Ken 9 No. IX., 1902. The Royal Borough of Kensington. REPORT OF THE MEDICAL OFFICER OF HEALTH For the four weeks, August 10th to September 6th, 1902; bein g the 33rd, 34th, 35th, and 36th Weeks of the Registration Year, 1902, TO WHICH IS APPENDED A REPORT ON THE SMALL-POX EPIDEMIC, 1901-2. To the Mayor, Aldermen and Councillors of the Borough Council. Sir, and Gentlemen, I.—I have to report that 278 births (males 126, females 152), and 180 deaths (males 104, females 76), were registered in the four weeks ended September 6th. After making due allowance for increase of population, the births were 19, and the deaths 14, below the numbers registered in the corresponding weeks in the previous ten years. The births were equivalent to an annual rate of 20.4 per 1.000 persons living, or 1.3 per 1,000 below the decennial average (21.7). The deaths were equivalent to an annual rate of 13.2 per 1,000, or TO per 1,000 below the decennial average (14.2). The rate in the successive weeks was 11.4, 12.9, 14.4, and 14.1. The death-rate in the Metropolis was 15.7 per 1,000; 2.5 above the rate in Kensington, and 3.3 below the decennial average (19.0). Seventyfive of the deaths of Kensington parishioners were of children under 5 years of age, including 50 under 1 year. Fifty-five persons died at 60 and upwards. Eighteen deaths were caused by the diseases of the respiratory organs, including bronchitis 5, and pneumonia 12. The deaths from phthisis were 18, from diseases of the heart 18, and from tubercular or scrofulous diseases of children under 5 years of age, 1. Localised Death-Rates. —The subjoined table shows the number of deaths and the death-rate in the Borough, as a whole, and in the registration Sub-districts, the Parliamentary Divisions, and the several Wards:- Deaths in the four weeks. Death Rate. Population. Locality. The Borough 177,500 180 13.2 Sub-districts :— I Kensington Town 128,660 160 16.2 Brompton 48,840 20 5.3 Parliamentary Divisions:— North Kensington 91,510 128 18.2 South Kensington 85,990 52 7.9 Wards: — St. Charles 22,060 30 17.7 Golborne 26,440 34 16.7 Norland 23,580 46 25.4 Pembridge 19,430 18 12.0 Holland 20,500 21 13.3 Earl's Court 18,140 11 7.9 Queen's Gate 14,340 5 4.5 Redcliffe 18,790 10 6.9 Brompton 14,220 5 4.6 2. —Zymotic Diseases. —The deaths from the principal diseases of the zymotic class were 31, and 5 below the corrected decennial average number. In the Metropolis, as a whole, the deaths from these diseases were 1,050, and 522 below the corrected average. Measles.—The deaths from measles were 2, as compared with 5, 7, and 3, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 99, and 25 below the corrected average. Whooping-Cough. —The deaths from whooping-cough were 3, as compared with 4, 1, and 2, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 142, and 29 above the corrected average. Diarrhœa. —The deaths from diarrhœa were 23, as compared with 4, 5, and 10, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 637, and 422 below the corrected average. Of the 637 deaths from this cause in the Metropolis, 610 were of children under five years of age, 527 of them in the first year of life. All save one of the 23 deaths in Kensington were of children under five, 18 of them being less than one year of age. Fever.—Four cases of enteric fever were recorded (2 in North Kensington, and 2 in South Kensington), of which 2 (1 from North Kensington and 1 from South Kensington) were removed to hospital. There was one death from this cause (at home) of a North Kensington person, as compared with 1, 2, and 2, in the three preceding fourweekly periods. In the Metropolis, as a whole, the deaths from this cause were 47, and 8 below the corrected average. There were 303 cases in the Asylums Board Hospitals on the 6th inst., as compared with 146, 236, and 295, on June 14th, July 12th, and August 9th; and 173 cases were admitted in the four weeks, as compared with 117, 176, and 200, in the three preceding four-weekly periods. The notifications of cases were 324, as compared with 212, 318, and 356, in the three preceding four-weekly periods. Scarlet Fever.—Twenty-six cases of scarlet fever were recorded (21 in North Kensington and 5 in South Kensington), of which 24 (20 from North Kensington and 4 from South Kensington) were removed to hospital. There was one death from this cause (in hospital) of a North Kensington person, as compared with no death in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 45 (and 27 below the corrected average), as compared with 43, 40, and 46, in the three preceding four-weekly periods. There were 2,713 cases in the Asylums Board and London Fever Hospitals on the 6th inst., as compared with 2,347, 2,352, and 2,591, on June 14th, July 12th, and August 9th; and 1,227 cases were admitted to the Asylums Board Hospitals in the four weeks, as compared with 1,191, 1,181, and 1,408, in the three preceding four-weekly periods. The notifications of cases were 1,412, as compared with 1,389, 1,363, and 1,598, in the three preceding four-weekly periods. Diphtheria.—Seven cases of diphtheria were recorded (3 in North Kensington and 4 in South Kensington), of which 7 (3 from North Kensington and 4 from South Kensington) were removed to hospital. There was one death from this cause (in hospital), of a North Kensington person, as compared with 0, 1, and 1, in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 68 (and 78 below the corrected average), as compared with 58, 61, and 93, in the three preceding four-weekly periods. There were 1,007 cases in the Asylums Board Hospitals on the 6th inst., as compared with 957, 954, and 1,054, on June 14th, July 12th, and August 19th; and 561 cases were admitted in the four weeks, as compared with 574, 604, and 712, in the three preceding fourweekly periods. The notifications of cases were 718, as compared with 758, 783, and 882, in the three preceding four-weekly periods. Small-pox.—Seventy-three cases of small-pox were notified in London (22, 26, 12, and 13, in the successive weeks), as compared with 963, 1,510, 1,662, 1,242, 893, 907, 355, and 140, in the eight preceding four-weekly periods. The contributory boroughs are shown in the table at page 151. Twelve deaths were registered from this cause (compared with 162, 221, 289, 230, 166, 130, 67, and 30, in the eight preceding periods); 5, 3, 2, and 2, in the successive weeks, the corrected decennial average for the corresponding weeks being 5.9. One of the deaths took place at the South Wharf Shelters, the remainder at the Asylums Board hospitals. Two of the deaths belong to each of the boroughs of Bethnal Green, Islington, Finsbury, Bermondsey, and Stepney, and one each to Battersea and Hammersmith. One case of the disease was notified in Kensington during the four weeks, of which I subjoin the particulars in continuation of the histories of Cases 1 to 104, given in the ten preceding reports—November 3rd, 1901, to August 9th, 1902. Case 105. Jessie W., aged 22, an assistant book-keeper, fell ill 4th August, the rash appeared on the 7th, and she was removed on the 8th. She contracted the disease from her fiance in an adjacent borough. Chicken-pox. —The period for which the Council made chickenpox a notifiable disease, under the provisions of the Public Health (London) Act, 1891, Section 56 (Sub-section (1) ), expired on the 5th August. But on 7th May the London County Council, in the exercise of their powers under Sub-section (6), extended the provisions of the section to the whole Metropolis for a period of six months, which will expire on 7th November. The cases notified as chicken-pox, during the thirty-six weeks ended 6th September, were approximately 17,540, including 393 in Kensington. In connection with this subject reference may be made to a letter addressed by the The Small-pox Epidemic of 1901-2 is specially dealt with in "A Retrospect," at p. 154. Council of the Borough of Islington (on 5th August.) to the Loudon County Council, intimating their opinion that notification of chickenpox had had "little or no result in bringing to light cases of smallpox, and that, apart from this (its primary object), it is not only useless, but the cause of unnecessary expense to the ratepayers." The Islington Borough Council being of opinion that the order of the County Council should be rescinded, requested the County Council to take steps accordingly, and expressed the hope that the other Borough Councils would see fit to take similar action. It is probable that the County Council will not have cause to renew their order in November. It may be mentioned that in Kensington, among cases notified as chicken-pox, two persons were found to be suffering from small-pox, and were removed to hospital; whilst the Medical Officer of Health of another Borough reported, in July, that in the said Borough fifteen cases notified as chicken-pox were found to be small-pox, and were removed to hospital, and that these cases were responsible for another twenty-five cases of small-pox; so that it is scarcely correct to characterise the notification of chicken-pox as "useless." 3.—Deaths in Public Institutions. —Thirty-five deaths of parishioners were registered at the Borough Infirmary, and 19 at outlying public institutions, etc. 4. —Deaths op Non-Parishioners.—There were 48 deaths in the Borough of persons who were not parishioners; viz., 7 at the Brompton Consumption Hospital, 39 at the St. Marylebone Infirmary, Notting-hill, one at St. Joseph's House, Notting-hill, and one at the Jubilee Hospital. These cases are excluded from our statistics. 5. —Notifications of Infectious Disease in the Metropolis.— I append (page 151) a summary of the cases of infectious disease notified to the several Metropolitan Medical Officers of Health (and by them reported to the Metropolitan Asylums Board, as the Act directs), 4,143 in number; including small-pox, 73, scarlet fever, 1,412, diphtheria and membranous croup, 730, and enteric fever, 319. The cases notified in the three preceding four-weekly periods were 7,108, 6,362, and 4,859, respectively. The Kensington notifications, 90 in number, were localised as follows:— [TABLE. Smallpox. Chickenpox. Scarlet Fever. Diphtheria. Enteric Fever. Erysipelas. Total. Sub-Districts. 2 17 80 Kensington Town 1 31 2 24 5 Brompton 2 2 2 2 10 Parliamentary Divisions. 3 2 64 North Kensington 1 20 22 16 South Kensington 13 4 4 2 3 26 I Wards. - 5 1 - 5 13 St. Charles 2 10 2 1 25 Golborne 9 3 4 - 4 2 Norland 1 11 4 - 5 5 - 1 15 Pembridge 7 2 - - 9 Holland 2 Earl's Court 4 6 2 Queen's Gate Redcliffe - 1 3 2 2 1 7 2 - - - 1 1 - - Brompton 6.—Inquests.—The cause of death in 19 cases, including 14 from violence, was returned by coroners. The cause of death in 6 of these cases is stated to have been ascertained by post-mortem examination. An inquest was held on the body of a non-parishioner. 7.—Tabular Statements. —By direction of the Public Health Committee, the customary statement of the principal items of the work of the Sanitary Inspectors, and the statement of the work of the Lady Inspectors of Workshops, etc., where women are employed, for the four weeks ended September 6th, are appended to this report (vide pages 152 and 153). I have the honour to be, Sir, and Gentlemen, Your most Obedient Servant, T. ORME DUDFIELD, Medical Officer of Health. Public Health Department, Town Hall, Kensington, W. September 11th, 1902. [The Small-Pox Epidemic, 1901-2: A Retrospect. Page 154. - - - - - - - - - - - - - - - Cases of Infectious Disease notified in the several Metropolitan Boroughs in the Four Weeks ended Saturday, 6th September, 1902. Name of Borough. Small-pox. Chicken-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Membranous Croup. Cholera. Totals. Population, 1901. West. 1 33 26 4 ... ... ... 19 ... ... 90 176,628 7 Kensington 20 5 1 13 ... ... 1 143,976 Paddington ... ... 59 7 12 22 1 80 Hammersmith 2 16 ... 112,239 ... ... 2 29 7 1 30 Fulham ... 15 2 137,289 1 63 7 ... 145 27 ... ... 6 3 ... Chelsea ... 51 ... 23 ... ... ... 5 73,842 14 40 5 ... 120 City of Westminster ... 40 ... ... 12 ... ... 183,011 23 North. St. Marylebone 2 47 17 6 ... ... 1 15 ... ... 118 133,301 30 Hampstead 9 6 5 ... ... ... 3 35 81,942 12 ... ... ... 92 62 1 17 1 ... 228 St. Pancras ... 17 ... ... 235,317 38 36 308 122 25 ... 2 ... ... 334,991 Islington 7 66 50 ... ... Stoke Newington ... 11 3 3 ... 8 4 ... ... ... 29 51,247 ... 47 1 18 1 ... 219,272 Hackney 50 59 21 ... ... 197 Central. ... 20 22 14 ... ... ... 1 7 1 ... 65 59,405 Holborn 19 41 15 ... Finsbury 4 8 ... ... ... 101,463 ... 13 100 ... City of London 2 4 2 9 3 ... ... ... ... ... 26,923 20 East. 3 40 28 17 20 ... ... ... 20 ... ... 128 118,637 Shoreditch Bethnal Green 16 37 58 20 6 13 24 1 ... 129,680 ... ... 169 ... 57 ... 12 119 101 40 3 395 298,600 Stepney ... ... 2 19 168,822 Poplar 41 26 ... ... 1 ... 5 50 ... ... 21 163 Southwark ... 37 37 27 ... ... 2 40 ... 247 206,180 104 4 Bermondsey 16 28 16 ... ... ... ... ... 130,760 49 11 123 Lambeth 62 6 75 46 14 ... 3 ... 37 1 ... 244 301,895 South. Battersea 77 48 6 ... ... 1 15 ... ... 167 169,907 1 19 Wandsworth 51 9 ... ... 2 24 1 ... 196 232,034 ... 60 49 76 100 Camberwell 35 9 ... ... ... 22 ... ... 242 259,339 ... 48 10 110,398 Deptford 52 21 6 ... ... 138 1 ... ... ... Greenwich 20 13 95,770 1 37 4 ... ... 10 ... ... ... 85 3 39 43 127,495 Lewisham 29 5 ... ... 1 11 132 1 ... 14 13 2 62 117,178 Woolwich 21 5 ... 1 6 ... ... ... ... ... ... ... Port of London 1 ... ... 6 ... 7 ... ... 4,143 Grand Totals 73 — ... 5 718 319 19 497 12 ... 1088 1,412 [TABLE Statement by the Medical Officer of Health of the principal items of the Work of the Sanitary Inspectors during the four weeks ended September 6th, 1902. Sanitary District. DESCRIPTION OF WORK. No. 1. No. 2. No. 3. No. 4. No. 5. No. 6. No. 7. No. 8. No. 10. No. 9. Total. Inspection of Houses. ... ... 349 ... ... 721 545 554 626 572 606 563 673 5671 Number inspected from December 29th to August 9th... 462 33 ... 42 40 53 83 55 67 40 48 461 Number inspected during the four weeks 22 34 53 74 49 38 40 ... 44 354 Inspected on Complaint 33 20 6 9 6 29 4 107 House-to-House Inspections ... 101 180 459 68 ... ... ... 92 74 112 69 14 ... 1194 ... 25 ... ... ... Registered Houses inspected December 29th to August 9th ... 14 18 9 ... 6 3 ... ... 50 „ „ inspected during the four weeks 2 362 29 393 Registered Houses (roomsfurnished) inspected from Dec. 29th to Aug. 9th ... ... ... ... ... ... ... 7 ... 48 ... 25 „ „ „ „ inspected during the four weeks Re-inspections of Houses. 1295 1356 1239 966 880 1008 965 11928 1797 886 1536 Number re-inspected from December 29th to August 9th 28 169 63 894 ... 110 111 71 127 51 Number re-inspected during the four weeks 164 Inspections of Dairies, Milkshops, etc. (No. in Borough. 275) ... ... 7 16 2 ... 4 ... 2 31 ... ... ... 152 Statement by the Medical Officer of Health of the work of the Lady Inspectors of Workshops, &c., where women are employed, for the four weeks ended 6th September, 1902. North Kensington. South Kensington. Dressmakers. Laundries. Miscellaneous. Total. Dressmakers. Laundries. Miscellaneous. Total. Total whole Borough. Description of Work. 1 Total number of Houses visited 3 51 32 86 2 ... 1 3 89 Workshops and Workplaces - Newly discovered and registered ... ... ... ... 1 ... 1 2 2 2 3 „ Workrooms therein measured ... ... ... ... 1 ... 1 2 2 4 „ Number of Inspections of 3 41 25 69 2 ... 1 3 72 5 „ Number of Re-inspections of ... 10 ... 10 1 ... 3 4 14 6 Workrooms —Number of Inspections of 3 249 27 279 4 ... 1 5 284 7 „ Found to be overcrowded ... ... ... ... ... ... ... ... ... „ Found to be insufficiently ventilated 8 ... 3 2 5 ... ... ... ... 5 9 „ Found to be in a dirty condition ... 3 ... ... ... ... 14 11 14 10 „ Cards distributed shewing number of persons permitted in each room 4 ... 1 5 1 ... 1 2 7 11 Houses visited for inquiry, at which no female hands were employed* ... ... 7 7 ... ... ... ... 7 12 Statutory notices and written intimations issued ... 12 ... 12 ... ... 1 1 13 13 Nuisances reported to the Medical Officer of Health and entered in Complaint Book ... ... 3 3 ... ... ... 3 ... * Houses where the Business Plate, or the Directory, or Newspaper Advertisements, implied the probability that Female Workers would be employed, but at which none were found. THE SMALL-POX EPIDEMIC OF 1901=2: A RETROSPECT. A few cases of small-pox, and a very few deaths from this cause, continue to be notified and registered week-by-week, but for all practical purposes the epidemic of 1901-2 may be considered at an end. On September 6th, there were only 95 cases under treatmentall at Long Reach (temporary) Hospital. The Hospital Ships were finally closed in July. The Gore Farm Hospitals have been vacated. The Orchard (temporary) Hospital, although furnished and made ready for patients, was never opened. The present time, therefore, would seem to be appropriate for a review of the epidemic as it affected Kensington, and other parti of the Metropolis, summarised from the thirteen four-weekly reports, for the period of 52 weeks commenced August 11th, 1901, and ended August 9th, 1902. Prior to the former date there had been, in 1901, only one case of small-pox in the borough —that of a gentleman who had become infected in Paris,* whilst in London the total cases notified were only 41, all told. Since the latter date, and during the period covered by this report, only 73 cases have been notified, including one in Kensington, early in the month of August. During the intervening period of 52 weeks, the notifications of cases in Kensington were 106, and the deaths, including three of nonparishioners, 12. The notifications in London, as a whole, were 9,335, the deaths 1,518, of which all but 86 occurred in hospital. Tables A and B, of Notifications and Deaths, in the several boroughs (pages 163 and 164), show the rise, the progress, and the decline of the epidemic. Table C (page 165) summarises the statistics. All things considered, Kensington has come very well out of the trouble—thanks, largely, to the fairly well-vaccinated condition of the population. Hampstead and Chelsea had the fewest notified cases (26 and 44 respectively) proportionally to population. Kensington comes next. The small-pox death-rate was lowest in Kensington if the deaths of non-parishioners are excluded, viz., 0.5 per 10,000. Table D, at page 166, shows the number of cases in the Borough, as a whole, and in the Registration Sab-districts, the Parliamentary Divisions and the nine Wards. * See No. 1 Monthly Report, 1901, page 4. In this connection it may be mentioned that the epidemic was thought to have originated, in August, through the importation of cases from Paris; and to have been spread by infected clothing, among the employees at a suburban laundry. The boroughs first to be severely affected were St. Pancras and St, Marylebone. Eighty-nine cases occurred in North Kensington (population 91,500), which comprises four Wards, and only 17 in the five Wards comprised in South Kensington (population 86,000). The incidence of the disease upon streets and houses is exhibited in Table E (pages 167-168). In 58 instances there was but one case to a house, in 7 instances two cases, in 4 instances three cases, in 4 instances four cases. In a single instance there were six cases in a house. The cases comprised 61 of males and 45 of females; the ages of the patients are set out in the following table, which also shows the number of deaths (including three of non-parishioners) at different age-periods:— Age-period. Notifications. Deaths. 0-1 2 1 1-5 1 5-10 4 10-20 24 - - 3 20-40 56 4 3 40-60 16 60 and upwards 3 1 106 12 Totals Table F (page 169) shows particulars of the fatal cases, of which 8 belong to North Kensington and 4 to South Kensington. The subjoined table shows that, with few exceptions, the patients belonged to the poorer classes, who are not characterised by overmuch belief in the efficacy of vaccination, nor, as a rule, by willingness to accept re-vaccination, as an ordinary measure of precaution, in the absence of imminent danger. Occupations of the persons attacked by small-pox in Kensington in 52 weeks, 11th August, 1901, to 9th August, 1902— Labourers, carmen, hawkers 40 Artisans 26 Shop-keepers and assistants 16 Laundry women and ironers 6* Lodging-house keeper 1 Domestic servants 5 Clerks 4 Postman 1 Omnibus proprietor 1 "Auctioneer" (Common Lodging-house case) 1 Unknown (3) None (2) 5 Total 106 * Five of these were secondary cases, the origin of one case only, is unknown. The histories of Kensington cases were duly set out in the successive monthly reports, but brief reference may be made here to cetain groups of cases in illustration of modes of spread of the disease:— (1) A lad, employed in another boroug, the nature of whose slight illness was not recognized, infected five inmates of the house in which he resided. (No. 9 Report, 1901, page 122.) (2) A gentleman, living in furnished apartments, the nature of whose indisposition was not recognized, infected a charwoman employed at the house, also his landlady and her niece. The charwoman's case was the first to be notified. She, in turn, infected a man with whom she cohabited, and a sister. (Cases 11 —16, No. 1 Report, 1902, page 5.) (3) A man, employed at Grays, in Essex, an infected district, came home ill and infected his son and daughter. (Cases 23—25, No. 2 Report, page 23.) (4) Two brothers, engaged in work at Dagenham Smallpox Hospital, contracted the disease, which they developed at home in Kensington. (Cases 39—40, No. 3 Report, page 58.) (5) A horsekeeper and a post-office official infected at a house in another borough developed the disease in Kensington. (Cases 41 and 42, No. 3 Report, page 58.) (6) Two lodgers, and the night deputy, at a common lodging-house apparently contracted the disease from a previous unrecognized case in the same dormitory. (Cases 30 and 31, No. 2 Report, page 23; case 32, No. 3 Report, page 57). (7) A man, from ) art ford, at a common lodging-house, infected before arrival in the borough, was the source of infection to the bedmaker. (Case 57, No. 4 Report, page 85, and case 67, No. 5 Report, page 97.) (8) A man, who had an illness variously described as "measles," and as "blood poisoning, "infected his mother and his sister. (Cases 54—56, No. 4 Report, page 85.) (9) A woman in attendance at a general hospital had come in contact with a male out-patient in a highly infectious condition. *The nature of this woman's consequent slight illness was not recognized, the result being that two persons contracted the disease from her. One of them was removed to the Western Fever Hospital for supposed "scarlet fever," which proved to be hemorrhagic small-pox, to which he soon succumbed. (Cases 51—53, No. 4 Report, page 85.) * Another woman (case 50) who had come in contact with this same man was notified as chicken-pox, but was found to be suffering from small-pox and sent to hospital. There were cases in other boroughs, owning the same origin. (10) Two children (unvaccinated) who fell ill simultaneously (no history of infection), infected two other children in the same house. (Cases 58 and 59, No. 4 Report, page 86, and cases 62 and 63, No. 5 Report, page 96.) (11) An anonymous letter led to discovery of six cases in one house. The first case was that of a boy, the nature of whose illness there is reason to belie re was known (or suspected ) by his mother, whom, as well as four other persons, lie infected. (Cases 73 to 78, No. 6 Report, page 106.) (12) A carman (source of infection unknown) infected his wife and two children. (Cases 81—84, No. 6 Report, page 107.) (13) Three days after arrival in the borough, a boy fell ill; the disease was not recognized. He infected three other members of the family, from whom four sisters, in another house, contracted the disease, and in a third house the fiance of one of them. (Cases 88 to 91, No. 6 Report, page 197, and cases 93 to 97, No. 7 Report, page 124.) (14) Two men were infected by their father, whom they had visited before his removal to hospital: a third son, who had slept with his father, escaped. (Cases 101—103, No. 8 Report, page 138.) Amongst individual cases the following are deserving of mention, some of them as indicating sources of infection outside the Borough. Cases 1 and 2 (No. 13 Report, 1901, page 176) imported from another Borough. Case 3 (No. 3 Report, page 177). A youth employed in Kensington, fell ill simultaneously with a fellow employe who resided in another Borough, whose two brothers, moreover, were stricken at the same time. The obviously common source of infection was not traced. Case 4 (No. 14, page 195) was on a visit in another Borough at the date of infection. Case 5 (No. 14, page 196) employed in another Borough, as a bedmaker, at a Rowton House where there were cases of small-pox, was sent home with the premonitory symptoms of small-pox. Case 6 (No. 14, page 14) was infected at the Casual Ward in another Borough, before coming to reside at a Boys' Home in Kensington. Case 8 (No. 1 Report, 1902, page 4). A public-house manager, thought to be suffering from chicken-pox, infected a barmaid who fell ill of small-pox in another Borough. Case 10 (No. 1, page 5). A woman who had previously had small-pox, was infected by her husband. Case 17 (No. 1, page 6). A young woman infected by her fiance in another Borough. Case 18 (No. 1, page 6). An infant infected by a relation on a visit from Grays, Essex, who also infected his own children. Case 19 (No. 1, page 6). A young woman who came home ill, having been infected in another Borough. Case 21 (No. 2, page 22). A woman, who had slept one night only at a common lodging-house in the Borough, was, two days afterwards, removed to hospital from the infirmary, to which she had been sent for observation. Case 26 (No. 2 Report, page 23). A woman who paid one visit to her son in another Borough, prior to his removal to hospital. Case 27 (No. 2 Report, page 23). A man notified as suffering from chicken-pox. Cases 34 to 36 (No. 3 Report, page 57). Three men, who gave false addresses; one of them was traced to his wife's residence in another Borough (where he infected his wife and her father); one unknown at the address given, a common lodging-house, and a third a lodger, for one night only, at the same house. Case 37 (No. 3 Report, page 58). A child, aged 5, treated at home for an illness, transient and trivial, had only two spots on the face. Case 45 (No. 2 Report, page 58). A man treated at home; disease diagnosed an hour or two before death. Case 46 (No. 3, page 59), An operative baker, who was infected by a fellow workman at an underground bakehouse in another Borough. Case 66 (No. 5 Report, page 97). A woman infected by her brother (an unrecognised case) in another district. Case 69 (No. 5 Report, page 97). A man removed from a general hospital, having recently come from Dartford, an infected district. Case 80 (No. 6 Report, page 107). A woman in domestic service who had recently come from another Borough. Case 86 (No. 6 Report, page 107). A laundry woman infected by a fellow worker with whom she lived. Case 87 (No. 6 Report, page 107). A tailor infected by a fellow workman in another Borough. A feature in the above cases, grouped and individual, is that the "contacts," or secondary cases, were in nearly every instance infected before any notification of illness in the primary cases was received. In very few instances were there any secondary or "contact" cases who had become infected after the receipt of the notification of the primary cases. In some 27 cases the sufferers were infected in other districts, and, arising out of these, there were a number of secondary cases. In some 48 cases the source of infection could not be traced, but several of these were imported cases. All of the common lodginghouse cases were imported. Preventive Measures.—In the first rank of measures for the prevention of spread of disease comes — Isolation, which was secured in nearly every case by the removal of the patient to hospital. The removal was effected in 73 cases by medical practitioners, on their own applications and certificates, under the unique system which has been in operation in Kensington since 1887- the Sanitary Authority paying a small fee for the service. In 28 cases the patients were removed by the department, usually upon the notification certificate. Five cases were not removed to hospital: viz., a public-house manager, whose illness had been diagnosed as chicken-pox (case 8, No. 1 Report, page 4); an omnibus proprietor, whose case (45, No. 3 Report, page 58) was reported after death; a gentleman (case 12, No. 1 Report, page 5); a woman (case 53, No. 4 Report, page 85), the nature of whose illness was not recognized; and a child, well isolated, and scarcely at all ill (case 37, No. 3 Report, page 58). Ambulance Service. —The patients were removed in every case in the ambulances of the Asylums Board with a promptitude altogether commendable —many of them at night. Hospital Service. —The accommodation from the first was ample. In August, 1901, there were some 1,442 beds available, or that could have been made available, viz., 250 at the ships, and 1,192 at the Gore Farm Hospitals, the accommodation at which was largely extended (raising the aggregate to about 1,850 beds) before the close of the epidemic. A temporary hospital for 300 patients was erected at Long Reach, and this is the only one now in use. Another temporary structure, the Orchard Hospital, at Joyce Green, with accommodation for 800 beds was rapidly constructed, but, fortunately, was not found necessary. [The permanent hospital at this site, intended for the reception of 940 patients, is approaching completion.] The accommodation at the several hospitals aggregated about 3,200 beds; whilst the patients at any one time scarcely exceeded half that number. Disinfection. —Upon the removal of a patient the Council's staff disinfected the sick room or rooms without loss of time, and the contractors removed the bedding.* This was frequently done *One of the contractors' employes became infected, having delayed to follow advice to get revaccinated. (Sec No. 14 Report, 1901, page 198.) at night. It was not thought necessary to "strip" the wall papers —a course adopted in some Boroughs. In no instance was there any spread of the disease suggesting that the disinfection, whether of rooms or infected articles, had been ineffective. Sulphur fumigation was universally practised in the disinfection of rooms. All washable articles were cleansed after disinfection. Revaccination. —Without loss of time the Vaccination Officer, and in the large majority of cases the Public Vaccinator also, was informed of the occurrence of the outbreak, and vaccination or revaccination was offered to every "contact" and readily accepted by most of them. A considerable number of operations were performed by the District Poor-Law Medical Officers also, these being authorised to vaccinate or re-vaccinate the inmates of a house where small-pox had occurred. I have every reason to be satisfied with the services rendered by all the Officers of the Guardians in this respect. In a special Report (No. 10, 1901), the question of vaccination and re-vaccination was dealt with, especially in connection with the examination of the aims of children in elementary schools —Board and Voluntary. A large number of children were found to be unprotected —the majority of them had been born without the Borough —and were vaccinated forthwith. There were many revaccinations of elder children, and their parents, and other inmates at the homes—vaccination on the school premises was prohibited — and it is common knowledge that a very large number of other persons sought and obtained protection at the hands of the Public Vaccinators and other medical practitioners. Primary vaccinations, moreover, were unusually numerous, but statistical information on the subject is not at present available. Little information respecting the state of vaccination, or otherwise, was forthcoming, the large majority of the patients having been removed before receipt of a notification of the outbreak. Such information, in respect of so few cases, would have little value; it is to be anticipated, moreover, that the Asylums Board will publish the statistics of the vaccination-state of the more than 10,000 persons admitted to their hospitals. In the second Report for 1902 (p. 28) reference was made to a preliminary statement by the Managers on this subject, and in the fourth Report (p. 87) statistics, furnished by the Registrar- General, were cited as to the state, as to vaccination, or otherwise, of over 1,000 fatal cases. Contacts. —The incubation period of small-pox is about 12-14 days, and in order to prevent spread of disease it became necessary to exercise supervision of persons who had been exposed to infection. The names and addresses of these "contacts" were obtained, and the several persons were visited daily, from the twelfth to the fifteenth day after the first and the last exposure to infection. Several contacts who had been exposed to infection before the receipt of the notification certificate fell ill, but scarcely any of the others, when the sick person had been promptly notified and removed, and the usual preventive measures had been It was not thought necessary to prevent the contacts from following their usual pursuits. They were invited to place themselves in communication with the Department, should occasion arise, and some did so. Only in one case was it thought desirable to stop a man from work: he was an operative baker who for two or three nights had pursued his occupation (in another Borough) at an underground bakehouse with a fellow workman who was suffering from small-pox. He subsequently fell ill and was removed to hospital. (Case 46, No. 3 Report, page 59.) The Action of the Board of Guardians. —At the commencement of the epidemic the Guardians issued posters giving public information of the arrangements made for vaccination and revaccination, together with the names and addresses of the public vaccinators. The Guardians also adopted the precaution of having the inmates of the casual wards examined daily by one of their medical officers, who revaccinated all who were willing to submit to the operation. No ease was discovered amongst the casuals; but several outbreaks occurred at common lodging-houses, the primary case having been an imported one in every instance. General Precautionary Measures. —Never before was London so well prepared to deal with an epidemic, whether regard be had to means of removal and isolation of the sick, or the diffusion of information as to the occurrence of outbreaks, the names and addresses of contacts, etc. Through the intermediary of the medical officer of health of the London County Council there was daily intercommunication between the borough medical officers of health, which kept each fully informed of the occurrence of illness in other districts of the metropolis The Asylums Board, moreover, forwarded to each medical officer daily a list of deaths and discharges at the several hospitals; and, weekly, a list of cases admitted, embracing a short history of each, indicating, where possible, the source of infection. Diagnosis of Small-pox. —Comparatively few medical men of the present generation have had opportunities for becoming practically acquainted with small-pox. To this circumstance, leading to failure to recognise the disease, spread of the malady is not infrequently due. Mild and modified cases are mistaken for chicken-pox. Having regard to this difficulty, I ventured to suggest to the Asylums Board the desirability of placing one or more of their experts at the service of medical men to aid them in the diagnosis of doubtful cases, but the Managers did not accede to the suggestion. The County Council, subsequently, appointed certain practitioners to render this aid, but the gentlemen so appointed could not, in some instances at least, claim to possess the expert knowledge necessary to the discharge of so delicate and difficult a duty. No case of small-pox in London was removed direct from home to hospital. Every case was removed, in the first instance, to the South Wharf Shelters at Rotherhithe, and thence —if found to be suffering from small-pox —to Long Reach. If the case was doubtful it was detained for observation. If it was clearly not small-pox the patient was vaccinated or re-vaccinated and sent home—information in such cases being forwarded to the Medical Officer of Health. A few such cases occurred in the Borough and happily not one of them was the worse for the journey. Medical practitioners were encouraged by the Asylums Board experts to send doubtful cases to the shelters, for diagnosis, which was the best practicable course, the Board having, as above stated, felt unable to supply the service of an expert at the patient's home. [On this subject of diagnosis of doubtful cases, vide Reports Nos. 9 and 14, 1901, pages 124 and 196, and No. 2 Report, 1902, page 26.] Conclusion.—I thought it desirable at the commencement of the epidemic, which, as we have seen, was mainly confined to North Kensington, to charge the Chief Sanitary Inspector with the sole responsibility of carrying out the arrangements designed to prevent the spread of disease, and it is simple justice to acknowledge that he fulfilled this duty, which included the visitation of some hundreds of "contacts" —by day and night, on week-days and Sundays alike, to my entire satisfaction, and, I may add, with signal success. 22 20 North. St. Marylebone 9 10 13 27 37 42 17 9 17 3 ... 226 133.301 16.9 2 3 1 ... 2 1 1 1 3 1 4 6 26 81,942 3.2 Hampstead 1 24 56 50 29 43 82 58 72 32 42 St. Pancras 73 46 4 611 235,317 25.9 3 14 42 22 54 26 Islington 15 13 16 54 56 32 2 349 334,991 10.4 3 4 1 13 6 1 4 Stoke Newington Hackney 2 9 15 10 2 70 51,247 13.6 ... 3 44 38 23 5 11 4 10 77 127 57 52 1 452 219,272 20.6 2 2.2 North. St. Marylebone 1 1 ... 1 2 29 133,301 3 6 7 3 ... 2 1 ... Hampstead ... 1 ... 1 ... 1 1 ... 5 81,942 1 0.6 ... 11 10 14 9 17 8 9 11 9 4 123 235,317 5.2 St. Pancras 6 8 7 1 2 4 6 1 8 7 13 ... 10 5 2 59 331,991 Islington 1.8 ... ... 1 ... ... 2 ... 14 51,247 Stoke Newington 1 2 2 4 2 2.7 2 1 1 1 10 3 11 15 17 9 ... 4 ... 74 219,272 Hackney 3.4 11 Central. Holborn 1 ... ... ... ... ... ... ... 2 13 12 22 10 ... 2 ... 76 69,405 ... ... 2 1 ... 12.8 1 4 7 9 8 1 1 ... 5 ... ... ... 40 101,463 Finsbury 2 2 3.9 City of London 3 1 ... ... 2 2 1 9 26,923 3.3 4 30 9 Shoreditch ... 1 4 ... 3 ... 24 3 2 80 118,637 6.7 East. 13 8 Bethnal Green 5 11 15 7 2 61 129,680 4.7 23 1 3 47 21 3 277 298,600 Stepney ... 7 11 62 74 19 6 9.3 4 21 13 Poplar ... ... ... ... ... ... ... 2 4 7 14 19 13 5 1 103 168,822 6.1 6 6 Southwark ... 1 1 12 7 12 16 14 9 5 2 91 206,180 4.4 3 Bermondsey ... ... 5 4 5 1 2 9 5 3 ... 37 130,760 2.8 3 7 15 7 2.1 Lambeth 1 ... ... 1 10 ... 9 8 2 2 65 301,895 2 Battersea ... ... ... 6 4 4 5 4 4 1 ... 30 169,907 1.8 South. ... 3 5 ... ... ... ... 3 29 Wandsworth ... ... ... Camberwell ... ... 1 6 8 1 ... ... 2 232,034 1.2 1 6 ... 3 12 14 13 13 5 2 69 259.339 2.7 2.8 Deptford ... ... ... ... ... 4 10 9 7 ... 1 ... 31 110,398 ... 5 4 4 7 7 2 1 ... 95,770 3.1 Greenwich ... ... ... 30 Lewisham ... ... ... ... ... 1 3 4 7 ... 1 2 18 127,495 1.4 13 Woolwich ... ... 1 1 3 1 7 ... 4 2 1 33 117,178 ... 2.8 219 289 229 16 73 91 162 166 130 67 26 30 1,518 Totals 20 164 ... ... *Cases admitted to Hospital in London 194 690 983 1,678 1,367 345 10,086 121 903 1,098 136 310 439 1,822 Brompton 48,840 10 9 10 10 - - - - Parliamentary Divisions— 89 59 45 5 4 North Kensington 91,510 44 4 1 South Kensington 85,990 17 14 15 13 2 - - - Wards— 22,060 15 5 8 16 1 - - 1 1 2 2 - North K. St. Charles Golborne 26,440 27 14 19 5 2 - Norland 23,580 29 13 20 16 2 1 - - - - Pembridge 19,430 18 12 12 8 2 - - 3 3 3 - - - - South K. Holland 20,500 3 Earl's Court 18,140 1 1 1 1 - - - - Queen's Gate 5 3 3 1 2 14,340 Redcliff 6 5 2 6 6 - - - - - - - 18,790 2 - Brompton 2 2 14,220 TABLE E. Streets, and Number of Houses in each Street, in North Kensington, Invaded by Small-pox, and Cases Notified (11th August, 1901, to 9th August, 1902). Ward. No. of Houses Invaded. Streets. No. of Cases. Blechynden Street 2 3* St. Charles 1 Calverley Street 1 Lancaster Road 1 4 4 Rackham Street 1 Walmer Road 3 3 Golborne Adela Street 1 1 Bevington Road 1 1 Bosworth Road 2 7 Edenham Street 1 1 Faraday Road 1 1 Hazlewood Crescent 1 4 Kensal Road 1 1 Southam Street 3 3 South Row Swinbrook Road 1 1 1 1 Tavistock Road 1 1† Telford Road 1 1 Wheatstone Road 1 1 Wornington Road 3 3 † Norland. Bangor Street 1 1 Clarendon Road 1 1 Cornwall Road 1 1 Crescent Street 2 4* Hesketh Place 2 1 Norland Road North 1 1 Norland Square 1 1 St. James's Place 1 1 St. Katharine's Road 3 3 Sirdar Road 2 2 Talbot Grove 2 3 Tobin Street 2 7 Walmer Road 2 2† Pembridge Buckingham Mews 1† 1 Buckingham Terrace 1 2 Convent Gardens 1 1 Cornwall Road 1 2 Denbigh Road 1 3 High Street, Notting Hill 1 1 Ladbroke Road 1 1 Lancaster Road 1 3 Linden Gardens 1 1 Lonsdale Road 1 1 Portobello Road 1 1 Westbourne Grove 1 1 * Two fatal cases. † One fatal case. TABLE E — continued. TABLE E. - continued. Streets, and Number of Houses in each Street, in South Kensington, invaded by Small-pox, and Cases Notified (11th August, 1901, to 9th August, 1902). Ward. No. of Houses Invaded. Streets. No. of Cases. Holland 1 1* Campden Street Jameson Street 1 1* Newcombe Street 1 1 Earl's Court Wallgrave Terrace 1 1 2 Queen's Gate Kensington High Street 1 Lexham Gardens 1 1 Queen's Terrace Mews 1 2 1* Redcliffe Cromwell Road 1 1* Earl's Court Road 1 I field Road 2 2 Redcliffe Road 1 1 Seymour Place 1 1 1 Brompton Road 1 1 Chapel Place 1 * One fatal case. Wornington Road common Lodging-house. 5. Alfred D.† M. 53 Vaccinated in infancy, revaccinated 37 years ago. 36 "Auctioneer" Vaccinated in infancy Carman Jameson Street. 6. Samuel P. M. 20 38 169 Addendum. — lt has been thought well to restrict the above report to a history of the Epidemic itself, but many related subjects were dealt with in the monthly reports, among them the following: — The Ambulance Service, and The Transport of Small-pox patients from London to the Small-pox Hospitals, No. 3 Report, 1902, page 61; No. 6 Report, 1902, page 108; and No. 7 Report, 1902, page 125. Hospital Accommodation for Small-pox, No. 11 Report, 1901, page 143; No. 13 Report, 1901, page 178; No. 1 Report, 1902, page 6; and No. 2 Report, 1902, page 24. The Spread of Small-pox in Country Districts through visitation of the Sick in Hospital, No. 2 Report, 1902, page 25. Diagnosis of Small-pox, No. 14 Report, 1901, page 196. Diagnosis of Doubtful Cases of Small-pox, and Mistaken Diagnosis, No. 2 Report, 1902, pages 26 - 27. Isolation of " Contacts," No. 2 Report, 1902, page 25. Vaccination and Revaccination, No. 10, 1901 (Special Report); No. 14 Report, 1901, page 197; and No. 3 Report, 1902, page 59. Vaccination: Difficulty of procuring Calf Lymph, No. 2 Report, 1902, page 29. Vaccination Statistics, No. 2 Report, 1902, page 28; and No. 4 Report, 1902, page 87. Conference of the Sanitary Authorities on Small-pox ; The Resolutions adopted by the, No. 2 Report, 1902, page 30. Notification of Chicken-pox, No. 14 Report, 1901, page 197. The Small-pox Epidemic of 1871, No. 1 Report, 1902, page 9.