food.' 184 Subsequently, the Home Secretary received the deputation, when several of its members laid emphasis on the fact that the unsatisfactory condition of bakehouses seriously affected the wholesome character of bread. The right hon. gentleman, in reply, said that the 'Government would, by legislation, prevent—at least, so they proposed—the construction of underground bakehouses for the future. As to the question of inspection, he could not hold out any promise, but the memorial would be taken into careful consideration.' " The Chief Inspector of Factories, &c., again referred to the subject of bakehouses in his annual report for 1882 as follows :— 'Upon a review of the condition of bakehouses, and the very slender chance of any real and effectual amelioration taking place in the making and baking of bread, without the interposition of authority, I would desire to see legislative enactments laying down some broad rules, placing the control over the construction of bakehouses, and the maintenance of them in a healihy condition, in the hands of the local authority.' "The Chief Inspector went on to say that 'the Authority having control over the construction of bakehouses, and power to frame byelaws . . . should be the various local authorities having supervision over the sanitary condition of their districts.' But, strangely enough, whilst deeming the Sanitary Authorities of urban and rural sanitary districts competent for the discharge of these duties, he proposed to hand over the bakehouses in London to the Metropolitan Board of Works. Commenting upon this suggestion in my report for 1882, I observed that, ' Having regard to the desirability of uniformity in bye-laws, I should be content to see the power of framing such as are necessary for regulating the construction and sanitary supervision of bakehouses in the Metropolis, vested in the Metropolitan Board of Works, provided that the bye-laws so framed were submitted to the Local Government Board for confirmation, so as to ensure the revision of them by competent legal and medical experts; but the duty of inspection, and generally of carrying out the bye-laws, should be entrusted to the sanitary authorities, viz., the several vestries and district boards of works.' " In 1883 the views of your Vestry on the subject of bakehouse supervision were to some extent adopted, the Government having brought in and carried a Factory and Workshop Bill, one of the clauses of which restored to the Sanitary Authorities their former position as ' local authority,' so far as related to cleanliness, ventilation, overcrowding, and other matters affecting the sanitary condition of bakehouses ; viz., by enabling them to enforce Sections 3, 33, 34 and 35 of the Factory and Workshop Act, 1878.* The recommendations of your * It may be mentioned that I prepared an Abstract of the provisions of the Act so far as it related to bakehouses, with all necessary information for the guidance of master and journeymen bakers, a copy of which was furnished to the several occupiers of bakehouses in this parish. 185 Vestry,of course, went considerably beyond this, but, however desirable they might have been, it was impossible at so late a period of the Session to obtain for them the attention of Parliament. I felt it my duty, nevertheless, to request the consideration of the President of the Local Government Board to two necessary amendments of the Bill, including the insertion of words in Section 19, to give the Inspector of Nuisances the same power of entry as the Medical Officer of Health. But not even this was done, and the Bill, practically unaltered I believe, became law on the last working day of the Session. "The Society of Medical Officers of Health, desirous of making the most of the new Act, prepared ' Suggestions for Regulations with respect to Bakehouses,' for the guidance of the Sanitary Authorities. The Acts do not authorize the making of regulations or bye-laws, but it was felt that good would result should the Vestries see fit to adopt the suggestions of the Society for the guidance of their officers, and communicate them to bakehouse proprietors as an indication of the requirements of the law. This course was adopted by your Vestry ; the regulations were printed in large type and mounted on cardboard, and a copy was supplied to each bakehouse proprietor in the parish for suspension in the bakehouse. " The Regulations were as follows :— REGULATIONS. ' I. Every Bakehouse shall be kept ill a cleanly slate, and free from effluvia arising from any drain, privy, water-closet, or other nuisance. The floors shall be carefully swept at least once every 24 hours, and the sweepings shall be immediately placed in an impermeable covered receptacle, and removed from the bakehouse at not longer intervals than every seven days. ' 2. All the inside walls of the rooms of the bakehouse, and all the ceilings or tops of such rooms, and all the passages and staircases of the bakehouse, shall either be painted with oil, or varnished, or lime-washed. Where painted with oil or varnished, there shall be three coats of paint or varnish, and the paint or varnish shall be renewed once at least in every seven years, and shall be washed, with hot water and soap, once at least in every six months. Where lime-washed the lime-washing shall be renewed once at least in every six months. The cleansing should be done in the months of April and October. ' 3. The troughs and all the utensils used in the making of bread and pastry shall be kept scrupulously clean. ' 4. A place on the same level with the bakehouse, and forming part of the same building, shall not be used as a sleeping place, (a) Unless it is effectually separated from the bakehouse by a partition extending from the floor to the ceiling. (b) Unless there be an external glazed window of at least 9 superficial feet of area, of which at the least 4½ superficial feet are made to open for ventilation. 186 '5- No water-closet, earth-closet, privy, or ash-pit shall be within, or communicate directly with the bakehouse. '6. Any cistern for supplying water to the bakehouse shall be separate and distinct from any cistern for supplying water to a water-closet. '7. No drain or pipe for carrying off fæcal or sewage matter shall have an opening within the bakehouse, and every sink-waste, or other pipe used for carrying off surface water within the bakehouse, shall be efficiently trapped and disconnected from any drain. '8. Every bakehouse shall be efficiently lighted, shall be ventilated so as to render harmless all gases and dust, and shall not be overcrowded while work is carried on therein. ' 9. Every bakehouse shall be used for the purpose of the trade only. ' 10. No animal shall be kept in the bakehouse on any pretence whatever. '11. No person suffering, or who has recently suffered, from any infectious disease shall be permitted to enter the bakehouse, or take part in the manufacture or sale on the premises, of bread, biscuits or confectionery. '12. The owner or occupier of a bakehouse shall give immediate notice to the Medical Officer of Health of any case of infectious disease occurring on the same premises as the bakehouse. 1 PENALTIES.—Every bakehouse in which there is a contravention of Sections 3, 33, or 34 of the Factory and Workshop Act, 1878, which provide for the sanitary condition and cleansing of the bakehouse, shall be deemed not to be kept in conformity with the Act, and the occupier thereof is liable for default to a fine not exceeding tew pounds. 'The use of a bakehouse for sleeping purposes, or of a room on the same level as the bakehouse, insufficiently separated from it and insufficiently ventilated and lighted, is punishable under the 35th Section of the same Act by a fine not exceeding Twenty Shillings for the first offence, and of a sum not exceeding Five Pounds for every subsequent offence. • 'An infringement of the 15th Section of the Factory and Workshop Act, 1883, which prohibits— A direct communication between a water-closet, earth-closet, privy, or ash-pit, with the bakehouse; The supply of water to a bakehouse from a cistern also supplying a water-closet; The opening into a bakehouse of a drain carrying off faecal or sewage matter, is punishable by a fine not exceeding Forty Shillings, and a further fine not exceeding Five Shillings for every day during which the infringement is continued after a conviction.' "No further opportunity was afforded for dealing with the subject of bakehouse regulation until the Session of 1891, when a Government Bill to 'amend the law relating to Factories and Workshops' was introduced, which enabled me to recommend your Vestry to make a further effort in this direction. The Home Secretary, it will be remembered, had stated to the Operative Bakers' and Confectioners' Union, in 1883, that 'the Government would by 187 legislation prevent, at least they so proposed, the construction of underground bakehouses for the future.' But no provision of this sort found a place in the Bill of 1883, and the matter was not dealt with in the Bill of 1891. Referring to the subject of bakehouse regulation generally, in my third report for 1891, I stated that the Factory Bill did not stand alone 'in furnishing an opportunity for dealing with the question,' which, I said, 'might be dealt with in the Public Health (London) Bill, to the extent, at any rate, of enabling the County Council to make bye-laws for the regulation of bakehouses.' I therefore recommended a reference of the Bills to the Law and Parliamentary Committee, 'with power to make suitable representations to the Home Secretary, the President of the Local Government Board, and the County Council,' on the lines of the said report, which contained a summary of the matters more fully set out in the present report, and I specifically recommended that steps be taken to obtain for Sanitary Inspectors the power of entry to bakehouses, and to enable the Sanitary Authority, or the County Council, to make bye-laws for the regulation of bakehouses. "Representations were made to the Secretary of State upon these lines, and subsequently—a reply having been received to the effect that it was considered that the suggestion made as to giving powers to the Sanitary Authorities to make byelaws applicable to bakehouses was one rather to be dealt with in a Public Health Bill,—a communication was forwarded to the President of the Local Government Board, urging him to take the matter into consideration in connection with the Public Health (London) Law Amendment Bill, then before the House of Commons. Nothing came of the action taken, save that in the Factory and Workshop Act, 1891, the desired power of entry to bakehouses was given to the Sanitary Inspector. The two Acts referred to, taken together, increased the powers of the Sanitary Authorities in respect to measures for securing such improved sanitary conditions of bakehouses as are practicable, having regard to the usual underground position of the various premises ; but the Acts contain no provisions enabling any Authority, central or local, to make bye-laws, or to carry out such reforms as in my report for 1881 I had recom mended, and which cover a good deal of the matter dealt with in the report of the Public Health and Housing Committee of the Council above cited. " In conclusion, I would only further observe that it is matter for satisfaction that the said Committee should have taken in hand this question of Bakehouse regulation. It is one which the Council, from their position as central authority, will probably be able to carry to a successful issue. No exception can, I think, be taken to the view of the Committee that the Council 'should be empowered to make regulations ' in regard to bakehouses ; and little, if any objection can reasonably be made to the objects which regulations should subserve, 188 as formulated in the report of the Committee. Certainly your Vestry would be the last body to enter objection to this part of the scheme, which is in practical agreement with the views formulated many years ago—and as above set out—and which would have been carried into practice had the necessary legal powers, for which application was made, been given. But it is to be hoped, should the Council adopt the suggestion of the Committee in regard to the acquisition of power to make bye-laws, that they will not adopt the opinion of the Committee 'that the Central Metropolitan Authority rather than the Local Sanitary Authority should have charge of the bakehouses of London.' The precedent of the Public Heath (London) Act, 1891, is in point: the Council should be empowered to make bye-laws, but the duty of enforcing the bye-laws should rest with the Local Sanitary Authority." A copy of the above report was sent to every member of the Council, June 25th, the day preceding that on which the proposals contained in the report of the Public Health and Housing Committee were to be considered. To this report an amendment was moved to the effect— " That the Council, while concurring in the view that regulations governing the position, structure, and internal arrangements of bakehouses should be made by the Council for the whole of London, is of opinion that the licensing and supervision of bakehouses, and the duty of enforcing the Council's regulations, should rest upon the local sanitary authorities (the CDuncil having power to act on their default under section 100 of the Public Health (London) Act, and accordingly refers the matter back to the Committee with instructions to communicate with the President of the Local Government Board, and to ask him to propose an amendment of the law for the purpose." The amendment was adopted. But at the meeting of the Council, held on July 17th, the Public Health and Housing Committee submitted a further report as follows :— " We have again carefully considered the question, and we think with the Council that it would be well for the supervision of bakehouses and the enforcement of the regulations to rest upon the local sanitary authorities ; but we are still strongly of opinion that the Council should be the licensing authority, as well as the authority to make regulations. We cannot consider that it would be at all satisfactory for the licensing of bakehouses in London to be in the hands of forty or more different authorities, as under 189 such an arrangement it would be well nigh impossible to secure uniformity of administration. Before, therefore, communicating with the Local Government Board, we have decided to bring the matter again before the Council, and to ask it to vary its resolution, so as to provide for the licensing or registration of bakehouses to be in the hands of the Council, and not the local sanitary authorities. We recommend that the Council's resolution of the 26th of June last, so far as relates to the licensing of bakehouses, be rescinded, and that the Council do express the opinion that the licensing or registration of bakehouses should rest upon the Council, and not the local sanitary authorities." To this recommendation objection was raised by the mover of the amendment on the previous page, who moved "That the Council re-affirm its decision of June 26th." But after a discussion this amendment was negatived by a small majority and the recommendation of the Committee was approved. REFUSE MATTER. The prevention of nuisance in connection with the storage, collection, and conveyance of offensive substances coming under the general description "Refuse," was, until recently, a matter of no little difficulty: the bye-laws which the County Council and your Vestry made last year, under the provisions of the Public Health (London; Act, 1891, have facilitated action in dealing therewith. HOUSE REFUSE. The collection of ashes and miscellaneous rubbish from 22,000 inhabited houses, spread over an area of some 2,200 acres, and to the extent of 41,560 loads in 1893, is no light task. That it is, on the whole, satisfactorily performed, may be inferred from the relative fewness of complaints, in comparison with the number received when the work was in the hands of contractors. Relatively few as the complaints now are, a not inconsiderable proportion of them results from the 190 neglect of domestic servants, who often refuse to allow the refuse to be removed when the periodical call of the dustman is made. Nuisance, in the sanitary sense, need not arise even from a full dust-bin : when it does occur 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, whilst 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. It might be repeated with advantage. The work of dust collection has been systematised by division of the parish into districts, and provision has been made for inspection of dust-bins and oversight of the "dusting gangs," the entire arrangements being under the supervision of the Surveyor. A call is, or should be, 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 more rational system of daily, or, at any rate, frequent collection from movable 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 the refuse might be made. Nothing came of your Vestry's action, the Board having adopted the view of their Special Purposes and Sanitary Committee, to the effect that it was "not desirable to promote the 191 suggested legislation." The subject however is dealt with in the new Public Health Act, to a certain extent, as, in section 141, "the expression 'ash-pit' " is defined to mean " any ash-pit, dust-bin, ash-tub, or other receptacle for the deposit of ashes or refuse matter." The principle of a moveable receptacle being thus admitted, it is scarcely probable that builders in the future will go to the expense of erecting permanent dust-bins, which, as commonly mis-used, create or constitute a nuisance liable to be dealt with summarily under the Act. The bye-laws of the County Council relating to the storage and removal of house refuse are now in operation. 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 an easy distance of, the Parish; and other districts being able to supply the brickmakers' wants. The land acquired by your Vestry at Purfleet on the river Thames, would, it was thought, furnish a profitable outlet for the greater part of the refuse of the parish. Hitherto, however, little use has been made of this land, which is held in reserve in case of emergency. In previous reports I have intimated that a solution of the difficulty of sanitary disposal of house refuse would be found in cremation, which could, under proper conditions, be carried out successfully and without the creation of nuisance. This view is supported by the Medical Officer of Health and the Engineer to the London County Council, who, having made a thorough inquiry into the whole subject of Dust Destructors, in accordance with an instruction of the Public Health and Housing Committee, came to the conclusion that the cremation of house refuse may be effected, in a properly-constructed apparatus, without creating any 192 nuisance. The report of these officers having been forwarded by the Council to your Vestry, and referred to the Wharves and Plant Committee, I reported thereon, at the request of the Committee, dealing with the subject, of course, from the sanitary point of view. I stated that I agreed with the conclusion arrived at by the Medical Officer and the Engineer ; and assuming the conclusion to be correct, I further stated that "the process (of cremation) would appear to offer, in existing circumstances, the most effectual and economical, and the only sanitary method of dealing with the refuse of the parish, inasmuch as, at the minimum of cost, the offensive constituents of the domestic receptacle called a dust-bin, can be reduced in bulk by some three-fourths, the residuum, moreover, being not only innocuous, but, where the demand for such material prevails, also of some value." I concluded by commending the report to the favourable consideration of the Committee, "believing that the erection and utilisation of dust destructors in this parish would be a distinct advantage from the public health point of view." TRADE REFUSE. In a Special Report, dated March 13th, 1885, on " Sanitary, Nuisances Removal, and other cognate Acts," made in connection with an enquiry referred to the Law and Parliamentary Committee (April 9th, 1884), I stated that your Vestry "have power, and indeed are required, when called upon, to remove the refuse of any trade, &c., upon the application, and at the cost, of the owner or occupier of any house, &c. ; "and, I added, that "the section (of the Metropolis Local Management Act referred to) would apply in the case of trades which lead to the production of 'refuse' of an offensive character." This subject was fully dealt with in the said Report, and also in my Annual Report for 1887 (pages 176-189), of which a copy was forwarded to every member of 193 the London County Council in 1889. Beyond question, the Sanitary Authority should undertake the removal, at the cost of the owner, of all such " refuse " matters, of animal and vegetable origin, as may become, if left 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 it is precisely the refuse of an offensive character that the Sanitary Authority are not called upon or expected to remove—viz., that produced by butchers, fishmongers, fried fish dealers, poulterers, &c., who pay substantial sums for the service, which in the past has been conducted not seldom in an objectionable manner. As already intimated the bye-laws made by the County Council have enabled Sanitary Authorities to bring about improvements in the method of storage and of removal of these kinds of offensive refuse. STABLE REFUSE. In many of my Annual Reports mention has been made of the frequency of complaints in regard to accumulations of stable manure, as " the most common of recurring nuisances with which the Sanitary Inspectors have to deal." Your Vestry many years ago exercised the powers conferred by section 53 of the Sanitary Act, 1866, by giving public notice for " the periodical removal of manure or other refuse matter from mews, stables," &c. ; the regulations requiring such removal to be effected on " alternate days," the penalty for default being " twenty shillings per day for every day during which such manure or other refuse matter shall be permitted to accumulate." The non-removal is sometimes the fault of the coachman, who will not give the refuse away, the farmers, moreover, being, as a rule, unwilling to pay for it. At certain seasons—e.g., haymaking and harvest time—there is, no doubt, a difficulty in getting the receptacles cleared, m 194 farmers being too busy to collect the refuse. Formerly, when the parish consisted largely of market gardens, the cultivators of the soil were glad enough to get the manure, by satisfying the demands of the coachmen and others. Now that it has to be hauled long distances to suburban farms and gardens, stable-occupiers, moreover, being at the mercy of the waggoners, the case is far otherwise, and not unfrequently payment has to be made to ensure removal, however irregularly. The nuisance caused by the accumulation varies in degree according to the character of the receptacle in which the refuse is stored. When this is a well-paved and drained enclosure on the surface of the mews, consisting of a low curb carrying a moveable iron cage attached to the stable wall by hooks, air-currents circulating freely through the refuse, and removal being at once easy and complete, there is little or no nuisance, either in storage, or in transference to the waggon, or in conveyance through the streets. Brick receptacles, above ground, are more or less objectionable, for they are seldom thoroughly cleared out, short straw, &c. being left at the bottom. Nuisance is least when the bottom of such receptacles is on, or slightly above, the level of the surface of the mews, and provision is made for allowing moisture to drain away. But when the bottom of the receptacle is below the surface of the mews, and even though nominal provision has been made for drainage, nuisance is considerable; rain enters and cannot escape, as the drain (if any) gets choked ; the result being that the refuse rots, the receptacle becomes filthy, and the collector will not incur the defilement attending a perfect clearance. Sunken Dung Pits.—All of the evils above described are intensified in a high degree when the receptacle is entirely underground, being what is called a sunken dungpit—nearly always undrained, and covered with wooden flaps. The rain enters these pits, and mere confinement of the organic matters leads to very rapid putrefaction, the result being that, after a short detention, serious nuisance arises, to 195 the great discomfort of persons living in the vicinity. Were these pits cleared regularly, as required by the regulations, they would still be a cause of nuisance. Everyone who has observed the " steam " arising when the contents are disturbed, must have been annoyed by its horrible offensiveness. In a previous report I stated that " these sunken dung-pits are a nuisance in themselves, and that, as the use of them involves a continually recurring nuisance, it should be prohibited." Theuse of them is nowprohibited bythe bye-laws of the County Council, and in this parish large numbers of them have been abolished, suitable iron cages conformable to the requirements of the bye-laws having been substituted. From time to time the Sanitary Committee have had before them lists of stables at which the receptacles are not constructed in conformity with the bye-laws, and they have given directions for notices to be served for the necessary reconstruction or alteration of the said receptacles ; and, in the event of the parties failing to act upon such notices, for proceedings to be taken for the recovery of the penalties to which they will have rendered themselves liable. The issue of the said notices brought numerous communications from proprietors of stables, who had been called upon to abolish sunken dung pits, calling attention to the difficulties such a course would involve. In many of these cases it was resolved by your Vestry, on the recommendation of the Sanitary Committee, " that no action be taken for the abolition of the sunken dung pits provided the depth of such pits be limited to 3 feet 6 inches ; that they are properly drained ; that they are cemented inside, and that any structural defects are made good." In other cases your Vestry, whilst making temporary concessions, reserved " the right to call upon (the owners) at any time to abolish the sunken dung pits." In some cases it was suggested to the owners "to provide a moveable metal cage " receptacle for the dung ; in others the owners were called upon to provide a moveable metal cage on wheels— 156 a course which probably would be practicable in most of the cases in which, owing to the frontage of the stable being wholly occupied by doors, it is not possible to provide a fixed receptacle on the surface of the mews. Difficulty in Securing Removal of Stable Refuse. —The repealed Sanitary Act of 1866 enabled the " Nuisance Authority " (i.e., your Vestry) to contract with the occupiers of stables and cowhouses for the collection and removal of manure or other refuse matter; but the Authority could remove it only " with the sanction of the owner." The Public Health (London) Act, 1891, has not made any material difference in the position, for section 36 does no more than authorise the Sanitary Authority to collect and remove the refuse from stables, &c., " the occupiers of which signify their consent in writing to such removal," which would have to be done at the cost of the said authority. The necessary consent would ba forthcoming probably, in most cases, if it came to be known that the requirements of the law would be enforced in case of neglect on the part of the owner to comply with the regulations. In many, if not in the majority of cases, money is now paid by the owners for the removal of the refuse, and I see no reason why they should not be required to pay to the Local Authority a suitable fee for the service. Many persons would be glad to do so, and thus relieve themselves of a troublesome duty. At the same time, it is not improbable that the large amount of refuse produced in nearly two hundred mews, would have an aggregate value sufficient to pay the cost of a well-organised system of collection and removal to the country. Section 35 authorises a sanitary inspector to serve a notice on the owner of any accumulation of manure or other obnoxious matter, requiring him to remove it, and if the notice is not complied with within forty-eight (the Bill read 24) hours from the service thereof, the " matter " becomes the property of the Sanitary Authority, 197 and may be removed and disposed of by them at the cost of the former owner. This provision is not likely in practice to supersede enforcement of the regulations by proceedings for recovery of penalties; but it is occasionally useful. In a Special Report on " Sanitary, Nuisances Removal, and other cognate Acts," I placed my views on this subject generally, before your Vestry in 1885. The Law and Parliamentary Committee, to whom the report was referred, recognised "the necessity for making proper arrangements for the removal of manure and other refuse matter," but stated that " the Vestry had not depot accommodation, or staff or plant adequate to cope with so large a work." For this reason, they considered that the Vestry was not then "in a position to contract generally for the removal of manure and other refuse matter." The circumstances are now different, your Vestry having a large depot at Purfleet, to which the manure could be conveyed from the river and canal-side wharves, and where it would probably command a ready sale at a remunerative price for use on the land. The Sanitary Committee, in a report dated September 7th, 1892, stated that they were of opinion that the time had arrived when the Vestry should, on sanitary grounds, undertake the removal of such manure, &c., themselves. They accordingly recommended, "That it be referred to the Wharves and Plant Committee to consider and report as to the practicabilty of a scheme being adopted for this work to be undertaken by the Vestry." This was done, and on the 9th November, 1892, the said Committee reported that they were of opinion that "the expenses of any scheme to give effect to the collection and removal of the manure from the mews of the parish, would be so great as to render the proposal, at the present time, an impracticable one." The report was adopted by your Vestry. 198 THE HOUSING OF THE WORKING CLASSES. In my Annual Report for 1890, I dealt with the new legislation, by which the Acts relating to the housing of the working classes had been consolidated and amended, by the Housing of the Working Classes Act, 1890, and gave a detailed account of the action of the London County Council in connection with The Boundary Street Scheme, for acquiring an " unhealthy area" in Bethnal Green, fifteen acres in extent, at a net estimated cost, for the land and laying-out of new streets, of £300,000, or £20,000 per acre, a sum equal to fifty guineas for each person resident in the area ; and this not to provide the people with dwellings, but only to clear the land on which improved dwellings will be built for letting at current rates. The Council determined to deal with the area in sections, so as not to displace the population (some 5,719 in number) too rapidly. In my last report I stated that much had already been done to give effect to the scheme, by settlement of claims for property, by arrangements for arbitration where agreement could not be arrived at, and by compensation to the evicted tenants for cost of removal, &c.; and it was also stated, on the authority of the Public Health and Housing Committee, that " the gross cost of the scheme would be considerably less than the estimate." In March 1893, the Committee announced that the acquisition of the several properties within the area would soon be completed. An amended plan for laying out the area has since then been adopted. It consists of a system of radiating streets from a central open space which is to be laid out as an ornamental garden. The whole work is to be carried out in five sections. The Council will by their own Works Department erect the houses which are to be of four of five storeys. The roadways and sewers are about to be put in hand, at a cost of some £59,000. Asphalte is to be used for the roads, on hygienic grounds. The number of persons to be provided for has been reduced to 4,700. It is still expected that the net cost 199 of clearing the land, and making the sewers and roadways ready for building operations, will not exceed the original estimate of £300,000. On other areas acquired and cleared by the late Metropolitan Board of Works, the Council are about to erect houses for the working classes, with the sanction of the Home Secretary. Thus, cottage dwellings of two storeys are to be built on the Hughes Field Improvement area : similar dwellings will be erected on the Goldsmith-square area, which adjoins the Boundary-street area ; and ether schemes of the like kind are in contemplation. The monetary return sought in all these cases is, I believe, three per cent, per annum; it being assumed that this amount will pay interest on the capital outlay and provide for a sinking fund which, in a certain number of years, will reproduce the original outlay. In my Annual Report for 1888-89, I observed that it would be well could the County Council enter into competition with the owners of insanitary houses, by providing decent houses for the working classes, at a moderate but remunerative rent, under what was then known as Lord Shaftesbury's Act. The Council, it will have been seen, are now attempting in real earnest to do this. But they also recognize the impossibility of relieving, to more than a limited extent, the present unsatisfactory condition of things in regard to the housing of the working classes, by the provision of fresh accommodation in the form of model dwellings, whether undertaken by themselves or others. The bulk of the people, they admit, must live in existing houses, and be dependent on others for the enforcement of sanitary conditions ; and the Council are now able to realize what Sanitary Authorities ot older date, and their officials, have long known but too well—the colossal difficulties in the way of providing decent homes for the poor, at any reasonable or remunerative rate. Municipal Common Lodging Houses.—In former reports references have been made to the desirability of the County Council following the example of the Glasgow Corporation by providing Municipal Lodging Houses, and 200 in my last report I referred to the muncipal lodging-house in Parker Street, as having been completed and brought into operation early in 1893. It now appears that, owing to the working expenses of this establishment having been greater than expected, and to the fact that the capital outlay largely exceeded the estimate, the net return during the first fourteen months, was only If per cent, instead of the 3 per cent, requisite to pay interest on the outlay, and to reproduce the cost of the building in 55 years. The Council therefore resolved, upon the recommendation of the Public Health Committee, to raise the charge per bed per night from 5d. to 6d., as from 23rd June, 1894. The Committee are sanguine that the experience gained in this first experiment will enable them " to indicate in what way a cheaper form of construction can be secured, and which is certainly called for if the nightly charge is not to exceed 4d. a bed." MIGRATION AS A REMEDY FOR OVERCROWDING. By the Housing of the Working Classes Act, 1890, the County Council, but only with the sanction of the Home Secretary, are enabled to erect, purchase, or hire, houses, &c., without, as well as within, the Metropolis. The question will naturally arise, therefore, as I observed in my Report for 1889, 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 the provisions of what were formerly known as Cross's Acts, in London, must needs be a costly procedure at all times,* and * " The Metropolitan Board of Works carried through 22 Schemes, whereby 59 acres of land were acquired and cleared, on which accommodation has been provided for 38,231 persons. The amount thus expended by the Board, in giving effect to Cross's 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" (Annual Report of the Medical Officer of Health for 1888-89, page 130). 201 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, who need to live near their work, to obtain better and cheaper accommodation. A rent equal to that paid for two or three rooms in a model lodging-house in London, would certainly 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 would be diminished, and with it preventible disease resulting from this, the most perilous of insanitary conditions. The model dwellings erectcd on the sites cleared under Cross's Acts are not tenanted to any large extent by the poorest grades of the labouring classes, those who have been displaced by the clearings. Clerks, and superior artizans able to command constant employment, commonly occupy these healthy homes. Plenty of others of the like classes would donbtless be forthcoming, were the accommodation greatly extended. These, however, are the classes for whom it might be practicable to provide out of London. The Council having apparently, come to the conclusion that migration affords the most promising solution to a difficult question, some time since prepared a report, resulting from an exhaustive enquiry into the number of working men's trains running from and into London termini, showing what had been done in this direction by the railway companies, and what remained to be done, to give full effect to this great experiment, the success of which is in no inconsiderable measure the result of the Council's action. The Metropolitan Railway Company since June, 1892, have increased the facilities previously afforded, and they now run workmen's trains atthe following rates: For a distance of five miles, 2d.; from five to ten miles, 4d. ; from ten to fifteen miles, 6d. per journey: 202 these fares include the return journey in every case. Moreover, weekly tickets, in packets, are issued on this basis. A clause in the Act* for the construction of a new railway from Lincoln, &c. to London, provides that, " In respect of working men carried by working men's trains, between the London station of the Company and Neasden, and intermediate places, the company shall not be entitled to charge higher fares than are for the time being chargeable, or charged, by the Metropolitan Railway Company, by their workmen's trains between their Baker Street Station and Neasden and intermediate places." It follows, as a result of the action of the Metropolitan Railway Company, that the working classes in London will in time to come have still further facilities for cheap travelling. As it may not unreasonably be expected that an impetus will be given by these arrangements to the erection of houses for the working classes in the suburbs, we can but hope that care will be exercised to prevent the concessions being so misused as to involve the creation of slums outside London. The houses to be built should not be too large, nor too crowded on space. Working men, moreover, should be encouraged to become the owners of their cottage homes. It is also especially to be desired, that workmen's tickets should be issued, so far as practicable, to bond-fide workmen only, so that the suburbs may not be overrun by " outcast London." No new Improvement Schemes under Part I. of the Housing of the Working Classes Act, 1890, were undertaken by the County Council in 1893, but schemes under Part II. were initiated by Local Authorities, including the scheme adopted by your Vestry for dealing with the James Street area. The Manchester, Sheffield and Lincoln Railway (Extension to London), Act. 203 THE JAMES STREET AREA. In connection with this scheme closing orders have been obtained in respect of 22 houses. In three cases, the owners of as many houses made the houses fit for human habitation, and they are now occupied, although the owners were informed of the intention of your Vestry to apply to the Local Government Board for sanction to a scheme which would necessitate the demolition of the said houses, should the scheme be approved. The County Council may contribute to the cost of carrying out a scheme—to the extent of not more than one half of the net expenditure—when the scheme deals satisfactorily with the insanitary area, and when the need of such contribution is shown to the satisfaction of the Council. In case of disagreement between the Council and the Local Authority, the Home Secretary is authorised by the Act to specify the amount of the contribution (if any) to be made by the Council. The Council, have intimated that the James Street scheme is not one to which they should be called on to contribute. At the present time (July) the proposed improvement scheme has got no further than to the opening of the necessary inquiry by an Inspector of the Local Government Board. No other Improvement "Scheme" has been initiated in this parish. But in 1893 I gave certificates with respect to the unfitness for human habitation of 13 houses on the south side of William Street, Notting Dale, with the result that the said houses were temporarily closed by Justice's Order, pending the execution of extensive repairs, which were carried out to the satisfaction of your Vestry's Surveyor, whereupon a rescinding Order was granted, and the houses are now occupied by a more respectable class of persons than formerly. Three houses known as Thresher's Mews, in Tobin Street, Notting ' Dale, were in like manner closed by Justice's Order, and will, no doubt, be demolished; and two houses in Walmer Road, and two houses described as West Cottages (in Royal Crescent Mews) were closed for execution of extensive repairs, 204 Royal Crescent Mews.—In October I represented to the Sanitary Committee, under the provisions of the Housing of the Working Classes Act, that sixteen dwelling houses in Royal Crescent Mews were "in a state so dangerous or injurious to health as to be unfit for human habitation." The Sanitary Committee having inspected the said houses, and concurring in my opinion, proceedings were instituted to secure the closing of the houses as the Act directs. On two occasions the proceedings were vitiated, by objections having been taken on account of merely formal and technical defects in the terms of the summonses, the defendant at the same time protesting, through his solicitor, that he had a perfect defence on the merits; and on the first occasion he had provided himself with a Medical Officer of Health, in support of his case. Meanwhile, the defendant's Surveyor, recognizing the badness of the case, and the practical hopelessness of a defence on the merits, had proposed to the Committee to close the houses voluntarily, and to carry out whatever works the Committee might deem to be necessary to place the houses in a proper state of repair, so as to be fit for human habitation. I ventured to advise that no other course than that for compulsory closure by Justice's Order, would be satisfactory, seeing that the houses when thus closed, could not be re-opened without a rescinding order, on completion of the repairs to the satisfaction of the Committee. The Committee decided to adopt this course, and their decision having been communicated to the defendant, he at once agreed to closing orders being obtained, and they were obtained, subject to a condition to which the Committee would have consented from the first, viz., that the houses should be closed in four successive groups of four each. At the present writing eight of the houses have been so farrenovated as to justify an application for a rescinding order. It is a question however, whether it would not have been to the advantage of the owner, had we applied for a demolition order for each of the sixteen houses. 205 BYE-LAWS FOR HOUSES LET IN LODGINGS. Under the provisions of the Sanitary Acts of 1866 and 1874, your Vestry made regulations for houses let in lodgings or occupied by members of more than one family and some 1,800 houses have been registered thereunder. The said Acts having been repealed, and modified provisions for by-laws enacted, in the Public Health (London) Act, 1891, the Local Government Board addressed circular letters on the subject to the Sanitary Authorities in 1892, and again in 1894. In the latter communication the Board point out that the powers conferred by the new Act (section 94) "differ in some respects from those exerciseable under section 35 of the Sanitary Act, 1866, and section 47 of the Sanitary Law Amendment Act, 1874, in pursuance of which the Regulations now in force in (this) District were made," inasmuch as section 94 of the new Act "no longer provides that such matters as the enforcement of privy accommodation, the paving of premises, the notices to be given in cases of infectious or contagious disease, the cleansing of cisterns, or the keeping of water closets in good order, etc., shall be dealt with by regulations applicable to houses let in lodgings. These matters," it is added, "can be otherwise dealt with, in some cases by bye-laws made by the Sanitary Authority and applicable generally to all houses in the District whether let in lodgings or not, and in others by bye-laws made by the London County Council." The Board's letter was accompanied by copies of "a model series of bye-laws which they have caused to be prepared for the use of Sanitary Authorities under section 94 of the Act;" and it was stated that " these model forms were drawn up after very careful consideration by the Board of the Regulations which might be properly enforced in the case of the class of houses to which that enactment applies." The Board's model clauses deal with none of the subjects referred to, and it was suggested that your Vestry's existing regulations should be modified on the basis of the model clauses. This matter is still under consideration 206 COMMON LODGING-HOUSES. There are forty common lodging-houses in this parish, providing accommodation for 1,130 persons, as set out in the subjoined list, for which I am indebted to the courtesy of the Chief Commissioner of Police. Return shewing the number of Common Lodging Houses in the Parish of Kensington, and the number of persons of each sex for which the several houses are registered. Sanitary District. Name of Keeper. Address of Common Lodging House. No. of Single Lodgers, for which registered. No. ot Double Beds Authorized. Male. Female. Total. N. Byrne, Patrick 43, Bramley Road 40 – 40 – ,, Do. do. 45, do. 29 – 29 – ,, Marsh, Susan 88, Wornington Road 44 – 44 – ,, Redding, Stephen 153, , do. 8 – 8 – N.W. Gurney, John 21, Bangor Street 21 – 21 – ) ,, Do. do. 23, do. 9 9 10 ,, Do. do. 25, do. 19 12 31 – ,, Moore, John 29, do. 21 21 5 ,, Slater, William 10, do. 16 8 24 2 ,, Day, John 18, do. 32 – 32 – ,, Do. do. 20, do. 54 – 54 – ,, Reynold, Charles 35, do. 35 – 35 – ,, Crosson John 5, do. 30 – 30 – ,, Do. do. 7, do. 32 – 32 – ,, Do. do. 9, do. 19 – 19 – ,, Roberts, Rev. C. 11, Blechynder Street 15 – 15 – ,, Hankins, George 10, Crescent Street 23 7 30 1 ,, Do. do. 28, do. 2 14 16 7 ,, Do. do. 30, do. 30 – 30 – ,, Do. do. 40, do. 13 15 28 4 ,, Phipps. William. 25, do. 22 12 34 5 ,, Do. do. 27, do. 9 17 26 – ,, Do. do. 31, do. 34 – 34 – ,, Do. do. 33, do. – 13 13 7 ,, Hallet, Thomas 4, Hesketh Place – 9 9 5 ,, Do. do. 6, do. – 6 6 3 ,, Do. do. 8, do. – 14 14 3 ,, Simpson James 1, Mary Place 14 – 14 – ,, Do. do. 2, do 21 – 21 – ,, Davis, Mark 66, Saint Ann's Road 41 7 48 12 ,, Day, John 28, St. Clement's Road 12 – 12 8 ,, Do. do. 30, do. 35 – 35 – ,, Bailey, Henry 29, do. 30 – 30 – ,, Do. do. 31, do. 25 – 25 – n.e. Dyer, Ann 12, Blenheim Crescent 15 – 15 – ,, Sams, John 112 , Portobello Road 9 – 9 – C. Redman, John 28, Peel Street 13 – 13 – ,, Do. do. 24, do. do. 20 – 20 – ,, Do. do, 22, do. do. 23 – 23 – S.E. Chapman, James 10, New Street 36 36 – 207 TRANSFERENCE OF CONTROL OF COMMON LODGING HOUSES TO THE COUNTY COUNCIL In the month of November, 1892, a deputation from the Public Health Committee of the London County Council waited upon the Home Secretary, to urge the desirability of transferring from the police to the Council, the control of the Common Lodging Houses in the Metropolis within the jurisdiction of the Council. The Chairman of the Committee stated that the Council desired reform in the registration of Common Lodging Houses, and that the Council should be the authority for making and enforcing regulations and byelaws for the management of these houses. The Home Secretary expressed sympathy with the object of the deputation, admitting, nevertheless, that the police had performed their duty, in looking after the lodging houses, with great discretion, and in a thoroughly efficient manner. Nevertheless the suggested transfer is shortly to be effected, by provisional order under section 10 of the Local Government Act, 1888, and at the present writing the Council are about making arrangements with a view to the appointment of a staff of Inspectors (all males), to take over such part of the duties of the police in regard to these places as they can discharge. The police will still have the right of visitation, a very necessary provision, and one which to some extent removes the objection to the change of jurisdiction, the grounds of which were set out in my last annual report: I need do no more now, therefore, than re-iterate my protest against a duty of this kind being relegated to or assumed by the Council. The duty of making bye-laws with regard to common lodging-houses is one that the Council in any case should perform, but the duty of enforcing any byelaws which the Council may be authorised to make, should have been imposed upon the local sanitary authorities. Of late years there has been a considerable reduction in the number of common lodging houses and a concurrent great increase 208 in the number of shelters opened under the auspices of quasi-religious or philanthropic bodies, notably the Salvation Army and the Church Army. The number of common lodging-houses, which in 1890 was 962, had fallen at the end of 893 to 671. In that year the Shelters of the Salvation Army alone received an aggregate of considerably over a million persons, the nightly average number accommodated being about 3,000. The 671 common lodging-houses under the control of the police provided accommodation for 28,340 persons. During the year 81 houses were closed, and 88 keepers were served with notices to register their houses. Non-registered houses to the number of 156 were periodically visited to enforce the Acts. Three hundred and forty-eight houses were surveyed, and five keepers of registered houses were summoned and convicted for offences against the Act "for the well ordering of common lodging-houses" (14 and 15 Vict. cap. 28), which became law 24th July, 1851. Seventyone cases of illness other than infectious, occurred at the common lodging-houses, 47 of which resulted fatally, necessitating inquests being held ; and 213 cases of infectious diseases occurred, compared with 24 in 1892. The majority of these cases, no doubt, were small-pox, a disease which has been widely spread in many parts of the country through the agency of vagrants and other inmates of common lodginghouses, shelters, and casual wards, and was so spread in London, as already mentioned in this report in connection with the observations (at page 26) on that disease. 209 VAGRANTS AND THE SPREAD OF INFECTIOUS DISEASE. The influence of the migratory section of the population on the spread of infectious disease through the country was the subject, in July of the present year, of a Conference at the County Hall of Metropolitan and Provincial Sanitary Authorities, convened by the London County Council and presided over by the Chairman of that body. The conference was called "with a view to considering whether means can be adopted to prevent the spread of infectious disease" by vagrants. The resolutions of the conference, at which your Vestry was represented, were as follows:— "1. That common shelters which are not subject to the law relating to common lodging houses should be made subject to such law. "2. That the local authority should have power to require medical examination of all persons entering common lodging houses and casual wards, and that each inmate should on admission have a bath of fresh water. ''3. That the local authority should have power to order the keeper of a common lodging house, in which there has been infectious disease, to refuse fresh admissions for such time as may be required by the authority. "4. That the local authority should have power to require the temporary closing of any common lodging house in which infectious disease has occurred. "5. That the local authority should have power to require the detention of any inmate of a common lodging house or casual ward who may reasonably be suspected of being liable to convey infectious disease. "6. That means should be provided for the detention and isolation of any vagrant found wandering in a public place, if reasonably suspected of being liable to convey infectious disease. "7. That the local authority should have power to require the disinfection of the person and clothing of any person in a common lodging house or casual ward, whether infected or exposed to infection. "8. That arrangements should be made by which the occurrence of infectious disease in common lodging houses or casual wards should be made known by the local authority of the district to the local authorities of other districts. N 210 "9. That local authorities should be empowered to require the vaccination or re-vaccination of persons in common lodging houses or casual wards who are exposed to the infection of small-pox." Having regard to the importance of the subject; to the representative character of the conference; and to the fact that the County Council have taken up the matter in serious earnest, it may be reasonably hoped that legislative proposals, in the direction indicated in the foregoing resolutions, may, at no distant time, receive the consideration of Parliament. GLANDERS OR FARCY. In my last report I stated that the Board of Agriculture had issued a new Order dealing with these diseases of the equine race, which owe some of their importance to the fact that they are transmissible to man; and I explained the state of the law with reference to the matter, as defined in the Order. It is satisfactory to learn, from the annual report of the Chief Officer of the Public Control Department of the London County Council, that beneficial results have attended the exercise of the more stringent powers conferred on the Council, as the Local Authority under the Contagious Diseases (Animal) Acts, in relation to this matter, there having been "a striking reduction in the reported cases of glanders during the year"—viz., from 2,331 in 1892-3, to 1,377 in 1893-4, or about 40 per cent. In the Western District, which comprises the Parishes of Kensington, Fulham and Hammersmith, the cases reported in the twelve months ended 31st March, were 155. It is stated that "it has been found practicable to obtain the slaughter of every animal known to have been diseased, without the payment of compensation." There were three deaths in the human subject from this cause in London in 1893, the corrected annual averages, 1883-92, being 2.1. 211 RABIES. Provisions for the seizure, detention, and disposal of straydogs are contained in the Metropolitan Streets Act, 1867,which is carried out in the County of London by the Metropolitan Police. The aggregate of dogs killed in the five years, 1888-92, was 888, of which number 220 were, on post-mortem examination, found to be rabid. The numbers in the successive years were 49, 123, 32, 13, and 3. The seizures in 1889 were 330, the cases of rabies, 123. In 1893 the seizures were 127, and the deaths from rabies 8. This disease also is transmissible, as hydrophobia, to man, the aggregate deaths from which, in London, in the four years, 1888-91, were 14, of which 7 occurred in 1889. In 1892-93 there were no deaths from this cause. PUBLIC MORTUARY. The mortuary was opened in July, 1883. In the first year, to March 25th, 1884, 24 bodies were deposited; in the second year 67; in the third year 100; in the fourth year 97; in the fifth year 100; in the sixth year 128; in the seventh year 135; in the eighth year 207; in the ninth year 256; in the tenth year 239, and in the eleventh year, to March 25, 1894, 252. The bodies removed to the mortuary in the twelve months, were admitted upon application as follows:— 1. At the request of relatives of the deceased 3 2. At the request of undertakers 60 3. At the request of the Coroner (inquest c Cases of sudden death 114 Cases of violent death 42 – 156 4. Brought in by the Police Found dead 10 Accident cases 7 – 17 5. On account of death due to infectious disease 16 252 212 In 94 of the above cases post-mortem examinations were made by authority, principally under the Coroner's warrant. 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 during the time required to conduct a post-mortem examination ordered by the Coroner;" who "may order the removal of a dead body to and from such place for carrying out such examination, and the cost of such removal shall be deemed to be part of the expenses incurred in and about the holding of an inquest." * The Coroner orders the removal of bodies for this purpose in nearly all cases. Even now, however, too little use is made of the mortuary, and especially as a place of deposit for the bodies of those who have died from infectious disease. Medical men can effect the removal of the body, in such cases, by Justice's Order (Public Health (London) Act, 1891, sec. 89), if persons live or sleep in the room where the body is retained, or if the body is in such a state, from decomposition, as to endanger the health of the inmates of the same house or room. The Royal Commission on the Housing of the Working Classes (1885) recommended the provision of additional mortuaries in London. What, however, is even more wanted, at present, is power to require the removal of the dead to existing mortuaries, when removal is necessary on sanitary grounds. The Commissioners recognized this fact, by implication, in 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 * Coroners Act, 1887, section 24. 213 case where the body lies in a room which is used by other persons, it should, in the same manner, be removed." (Report, page 31). These powers have been given, textually, in the Public Health (London) Act, 1891, but they will be of little avail without the voluntary assistance of medical practitioners; for very rarely does the Medical Officer of Health hear of proper cases for removal, and then usually not until it is too late to intervene. It may be added that under the provisions of the new Act, Sanitary Authorities, alone or in combination, are required to provide mortuaries. INQUESTS AND CORONER'S COURT. The number of inquests held in the year ended 25th March last, was 196 : of these 172 were held at the Coroner's Court, and 24 at public institutions. In February, 1890, the County Council passed a resolution to the effect, "That all Coroners having jurisdiction within the administrative County of London, be instructed, as far as it is practicable, and accommodation is available, to cease holding inquests or Coroner's courts in public-houses." This resolution had good effect, the number of inquests held at public-houses in this parish having fallen in the same year to 37. In the past two years no inquest in this parish was held at a public-house. The room placed at the service of the Coroner at the Town Hall, is unsuitable for the purpose, but no better accommodation can be provided within the building. A scheme under consideration contemplates the acquisition of a site at the rear of the Town Hall. To give effect to it, compulsory power of purchase is necessary, and the County Council have consented to obtain such power for your Vestry by the insertion of a clause in their General Powers Act. The Public Health (London) Act, 1891, Section 92, requires the County Council to "provide and maintain proper accommodation for the holding of inquests," and enables them, by agreement with a Sanitary Authority, to provide and 214 maintain the same in connection with a mortuary, or a building for post-mortem examinations, belonging to or provided by that authority, and to do so on such terms as may be agreed on with the said authority. This is the course which the Council appear to be desirous of adopting, and it is made feasible by section 105 (c) which authorises the Sanitary Authority, with the consent of the Local Government Board, to borrow for the purpose of providing a building for the holding of inquests. Model plans of a Coroner's Court, and a group of mortuary buildings, including a post-mortem room and a mortuary chambers for infectious cases, with an explanatory memorandum, have been prepared by the County Council, at the suggestion of several sanitary authorities, both with a view to facilitating the execution of their duties under sections 88, 90, and 91, and also to " indicate the nature of the accommodation which the Council considers necessary for the holding of inquests, in the event of such accommodation being provided by the Sanitary Authority, under agreement with the Council, pursuant to section 92 of the same Act." DISINFECTION. The Public Health (London) Act, 1891, imposes additional duties on the Sanitary Authority in the matter of disinfection, the practical effect of the legislation of late years being to throw the entire cost of disinfecting houses, bedding, clothing, etc., upon the rates. The cost of this work to the parish has greatly increased since the Act came into operation at the beginning of 1892 : the amount expended in 1893, or rather in the official year ended 25th March, 1894, was £1,159 5 9, compared with £816 4s. 3d. in 1892, and £381 in 1891. In 1893 nearly 31,000 articles were disinfected, the weight of them being 64 tons 3 cwt. In 1892 the weight of the articles disinfected was 44 tons 2 cwt., their number 20,939. In 1891 the articles disinfected were 9,425, the weight 215 of them being under 20 tons. Last year 1,085 rooms in 1,015 houses were disinfected by your Vestry's staff, irrespective of those (a diminishing number) disinfected by the contractor in his private capacity. In 1892 the number of rooms disinfected free of cost was 683, compared with 364 in 1891. Duties of Sanitary Authorities with respect to Disinfection.—In the course of a debate in your Vestry last year, a question having been raised, whether the costs of disinfection should be defrayed by the Sanitary Authority, in the case of occupiers of houses in a position to defray the same ? I thought it desirable to offer some observations, explanatory of the law, and of our practice, in regard thereto. The report was as follows:— "Section 60 of the Public Health (London) Act, 1891, reads as follows:— (1) Where the Medical Officer of Health of any sanitary authority, or any other legally qualified medical practitioner, certifies that the cleansing and disinfecting of any house, or part thereof, and of any articles therein likely to retain infection, or the destruction of such articles, would tend to prevent or check any dangerous or infectious disease, the sanitary authority shall serve notice on the master, or, where the house or part is unoccupied, on the owner, of such house or part, that the same and any such articles therein, will be cleansed aud disinfected or (as regards the articles) destroyed, by the sanitary authority, unless he informs the sanitary authority within twenty-four hours from the receipt of the notice, that he will cleanse and disinfect the house or part, and any such articles, or destroy such articles, to the satisfaction of the Medical Officer of Health, or of any legally qualified medical practitioner, within a time fixed in the notice. (2) If either— (a) Within twenty-four hours from the receipt of the notice, the person on whom the notice is served does not inform the sanitary authority, as aforesaid, or (b) Having so informed the sanitary authority, he fails to have the house or part thereof, and any such articles, disinfected, or such articles destroyed as aforesaid, within the time fixed in the notice, or (c) The master or owner without such notice gives his consent, the house, or part, and articles, shall be cleansed and disinfected, or such articles destroyed, by the officers and at the cost of the sanitary authority, under the superintendence of the Medical Officer of Health. (3) For the purpose of carrying into effect this section the sanitary authority may enter by day on any premises. 216 (5) When the sanitary authority have disinfected any house, part of a house, or article, under the provisions of this section, they shall compensate the master or owner of such house, or part of a house, or the owner of such article, lor any unnecessary damage thereby caused to such house, part of a house, or article; and when the authority destroy any article under the section, they shall compensate the owner thereof, and the amount of any such compensation shall be recoverable in a summary manner. "Section 61 reads as follows:— (1) Any sanitary authority may serve a notice on the owner of any bedding, clothing, or other articles which have been exposed to the infection of any dangerous infectious disease, requiring the delivery thereof to an officer of the sanitary authority for removal for the purpose of destruction or disinfection ; and if any person fails to comply with such notice he shall, on the information of the sanitaiy authority, be liable to a fine not exceeding ten pounds. (2) The bedding, clothing, and articles, if so disinfected by the sanitary authority, shall be brought back and delivered to the owner free of charge, and if any of them sufter any unnecessary damage, the authority shall compensate the owner for the same, and the authority shall also compensate the owner for any articles destroyed; and the amount of compensation shall be recoverable in a summary manner. "It thus appears that if the 'master' or 'owner' of the house, or part, fails to respond to the 'notice' of the Sanitary Authority (section 60 (1) )—supposing such notice to have been served—viz., by not informing that body within twenty-four hours that he will disinfect the house, or part, and infected articles therein, the house and the articles must be disinfected by the Sanitary Authority at the public cost, whatever the position in life of such master or owner. Section 61 (1), enables—practically requires—the Sanitary Authority to enforce delivery of infected bedding, clothing, &c, for the purpose of destruction, or of disinfection, as the case may be, also at the public cost. The public, I may add, are now familiar with the law, and generally the Sanitary Authority are required to disinfect infected rooms, and articles therein, by the master of the house, who readily complies with the request for delivery of bedding, clothing, &c., to be taken away for disinfection. But the opportunity is afforded to people able to defray the cost of disinfection, to do so, by delivery of a printed notice, which I drew up, many years ago, to the following effect:— "Infectious Diseases: Disinfection.—The Sanitary Inspectors being frequently asked for advice as to the steps necessary to be taken for the disinfection of bedding, clothing, &c., after infectious disease, and to recommend a person to whom the work of disinfection may be safely entrusted, the Vestry have thought it desirable to state that Messrs.—of—, are employed by them to disinfect bedding, clothing, and other articles for persons who are unable to defray the whole or any part of the cost of the process. In mentioning this fact for the convenience of parishioners, and in further stating that they are satisfied with the way in which Messrs.—have conducted the work entrusted to them, the Vestry must not be understood to make a 217 preferential recommendation of Messrs.—over any other person or persons who may possess the means and conveniences for safely disinfecting infected articles ; or to be in any way responsible for Messrs. —charges, which must be a matter for arrangement between them and their employers." "Some 'masters' of houses prefer to employ a professional disinfector. As a general rule, however, even when the firm referred to are privately employed for the disinfection of bedding, clothing, etc., removed from the premises for the purpose, the disinfection of the house is entrusted to your Vestry's officers. "It should be explained that it is not customary to serve on the master or owner of the house, the 'notice ' referred to in section 60 (1). The practice is to visit the infected house on the day the notification of illness is received, should it arrive before 10 a m. ; or on the next day, should the notification arrive after the disinfecting staff have left the office to commence their day's work. The majority of the sick among the poorer classes, who live in lodgings—often a family in a room—are removed to hospital within a few hours of receipt of the notification certificates : often, indeed, the patients have already been removed to hospital, by the doctors, before the notifications are received by me. In such cases it is obvious that disinfection should not be delayed. Nor is it, for, as a general rule, it is done the same day. Whatever the rank of the sufferer, should it be found, on visiting the house, that the patient has been removed to hospital, the disinfection is done forthwith, if desired, so as to avoid the delay of some days which might ensue, were the Sanitary Inspector to apply to me for, and serve on the following day, the ' notice' referred to in section 60 (1). In some—but a diminishing number of—cases, where the sick have been treated at home, the disinfection is arranged for by the medical attendant without reference to me ; but in all such cases application is made to the medical attendant, at about the probable date of recovery, with a view of ascertaining whether the house, or part, and the articles therein, as well as the bedding, clothing, etc., have been disinfected to his satisfaction, as the Act requires." The expenditure on disinfection, including cleansing, of clothing, bedding, &c., will necessarily vary from year to year, in proportion to the relative prevalence of infectious disease; but under existing arrangements it will increase in proportion as the public become acquainted with the provisions of the Act. I append a statement of the monthly cost of this work for the official year ended 25th March, 1894, amounting to some £1,160. 218 £ s. d. April, 1893 43 1 10 May, „ 79 19 4 June, ,, 94 1 11 July, ,, 77 5 7 August, „ 143 12 1 September, ,, 85 11 11 October, ,, 119 3 6 November, ,, 216 9 10 December „ 91 3 5 January, 1894 90 19 5 February, ,, 56 6 3 March, „ 61 10 8 I have expressed to the Sanitary Committee my opinion that expenditure under this head is too great, and that it might be reduced under different arrangements. SHELTERS. In connection with the question of disinfection, I may not inappropriately recall to your Vestry's attention the fourth sub-section, of section, 61 of the Public Health (London) Act: it reads as follows:— "The vSanitary Authority shall provide, free of charge, temporary shelter or house accommodation, with any necessary attendants, for the members of any family in which any dangerous infectious disease has appeared, who have been compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the sanitary Authority." The sub-section is a re-enactment of a provision contained in section 15 of the now repealed Infections Disease {Prevention) Act, 1890, to which I directed your Vestry's attention in my tenth monthly report for that year (October 6th, page 104), and on other occasions. Nothing, however, has been done in this parish to give effect to the requirements of the section, which, it will have been observed, are of an obligatory character; and in London generally, only about one-third of the Sanitary Authorities have provided Shelters. It is said to be difficult to get the people to make use of the Shelters : my experience, nevertheless, testifies to the necessity for such accommodation, which might be provided in this parish, as it is in other districts, in connection with a Station for disinfection purposes. 219 PUBLIC BATHS AND WASHHOUSES. The Baths and Washhouses, at the junction of Lancaster-road and Silchester-road, Notting Hill, opened in April, 1888, have been well supported. But for the majority of parishioners the site is not sufficiently central for bathing ; and obviously it is too remote for washing purposes. The same objection 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 statistics contained in the successive Annual Reports of the Commissioners for Baths and Washhouses, show a constantly increasing use made of the washhouses, and are of a nature to encourage the hope that it may be found not merely desirable, but prudent also, to provide, at no distant time, for the wants of the poor in the central and southern parts of the parish. The total number of washers, 13,950 only, in the year ended March 25th, 1889, rose to 31,113, in the year ended March 25th, 1890, to 39,829 in the year ended March 25th, 1891; to 42,528 in the year ended March 25th, 1892; to 46,843 in the year ended March 25th, 1893 ; and to 49,513 in the year ended March 25th, 1894. The number of hours employed in washing in the six years consecutively, was 38,709, 84,352, 106,560, 104,223, 103,900, and 102,934. The Commissioners state that nearty 14,510 of the washers paid the minimum charge of 1½d., for one hour's attendance, and 16,000 paid for two hours' attendance, " which would seem to prove that the poorest occupants of the very poor neighbourhood surrounding the baths, are availing themselves of the benefit of the institution which was established mainly for their advantage." It is added that " the average time occupied by each woman was under 26/16 hours, at an average charge of about 3¼d., exclusive of soap, soda, blue, etc." The bathers, who in 1889-90 were 79,029; in 1890-91, 89,491; in 1891-92,93,557 and in 1892-93, 104,276, were 119,798in 1893-94: 220 males, 105,258, and females 14,540. The bathers in the swimming baths in 1893-94 were 70,384; and in private baths, 49,414. The male bathers in the swimming baths were 65,319, the women, 5,065. The male bathers in the private baths were 39,939, the women, 9,475. Taking both classes of baths together, the patrons, men and women, of the first class baths, were 32,151; of the second class baths, 31,264 ; of the third class baths, 56,383. There was an increased attendance of bathers of all classes of 15,522, compared with the number in the previous year. The Commissioners, in their Annual Report, state that "the amount received (during the year) of the Vestry towards the repayment of loans and interest, and to meet the expenses of maintaining the institution, was £5,151," being somewhat less than in the preceding year. The Sanitary Committee of the London County Council, in their report for the year 1889-90, stated that, having " considered the question of the advisability of the Council being invested with powers to establish public baths and laundries in all parts of London," they had "come to the conclusion that this was not one of the questions that pressed most for central administration, and that it might be deferred until district councils are created"; and with this view the Council concurred. PUBLIC SANITARY CONVENIENCES. There are only seventeen public urinals in the Parish—a very inadequate provision, which, however, is supplemented by numerous urinals at public houses to which the general public have access. Prior to 1893 there were but two sets of public water-closets, both for the male sex only, viz., at the rear of the Vestry Hall, and at Norfolk Terrace. Since then about £1,000 has been expended in the construction of an underground lavatory, with ample accommodation of water-closets and urinals, in the Old Brompton Road opposite the Oratory. 221 This place, likewise, provides for the necessities of the male sex only. Section 88 of the Metropolis Management Act, 1855, enables the vestries and district boards to " provide and maintain urinals, water-closets, and like conveniences for both sexes, in situations where they deem such accommodation to be required;" but your Vestry's efforts to provide this necessary accommodation for the male sex, are very generally thwarted by local opposition. Suitable sites exist, none better perhaps, or where provision of the kind is more needed, than in Kensington High Street; where, opposite the Church, an underground retiring place for both sexes, after the model of those at Trafalgar Square, Piccadilly Circus, and elsewhere in the central parts of London, might be constructed without nuisance in any sense of the word. Increased powers for the purpose of such provision are given by the Public Health (London) Act, 1891, which, to facilitate the construction of underground conveniences, vests the sub-soil of roadways in the Sanitary Authority, who, moreover, have power to compensate persons injured by the erection of these conveniences near their houses, &c. Accommodation is provided at about 170 public-houses—not of a satisfactory sort in many instances, but better than none at all, and much improved as the result of proceedings taken by your Vestry in 1888. The County Council, in May, 1889, signified to the vestries and district boards their opinion as to the necessity for Chalet accommodation for men and women; or for the construction of places giving such accommodation below the level of the ground, in the manner which has proved successful in many parts of the metropolis, 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." Little, however, has been done hitherto, in this parish, as we have seen, to give effect to the views of theCouncil. 222 DRAINAGE MAP OF THE PARISH. The attention of the Sanitary Committee having been directed to the desirability of a map being prepared showing the course, size, arid all other necessary particulars in respect of the sewers in this parish, I took occasion, in my tenth monthly report (October 18th) to refer to observations on the subject contained in my Annual Report for 1875, wherein I specified a Drainage Map as one of the Sanitary Wants of the Parish. The Report was to the following effect:— "It not unfrequently happens, when questions of drainage are under consideration, that the want of a good map of the narish showing the sewers is much felt, and I submit that it would be a wise and judicious expenditure to set about the preparation of such a map without delay, the wonderful growth of the parish having made the ordnance survey obsolete for a large portion of it. It would be desirable— "1. To obtain the thirty sheets of the ordnance survey on which, wholly or in part, the configuration of the parish is delineated, and to insert thereon all streets, mews, etc., which have been formed since the said survey was taken : "2. To show the system of sewers (as far as may be laid down from information in possession of the Vestry, or procurable) to present date, with report, indicating— (a.) Sewers in good condition, date of construction, size, and length. (b.) Sewers (or system of drainage) known to be inadequate to the requirements of the respective localities, with description of same. (c.) Sewers which, though possibly of sufficient capacity, may by reason of old age or otherwise, e.g. by defective material, construction, or level, be dangerous to the health of the locality. (d.) Sewers which have blind ends, and which, by pipe connection with other sewers, air shafts, or otherwise, might be ventilated. (e.) Sewers difficult of approach from insufficient number of manholes, etc. "Engineering experience would probably enlarge the scheme of such an inquiry; but I venture to say that the advantages in a sanitary point of view of such information as the above, followed up by execution of all necessary works, would be simply incalculable. The parish once surveyed to date, it would be easy, from time to time, to insert new streets and sewers, and we should thus have ready access at all times to information which is in almost daily requisition in the sanitary department." The monthly report in question was referred to the Sanitary Committee who recommended that the sewers should be traced on the ordnance sheets for the use of my department. The recommendation was adopted by your Vestry and the work has been done. 223 SANITATION OF PUBLIC ELEMENTARY SCHOOLS. Acting upon the instructions of the Sanitary Committee, the several Inspectors, in June last year, visited and reported on the condition of the public elementary schools in the parish. The reports of the Inspectors having been submitted to the Committee, notices were issued requiring the execution of necessary sanitary works. The several notices were accompanied by a circular letter to the school managers, intimating that your Vestry desired that the specified works might be carried out during the summer holidays. The Inspectors, subsequently reported that nearly all of the said works had been satisfactorily completed, and that the persons responsible for their execution had manifested a proper anxiety to comply with the requirements of the Committee. The inspections referred to did not extend to the underground drainage of the several schools, to which attention will have to be given. Some of the head teachers at Board Schools made application last year to the Works Committee of that body for a supply of disinfectants, which they may well have thought requisite, in view of the large number of children absent from school on account of illness, much of it of an infectious character,* and of the incessant use made of the sanitary conveniences. In one such case the Clerk to the Board informed the head teacher that "several applications for disinfectants had already been submitted to the Works Committee, and in each case had been declined:" it was stated, however, that " an application could be made by the schoolkeeper to (your) Vestry for a supply of disinfectants." Such an application was made, but before complying with it, I deemed it my duty to consult the Sanitary Committee, who * It was stated that at one school out of 2,130 children on the roll, some 570 were absent, the average number in attendance in the week ending 9th December, being about 1,560, instead of 2,130. 224 agreed with me that disinfectants should be provided for use in its schools by the School Board, and a letter to that effect was addressed to the Clerk to the Board. This letter having been considered by the Works Committee, the Clerk to the Board replied to it, stating that "in the opinion of the Committee it is unnecessary to use disinfectants in the schools of the Board, and they have, therefore, refused to supply them." "If, however," the letter continued, "the Vestry think it desirable that disinfectants should be used in Board Schools, and are prepared to supply them, the Committee will offer no objection to their doing so." The Sanitary Committee directed a further communication to be addressed to the Board, throwing upon that body and its Works Committee the responsibility of the above decision, which, whatever may be said in its favour on grounds of so-called "economy," does not show much enlightenment from the sanitary point of view. It is, however, in consonance with the "Code of instructions for the guidance of school-keepers," issued by the Works Committee ; section 81 of which reads as follows:—" Schoolkeepers are not supplied with disinfectants, as the Committee are of opinion that if the troughs, urinals, and w.c.'s are systematically and thoroughly flushed the use of disinfectants will be unnecessary." The School Board, or rather the Works Committee, raised objections to certain requirements of the Sanitary Committee for the provision of sparge-pipes with automatic flushing tanks for the urinals at some of the Board Schools. Ultimately, however, the required alterations were carried out, and I believe I am correct in stating that the Works Committee, equally with the teachers and others, are well satisfied with the result. 225 HYGIENIC CARRIAGE-WAYS AND PAVEMENTS. In a report of the Works and Sanitary Committee, dated 21st March, 1893, on an "Inspection of certain portions of the Notting-dale District," it was stated that "some of the streets have been asphalte-paved with manifest advantage in respect of cleanliness, and your Committee would gladly see this system of paving extended in the 'Potteries,' and in other poor districts." It is to be regretted that nothing has been done to give practical effect to the views of the Committee. Possibly the Committee may have been deterred from following up the matter by definite recommendations, on account of the considerable first outlay involved in laying down asphalte carriage-ways. But first cost is not the only point to be considered. Asphalte is a highly durable paving even where traffic is at a maximum. Where traffic is small and light, it is impossible at present to fix a limit to its durability. The expense of cleansing such roads, moreover, must be considerably less than in the case of macadam roads, which, on hygienic grounds, asphalte might often replace with advantage. This material, moreover, is pre-eminently adapted for the paving of courts and alleys (of which fortunately there are few in this parish) and for the paving of yards also. Its use would, as regards these last, completely satisfy all the requirements of the bye-laws, made under the provisions of the Public Health (London) Act, 1891. Your Vestry have power under the provisions of the Metropolis Management Act, to require such places as private mews to be properly paved, for which purpose asphalte might be used with advantage, and without danger, as far as horses are concerned, if kept properly cleansed. I am aware, of course, that there is no power to compel the use of asphalte in such cases, but good advice might, in some instances, at least, be followed ; and, at any rate, your Vestry could set a good example, and demonstrate the efficiency of the material, by asphalte-paving some of the narrower streets, a list of which, I suggest, might be brought O 226 up by the Surveyor, who, I have reason to believe, is at one with me in approval of such use of asphalte. This subject of the paving of carriage-ways,has been ably dealt with in a paper* read before the Society of Arts by an "expert" member of your Vestry. In this paper the comparative merits and demerits of the several materials used for paving purpose—granite, wood, asphalte —were passed in review. To asphalte, the second place was assigned in respect of noiselessness, safety for horses, and durability; the third place with respect to "economy," and the first with respect to the points which most concern me, viz., public hygiene and cleansing. "On the score of hygiene," the author of the paper asserts that "Asphalte holds preeminently the first place, owing to its impermeability, and the consequent impossibility of absorption on its part; and in addition to this it may be stated, in its favour, that it is more easily cleansed,and dries more readily than any other pavement." From time to time, your Vestry's Surveyor has recommended asphalte paving for appropriate situations in this parish, e.g., Chelsea Grove, Silchester Mews, &c. No one who has visited these places can be insensible to the great improvement thereby effected; and on sanitary grounds I should be glad to see the use of this material extended to many other like places in the poorer portions of the parish. * Carriage-way Pavements for Large Cities," by Lewis H. Isaacs, F.R.I.B.A., Assoc Inst., C.E., Surveyor to the Board of Works for the Holborn District. 227 OBSTRUCTIVE BUILDINGS. A proposal having been made with respect to the erection of a particular building in the parish, the Works and Sanitary Committee reported that they were unable to approve of the plan of the premises, in view of the probability that the building might, by stopping ventilation, prejudicially affect surrounding properties, and so might have to be reported by the Medical Officer of Health as an "obstructive building," within the meaning of the Housing of the Working Classes Act, 1890. The Committee recommended, and your Vestry directed, that the architect of the proposed building be so informed. With reference to the general question of "obstructive buildings," I thought it right to point out, for the information of your Vestry, that, should a Sanitary Authority decide to take proceedings under the provisions of the Act, for the demolition of an " obstructive building," the entire cost of the proceedings, including compensation to the owner of the building, would have to be defrayed by the said Authority. The Act naturally contemplates the removal of existing "obstructive buildings:" it can hardly have entered into the mind of Parliament that new buildings of an " obstructive" character would be allowed to be erected. SMOKE CONSUMPTION. The duty of dealing with smoke nuisances devolves upon the Sanitary Authority, under the provisions of the Public Health (London) Act, 1891. In a few instances there has been cause for complaint in this parish, and the proprietors of certain breweries, laundries, &c., have been cautioned. In some cases, nuisances of this description have been reported by the officers of the County Council—inspectors of explosives and coal officers—who "have been instructed to report any nuisance from black smoke of serious duration which comes to their notice in the course of their other duties." No proceedings have been taken hitherto by your Vestry in respect of offences of this nature, and it may be questioned whether it 228 would bepricticable, under the provisions of the Act, to obtain com iciion-;, unless ihe matter were handed over to some officer having technical knowledge of furnace-conduction, &c. as it ha-i to be p oved that the nuisa ce is due to preventable negligence on the part o! the owner, or to furnaces defectively constructed." GRAND JUNCTION CANAL. I referred in my last repor t to complaints that had been made respect ng the condition of parts of the Grand Junction and Regent's Canals, and to the action of the Vestries of Paddington, St. Maiylebone, and St. Pancras, in relation thereto. The C>unty Council, when forwaiding to your Vestry a copy of the report of the delegates of the three Vestries requested to be informed as to the condition of the Grand Junction Canal in this parish, whereupon I reported, after inspection of the canal, that there did not appear to be any objectionable condition calling for action on the part of your Vestry, and that I had received no complaints on the subject. The length of the portion of the canal in this parish is about half a mile, viz., from Plough Lane Bridge, Portobello Road, to the western limit of the gas works wall on the towing-path side, the Kensal Green Cemetery being on the other side. There are no houses on the banks, and no wharves or laybyes. No drains, save a few for surface water or for roof drainage, enter the canal, and there are no visible sources of pollution on the banks. In the early part of the current year, the Council forwarded to your Vestry a report by their Medical Officer of Health on the condition of the canals, in which it was stated that the Grand Junction Canal "appears to be systematically scavenged," and that " the water was found in a cleanly condition." At about the same time the Council resolved to take the opinion of Mr. Poland, Q.C., " Whether it would not be competent for the Attorney-General, if called upon by the Council, to proceed by public indictment 229 against the Canal Companies for creating a public nuisance, by their neglect of the proper management of their canals and basins within the metropolis"? Mr. Poland, in due course, stated his opinion that " the canals are 'premises' within the meaning of the Public Health (London) Act, 1891," but that this is " not a case in which the Government would be likely to instruct the Attorney-General to take up the prosecution, until after every effort had been made to put a stop to the nuisance under the Public Health (London) Act, 1891." Mr. Poland came to the conclusion, moreover, " that the Council cannot pay the expenses of a prosecution by indictment out of the County Fund," and he suggested " that at a convenient opportunity the Council should obtain from Parliament the power of spending money for this salutary purpose." He was further of opinion that " so far as the Grand Junction Canal is concerned " (this being the one in which we are interested) " there is no case against the Canal Company, having regard to the printed report" of the Council's Medical Officer of Health, referred to above. METROPOLITAN SEWAGE. In previous annual reports I have referred to the question of sewage-disposal as one of interest to all Metropolitan Sanitary Authorities ; and last year I had the satisfaction of reporting completion of the precipitation works at Crossness -^-the works at Barking had long been in operation—with consequent improvement in the condition of the river Thames. The Main Drainage Committee of the County * Council stated in a report, dated in May, and the fact appeared to be beyond dispute, that " the condition of the river continues to be in every way satisfactory." They added that " the analyses of the samples collected at high and low water off the outfalls, show that although the quantity of sea water present is steadily increasing, and therefore the daily downward movement of sewage matter proportionately decreasing, still the aeration is high and the evidence of pollution low." 230 In 1892, before the Crossness works were completed, upwards of 50,000,000,000 gallons of sewage were treated at the outfalls, and more than a million-and-a-half tons of sludge, precipitated therefrom, was taken out to sea in the Council's fleet of sewage vessels. Considerable outlay was incurred for materials for precipitation and deodorisation. Some 13,850 tons of lime, 3,140 tons of proto-sulphate of iron, 174 tons of manganate of soda, and a large quantity of sulphuric acid were used. The summer of 1893 having been exceptionally hot, the fact that no serious complaints of offensive smells were made is all the more significant. It is a significant fact, moreover, that fish are now to be found in parts of the river, from which, prior to the completion of the precipitation works, they were absent. It is but just to mention that the present method of dealing with the sewage was originated by the late Metropolitan Board of Works, and was in partial operation during their regime; the gigantic works for the purpose having been designed and largely carried out by their engineer. Sewer Emanations.—Sewer air investigations have been carried out for some time past, for the County Council, by Mr. J. Parry Laws, in conjunction with Mr. Dibdin the Chemist to the Council, which go to show that the microorganisms of sewer air are almost invariably less in number than the micro-organisms to be found in fresh air surrounding the sewer at the same time, in the same vicinity; and the "important conclusion" deduced from observation is, that " the micro-organisms of sewer air are derived from the microorganisms of fresh air and not from the micro-organisms of sewage." As it is deemed " most desirable to study the micro-organisms existing in sewage under various conditions, with a view to classifying them, and determining the relative frequency with which each different species occurs," and as it" will be necessary to determine whether some of the 231 isms isolated from sewage possess pathogenic properties," a medical expert has been associated with the chemists in this particular examination. In a report to the Council by the Main Drainage Committee, it has been stated that the hypothesis that sewer air is " dangerous, and a likely source of infection in certain specific diseases," has been found to be incorrect. It is not denied that " sewer air in some instances has apparently had some causal relation to zymotic disease" ; but it is said to be " conceivable that the danger of sewer air causing disease is an indirect one; (for) it may contain some highly poisonous chemical substances, possibly of an alkaloidal nature, which, though present in but minute quantities, may nevertheless produce, in conjunction with the large excess of carbonic acid, a profound effect upon the general vitality." Further reports on this important subject will be awaited with interest. WATER SUPPLY. Report of the Royal Commission.—The report of the Royal Commission appointed to inquire into the water supply of the Metropolis, which was presented last year, is very favourable indeed to the Companies, and confirms the accuracy of the views which, from time to time, during the last twenty years, I have submitted to your Vestry; to the effect that, for all practical purposes, the water supply of the Metropolis is excellent and satisfactory. Not a particle of evidence, so far as I am aware, was produced to the Commission, establishing any connection between the water and the occurrence of disease of any kind. In far distant years, when the water was not filtered with the care now bestowed upon that all important process, cholera was diffused by the agency of water in one Company's District, at the East End, through causes that might fairly be described as accidental. And should the conditions recur, the same thing might happen again. But this is not at all probable, and the risk 232 would be reduced to an almost infinitesimal minimum, were the provisions of the Acts for the prevention of river pollution duly carried out. The Commissioners are emphatic upon this point, and also in respect of the necessity for additional legislation to secure the prevention of such pollution, which greatly increases the difficulty and the cost of fitting river waters for human consumption. Professor Frankland's Report to the RegistrarGeneral, sets out the results of his monthly chemical analyses and physical and bacterioscopic examinations of the waters supplied by the several Water Companies. The weather in 1893, save in the months of February and October, was very favourable for the operations of the companies ; and, excepting in February and March, the water delivered by the Thames companies was of excellent chemical quality. More storage capacity, however, is required by the several companies. The East London Company possesses more storage than any other company, viz., for fifteen days; but even this was " not sufficient to circumvent the long flood of February." Notwithstanding this remediable defect, the samples of water examined were invariably clear and bright; for, even when analysis showed the admission of flood water, the water actually supplied to consumers was always efficiently filtered, clear and transparent. The average temperature of the different waters is remarkably uniform throughout the year, but the monthly variation in the case of river waters is great: the temperature of the deep well waters, on the other hand, is practically constant throughout the year. The Kent Company's water varied only from 51"8° Fahr., in January, to 55-6° in June, a range, therefore, of only 4 8" ; that of the Thames waters being 35'3°, viz. from 35'8°, in January, to 71T° in August. The deep well water is thus " cool and refreshing in summer, and is less likely to become frozen in the service pipes in winter; whilst river water at 71T° is unpleasantly 233 vapid, and at 35.8° is soon cooled to the freezing-point." Dr. Frankland refers to the "hardness" of the waters, which is almost entirely due to the presence of bicarbonate of li.ne in solution, "which in no way diminishes the fitness of the water for dietetic purposes," but makes it unsuitable for washing, and also causes incrustations and deposits in steam and kitchen boilers and hot-water pipes, thus diminishing its value for industrial purposes. The hardness can be largely reduced by Clark's softening process, By this process, which consists in treating the water with lime, the initial hardness of the Colne Valley Company's chalk water, which is much in excess of that of Thames water, is reduced to about a third of the hardness of river water. The hardness of the Thames water in 1893, was 19.6°. that of the Colne Valley supply being 7.1°. The organic material which the solid matter contains, if present in too large a quantity, may interfere with the palatability of the water, and give it a more or less brownish yellow tint. These effects were not produced in 1893. It is alleged, however, that the presence of even small proportions of organic matter is objectionable, partly on sentimental and partly on hygienic grounds, by reason of the origin of a part thereof, such as the drainage from manured land, effluents from sewerage works, and even raw sewage itself. This animal matter " may " be accompanied by zymotic poisons dangerous to health. These poisons, however, are " rapidly destroyed in running water exposed to sunlight, and the most minute microscopic examination of the water at the intakes has failed hitherto to discover a single pathogenic germ." It is now an established fact, moreover, "that efficient sand filtration would prevent the passage of such germs into the filtered water, even should they arrive in a living condition at the intakes of the companies. Thus the hygienic objection to the use of filtered water from the Thames is removed. This conclusion,"it is stated,'' is confirmed by the absence in London of zymotic diseases traceable to these waters," during the last 28 234 years ; the diseases' referred to being typhoid fever and cholera. At the present moment, when cholera has reappeared on the continent, it is reassuring to know that " recent bacteriological research .... has demonstrated that sand filtration is practically a perfect safeguard against the introduction of the cholera bacillus into drinking water." The bacterioscopic examination of the water supply has become, therefore, " an investigation of the highest importance from a hygienic point of vew," and to this Dr. Frankland is "each year devoting an increased amount of attention." The samples of waters examined are obtained immediately after the water has left the filters: thus the " maximum degree of sterility of each water is determined"— after all sources of contamination have been passed. The fewer " microbes found in a given volume at that moment, the less is the probability of pathogenic organisms being present." In the initial absence of such organisms, the indefinite multiplication of non-pathogenic organisms is of no consequence. In illustration of the bacterial condition of the Thames at the intakes, samples of raw river water, collected at the same time as the filtered water, are submitted to examination, and also samples pumped from the natural gravel beds near the river. The " bacterial amelioration " of this latter water is remarkable : " no such high degree of purification has been as yet obtained by gravel laid artificially for this purpose." It is shown that a "low temperature favours, probably not the multiplication but, at all events, the preservation of living spores in the river water;" the number found in the colder months being far in excess of those met with in the warmer months of the year. A great destruction of bacteria, moreover, is effected by storage. Particulars in regard to this are given in relation to the water supplied by the Chelsea Company, which has storage capacity equal to 14 7 days' supply, and filters the water through four feet of sand at the average rate of 1¾ gallons per square foot per hour. The average percentage 235 of microbes removed is 98.24: the maximum being 100.00, and the minimum 95.25 per cent. This company, it is stated, except in the month of August, delivered water of " a very high degree of bacterial purity ; rivalling, in many cases, deepwell water in this respect. In the month of February, indeed, when the Thames at the intake contained 13,947 microbes, or their spores, per c.c., this company's water, which was being pumped from the general filter well into the supply mains, was absolutely sterile."The" average number of microbes in 1 c.c. of the company's water during the year, omitting an abnormal sample in August, was 18. The West Middlesex Company has storage for 6.7 days : the average thickness of sand on the filter is 2.6 feet, the rate of filtration being about l⅓ gallons per square foot per hour. The average percentage of microbes removed was 98.87 ; the maximum being 99.94, the minimum 92.67 per cent. The average number of microbes per c.c. during the year, omitting an abnormal sample in August, was 15 only, " an excellent record." The lowest number was 5 per c.c., in December, " whilst the raw water at the intake contained at the same time 6,316 microbes per c.c. The Grand Junction Company have storage for 3½ days only; .the average thickness of sand on the filter is 1¾ feet, the average rate of filtration, per square foot per hour, being 2.2 gallons. The average percentage of microbes removed was 97.12, the maximum being 99.77, the minimum 85.95 per cent. Four of the samples collected from the general well at this Company's works at Kew—in January, June, August and December—"contained an excess of microbes over 100 per cent. ; and samples collected at Hampton, in February, June, and December, also contained an abnormal number of microbes." One filter at the Kew Bridge Works "never furnished an abnormal sample throughout the year" (but six samples only were examined), whilst another filter which had " undergone a thorough " (and prolonged) " washing of all the materials of which it was composed, so as to become practically a new filter, yielded, the 236 day after it was started, 479 microbes per c.c. ; and eleven days later it still contained 434 microbes or their spores per c.c." " Thus it would appear that the thorough washing of this filter had seriously impaired its quality for effecting bacterial purification." Dr. Frankland gives particulars, on the same lines, with regard to the other companies' waters, in which, however, we are not locally interested. These bacteriological investigations have been going on for twenty months, and they are being supplemented by an extensive series of experiments upon the conditions necessary for effective microbial filtration. Whilst refraining for the present from drawing any definite conclusions from the results contained in the tables which supplement the remarks on each of the companies waters, Dr. Frankland states that "efficient filtration does not appear to depend, essentially, upon the thickness of sand upon the filter beds .... A regular rate of filtration throughout the 24 hours is probably of much more importance than thickness of any filtering medium." " The maximum rate to secure bacterial purity should not exceed 21 gallons per hour per square foot of filter surface." It is stated that " the bacterial efficiency of sand filtration depends also, to a very large extent, upon the formation of a thin film upon the surface of the sand, derived from subsidences of suspended particles in the raw water supplied to the filters. This film forms a nidus for, and becomes thickly populated with, microbes, which, in all probability, aid materially in the purification of the water passing through the filter. This film should therefore be removed as seldom as possible, consistent with the passage of sufficient water through the filter." This statement represents the newest, and a very novel view on the subject, and will, at first, appear as surprising as the further statement that " new filters and thoroughly washed filters are very ineffective for a considerable time." It is suggested that it would be well " to ascertain by direct experiments the length of time required to bring a scraped or washed filter 237 into an efficient condition " to ensure bacterial purification of the water ; and a " suitable mode of passing a filter through the scraping and restarting process" is described, advice being given as to methods to be observed to secure the object in view— efficient purification. Supervision of the water supply is vested in a Water Examiner, appointed under the provisions of the Water Act, 1871, whose report for 1893 has not yet been published. The few particulars subjoined, are mainly taken from his monthly report for March, 1894. In that month, the Grand Junction Company supplied 46| gallons per head, daily, to their customers; the Chelsea Company, 36¾ gallons; the West Middlesex Company, 31 gallons. For domestic purposes, in 1893, the daily supply by the several companies, in the order given, per house, was 254, 249, and 200 gallons. CONSTANT SERVICE. The importance of a constant service cannot be overrated. It is the intention of the County Council to procure this advantage for Londoners, and the work is proceeding apace. In February of the current year, the Council served a notice on the West Middlesex Water Works Company to give a constant supply of water, on and after 1st July, to " a district in South Kensington bounded on the north by Cromwell Road ; on the east by a line running at the rear of the houses on the west side of Gloucester Road, and through the western side of Hereford Square to the Old Brompton Road ; on the south by Old Brompton Road and Richmond Road ; and on the west by the West London Extension Railway." In March, 1894, the Grand Junction Company were giving a constant supply to all the houses in their district, the West Middlesex Company to 89 per cent., the Chelsea Company to 51 per cent. The eight companies which supply London were, at that date, giving constant supply to 613,187 out of a total of 803,054 houses, or 76 per cent, of the total number of supplies—the East London Company coming next after the Grand Junction Company with 99 per cent. 238 storage.—The number of days' supply represented by the capacity of the subsiding reservoirs, for storing unfiltered water, belonging to each of the local companies, was as follows : Chelsea 14.7, Ws est Middlesex 6.7, Grand Junction 3.5. The East London Company now heads the list having storage equal to a supply for 15.1 days. It should be stated that the Grand Junction Company have the means, during floods, of pumping from the gravel beds adjoining the Thames, and this is practically equivalent to an addition to their storage resources. Filtration.— Provision was made by the Metropolis Water Act, 1852, (sec. 4), for the efficient filtration of the water before distribution. Testimony is uniform that this provision is duly carried into effect. The late Sir Francis Bolton, the first Water Examiner appointed under the Water Act of 1871, laid down the conditions necessary to secure this object; viz. (1) Storage in subsiding reservoirs of capacity sufficient to avoid the necessity of intake of flood waters ; (2) a sufficient area of properly constructed filter beds ; and (3) the limitation of filtration to a certain speed, represented by the passage of about 540 gallons per square yard of filtering area in 24 hours, or 2½ gallons through each square foot of surface per hour. These conditions, as we have seen, are complied with by the several companies. Whatever the condition of the water when taken from the river, or passed on to the filtering beds, the filtered water as delivered to consumers is uniformly bright and clear. In former reports I have fully described the mode and apparatus of filtration, and to those reports I may refer for detailed information on the subject. Deterioration of Water in Dirty Cisterns.—It need hardly be said that filtration, however perfect, avails little, if the water is allowed, as frequently happens, to be fouled after delivery. The attention of householders cannot, therefore, be too frequently drawn to the necessity for the 239 periodical cleansing of cisterns for potable water, These receptacles, moreover, should be covered, 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. The Public Health (London) Act, 1891 (sec. 50), conferred power on the Sanitary Authority to make bye-laws for the cleansing of cisterns, and this has been done. Other Requirements.—When "constant supply" is given, a screw-down draw-off trap should be affixed to the rising main, or service pipe, so that the water for drinking and culinary purposes may be drawn therefrom, fresh and uncontaminated, without the intervention of cisterns, which are requited for washing, flushing, baths, and similar purposes. A stop-valve, moreover, should be fixed outside the premises to prevent damage to the house in case of pipes burst by frost or other causes, and this is now generally done. CuttinG-OFF Powers.—I have had occasion more than once in these reports, to express dissatisfaction with regard to the power of the companies to cut off the domestic supply of water for non-payment of the rate, and have expressed the view that they should be left to their remedy, like oth6r traders, for the recovery of debts, in course of law. The companies can, if they think fit, require prepayment of the rate. Any course would be preferable to the barbarous one of cutting off the supply, which, I doubt not, will, ere very long, be prohibited by law—suitable provision being made to secure to the companies requisite facility for enforcing their legal rights. My views, familiar enough to your Vestry, are also, I believe, well known to the Water Companies, one of which, last year, took a step in the right direction, worthy of all praise, and of the enlightenment by which the conduct of its business has for many years been characterised. I refer to the East London Water Company, which, it will be remembered, also took the lead in respect of the 240 constant service, which is practically universal in their district, some 99 per cent, of the houses being supplied on this system. This Company has decided, on sanitary and other grounds, not to disconnect the water from houses in their district on account of non-payment of the rate, but to have recourse to the necessary procedure at the Police Court for the recovery of arrears. Proceedings were taken by the company, in 1893, against six of their customers for non-payment of the waterrate, and, needless to say, the presiding magistrate, at the North London Police Court, made an order for payment of the amount due, with costs. It is to be hoped that the other companies will adopt the laudable practice thus initiated. Early in the current year, your Vestry, in common with other Sanitary Authorities, received a letter from the Vestry of Fulham, suggesting co-operation in an endeavour to obtain "an alteration of the law, so as to deprive water companies of the power, which they at present possess, of rendering premises insanitary by cutting off the water supply." The letter was referred to the Sanitary Committee, who reported that "this question had been under the consideration of the Vestry upon various occasions in past years," and that they " thought it desirable to submit a short summary of the proceedings" with relation thereto, as follows :— " In 1882, the question as to the power of Water Companies to cut off the water supply if the rate was not paid, was brought forward by the Medical Officer of Health in reports presented by him to the Sanitary Committee, upon whose recommendation the Vestry passed a resolution to the effect that the sections of the Water Acts, confeiring upon Water Companies the power of cutting off water, should be repealed, and that other powers to enable the companies to recover rates should be substituted therefor. " The matter was again brought before the Vestry in 1884, by the action of one of the Water Companies supplying Kensington, whereby 80 people, residing in a Mews, were deprived of the supply for which they had paid the landlord in their weekly rents, he, however, not having paid the rate. This action led to communications being addressed by the Vestry 241 to the Local Government Board, and to the several Sanitary Authorities; and the prominence thus given to the subject contributed to bring ahout a partial remedy by legislation. Advantage was also taken of the sitting of the Royal Commission on the Housing of the Working Classes, to send to every member of the Commission a copy of the Reports of the Medical Officer of Health, and of the correspondence on the case in question, with the result that, in their report, published in 1885, the Commission recommended that the companies should be deprived of the summary power to cut off the water supply. The Vestry supported a Bill introduced by Lord Camperdown in that year, and intended to settle the question, but the Bill was thrown out by the Commons. " A very useful measure, the Water Companies (Regulation of Powers) Bill, was brought in by Mr. Forrest Fulton in 1887, having for its object the limitation of the powers of Water Companies to cut off the tenants' water supply where the rate was paid by the landlord. The Vestry presented a petition to the House of Commons in favour of the Bill, which ultimately became law. " The Poplar District Board of Works in 1890, addressed a memorial to the Local Government Board, asking them to take further action to deprive Water Companies of the powers which they still possessed of cutting off the water supply from occupied premises. A copy of this memorial was submitted to the Vestry, when it was resolved, upon the recommendation of the Law and Parliamentary Committee, to address a communication to the Local Government Board expressing approval of the principle laid down in the memorial. Nothing, however, came of the action taken by the Sanitary Authorities on this occasion. " By section 49 of the Public Health (London) Act, 1891, the Water Companies are required to give notice to the Sanitary Authority when they cease to supply any dwelling house with water, from any cause, thereby giving effect to the views contained in a resolution passed by the Vestry on the subject in 1882 ; and as by section 48 (1) of the same Act, any occupied House without a sufficient supply of water is constituted a nuisance liable to be dealt with summarily under the Act, the powers of the Vestry are practically used as a means to enforce payment of the water-rate." The report of the Committee was adopted, and also the recommendation, " That a copy of the Annual Report of the Medical Officer of Health for the year 1891, be forwarded to the Vestry of Fulham with an intimation that this Vestry are in accord with them as to the desirability of the Water Companies being deprived of the powers they still possess to cut off water from occupied premises and will be fully prepared to co operate with them in any practicable proposal which they may bring forward for attaining this object." P. 242 THE WATER REGULATIONS. The Water Regulations framed by the Companies, under the Act of 1871, contain many useful provisions, and it would be well were express power given to Sanitary Authorities, enabling them to enforce such of them as have a distinctly sanitary bearing. The twenty-first regulation deals with the subject of Flushing-Tanks for the supply of water closets, providing that the tank or service-box shall not be capable of discharging more than two gallons at a flush, a quantity which the so-called two-gallon flushing tank is practically unable to deliver. The attention of the Sanitary Authorities was called, in 1892, by the St. Giles's District Board of Works, to the desirability of an amendment of the regulation, so as to allow of the provision of a tank of threegallons capacity, on the ground that a two-gallon receptacle does not furnish a flush of water sufficient to secure the effective action of a water-closet. The District Board desired the support of the Sanitary Authorities to an application they had made to the Local Government Board, to take steps " with a view to the 21st Regulation being altered, so as to provide for the use of cisterns or service-boxes which will permit a discharge of not less than three gallons of water at each flush." The proposal was supported by your Vestry, although I had the satisfaction of stating that the local companies did not raise objection to the fixing of tanks of three-gallons capacity, which is all, I think, we could fairly ask of them. The Local Government Board desired to be informed of the view taken by the several Sanitary Authorities on the subject, and the correspondence which passed between the Board and those authorities was subsequently forwarded by the Board to the County Council, with a request for the Council's observations thereon. The matter was considered by the Public Health and Housing Committee of the Council, who reported in favour of a three-gallon flush, and recommended that Regulation 21 should be amended accordingly. The Committee did not think 243 that the regulation, as amended, should be immediately retrospective, but that on and after 1st January, 1901, the altered regulation should apply to all flushing cisterns. In December last the Council adopted the recommendations of the Committee, with an important modification, and decided to inform the Local Government Board that they were " strongly of opinion— 44 (a) That regulation 21 under the Metropolis Water Act, 1871, should be amended so as to read as follows :— * Every water-closet cistern or water-closet service box hereafter fitted or fixed, in which water supplied by the Company is to be used, shall have an efficient wasie-preventing apparatus so constructed as to be capable of discharging three gallons of water at each flush.' * 44 (b) That the requirements as to the supply of water to water-closets should apply equally to the supply of water to sinks used for receiving any solid or liquid filth.. 44 (c) That a regulation should be made which shall prevent cisterns being brought into use for supplying water for domestic purposes, or for food for beasts, so long as they directly supply any water-closet, or sink used for receiving any solid or liquid filth. 44 (d) That in all cases where any premises have a constant water service, one or more taps should be provided, in connection with the rising mains for the supply of water for drinking purposes." But, in January, 1894, the Local Government Board pointed out to the Council that the modification of regulation 21 in the form proposed, was inadmissible, as " the scope of the regulations is limited to the prevention of waste, misuse, undue consumption, and contamination of water, and the recommendation («) as amended by the Council, could not be considered as having any of these purposes for its object." The Public Health Committee admitted the validity of this criticism, and repeated their former recommendation, to the effect " that the cisterns should be capable of discharging * The Committee's recommendation was to the effect that the apparatus should "not be capable of discharging more than three gallons of water at each flush." 244 not more than three gallons." The Committee, moreover, reported that the Council could, if it thought fit, make a byelaw, under Section 39 of the Public Health (London) Act, 1891, " prescribing a minimum capacity of flushing cisterns, but, as the bye-laws under this Act have so recently come into operation," they did not advise this course for the present. The Local Government Board expressed an opinion, that " the most convenient method of bringing the question to an issue, will be for the Council to make formal application to the water companies, under Section 19 of the Act of 1871, to make such alterations as the Council may judge to be reasonable, and as are warranted by the Act; and that in the event of the companies' refusal, it will be competent for the Board to proceed in the manner directed in the section." The Committee accordingly recommended that they be " authorised to make formal application to the London Water Companies for the amendment of their regulations in the particulars specified in the recommendations made in December last," as quoted above, and this recommendation was adopted by the Council. In a report dealing with this queston (No. 12,1892, p. 149) and recommending your Vestry to comply with the request of the St. Giles's Board, for co-operation, I also advised that the Local Government Board should be requested to obtain amendment of the 14th Regulation likewise, so as to require the Water Companies to serve a notice upon consumers to sever all connections of waste-pipes of cisterns with drains. Your Vestry had made a representation to the Board on this subject, eleven years ago, which was supported by many of the Sanitary Authorities. The local companies were at the same time requested to exercise their power to enforce the cutting-off of waste-pipes ; but they took no step beyond—in common with the other companies—issuing a circular letter to their customers, indicating the desirability of such severance being effected, in conformity with the advice given by the Medical 245 Officer to the Board, in view of a threatened visitation of Cholera. The Board had communicated to the Sanitary Authorities the views of their Medical Officer, as to cutting off all connexion of waste-pipes with drains, a point on which the late Sir Francis Bolton, the Water Examiner, had been insisting, in his reports, for years, but without effect. Should there be an outbreak of Cholera this year, it is probable that the Board will again give similar advice to the Sanitary Authorities, as they did last year, but without taking any steps to enable those Authorities to give effect to their advice, viz., by procuring the desired amendment of the fourteenth regulation. It would be well could the Board be induced to comply with the recommendation transmitted to them by jour Vestry on the subject, in 1883; when, moreover, they were also asked to obtain power to enable Sanitary Authorities to enforce other of the regulations having a sanitary bearing: those numbered 9, 10, 11, 13, 14, 16, 17, 20, 21, 22, 24,25,31, and 32, being specified. Your Vestry's action in this important matter was fully set out in my Annual Report for 1882-83 (pages 117 to 126 inclusive) and I would recommend that the attention of the Local Government Board(or better still, that of the County Council) be again invited to the subject. It may be here mentioned that the regulations of the Water Companies were made in 1872, under the provisions of sees. 17—25 of the Metropolis Water Act, 1871, and have never been altered. But any company may repeal or alter existing regulations, or make new regulations instead of any of the same (sec. 18), and if the Metropolitan Authority (i.e. the County Council) or any ten consumers of the water supplied by any company, request the Company, in writing, to repeal or alter any of the regulations, or to make new regulations instead of any of the same, and the company refuse to do so, the Local Government Board may appoint a competent person to report as to the expediency of altering or repealing such regulations, or of making new regulations, in conformity with such request, and 246 on the report of such person the Board may make alterations in the regulations as they think fit. No alteration or repeal of any existing regulations, or any regulation newly made by the company, has any force or effect unless or until the same shall have been confirmed by the Local Government Board. In the report above referred to, I stated that " the most likely course to attain the object the St. Giles's District Board had in view, would be to approach the Metropolitan Authority, whose intervention would probably be successful ; " and this opinion, it would appear, is likely to prove correct. GAS. The subjoined Tables, based on the quarterly reports of the Chief Gas Examiner, summarise 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 16 candles, was as follows :— Maximum. Minimum. Average. Quarter ended March 31st 16.8 16.1 16.3 Quarter ended June 30th 16.9 15.9 16.4 Quarter ended September 30th 17.5 16.0 16.5 Quarter ended December 31st 17.5 15.7 16.6 Averages, whole year 17.2 15.9 16.4 It appears from these results, that the average illuminating power of the gas, at the station, was higher than the Parliamentary standard, and that, excepting on two occasions, the minimum was equal to or above the requirement. 247 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. 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 11.8 8.0 9.5 Quarter ended June 30th 12.6 8.4 10.0 Quarter ended September 30th 15.8 5.1 9.4 Quarter ended December 31st 11.3 7.6 9.4 Averages, whole year 12.9 7.3 9.6 Averages, 1892 13.6 8.9 10.6 Averages, 1891 15.4 9.4 12.0 Averages, 1890 16.0 10.7 13.1 Averages, 1889 14.0 9.3 11.0 Averages, 1888 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 Parliament, 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. 248 Variation in Illuminating Power.—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 having 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 shewn to be defective at the regular testing place. The above facts point to the necessity for an 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 shews to be defective in lighting power. Effect has not hitherto been given to this recommendation. Standard of Light.—The Metropolitan Board, also in 1884, suggested the expediency of an alteration in the standard of light prescribed by the statutes. It is required that the illuminating power of the gas shall, when consumed at the rate of five cubic feet an hour, by means of a standard argand gas burner, be equal in intensity to the light given by 16 sperm candles of 6 to the pound, each burning at the rate of 120 grains per hour. 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 Report of the Board for 1887, the subject was again dealt with, and it was stated 249 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 Harcourt, one of the gas referees, appeared to possess, in a higher degree than any other, the merits of simplicity, accuracy, and reliability. The County Council, through its Sanitary and Special Purposes Committee, took up the subject, having addressed a communication to the Board of Trade (in July, 1889), with a view to steps being taken for (1) providing a trustworthy standard of light; (2) prescribing a standard photometer with which all official photometers should be compared, and (3), giving legal force to tests made with a portable photometer ; the reasons for which are fully set out in the Committee's communication. During 1891 the subject continued to receive the attention of the Committee, and formed the subject of several reports. The Board of Trade, moreover, undertook to appoint a scientific Committee to consider what the standard of light should be ; but having no fund out of which to defray the costs of the contemplated enquiry, they asked if the Council would defray the expense? a course the Committee were not prepared to recommend, as the Council have no power to make any payment for such a purpose. The Committee, therefore, recommended that steps should be taken to promote a Bill " for substituting a more exact standard of light for that now prescribed," and this course, doubtless, would have been adopted, but for the liberality of the South Metropolitan Gas Company, who undertook to bear the whole of the expenses of a Committee, which the Board of Trade thereupon agreed to appoint. The Committee was to be composed of two members nominated by the Council, one by the Corporation, three by the London Gas Companies, together with the three Gas Referees, and two independent scientific men. What result has followed the investigations made by the Committee, if any, I am unable to state, not having seen any reference to their proceedings. 250 It now only remains for me, in bringing this Report to a conclusion, to offer my thanks to all who have contributed by their assistance to whatever success may have attended our Public Health work during the past year. To your Vestry I am indebted for continuance of the confidence which, for twenty-three years, has enabled me to carry out, with pleasure and satisfaction, the duties of my office, and to superintend a Department of Local Administration the importance of which is now universally recognised. I am, Gentlemen, Your obedient Servant, T. ORME DUDFIELD, Medical Officer of Health. Public Health Department, Town Hall, Kensington, July, 1894. 251 APPENDIX. Note.—The forms for Tables I., to VI. inclusive, were arranged by the Society of Medical Officers of Health, with the object of securing uniformity in Statistical Returns. 252 TABLE I. Showing Population, Inhabited Houses, Marriages, Births, and Deaths, in 1893, and in the preceding ten years : gross numbers. The Year. Estimated Population* No. of Inhabited Houses.‡ Marriages. Registered Births. Deaths. Total, all Ages ‡ Under One Year. Under Five Years. In Public Institutionsn 1893 167,000 22,050 1,540 3,661 2,916 625 965 740 1892 166,700 22,050 1,584 3,718 2,882 587 972 687 1891 160,400 22,002 1,569 3,847 3,066 633 968 773 1890 166,080 21,800 ** 1,511 ** 3,864 2,951 651 1,095 612 1889 165,760 21,700 1,491 3,698 2,412 489 789 570 1888 165,450 21,600 1,497 3,776 2,825 604 1,077 590 1887 165,140 21,566 1,561 3,941 2,872 680 1,129 608 188G 164,820 . ' 21,500 1,605 4,149 2,756 636 1,029 604 1885 164,500 21,420 1,480 4,032 2,768 653 1,085 561 1884 164,180 21,390 ** 1,498 ** 4394 ** 2,638 689 1,034 460 1883 163,860 21,030 1,616 4,230 2,615 602 982 487 Average, 0 years 1883-92. 165,289 21,595 1,541 3,964 2,778 622 1,016 595 Population in 1861, 70,108; 1871, 120,299: 1881, 163,151 ; 1891, 166,308. Average Number of Persons to each house at Census : in 1861, 7.4 ; in 1871, 7.6 ; in 1881, 8.1 ; in 1891, 7.56. Area of Parish, 2,190 acres. Number of persons to an acre (1893), 76.2. *For statistical purposes the population is estimated to the middle of the year, on the basis of the rate of increase in the preceding inter-censal period, checked by the known number of inhabited houses, and by the average number of persons per house, as ascertained at the last Census. † The data are somewhat unreliable. The Census number, which includes houses occupied only by caretakers, is given for 1891. ‡ 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 instituons, including the Asylums Board Hospitals. ** In 53 weeks. 253 TABLE II. Showing the Annual Birth-rate and Death-rate ; Death-rates of Children, and Proportion of Deaths in Public Institutions to 1,000 Deaths, for the year 1893, and the preceding ten years. The Year. Birth-rate per 1,000 of the Population. Death-rate per 1,000 of the Population. Deaths of Children under one year; per 1,000 of Registered Births. Deaths of Children under one year ; per 1,000 of Total Deaths. Deaths of Children under five years ; per 1,000 of Total Deaths. Deaths in Public Institutions ; per 1,000 of Total Deaths. 1893 21.9 17.5 170 214 331 254 1892 22.3 17.2 158 204 337 238 1891 23.1 18.4 164 206 315 252 1890 23.3 17.8 168 221 371 207 1889 22.3 14.6 132 203 327 236 1888 22.8 17.1 160 214 381 208 1887 23.9 17.4 172 237 393 212 1886 25.2 16.7 154 230 373 219 1885 24.5 16.8 161 236 392 202 1884 26.8 16.1 157 261 392 174 1883 25.8 16.0 142 230 375 186 Average of 10 years, 1883-92. 24.0 16.8 157 224 366 213 * 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 year 1883, the deaths at Brompton Consumption Hospital are included as compensation for an unknown number of deaths of Parishioners at outlying Public Institutions. TABLE III. Deaths registered from all causes in the year 1893. (Exclusive of the Deaths of Non-Parishioners at Public Institutions within the Parish, but inclusive of the Deaths of Parishioners at Public Institutions, etc., without the Parish.) For a Summary of this Table see Page 72. CAUSES OF DEATH. AGES. Total under Five Years of Age. Grand Total All Ages. subdistrict. 0 to 1. 1 to 5. 5 to 15. 15 to 25. 25 to 35. 35 to 45 45 to 55. 55 to 65. 65 to 75. 75 to 85. 85 and upwards. Kensington Town Brompton. (CLASSES.) I. SPECIFIC FEBRILE or ZYMOTIC DISEASES 144 140 44 21 33 15 18 35 27 17 6 284 500 417 83 II. PARASITIC DISEASES 2 ... 1 ... ... ... ... ... ... 1 ... 2 4 2 2 Ill DIETETIC DISEASES 3 ... ... ... 6 6 5 2 1 1 ... 3 24 17 7 IV. CONSTITUTIONAL DISEASES 42 38 30 49 58 84 76 53 52 19 3 80 504 391 113 V. DEVELOPMENTAL DISEASES 83 ... ... ... ... ... ... 1 15 48 28 83 175 138 37 VI. LOCAL DISEASES 231 143 51 35 63 127 183 220 255 138 35 374 1481 1157 324 VII. DEATHS FROM VIOLENCE 14 1 7 9 3 7 14 9 6 5 2 2 21 78 56 22 VIII. DEATHS FROM ILL-DEFINED AND NOT SPECIFIED CAUSES 106 12 2 4 4 2 4 6 7 3 ... 118 150 127 23 625 340 137 112 171 248 295 323 362 229 74 965 2916 2305 611 I. SPECIFIC FEBRILE or ZYMOTIC DISEASES. 1.—Miasmatic Diseases. Small-pox 3 ... ... 1 2 ... 2 1 ... ... ... 3 9 9 ... Measles 4 13 1 ... ... ... ... ... ... ... ... 17 18 16 2 Scarlet Fever 4 28 12 4 2 ... 1 ... ... ... ... 32 51 46 5 Tvphus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping-Cough 26 35 4 ... ... ... ... ... ... ... ... 61 65 56 9 Diphtheria 5 42 25 3 3 1 3 ... ... 1 ... 47 83 65 18 Simple Continued or Ill-defined Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric or Typhoid Fever ... ... ... 4 9 2 ... 2 ... ... ... ... 17 14 3 Other Miasmatic Diseases—Influensa 2 5 1 2 12 6 9 24 21 9 2 7 93 75 18 2.—Diarrhal Diseases. Simple Cholera 1 ... ... ... 1 ... ... 1 2 ... ... 1 5 4 1 Diarrhoea, Dysentery 76 13 ... 1 ... ... ... 1 ... 5 2 89 98 82 16 3.—Malarial Diseases. Remittent Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Zoogenous Diseases. Cow -pox, and effects of Vaccination ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5.—venereal Diseases. Syphilis 20 3 ... 2 ... 3 ... ... ... ... ... 23 28 25 3 Gonorrhoea, Stricture of the Urethra ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 ... 6.—Septic Diseases. Erysipelas 2 1 1 1 ... ... 1 4 3 2 - 2 3 17 11 6 Pyaemia, Septicaemia 1 ... ... ... ... ... 1 2 1 ... ... 1 5 5 ... Puerperal Fever ... ... ... 3 4 3 ... ... ... ... ... ... 10 8 2 144 140 44 21 33 15 18 35 27 17 6 284 500 417 83 II.—PARASITIC DISEASES. Thrush and other Vegetable Parasitic Diseases 2 ... 1 ... ... ... ... ... ... 1 ... 2 4 2 2 Worms, Hydatids, and other Animal Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... 1 ... ... ... ... ... ... 1 ... 2 4 2 2 III.—DIETETIC DISEASES. Want of Breast Milk—Starvation 3 ... ... ... ... ... ... ... ... ... ... 3 3 2 1 Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chronic Alcoholism ... ... ... ... 3 6 5 2 1 1 ... ... 18 12 6 Delirium Tremens ... ... ... ... 3 ... ... ... ... ... ... ... 3 3 ... 3 ... ... ... 6 6 5 2 1 1 ... 3 24 17 7 IV.—CONSTITUTIONAL DISEASES. Rheumatic Fever, Rheumatism of the Heart 1 1 4 ... 2 6 ... ... 1 ... ... 2 15 15 ... Rheumatism ... ... ... 1 ... 2 1 1 ... 1 ... ... 6 5 1 Gout ... ... ... ... ... ... 1 1 3 2 ... ... 7 6 1 Rickets 2 1 ... ... ... ... ... 1 ... ... ... 3 4 3 1 Cancer, Malignant Disease ... ... ... 1 5 18 29 36 36 12 3 ... 140 105 35 Tabes Mesenterica 16 3 1 ... ... ... ... ... ... ... ... 19 20 17 3 Tubercular Meningitis, Hydrocephalus 8 22 9 3 ... ... ... ... ... ... ... 30 42 39 3 Phthisis 1 2 4 36 46 51 42 10 6 1 ... 3 199 150 49 Other forms of Tuberculosis, Scrofula 13 9 12 6 3 2 ... 1 ... ... ... 22 46 34 12 Purpura, Hæmorrhagic Diathesis ... ... ... ... .... ... ... ... ... ... ... ... ... ... ... Anæmia, Chlorosis, Leucocythæmia 1 ... ... 1 ... 1 ... 1 2 1 ... 1 7 4 3 Glycosuria, Diabetes Mellitus ... ... ... 1 2 2 2 2 4 2 ... ... 15 11 4 Other Constitutional Diseases ... ... ... ... ... 2 1 ... ... ... ... ... 3 2 1 42 38 30 49 58 84 76 53 52 19 3 80 504 391 113 DEVELOPMENTAL DISEASES. Premature Birth 71 ... ... ... ... ... ... ... ... ... ... 71 71 53 18 Atelectasis 7 ... ... ... ... ... ... ... ... ... ... 7 7 7 ... Congenital Malformation 5 ... ... ... ... ... ... ... ... ... ... 5 5 5 ... Old Age ... ... ... ... ... ... ... 1 15 48 28 ... 92 73 19 83 ... ... ... ... ... ... 1 15 48 28 83 175 138 37 VI.—LOCAL DISEASES. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes 12 18 5 2 3 1 1 5 ... ... ... 30 47 38 9 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis 1 ... ... 1 2 8 20 34 38 26 8 1 138 101 37 Insanity, General Paralysis of the Insane ... ... ... ... 2 1 5 2 2 ... ... ... 12 12 ... Epilepsy ... 1 2 1 3 2 3 2 ... ... ... 1 14 8 6 Convulsions 47 5 ... ... ... ... ... ... ... ... ... 52 52 45 7 Laryngismus Stridulus (Spasm of Glottis) 2 3 ... ... ... ... ... ... ... ... ... 5 5 3 2 Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... ... ... ... 1 1 4 ... 2 ... ... 8 6 2 Other Diseases of Nervous System 1 1 ... 1 2 7 7 3 7 ... ... 2 29 18 11 2.—Diseases of Organs of Special Sense. (e.g., of Eye, Ear, Nose) 1 ... 3 1 ... ... ... ... ... ... ... 1 5 4 1 3.—Diseases of Circulatory System. Pericarditis ... ... ... 2 ... 1 ... 1 1 ... ... ... 5 4 1 Acute Endocarditis ... ... 1 ... 1 2 ... ... ... ... ... ... 4 3 1 Valvular Diseases of Heart ... 1 2 1 5 12 6 5 10 5 ... 1 47 32 15 Other Diseases of Heart 1 1 4 3 6 13 25 35 42 12 2 2 144 99 45 Aneurism ... ... ... ... ... 2 2 2 1 1 ... ... 8 6 2 Embolism, Thrombosis ... ... ... ... ... ... 2 ... 5 ... 1 ... 8 4 4 Other Diseases of Blood Vessels ... ... ... ... ... 1 ... 1 ... 1 ... ... 3 2 1 4.—Diseases of Respiratory Organs. Laryngitis 2 3 1 ... ... ... ... ... ... ... ... 5 6 6 ... Croup ... 7 2 ... ... ... ... ... ... ... ... 7 9 7 2 Emphysema, Asthma ... ... ... ... 1 2 5 4 4 1 ... ... 17 12 5 Bronchitis 86 55 7 1 4 15 38 56 69 58 13 141 402 355 47 Pneumonia 12 24 8 6 15 27 25 16 20 7 13 36 163 128 35 Pleurisy ... 3 2 4 5 1 ... 9 6 2 1 3 33 23 10 Other Diseases of Respiratory System 13 5 2 ... ... 1 4 5 6 2 3 18 41 29 12 5.—Diseases of Digestive System. Dentition 7 5 ... ... ... ... ... ... ... ... ... 12 12 10 2 Sore Throat, Quinsy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of Stomach 3 1 ... 5 2 ... 2 2 3 3 ... 4 21 14 7 Enteritis 35 4 2 1 ... ... 1 1 ... 4 ... 39 48 44 4 Obstructive Diseases of Intestine 2 1 ... ... 1 1 3 2 12 2 1 3 25 17 8 Peritonitis ... 1 6 2 1 3 2 3 1 ... ... 1 19 15 4 Ascites ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 ... Cirrhosis of Liver ... ... ... 1 1 4 3 8 5 ... ... ... 22 15 7 Jaundice, and other Diseases of the Liver 3 2 ... 1 2 1 4 3 4 5 2 5 27 20 7 Other Diseases of Digestive System 1 1 2 ... 1 1 ... ... 1 ... ... 2 7 5 2 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen.) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7.—Diseases of Grandlike Organs of Uncertain Use. (e.g., Bronchocele, Addison's Disease.) ... ... ... ... ... 2 ... ... ... ... ... ... 2 2 ... 8.—Diseases of Urinary System. Nephritis ... ... ... ... ... 2 2 2 3 2 ... ... 11 8 3 Bright's Disease, Albuminuria ... ... ... ... 1 4 11 9 7 ... ... ... 32 22 10 Disease of Bladder or of Prostate ... ... ... ... ... 1 1 ... 1 3 1 ... 7 4 3 Other Diseases of the Urinary System ... 1 1 ... 1 4 3 3 4 1 ... 1 18 14 4 9.—Diseases of Reproductive System. 1 18 14 4 a. Of Organs of Generation. Male Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Female Organs ... ... ... 1 2 3 2 1 2 ... ... ... 11 8 3 b. Of Parturition. Abortion, Miscarriage ... ... ... 1 1 1 ... ... ... ... ... ... 3 1 2 Puerperal Convulsions ... ... ... ... ... 1 ... ... ... ... ... ... 1 1 ... Placenta Prævia, Flooding ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Childbirth ... ... ... ... 1 2 ... ... ... ... ... ... 3 3 ... 10—Diseases of Bones and Joints. Caries, Necrosis ... ... 1 ... ... ... 1 ... ... ... ... ... 2 2 ... Arthritis, Ostitis, Periostitis ... ... ... ... ... ... 2 ... ... ... ... ... 2 2 ... Other Diseases of Bones and Joints ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... 1 11.—Diseases of Integumentary System. Carbuncle, Phlegmon 1 ... ... ... ... ... ... 2 1 ... ... 1 4 3 1 Other Diseases of Integumentary System 1 ... ... ... ... ... ... ... ... 1 ... 1 2 1 1 231 143 51 35 63 127 183 220 255 138 35 374 1481 1157 324 VII.—DEATHS FROM VIOLENCE. 1.—Accident or Negligence. Fractures and Contusions ... 3 4 ... 4 9 6 4 2 1 2 3 35 24 11 Gun-shot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Burn, Scald 1 4 2 ... ... ... 1 ... ... ... ... 5 8 7 1 Poison ... ... 1 ... ... 1 ... ... ... ... ... ... 2 1 1 Drowning ... ... 1 ... 1 1 ... ... ... ... ... ... 3 3 ... Suffocation 13 ... ... ... ... ... ... ... ... ... ... 13 13 12 1 Otherwise ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2.—Homicide. Manslaughter ... ... ... 1 ... ... ... ... ... ... ... ... 1 1 ... Murder ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3.—Suicide. Gun-shot Wounds ... ... ... ... ... ... 2 ... 1 ... ... ... 3 2 1 Cut, Stab ... ... ... ... ... 3 ... ... ... 1 ... ... 4 1 3 Poison ... ... ... 1 2 ... ... 2 ... ... ... ... 5 1 4 Drowning ... ... 1 1 ... ... ... ... ... ... ... ... 2 2 ... Suffocation ... ... ... ... ... ... ... ... 1 ... ... ... 1 1 ... Otherwise ... ... ... ... ... ... ... ... 1 ... ... ... 1 1 ... 4.—Execution. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 14 7 9 3 7 14 9 6 5 2 2 21 78 56 22 VIII.—DEATHS FROM ILL-DEFINED AND NOT SPECIFIED CAUSES. Dropsy ... ... ... ... ... ... ... ... 1 1 ... ... 2 2 ... Debility, Atrophy, Inanition 103 11 ... 1 ... ... ... ... ... ... ... 114 115 98 17 Mortification ... ... ... 1 ... ... ... ... ... 1 ... ... 2 2 ... Tumour ... ... ... 1 ... ... ... ... ... 1 ... ... 5 4 ... Abscess ... ... ... ... 1 ... ... ... 2 ... ... ... 3 2 1 Hemorrhage ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 ... Sudden Death (Cause not ascertained) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Causes not specified or ill-defined 3 1 2 2 2 2 3 3 4 ... 4 22 18 i 4 106 12 2 1 4 4 2 4 6 7 3 118 150 127 23 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 Years of Ages. Grand Total All ages. Kensington Town. Brompton. AGES. SUB- DISTRICT. 256 TABLE IV. Showing the number of Deaths at all ages in 1893, from certain groups of Diseases, and proportions to 1000 of Population, and to 1000 Deaths from all causes : also the number of Deaths of Infants, under one year of age, from other groups of Diseases, and proportions to 1000 Births, and to 1000 Deaths from all causes under one year. Division I. (Adults). Total Deaths. Deaths per 1000 of Population at all ages. Deaths per 1000 of Total Deaths., at all ages. 1. Principal Zymotic Diseases 341 2.0 117 2. Pulmonary Diseases 669 4.0 229 3. Principal Tubercular Diseases 269 1.6 92 Division II. (Infants under one year). Total Deaths. Deaths, per 1000 of Births. Deaths, per 1000 of Total Deaths under one year. 4. Wasting Diseases 177 48 284 5. Convulsive Diseases 62 17 99 NOTES. 1, Includes Small-pox, Measles, Scarlet Fever, Diphtheria, Whooping-cough, Typhus Fever, Enteric (or Typhoid) Fever, Simple Continued Fever, and Diarrhoea. One hundred and eleven 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). 257 TABLE V. Showing the Number of Deaths from the Principal Diseases of the Zymotic Class in the ten years 1883-92, and in the year 1893. Diseases. 1883. 1884. 1885. 1886. 1887. 1888. 1889. 1890. 1891. 1892. Annual Average of ten years 1883-92. Proportion of Deaths to 1000 Deaths in ten years 1883-92. Deaths in 1893. Proportion of Deaths to 1000 Deaths in 1893. Small-pox 1 26 25 0 1 0 0 0 0 0 5.3 1.9 9 3.1 Measles 39 32 111 56 108 124 14 140 29 109 76.2 27.4 18 6.2 Scarlet Fever 28 18 7 11 44 26 28 26 16 36 24.0 8.6 51 17.5 Diphtheria 24 17 22 30 40 89 111 35 28 31 42.7 15.4 83 28.5 Whooping-cough 44 81 98 82 86 100 26 93 84 63 75.7 27.3 65 22.3 Typhus Fever 2 0 0 0 0 0 0 0 0 0 0.2 ... ... ... Enteric Fever 30 26 12 11 11 21 19 15 24 15 18.4 6.6 17 5.8 Simp. Continued Fever 3 4 0 0 2 2 0 0 1 2 1.4 0.5 ... ... Diarrhoea 80 110 86 90 124 58 71 78 91 77 86.5 31.1 98 33.6 TOTALS. Kensington. 251 314 361 280 416 420 269 387 273 333 330.4 118.8 341 117.0 London. 10801 13629 11261 11121 12684 10803 9709 12279 9675 11983 11394 136.8 13223 144.4 England & Wales 58972 71762 57726 62859 64676 50684 61027 59698 53221 56032 59666 110.8 73499 128.9 258 TABLE VI. Summary of the Work of the Sanitary Inspectors during the year 1893—94. Sanitary Districts.* No of Complaints mode by Inhabitants. No. of Houses, Premises, &c., inspected. No. of Re-inspections of Houses, Fremises, Results of Inspection. House Drains. Water Closets. Dust Receptacles. Water Supply. Miscellaneous. Written Intimations of Nuisances Served. Notices served by order of the Works and Sanitary Committee. Final Notices signed by Medical Officer served. Houses, Premises, &c., Cleansed, Repaired, Whitewashed, &c. Houses Disinfected after illness of an Infectious character.§ Constructed, Repaired, Cleansed, See. Ventilated, Trapped, &c. Constructed, Repaired, &c. Supplied with Water. Soil-pipes Ventilated. New provided. Repaired, Covered, &c. Cisterns erected. Cisterns Cleansed, Repaired, Covered, etc. Waste-pipes connected with Drains, &c., abolished. No. of Lodging Houses Registered under 94th Section of the Public Health (London) Act, 1891. t Yards and Areas paved and Drained. Animals removed, being improperly kept. Regularly Inspected. Legal Proceedings, i.e.,, Summonses. Bakehouses. Licensed Cowsheds. Licensed Slaughter-Houses. North. 248 702 371.3 423 267 -34 86 343 142 106 148 190 109 35 29 24 47 26 ... 146 3 18 ... 1 10 N.E. 155 739 3206 248 2.34 44 607 115 413 219 195 168 152 116 134 122 169 87 ... 186 14 29 2 2 2 †N.W. 259 1347 7079 639 721 150 245 164 212 217 57 226 48 52 153 9 111 20 ... 207 ... 28 3 5 8 Central 110 348 476 164 7.3 15 128 129 266 159 136 121 118 29 83 59 99 86 ... 163 ... 11 1 5 3 S.E. 185 2256 2579 587 264 22 4.32 131 410 123 59 354 241 7 117 6 115 156 ... 13 ... 28 ... 1 5 S.W. 187 1088 3560 663 3-38 38 288 1.38 155 158 351 217 128 84 91 42 135 6 ... 368 3 22 2 1 7 1141 6480 20613 2724 1897 303 1786 1020 1598 982 946 1276 796 323 607 262 676 381 ... 1083 20 136 8 15 35 * For a description of the Sanitary Districts, see page 164. † The total number of houses on the Register in March, 1894, in round figures, was 1800. ‡ Two Inspectors work in this District. § Done under the supervision of the Inspector for the Central District. 259 TABLE VII. Showing the Death-rate per 1000 persons living: the Annual Rate per 1000 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 1893, and in the preceding ten years. The Year. Deaths per 1000 living. Total Derails from seven principal Zymotic Diseases, Kensington. Annual rate of mortality per 1000 living, from seven principal Zymotic Diseases. Proportion of Deaths to 1000 Deaths, from seven principal Zymotic Diseases. The Year. Kensington. London. Kensington. London. Kensington. London. 1883 16.0 20.8 251 1.5 2.8 96 134 1883 1884 16.1 20.9 314 1.9 3.5 119 164 1884 1885 16.8 20.4 361 2.2 3.0 130 140 1885 1886 16.7 20.6 280 1.7 2.8 101 135 1886 1887 17.4 20.3 416 2.5 31 144 154 1887 1888 171 19.3 420 2.6 2.7 148 137 1888 1889 14.6 18.4 269 1.6 2.3 111 128 1889 1890 17.8 21.4 387 2.3 2.8 131 134 1890 1891 18.4 21.4 273 1.6 2.3 89 107 1891 1892 17.2 20.6 333 2.0 2.8 115 136 1892 AVERAGE OK TEN YEARS 1883-92. 16.8 20.4 330 2. 0 2.8 118 137 AVERAGE OF TEN YEARS 1883-92. 1893. 17.5 21.3 341 2.0 3.1 117 136 1893 260 TABLE VIII. Comparative Analysis of the Mortality in all London, and in Kensington in 1893. Annual Death-rate per 1000 living, from all causes. Annual Death-rate per 1000 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 21.3 3.1 16.4 23.8 23.8 14.4 3.7 8.1 26.9 0.9 Kensington 17.5 2.0 17.0 21.4 29.5 11.7 2.7 7.2 25.4 0.1 *Viz.—Parish Infirmary and Workhouse, Brompton Consumption Hospital, so far as relates to Deaths of Parishioners therein, and outlying Public Institutions, i.e., General and Special Hospitals, etc. table ix. Showing the Localities in which Fatal Cases of the Principal Diseases of the Zymotic class occurred in 1893. kensington town registration sub-district. Locality. Small-pox. Measles. Scarlet Fever. Diphtheria. Whoopingcough. Enteric Fever Diarrhcea. Total, Locality. Small-pox. Measles. Scarlet Fever. Diphtheria. Whoopingcough. Enteric Fever. Diarrhœa. Total. Abingdon Road ... ... 1 ... ... ... ... 1 Johnson Street ... ... ... 1 ... ... ... 1 Abingdon Villas ... ... ... 1 ... ... ... 1 Kensington Court 1 ... 1 ... ... 1 ... 3 Acklam Road ... ... 2 2 1 ... 2 7 Kensington High Street ... ... 1 1 ... ... ... 2 Adam & Eve Mews ... ... ... 1 ... ... ... 1 Kensington Infirmary ... 2 4 1 7 ... 9 23 All Saints Road ... ... ... 2 ... 1 ... 3 Kensington Park Mews ... ... ... 1 ... ... ... 1 Appleford Road ... ... ... ... ... ... 2 2 Kensington Park Road ... ... 1 1 ... ... 2 4 Archer Mews ... ... ... 1 ... ... ... 1 Kensington Place ... ... ... 1 ... ... 1 2 Bangor Street ... ... ... ... ... ... 2 2 Kingsley Mews ... ... ... 2 ... ... 2 Basing Road ... ... ... ... ... ... 3 3 Ladbroke Grove Road ... ... ... 1 4 ... 1 6 Bedford Terrace ... ... 1 ... ... ... ... 1 Lancaster Road ... ... ... 1 ... ... 1 2 Bevington Road ... 1 2 1 2 ... ... 6 Lansdowne Road ... ... 1 ... ... ... ... 1 Blechynden Mews ... ... 1 ... i ... ... 2 Lonsdale Road ... ... ... ... 2 ... 1 3 Bloomfield Yard ... ... 1 ... ... ... ... 1 Mall, The ... ... ... 1 ... ... ... 1 Bosworth Road ... ... ... 1 ... ... 1 2 Mary Place ... ... 1 ... 1 ... ... 2 Bramley Road ... ... 1 ... ... ... 1 2 Murchison Road ... ... ... ... ... 1 ... 1 Branstone Street 1 ... ... ... ... ... 1 2 Peel Street ... ... 1 ... ... ... 1 2 Bulmer Place ... ... ... 1 ... ... ... 1 Pembridge Square ... ... ... ... ... 1 ... 1 Bulmer Terrace ... ... ... 1 ... ... ... 1 Portland Road ... ... ... ... 1 ... 4 5 Calverley Street ... ... 1 ... 1 ... ... 2 Portobello Road 2 1 2 2 3 1 2 13 Cambridge Gardens ... ... 1 ... ... ... ... 1 Princes Road ... ... ... 1 1 ... ... 2 Campden Hill ... ... ... 2 ... ... ... 2 Rackham .Street ... 1 ... 2 ... ... ... 3 Campden Hill Road 1 ... ... 1 ... ... ... 2 Rendle Street ... 2 ... ... ... ... ... 2 Campden Houses ... ... ... 1 ... ... ... 1 Royal Crescent Mews, East ... ... ... 1 ... ... ... 1 Campden Street ... ... ... 1 ... ... ... 1 St. Ann's Road ... ... ... ... ... ... 3 3 Charles Street, Notting Hill ... ... 2 ... ... ... 1 3 „ Clement's Road ... i ... 2 ... ... 1 4 Chesterton Road ... 1 ... ... 1 ... 1 3 „ Ervan's Road ... ... 1 2 1 ... ... 4 Church Street ... ... ... ... ... 1 ... 1 „ George's Road ... ... ... 2 ... ... ... 2 Clarence Mews ... ... ... 2 ... ... ... 2 ,, Helen's Gardens ... ... ... ... ... 3 ... 3 Clarendon Road 1 ... 2 ... ... ... ... 3 ,, Katherine's Road ... ... ... ... 3 ... 2 5 Convent Gardens ... ... ... ... 1 ... 1 2 ,, Luke's Mews ... 1 ... ... 1 ... ... 2 Cornwall Road ... ... ... 1 1 ... 1 3 ,, Mark's Road ... ... ... 1 ... ... ... 1 Cottesmore Gardens 1 ... ... ... 1 Scarsdale Terrace ... ... ... 1 ... ... ... 1 Cousens Terrace ... ... ... 1 ... ... ... 1 Silchester Road ... ... ... 1 ... ... ... 1 Crescent Street ... ... 1 2 1 ... 2 6 Silchester Terrace ... ... ... 1 ... ... ... 1 Dartmoor Street ... ... 2 2 ... ... ... 4 Southam Street ... 1 ... ... 2 ... 4 7 Durham Villas ... ... ... 2 ... ... ... 2 Stoneleigh Street ... ... ... ... 1 ... 1 2 Earl's Court Road ... ... ... ... ... 1 ... 1 Swinbrook Road ... ... 1 1 3 ... ... 5 Earl's Terrace ... ... 1 ... ... ... ... 1 Tavistock Crescent ... ... 1 ... 1 ... ... 2 Edenham Street ... ... ... 1 ... ... 1 2 Tavistock Mews ... ... ... ... 1 ... 1 2 Elgin Mews ... ... l ... ... ... ... 1 Telford Road ... 1 1 ... ... ... ... 2 Golborne Gardens ... ... ... ... ... 1 ... 1 Treverton Street ... ... ... ... 1 ... 2 3 Golborne Road ... ... l ... ... ... ... 1 Uxbridge Houses 1 ... ... ... ... ... ... 1 Golden Mews 2 ... ... ... ... ... ... 2 Walmer Road ... ... ... ... 2 ... 1 3 Hazlewood Crescent ... ... 1 ... ... ... 1 3 Western Terrace ... ... i ... 1 ... ... 2 High Street, Notting Hill ... ... ... ... ... 1 ... 1 Wheatstone Road ... 1 ... 1 ... 1 1 4 Holland Park Gardens ... ... ... 2 ... ... ... 2 William St., Notting Hill Gate ... ... ... 1 ... ... ... 1 Hornton Street ... ... ... ... ... 1 ... 1 Wornington Road ... 2 7 5 3 ... 3 20 Hurstway Street ... ... l ... 1 ... ... 2 brompton sub-district. Barkston Gardens ... ... ... 1 ... ... ... 1 Harrington Gardens ... ... ... ... ... 1 ... 1 Boltons, The ... ... 1 ... ... ... ... 1 I field Road & Adrian Terrace ... ... ... 3 1 ... 3 7 Chapel Place ... ... ... 1 ... ... ... 1 Onslow Gardens ... ... ... 1 ... ... ... / 1 Clareville Grove ... ... ... ... ... 1 ... 1 Redcliffe Gardens ... ... ... 1 ... ... ... 1 Colbeck Mews ... ... l 1 ... ... ... 2 Seymour Place ... ... ... ... 2 ... ... 2 Coleherne Mews ... ... 2 ... ... ... ... 2 Stanhope Mews East ... ... 1 1 ... ... ... 2 Cresswell Gardens ... ... ... 1 ... ... ... 1 Sussex Place ... ... ... 1 ... ... ... 1 Egerton Gardens ... ... ... 1 ... ... ... 1 The Grove ... ... ... ... ... i ... 1 Elvaston Mews ... ... ... 1 ... ... ... 1 Warwick Road ... ... ... 1 ... ... ... 1 Fenelon Road ... ... ... ... 3 ... ... 3 Wetherby Mews ... ... ... 1 ... ... ... 1 Fulham Road ... ... ... 1 ... ... ... 1 Yeoman's Row ... ... ... 1 ... ... ... 1 Gloucester Road ... ... ... l ... ... ... 1 TABLE IXA. Showing List of Streets and Places from which cases of Infectious Disease were notified, under the provisions of the Public Health (London) Act, 1891, during the year 1893. The Registration Sub-Districts are Kensington Town (K T), and Brompton (B) Street or Place. Registration Sub-District. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Croup. Total. Street or Place. Registration Sub-District. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Croup. Total. Abingdon Road KT ... 4 1 ... ... ... ... 5 Kenway Road B ... 1 ... ... ... ... ... 1 Abingdon Villas „ ... ... 1 ... ... ... ... I Kingsley Mews K T ... ... 2 ... ... ... ... 2 Absalom Road ... 4 1 1 ... 1 ... 7 King Street K T ... ... 1 ... ... ... ... 1 Acklam Road ... 14 6 ... 1 2 ... 23 Kramer Mews B ... 1 ... ... ... ... ... 1 Adair Road „ ... 3 ... ... ... ... ... 3 Ladbroke Crescent K T ... 1 ... ... ... 1 ... 2 Adam and Eve Mews „ ... ... 4 ... ... ... ... 4 Ladbroke Garden „ ... 1 ... ... ... ... ... 1 Adam's Cottages „ 1 ... ... ... ... ... ... 1 Ladbroke Grove „ ... 4 2 1 ... 1 ... 8 Addison Gardens „ ... ... ... ... ... 1 ... 1 Ladbroke Grove Road „ 1 11 3 ... ... 2 ... 17 Addison Road „ ... 5 ... 1 ... ... ... 6 Ladbroke Road „ ... ... ... ... ... 1 ... 1 Addison Road North „ ... 3 ... ... ... ... ... 3 Ladbroke Square „ 1 ... ... ... ... 1 ... 2 Addison Terrace „ ... 2 ... ... ... ... 3 Ladbroke Terrace „ ... 4 ... ... ... ... ... 4 Admiral Place „ ... I 1 ... ... ... ... 2 Ladbroke Terrace Mews „ ... 1 ... ... ... ... ... 1 Albert Mews „ ... 2 ... ... ... ... ... 2 Lancaster Road „ ... 19 4 1 ... 3 ... 27 Alexander Square B ... ... ... 2 ... ... ... 2 Lansdowne Crescent „ ... 2 ... ... ... ... ... 2 Alfred Place West „ ... ... ... ... ... 1 ... 1 Landowne Road „ ... 3 ... 1 ... ... ... 4 Allen Terrace KT ... 1 ... ... ... ... ... 1 Ledbury Road „ ... 1 ... ... ... 1 ... 2 All Saint's Road „ ... 4 3 1 ... ... ... 8 Lexham Garden B ... 2 1 ... ... ... ... 3 Alma Cottages „ ... 1 ... ... ... ... ... 1 Laxham Mews „ ... ... 1 ... ... 1 ... 2 Alveston Mews B ... 3 ... ... ... 1 ... 4 Linden Gardens K T ... 1 1 ... ... ... ... 2 Angola Mews KT ... 1 ... ... ... 2 ... 3 Lion Mews „ ... ... ... ... ... 1 ... 1 Appleford Road „ ... 4 1 ... ... ... ... 5 Lionel Mews „ 1 ... ... ... ... ... ... 1 Archer Mews „ ... ... 1 ... ... ... ... 1 Longridge Road B ... 4 ... 2 ... ... ... 6 Archer Street „ ... 4 ... ... ... 1 ... 5 Lonsdale Road K T ... 4 ... 1 ... 1 ... 6 Argyll Road „ ... 1 1 ... ... ... ... 2 Lonsdale Yard „ ... 1 ... ... ... ... ... 1 Arundel Gardens „ ... 1 1 1 ... ... ... 3 Lorne Gardens „ ... ... 3 ... ... 1 ... 4 Ashburn Mews B ... 1 ... ... ... ... ... 1 Astwood Mews „ ... 1 ... ... ... ... ... 1 Mall Chambers K T ... ... 1 ... ... 1 ... 2 Atherstone Mews „ ... ... 1 ... ... ... ... 1 Manchester Mews „ ... ... ... 1 ... ... ... 1 Aubrey Road K T ... 1 2 ... ... ... ... 3 Manchester Road „ 1 1 ... ... ... 1 ... 3 Manchester Street „ ... 4 ... 1 ... 1 ... 6 Ball Street K T ... 1 ... ... ... ... ... 1 Manson Mews B ... 1 ... ... ... ... ... 1 Bangor Street ,, 1 6 3 ... ... 2 ... 12 Manson Place „ ... ... ... ... ... 1 ... 1 Barandon Street ,, ... ... ... ... ... 2 ... 2 Marloes Road K T & B ... 1 ... ... ... ... ... 1 Barker Street B ... 4 ... ... ... I ... 5 Martin Street KT ... 1 1 ... ... 1 ... 3 Barkston Gardens „ 1 2 2 1 ... ... ... 6 Mary Place „ 2 1 ... ... ... ... ... 3 Barkston Mansions „ ... ... ... ... ... 1 ... 1 Melbury Road „ ... 4 ... ... ... ... ... 4 Bassett Road K T ... 1 ... ... ... ... ... 1 Merton Road „ ... ... 2 ... ... 1 ... 3 Beauchamp Place B ... ... ... ... ... 1 ... 1 Montpelier Mews B ... ... 2 ... ... ... ... 2 Bedford Gardens K T 1 ... 2 ... ... 1 ... 4 Montpelier Street „ ... ... 1 ... ... ... ... 1 Bedford Terrace „ ... ... 1 ... ... ... ... 1 Morton Mews „ ... 1 ... ... ... ... ... 1 Bevington Road „ ... 3 3 ... ... 1 ... 7 Munro Mews KT ... ... ... ... ... 1 ... 1 Bina Gardens B ... 2 ... ... ... ... ... 2 Murchison Road „ ... ... ... 1 ... ... ... 1 Blagrove Road K T ... 3 ... ... ... ... ... 3 Blechynden Mews „ ... 1 ... ... ... ... ... 1 Nevern Mansions B ... 1 ... ... ... ... ... 1 Blechynden Street „ ... 3 1 1 ... 2 ... 7 Nevern Square „ ... I 1 ... ... ... ... 2 Blenheim Crescent „ ... 13 2 1 ... 2 ... 18 Newcombe Street K T ... ... 2 ... 1 ... ... 3 Blithfield Street „ 1 1 ... ... ... 1 ... 3 New Street B ... 2 1 ... ... ... ... 3 Blomfield Yard „ ... 1 ... ... ... ... ... 1 Norfolk Place K T ... 3 ... ... ... ... ... 3 Bolton Gardens B ... 2 ... ... ... ... ... 2 Norfolk Terrace „ ... 2 ... ... ... 1 ... 3 Bolton Gardens West „ ... ... ... ... ... 1 ... 1 Norland Place „ ... ... ... 1 ... ... ... 1 Bolton Mews, Notting Hill K T ... ... 1 ... ... ... ... 1 Norland Road „ ... ... 1 ... ... 2 ... 3 Bolton Mews, S. Kensington B ... ... ... ... ... 1 ... 1 Norland Square „ 1 ... ... ... ... ... ... 1 Bolton Road K T 1 1 ... ... ... ... ... 2 Norland Stables „ ... ... 1 ... ... ... ... 1 Bomore Road „ 1 ... ... ... ... ... 1 2 Norland Terrace „ ... 1 ... ... ... ... ... 1 Bosworth Road „ 4 2 1 ... ... 2 ... 9 North Street, St. Marks B ... ... 1 ... ... ... ... 1 Boyne Terrace „ ... ... ... ... ... 1 ... 1 Notting Hill Grove K T ... ... 1 ... ... ... ... 1 Bramham Gardens B ... 1 ... ... ... ... ... 1 Notting Hill Terrace „ ... 1 1 ... ... ... ... 2 Bramley Road K T 1 4 1 ... 1 ... ... 7 Bransford Street „ ... 1 ... 1 ... ... ... 2 Old Manor Yard B ... 2 ... ... ... ... ... 2 Branstone Street „ 1 2 ... ... ... ... ... 3 Onslow Gardens „ ... ... 1 ... ... ... ... 1 Brechin Place B ... 1 ... ... ... ... ... 1 Onslow Mews „ ... 1 ... ... ... ... ... 1 Brompton Road „ ... ... ... ... ... 1 ... 1 Onslow Square „ ... 1 ... ... ... ... ... 1 Brompton Square „ ... 1 2 ... ... 1 ... 4 Osten Mews „ ... 1 1 ... ... ... ... 2 Brunswick Gardens K T ... 1 ... ... ... ... ... 1 Ovington Gardens „ ... 1 ... ... ... ... ... 1 Buckingham Terrace „ ... 1 1 ... ... ... ... 2 Ovington Square „ ... 1 ... ... ... ... ... 1 Bulmer Place „ ... 1 3 ... ... 2 ... 6 Oxford Gardens K T ... 3 1 2 ... 2 ... 8 Bulmer Terrace „ ... 8 3 1 ... ... ... 12 Oxford Mews „ ... ... ... ... ... 1 ... 1 Bute Street B ... 2 ... ... ... ... ... 2 Palace Gardens Mansions K T 1 2 ... ... ... ... ... 3 Calverley Street K T ... ... 2 ... ... 1 ... 3 Palace Gardens Mews „ ... 1 ... ... ... ... ... 1 Cambridge Gardens „ ... 1 ... ... ... ... ... 1 Palace Gardens Terrace „ ... 3 ... ... ... ... ... 3 Campden Grove „ ... 1 1 ... ... ... ... 2 Palace Gate „ ... ... ... ... ... 1 ... 1 Campden Hill „ ... ... 4 ... ... ... ... 4 Pamber Street „ ... ... 3 ... ... ... ... 3 Campden Hill Gardens „ ... 2 2 ... ... ... ... 4 Peel Street „ ... 6 14 ... ... 4 1 25 Campden Hill Road „ 4 1 1 ... ... ... ... 6 Pelham Crescent B ... 1 ... ... ... ... ... 1 Campden Hill Square „ ... 1 ... ... ... ... ... 1 Pelham Mews KT ... 4 ... ... ... ... ... 4 Campden House Road „ ... 1 ... ... ... ... ... 1 Pelham Place B ... 1 ... ... ... ... ... 1 Campden Street „ ... 4 4 ... ... 2 2 12 Pembridge Crescent K T ... 1 ... ... ... ... ... 1 Chapel Place B ... 1 2 ... ... ... ... 3 Pembridge Gardens „ ... ... 1 ... ... ... ... 1 Chapel Road KT ... 1 ... ... ... ... ... 1 Pembridge Place „ ... ... 1 ... ... 1 ... 2 Charles Street, Notting Hill „ ... 5 ... ... ... ... ... 5 Pembridge Road „ ... ... 2 ... ... ... ... 2 Charles Street, Kensington Sq „ ... 4 ... ... ... ... ... 4 Pembridge Square „ ... 2 ... ... ... ... ... 2 Charlotte Terrace „ ... ... ... ... ... 1 ... 1 Pembridge Villa „ ... 3 ... ... ... 1 ... 4 Chepstow Place „ ... 1 ... ... ... 1 ... 2 Pembroke Gardens „ ... ... ... 1 ... ... ... 1 Chepstow Tavern Mews „ ... ... ... ... ... 1 ... 1 Pembroke Mews „ ... 1 ... ... ... ... ... 1 Chepstow Villas „ ... 2 1 ... ... 1 ... 4 Pembroke Cottages „ ... 1 ... ... ... ... ... 1 Chesterton Road „ ... 1 ... ... ... 1 ... 2 Pembroke Road B ... 5 ... ... ... ... ... 5 Child's Passage B ... 1 ... ... ... ... ... 1 Penywern Road „ ... 1 1 1 ... ... ... 3 Child's Place „ ... 1 1 ... ... ... ... 2 Percy Villas KT ... 2 ... ... ... ... ... 2 Child's Street „ ... 2 1 ... ... ... ... 3 Petersham Mews „ ... 1 ... ... ... ... ... 1 Church Court K T ... 1 1 ... ... 1 ... 3 Philbeach Gardens B ... 3 ... 1 ... 2 ... 6 Church Street „ ... 2 3 2 ... ... ... 7 Phillimore Gardens K T ... ... 1 ... ... ... ... 1 Clanricarde Gardens „ ... 1 ... ... ... ... ... 1 Pitt Street K T ... 1 ... ... ... ... ... 1 Clarence Mews „ ... ... 2 ... ... ... ... 2 Portland Place „ ... 2 ... ... ... ... ... 2 Clarendon Place „ ... 1 ... ... ... ... ... 1 Portland Road „ ... 9 3 1 ... 7 1 21 Clarendon Road „ 2 9 ... ... ... 2 ... 13 Portobello Road „ 22 17 3 3 ... 8 ... 53 Clareville Grove B ... ... ... 1 ... ... ... 1 Powis Gardens „ ... 13 1 ... ... ... ... 14 Cleveland Terrace Gardens „ ... 1 ... ... ... ... ... 1 Powis Square „ ... 1 ... ... ... ... ... 1 Cluny Mews „ ... 2 ... ... ... ... ... 2 Princes Mews B 2 1 ... ... ... ... ... 3 Clydesdale Road K T ... ... ... 4 ... ... ... 4 Princes Place K T ... ... ... ... 1 2 ... 3 Codrington Mews „ ... ... 2 ... ... ... ... 2 Princes Road „ 1 3 5 ... ... 2 ... 11 Colbeck Mews B ... 3 1 ... ... ... ... 4 Princes Yard „ ... 3 1 ... ... ... ... 4 Coleherne Mews „ ... 4 ... ... ... ... ... 4 Providence Terrace B ... 1 ... ... ... 1 ... 2 Coleherne Road „ ... 1 ... ... 1 ... ... 2 Coleherne Terrace „ ... ... ... ... ... 1 ... 1 Queen Anne's Terrace K T 2 2 ... ... ... ... ... 4 Collingham Gardens „ ... 2 ... ... ... ... ... 2 Queen's Gate K T & B ... 3 ... ... ... ... ... 3 Collingham Place „ ... 1 ... ... ... 1 ... 2 Queen's Gate Gardens „ ... 1 ... 1 ... ... ... 2 Collingham Road „ ... ... 1 ... ... ... ... 1 Queen's Gate Place Mews B ... ... ... 1 ... ... ... 1 Colville Gardens K T ... 1 1 ... ... ... ... 2 Queensberry Mews East „ ... ... ... 1 ... ... ... 1 Colville House „ ... 1 ... 1 ... ... ... 2 Queensberry Place „ ... ... ... 1 ... ... ... 1 Colville Square „ ... 2 ... ... ... ... ... 2 Queen's Place K T ... 1 ... ... ... ... ... 1 Colville Terrace „ ... 2 2 ... ... ... ... 4 Queen's Road „ ... 1 ... ... ... ... ... 1 Convent Gardens „ ... 3 ... ... ... ... ... 3 Queen's Terrace Mews „ ... 1 ... ... ... ... ... 1 Cornwall Gardens k T & B ... 2 2 ... ... ... ... 4 Cornwall Road K T ... 14 10 1 ... 5 ... 30 Rackham Street K T ... 9 4 ... ... ... ... 13 Cottesmore Gardens „ ... ... 1 2 ... ... ... 3 Raddington Road „ ... 1 1 ... ... 1 ... 3 Courtfield Gardens B ... 2 1 ... ... ... ... 3 Radnor Terrace „ ... 2 ... ... ... ... ... 2 Courtfield Road „ ... 1 1 ... ... ... ... 2 Raymede Street „ ... 3 ... ... ... 2 ... 5 Cousin's Cottage K T ... ... ... ... ... 1 ... 1 Redcliffe Gardens B ... 3 5 ... ... ... ... 8 Cousin's Terrace „ ... ... 1 ... ... ... ... 1 Redcliffe Road „ ... 1 ... ... ... 2 ... 3 Cranley Gardens B ... 3 ... ... ... 1 ... 4 Redcliffe Square „ ... 3 3 ... 1 1 ... 8 Cranley Place „ ... 1 ... ... ... ... ... 1 Relton Place „ 1 ... ... ... ... ... ... 1 Crescent Place „ ... ... 1 ... ... ... ... 1 Rendle Street K T ... ... ... ... ... 1 1 2 Crescent Street K T ... 1 3 ... ... 5 ... 9 Richmond Road B ... ... ... ... ... 1 ... 1 Cromwell Gardens B ... 2 ... ... ... ... ... 2 Rillington Place K T ... 1 ... ... ... ... ... 1 Cromwell Road „ ... 5 4 2 ... 1 ... 12 Roland Houses B ... 1 ... ... ... ... ... 1 Royal Crescent K T ... 4 ... ... ... ... ... 4 Dartmoor Street K T ... 5 11 ... ... 1 ... 17 Royal Crescent Mews „ ... ... 1 ... ... 1 ... 2 Dawson Place „ ... ... ... ... ... 1 ... 1 Royal Mews East „ ... 1 1 ... ... ... ... 2 Denbigh Terrace „ ... 3 4 ... ... ... ... 7 Russell Gardens „ ... 1 1 ... ... ... ... 2 Drayton Gardens B ... 8 1 1 ... ... ... 10 Russell Road „ ... 1 1 ... ... ... ... 2 Drayton Terrace „ ... 3 ... ... ... ... ... 3 Duke's Lane K T ... 1 2 ... ... ... ... 3 St. Alban's Road K T ... 2 1 ... ... 1 ... 4 Dulford Street „ ... ... ... ... ... 1 ... 1 St. Ann's Road „ ... 2 1 ... ... ... ... 3 Durham Place „ ... ... 1 ... ... 1 ... 2 St. Ann's Villas „ ... 3 ... ... ... 1 ... 4 Durham Villas „ ... 1 3 ... ... ... ... 4 St. Charles' Square „ ... 1 ... 1 ... ... ... 2 St. Clement's Road „ 2 3 3 ... ... 3 ... 11 Eardley Crescent B ... ... 1 ... ... 1 ... 2 St. Ervan's Road „ ... 10 2 1 ... ... ... 13 Earl's Court Gardens „ ... 6 2 ... ... ... 1 9 St. George's Road „ ... 4 2 ... ... 4 ... 10 Earl's Court Road K T & B ... 3 1 3 ... 2 ... 9 St. George's Terrace „ ... 1 ... ... ... ... ... 1 Earl's Court Square B ... 2 ... ... ... ... ... 2 St. Helen's Gardens „ ... ... ... 3 ... ... ... 3 Earl's Terrace K T ... 3 ... ... ... 1 ... 4 St. James's Square „ ... 1 1 ... ... ... ... 2 East Road Mews „ ... ... 1 ... ... ... ... 1 St. James's Terrace „ ... 1 ... ... ... ... ... 1 Edenham Street „ ... 3 1 ... ... 2 ... 6 St. John's Mews „ ... ... ... ... ... 1 ... 1 Edge Street „ ... ... 1 ... ... 2 ... 3 St. Katherine's Road „ ... 5 1 1 ... 7 ... 14 Edinburgh Road „ ... ... 1 ... ... ... ... 1 St. Luke's Mews „ ... 2 ... ... ... ... ... 2 Edinburgh Terrace „ ... 4 ... ... ... ... ... 4 St. Luke's Road „ ... 3 ... ... ... ... ... 3 Egerton Gardens B ... 4 3 3 ... ... ... 10 St. Mark's Road, Fulham Road B ... 1 ... ... ... ... ... 1 Eldon Road K T ... 2 ... ... ... ... ... 2 St. Mark's Road, Notting Hill K T ... 4 1 ... ... ... ... 5 Elgin Crescent „ ... 4 2 1 ... ... ... 7 St. Mary Abbott's Terrace „ ... ... 1 ... ... ... ... 1 Elgin Mews „ ... 1 2 ... ... ... ... 3 St. Mary's Road „ ... 1 ... ... ... ... ... 1 Elsham Road „ 1 ... ... 1 ... ... ... 2 St. Mary's Terrace „ ... 1 ... ... ... ... ... 1 Elvaston Mews „ ... ... 1 ... ... 1 ... 2 St. Quintin's Avenue „ ... 1 ... 1 ... ... ... 2 Elvaston Place „ ... 1 ... ... ... ... ... 1 Scampston Mews „ ... 1 ... ... ... ... ... 1 Emperor's Gate B ... 1 ... 1 ... ... ... 2 Scarsdale Terrace „ ... ... 1 ... ... ... ... 1 Ernest Street K T ... 1 3 ... ... 1 ... 5 Searsdale Villas „ ... 2 ... ... ... ... ... 2 Evelyn Gardens B ... 3 1 1 ... ... ... 5 Seymour Place B ... 4 2 ... ... ... ... 6 Shaftesbury Cottages B ... 1 ... ... ... ... ... 1 Faraday Road K T ... 7 1 1 ... 1 ... 10 Shaftesbury Mews K T ... ... 1 ... ... ... ... 1 Farnell Mews B ... 1 ... ... ... ... ... 1 Shaftesbury Road B ... 4 ... ... ... 1 ... 5 Fawcett Street „ ... ... ... 1 ... ... ... 1 Silchester Road K T ... 6 1 1 ... 1 ... 9 Fenelon Road „ ... 4 ... ... ... ... ... 4 Silchester Terrace „ ... ... 1 1 ... ... ... 2 Finborough Road „ ... 6 ... 1 ... 1 ... 8 Silver Street „ ... 2 1 ... ... ... ... 3 Fopstone Road „ ... ... 1 ... ... ... ... 1 Southam Street „ 7 31 2 2 1 6 ... 49 Fowell Street K T ... 6 ... ... ... ... ... 6 Southend Row „ 1 1 ... ... ... ... ... 2 Fulham Road B ... 6 1 1 ... 1 ... 9 South Kensington Museum B ... ... ... 1 ... ... ... 1 South Street, St. Mark's „ ... 1 ... ... ... ... ... 1 Gasper Mews B 1 1 ... ... ... ... ... 2 Spear Mews „ ... 3 ... ... ... ... ... 3 Gilston Road „ ... 1 ... ... ... ... ... 1 Stanhope Mews East „ ... 1 3 ... ... ... ... 4 Gledhow Gardens „ ... 2 1 ... ... ... ... 3 Stanley Crescent K T ... 1 ... ... ... ... ... 1 Gloucester Road K T & B ... 4 2 ... ... ... ... 6 Stoneleigh Street „ ... 8 ... ... ... 1 ... 9 Gloucester Terrace B ... 2 ... ... ... ... ... 2 Stratford Road K T & B ... 4 ... ... ... ... ... 4 Gloucester Walk K T ... 1 ... ... ... ... ... 1 Summer Place Mews B ... ... 1 ... ... ... ... 1 Golborne Gardens „ ... 5 ... 1 ... 2 ... 8 Sussex Place „ ... 1 2 ... ... ... 1 4 Golborne Mews „ ... ... ... ... 1 ... ... 1 Swinbrook Road K T ... 16 1 ... ... 3 ... 20 Golborne Road „ 2 4 1 ... ... ... ... 7 Sydney Place B ... ... 2 ... ... ... ... 2 Golborne Terrace „ ... ... 1 ... ... 1 ... 2 Golden Mews „ 4 ... ... ... ... ... ... 4 Tabernacle Terrace K T ... 1 ... ... ... ... ... 1 Gordon Place „ ... 3 ... ... ... 1 ... 4 Talbot Grove „ ... 5 1 1 ... 2 ... 9 Graham Cottages „ ... ... ... ... ... 1 ... 1 Talbot Road „ ... 3 ... ... ... ... ... 3 Grenville Place B ... 1 ... ... ... ... ... 1 Tavistock Crescent „ ... 8 1 ... ... 1 ... 10 Tavistock Road „ ... 2 2 ... ... 1 1 6 Hanover Terrace K T ... 1 ... ... ... ... ... 1 Telford Road „ ... 5 1 ... ... 2 ... 9 Harcourt Terrace B ... 1 ... 1 ... ... ... 2 Templeton Place B 1 1 1 1 ... ... ... 3 Harrington Gardens „ ... ... ... 1 ... ... ... 1 Testerton Street K T ... 3 1 ... ... ... ... 4 Harrington Mansions „ ... ... 1 ... ... ... ... 1 The Boltons B ... 1 ... ... ... ... ... 1 Harrington Road „ ... ... 1 ... ... ... ... 1 The Grove „ ... 3 ... 1 ... ... ... 4 Hazlewood Crescent K T 1 9 1 6 ... ... ... 17 The Mall K T ... 1 1 ... ... ... ... 2 Hesper Mews B ... 3 ... ... ... ... ... 3 Thorpe Mews „ ... 1 ... ... ... ... ... 1 Hewer Street K T ... 6 ... ... ... ... ... 6 Thurloe Square B ... ... 1 ... ... 1 ... 2 Highlever Road „ 1 1 ... ... ... ... ... 2 Tobin Street K T ... 2 ... ... 1 2 ... 5 High Street, Notting Hill „ ... 1 1 1 ... 2 ... 5 Treadgold Street „ ... 2 ... ... ... ... ... 2 Hogarth Place B ... ... 1 ... ... ... ... 1 Trebovir Road B ... 7 1 ... ... ... ... 8 Hogarth Road „ ... 1 ... ... ... ... ... 1 Tregunter Road „ ... 2 ... 1 ... ... ... 3 Holland Mews K T ... 1 ... ... ... ... ... 1 Treverton Street K T 2 9 1 1 ... 4 ... 17 Holland Park „ ... 1 ... ... ... ... ... 1 Holland Park Gardens „ ... ... 2 1 ... 1 ... 4 Union Terrace K T ... ... ... ... ... 1 ... 1 Holland Park Mews „ ... 2 ... ... ... ... ... 2 Upper Addison Garden „ ... 2 ... ... ... ... ... 2 Holland Place „ ... ... ... ... ... 1 ... 1 Upper Highlever Road „ ... ... 1 ... ... ... ... 1 Holland Road „ ... 3 ... ... ... ... ... 3 Uxbridge Houses „ 2 ... ... ... ... ... ... 2 Holland Street „ ... 2 1 ... ... 2 ... 5 Uxbridge Street „ ... 1 3 ... ... 2 ... 6 Holland Villas Road „ ... 2 1 ... ... ... ... 3 Hollywood Road B ... ... 1 1 ... ... ... 2 Vernon Mews K T ... 1 ... ... ... ... ... 1 Horbury Mews K T ... ... 1 ... ... ... ... 1 Victoria Dwelling „ ... 2 1 ... ... ... ... 3 Hornton Place „ ... ... 1 1 ... 1 ... 3 Victoria Grove „ ... 3 1 ... ... ... ... 4 Hurstway Street „ ... 1 1 ... ... 1 ... 3 Virginia Place „ ... ... ... ... ... 1 ... 1 Ifield Road B ... 10 6 ... ... 2 ... 18 Wallgrave Road B ... 8 ... ... ... ... ... 8 Inverness Gardens K T ... ... 1 ... ... ... ... 1 Wallgrave Terrace „ ... 2 ... ... ... ... ... 2 Walmer Road K T ... 9 6 1 ... 3 1 20 Jameson Street K T ... 3 2 ... ... 2 ... 7 Warwick Gardens „ ... 1 ... ... ... 1 ... 2 Johnson Street „ ... ... 2 ... ... ... ...I 2 Warwick Road K T & B ... 7 2 ... ... 1 ... 10 Joliffe's Yard „ ... ... ... ... ... 1 ... 1 Warwick Street K T 1 1 ... ... ... ... ... 2 Westbourne Grove „ ... 5 ... ... ... ... ... 5 Kelso Place K T ... ... ... ... ... 1 ... 1 Western Dwellings „ ... 1 ... ... ... ... ... 1 Kempsford Gardens B ... 1 ... ... ... ... ... 1 Western Terrace „ ... 3 ... ... ... ... ... 3 Kenilworth Street K T ... 1 1 ... ... 1 ... 3 West Cromwell Road B ... 1 ... ... ... ... ... 1 Kensal Road „ ... 1 ... ... ... ... ... 1 Westgate Terrace „ ... ... 1 ... ... ... ... 1 Kensington Court Mansions „ 1 1 ... 1 ... ... ... 3 West Mews K T ... ... 1 ... ... ... ... 1 Kensington Court Mews „ ... 1 ... ... ... ... ... 1 Wetherby Mews B ... 1 2 ... ... ... 2 3 Kensington Gate „ ... 1 ... ... ... ... ... 1 Wheatstone Road K T 2 6 3 4 ... 1 ... 17 Kensington High Street „ ... 3 2 ... ... 1 ... 6 William Street, Notting Dale „ ... 1 ... ... ... ... ... 2 Kensington Infirmary „ 2 33 ... 1 ... 54 1 91 William Street, Notting Hill „ ... 1 1 ... ... 7 ... 2 Kensington Palace Mansions „ ... 1 ... ... ... ... ... 1 Wornington Road „ 11 31 6 2 ... ... ... 57 Kensington Park Gardens „ ... 2 ... ... ... 1 ... 3 Wright's Lane „ ... ... 1 ... ... ... ... 1 Kensington Park Mews „ ... ... 1 ... ... ... ... 1 Wynnstay Gardens „ ... 1 ... ... ... ... ... 1 Kensington Park Road „ ... 3 3 1 ... 1 ... 8 Kensington Place „ ... 5 5 1 ... 1 ... 12 Yeomans Row B 2 ... 2 2 ... ... ... 6 Kensington Square „ ... 2 2 ... ... ... ... 4 Young Street K T ... 1 2 ... ... ... ... 3 Kensington Workhouse „ ... ... 1 ... ... ... ... 1 In addition to the above, one case of Typhus Fever was notified from St. Clement's Road ; two cases of Cholera from Kensington Infirmary and Ladbroke Road respectively; and eight cases of "Continued Fever," viz.: two each from Princes Mews, Notting Hill, and Southam Street, and one each from Earl's Court Gardens, Gordon Place, Kensal Road, and Petersham Mews. 265 TABLE X. Return respecting the Vaccination of Children whose births were Registered in 1892.* DATE. Registration Sub-Districts comprised in Vaccination Officers District. Number of Births returned in Birth List Sheets. Number of these Births duly entered in Columns 10, Hand 13 of the Vaccination Register (Birth List Sheets), viz. : Number of these Births which are not entered in the Vaccination Register, on account (as shewn by Report 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 Vaccination. " Had Small-pox" Column 13 Dead, Un-vaccinated. 1892. 1 2 3 4 5 6 8 9 10 11 1st January to 31st Dec Kensington Town 3084 2467 13 1 289 42 ... 267 5 Brompton 644 534 ... ... 41 10 ... 59 ... Total 3728 3001 13 1 330 52 ... 326 5 * The return for 1893, is not yet complete 266 TABLE XI. LICENSED SLAUGHTER-HOUSES. SOUTH OF UXBRIDGE ROAD. LOCALITY. LICENSEE. 10, Kensington High Street Mr. Evans 35, Earl's Court Road Mrs. Matson 183, Brompton Road Mr. Joyce 21, Peel Place, Silver Street ,, Osborne 15, Silver Street . Mrs. Wright 133, High Street, Notting Hill Mr. Candy 20, Addison Terrace, ditto „ Austin NORTH OF UXBRIDGE ROAD. Lonsdale Mews Mr. Grove 13, Archer Mews . ,, Bawcombe 10, Edenham Mews ,, Goddard 61, Silchester Road ,, Shattock 195, Clarendon Road ,, Thome 235, Walnier Road „ Van 41, Prince's Place . ,, Grant 4, Royal Crescent Mews Brooker 267 TABLE XII. LICENSED COWSHEDS. SOUTH OF UXBRIDGE ROAD. LOCALITY. LICENSEE. Campden Street (Yard in) Mr. Lunn Newland Terrace (rear of) „ Tisdall Redfield Lane, Earl's Court „ Cross NORTH OF UXBRIDGE ROAD. 187, Walmer Road Mr. Amsby 27, Tobin Street . „ Copperwheat 5, Ledbury Mews . ,, Liddiard 23, Bramley Road „ Tame Portobello Road (rear of 209) Aylesbury Dairy Company