No. III., 1903. The Royal Borough of Kensington. REPORT OF THE MEDICAL OFFICER OF HEALTH For the four weeks, March 1st to March 28th, 1903; being the 9th, 10th, 11th, and 12th Weeks of the Registration Year, 1903. COUNCIL. Sir, and Gentlemen, 1. I have to report that 269 births (males 140, females 129), and 215 deaths (males 95, females 120), were registered in the four weeks ended March 28th. After making due allowance for increase of population, the births were 29 and the deaths 53 below the numbers registered in the corresponding weeks in the previous ten years. The births were equivalent to an annual rate of 19.6 per 1.000 persons living, or 1.9 per 1,000 below the decennial average (21.5). The deaths were equivalent to an annual rate of 15.7 per 1,000, or 3.9 per 1,000 below the decennial average (19.6). The rate in the successive weeks was 11.7, 19.9, 16.7, and 14.6. The death-rate in the Metropolis was 16.6 per 1,000; 0.9 above the rate in Kensington, and 5.4 below the decennial average (22.0). Sixtyeight of the deaths of Kensington parishioners were of children S 50—0 1003 - 500—4-03 40 under 5 years of age, including 44 under one year. Seventy persons died at 60 and upwards. Forty-two deaths were caused by the diseases of the respiratory organs, including bronchitis 22, and pneumonia 13. The deaths from phthisis were 28, from diseases of the heart 15, and from tubercular or scrofulous diseases of children under 5 years of age, 4. Localised Birth and Death-Rates.—The subjoined table shows the number of births and deaths, and the birth-rate and the deathrate, in the Borough, as a whole, and in the registration Sub-districts, the Parliamentary Divisions, and the several Wards: — Population. Births in the four weeks. Deaths in the four weeks. Locality. Birth Rate. Death Rate. The Borough 178,000 269 19.6 215 15.7 Sub-districts: — 23.7 Kensington Town 129,020 235 174 17.5 34 9.0 41 10.9 Brompton 48,980 28.5 Parliamentary Divisions: — North Kensington 91,770 201 136 19.3 South Kensington 86,230 68 10.2 79 11.9 Wards:— 27.6 St. Charles 22,120 47 23 13.5 26,520 Golborne 60 29.4 60 29.4 23,650 30.2 34 Norland 55 18.7 Pembridge 19,480 39 26.0 19 12.7 Holland 20,560 20 12.6 21 13.3 Earl's Court 18,190 14 10.0 19 13.6 Queen's Gate 14,380 7 6.3 13 11.7 12.4 13 9.0 Redcliffe 18,840 18 Brompton 14,260 9 8.2 13 11.8 2. —Zymotic Diseases. —The deaths from the principal diseases of the zymotic class were 22, and one below the corrected decennial average number. In the Metropolis, as a whole, the deaths from these diseases were 686, and 112 below the corrected average. 41 Measles. —There was no death from measles, as compared with 1, 0, and 0, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 267, and 27 above the corrected average. Whooping-Cough. —The deaths from whooping-cough were 15, as compared with 2, 16, and 26, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 204, and 26 below the corrected average. Diarrhoea.—The deaths from diarrhœa were 2, as compared with 1, 5, and 1, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 82, and 30 above the corrected average. Fever. —Six cases of enteric fever were recorded (4 in North Kensington and 2 in South Kensington), of which 5 (4 from North Kensington and 1 from South Kensington) were removed to hospital. There was one death from this cause (at the Borough Infirmary) of a North Kensington person, as compared with 3, 0, and 2, in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 20, and 15 below the corrected average. There were 99 cases in the Asylums Board Hospitals on the 28th March, as compared with 210, 172, and 125, on January 3rd, January 31st, and February 28th ; and 61 cases were admitted in the four weeks, as compared with 119, 86, and 51, in the three preceding fourweekly periods. The notifications of cases were 108, as compared with 227, 175, and 129, in the three preceding four-weekly periods. Scarlet Fever.—Thirty-three cases of scarlet fever were recorded (26 in North Kensington and 7 in South Kensington), of which 26 (22 from North Kensington and 4 from South Kensington) were removed to hospital. There was one death from this cause (at home) of a South Kensington person, as compared with 2, 0, and 0, in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 26 (and 20 below the corrected average), as compared with 42, 37, and 31, in the three preceding four-weekly periods. There were 1,756 cases in the Asylums Board and London Fever Hospitals on March 28th, as compared with 2,378, 2,019, and 1,851, on January 3rd, January 31st, and February 28th ; and 857 cases were admitted to the Asylums Board Hospitals in the four weeks, as compared with 970, 869, and 837, in the three preceding four-weekly periods. The notifications of cases were 990, as compared with 1,151, 1,031, and 943, in the three preceding fourweekly periods. 42 Diphtheria.—Thirteen cases of diphtheria were recorded (7 in North Kensington and 6 in South Kensington), all of which were removed to hospital. There were 3 deaths from this cause (all in hospital, and of North Kensington persons), as compared with 3, 0, and 1, in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 83 (and 78 below the corrected average), as compared with 94, 64, and 79, in the three preceding four-weekly periods. There were 900 cases in the Asylums Board Hospitals on March 28th, as compared with 939, 942, and 1,037, on January 3rd, January 31st, and February 28th ; and 497 cases were admitted in the four weeks, as compared with 825, 527, and 614, in the three preceding four-weekly periods. The notifications of cases were 641, as compared with 710, 662, and 735, in the three preceding four-weekly periods. Small-pox.—Ten cases of small-pox were notified in London (3, 1, 2 and 4, in the successive weeks), as compared with 10, 14, and 11, in the three preceding four-weekly periods. The contributory boroughs are shown in the table at page 52. Two deaths were registered from this cause (one in hospital), as compared with 0, 2, and 1, in the three preceding four-weekly periods: both belonged to the Borough of Stepney. 3. —Deaths in Public Institutions.—Thirty-nine deaths of parishioners were registered at the Borough Infirmary, and 34 at out-lying public institutions, etc. 4. —Deaths of Non-Parishioners.—There were 44 deaths in the Borough, of persons who were not parishioners; viz., 4 at the Brompton Consumption Hospital, 38 at the St. Marylebone Infirmary, Notting Hill, and two at St. Joseph's House, Notting Hill. These cases are excluded from our statistics. 5. —Notifications of Infectious Disease in the Metropolis.— I append (page 52) 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), 2,093 in number; including small-pox, 10, scarlet fever, 990, diphtheria and membranous croup, 657, and enteric fever, 107. The cases notified in the three preceding four-weekly periods were 3,321, 2,743, and 2,191, respectively. 43 The Kensington notifications, 62 in number, were localised as follows:— Scarlet Fever. Diphtheria. Enteric Fever. Erysipelas. Total. Sub-Districts. Kensington Town 28 9 6 6 49 Brompton 5 4 - 4 13 Parliamentary Divisions. North Kensington 26 7 4 4 41 South Kensington 7 6 2 6 21 Wards. 9 1 2 St. Charles 2 14 Golborne 12 3 2 1 18 Norland 3 1 1 1 6 Pembridge 2 1 - - 3 Holland 2 - - 2 - Earl's Court 2 1 2 1 6 Queen's Gate - 2 - 2 4 Redcliffe - - 3 4 1 Brompton 3 2 - - 5 6. —Inquests.—The cause of death in 22 cases, including 11 from violence, was returned by coroners. The cause of death in 8 of these cases is stated to have been ascertained by post-mortem examination. Inquests were held on the bodies of 3 non-parishioners. 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 March 28th, are appended to this report (vide pages 53 and 54). 8. — Removal of Offensive Trade and other Refuse. —A Conference of London Sanitary Authorities held at the County Hall, 29th June and 7th November, 1900, adopted (inter alia) the following resolutions :— "(a) That, in the opinion of the Conference, the sanitary authority should be empowered to employ a sufficient number of scavengers, or contract with any scavengers, whether a company or individuals, for 44 collecting and removing trade refuse of an offensive or noxious nature from any premises within their district, at a charge to be fixed by the local authority, or, in the event of dispute, by a police magistrate. "(b) That, in the opinion of the Conference, the sanitary authority should be empowered to employ, if they think fit, a sufficient number of scavengers, or contract with any scavengers, whether a company or individuals, for collecting and removing the manure and other refuse matter from any stables and cow-houses within their district, at a charge to be fixed by the local authority, or, in the event of dispute, by a police magistrate." The subject, which had engaged the attention of the County Council more or less since the Conference, has recently been brought by them to the notice of the Metropolitan Borough Councils in the circular letter referred to the Public Health Committee. The County Council do not regard the matter of removal of manure "as one of great urgency," but state that it has been " noted for consideration in connection with any general amendment of the Public Health (London) Act." They, however, are "considering the question of the collection of all offensive trade refuse by the sanitary authorities," and desire " before proposing any amendment of the law in this direction .... to hear the views " of those bodies thereon. Appended to the letter are draft clauses " enabling sanitary authorities to undertake the duty referred to," and the County Council desire to be informed " whether such clauses would meet with the support" of the Council. The suggested clauses two as follows: — It shall be the duty of every sanitary authority— 1. (a) To employ a sufficient number of scavengers, or to contract with any scavengers, whether a company or individuals, for collecting and removing at proper periods, of which sufficient notice shall hi all trade refuse of an offensive or noxious nature from any premises within their district, and also for the due cleansing at proper periods of all receptacles for storing such offensive or noxious refuse. (b) Where such refuse is not removed from any premises in the district at the period so fixed as aforesaid, and the owner or occupier serves on the sanitary authority a written notice requiring removal of such refuse, to comply with such notice within 48 hours after that service, exclusive of Sundays and public holidays. 2. If a sanitary authority fail, without reasonable comply with this section, they shall be liable to a line not exceeding twenty pounds. 3. Offensive or noxious trade refuse shall mean all trade refuse in such a condition as to be, or to be liable to become, offensive or noxious. If any dispute or difference of opinion arises between the owner or occupier and the sanitary authority as to what is considered as offensive or noxious trade refuse, a petty sessional court, on complaint made by cither party, may by order determine whether the subject matter of dispute is offensive or noxious trade refuse, and the decision of that court shall be final. 4. The owner or occupier of any premises from which such refuse 45 is removed shall pay to the sanitary authority a reasonable sum, either by way of annual payment or in respect of each such removal, and such sum in case of dispute shall be settled by the order of a petty sessional court. With reference to this important question: I beg to submit that it is desirable that the sanitary authority should have power, and be required, to remove offensive trade and other refuse, as recommended by the Conference in 1900; and that the suggested clauses are suitable for giving effect by legislation to the resolutions of the said Conference. Personally, I regard the matter of the removal of stable manure by the sanitary authority as being " one of great urgency," and, as it could be dealt with in any Bill enabling sanitary authorities to remove other forms of offensive refuse, I recommend that the County Council be requested to draft a clause or clauses dealing therewith. The subject generally is one in which the Kensington Sanitary Authority have lone- taken an interest. It was dealt with in my report (July 24th, 1878) on "Filth Removal," the refuse therein particularly adverted to being that from cow-houses; complaints having been received with regard to the conveyance of this offensive matter through the streets in the daytime. In the annual report for 1880 (page 114), I drew the late Vestry's attention to the "difficulty experienced in preventing nuisance from accumulations of offensive matters coming under the general description, Refuse"—a difficulty "common to all parts of the Metropolis, and calling for legislative interference for its abatement." I brought the subject, the same year, to the attention of the Society of Medical Officers of Health, and a special committee, over which I presided, was appointed to consider and report —" on the best and most convenient ways of dealing with animal and vegetable trade refuse, e.g., from slaughter-houses, fishmongers', poulterers', and greengrocers' shops, etc., and with the refuse of stables and cowhouses, with a view to its collection, removal, and ultimate disposal, whether by utilisation or destruction." The report of this committee, unanimously adopted by the Society, was printed in my annual report for 1880 (page 114). The conclusion arrived at with respect to trade refuse, such as that of " slaughter-houses, and the refuse of the trades of fishmonger, poulterer, greengrocer, etc."—being of organic origin and liable to decomposition—was that " the nuisance authority should have power and obligation to collect, remove, and dispose" of it, and " should receive reasonable compensation for so doing." With respect to stable and cowshed refuse, the Society advised 46 "that the nuisance authority should have the right to collect it when the owner was in default, and to charge him with the cost of so doing" ; the default being non-compliance with the Regulations, passed under the provisions of the 53rd section of the Sanitary Act, 1866, for the " periodical removal of manure," etc., by the owner thereof. The report of the Society was forwarded (in 1881 ) to the several Sanitary Authorities, anil to many members of Parliament —but nothing came of it. In 1883 I called attention to nuisance from "stenches arising in the collection and storage of fat, and other animal matters, in a putrid condition," on the premises of marine store dealers, and the Vestry made representations to the Metropolitan Board of Works. which, apparently fruitless at the time, subsequently led to consideration of the subject generally. In a special report on " Sanitary. Nuisances Removal and other Cognate Acts " (March 13th, 1885), made at the request of the Law and Parliamentary Committee,* I drew attention to unused powers vested in the Metropolitan Board of Works, section 202 of the Metropolis Loral Management Act. 1855, enabling them to make by-laws for " works of cleansing and of removing and disposing of refuse." In November, 1887, a circular letter was received from the Clerk to the Metropolitan Board of Works showing that the representations of the Vestry had not been without effect. It was to the following effect: — "The Special Purposes and Sanitary Committee of the Board have under consideration the question of the nuisance caused in the collection, and conveyance through the streets of the Metropolis, of offensive substances, such as fish offal, blood, kitchen stuff, and other refuse. It has been represented to the Board that the existing provisions in the Nuisances Removal Acts, and in the Local Management Acts, bearing upon the matter, do not enable the Local Sanitary Authorities to deal authoritatively and effectively with the nuisance, and that additional * It had been referred to the Committee to enquire " whether the provisions of the various Acts have been and are being enforced by the Vestry a3 fully as the circumstances of the Parish demand ; and if not. to advise as to the steps it is desirable to take for their better enforcement; and also whether any amendment of the law may appear necessary." The report of the Committee, having been adopted unanimously by the Vestry, was remitted to them and to the Works, Sanitary and General Purposes Committee jointly, with a view to their advice " as to the best means to be adopted for carrying out the recommendations." The Committees reported on the reference in April, 1886. The two reports and the reports of the Surveyor and the Medical Officer of Health were sent to the Metropolitan Board of Works, the Vestries and District Boards, etc., and in 1889 to the London County Council and the individual members thereof. (See Annual Reports, 1887, pp. 148-162, and 1890, p. 132.) 47 legislative powers are necessary. The Committee are quite satisfied that serious nuisance does arise from this source, but before recommending the Board to take any steps for obtaining an amendment of the law, the y are desirous of ascertaining the views of the several Vestries and District Boards of the Metropolis on the subject, especially as the Committee understand that in some districts the Local Authority has succeeded in effecting the removal of offensive substances without nuisance. "The Committee have, therefore, Instructed me to request your Board to he good enough to furnish the following information : — "1. Whether nuisance is experienced in your district in the collection of offensive material, and in its conveyance through the streets, and, if so, the nature and extent of the nuisance. "2. If your Board have taken any steps for preventing nuisance from this source, and, if so, what steps, and with what results. "3. Under what statutory provisions you have acted, and if you consider such provision- adequate to the purpose of preventing nuisance. "The Committee will be glad to receive any information which your Board may be good enough to afford them during the present month, as they propose to report on the subject early in December. Recognizing the importance of the communication, I made a Special Report on the subject (17th November, 1887) dealing with it as follows: — "Nuisance is experienced in this Parish in 'the collection of offensive material, and in its conveyance through the streets ;' and in its prior to removal. "Fish and Poultry Offal. — In regard to this refuse, perhaps the most offensive of all, the arrangements appear to be wholly unsatisfactory, arising in large measure from the fact that there is no Systematic collection of it. The fishmongers experience much trouble in getting rid of it, and cannot place dependence on the collectors, who, nevertheless, are paid for their services. The offal appears to be collected in part for boiling-down for pigs' food ; it is also removed in manure carts, then, presumably, finding its way on to the land. As a ride it is collected daily, and mostly in the latter part of the day. It is rarely stored in impermeable covered vessels, and as it rapidly decomposes, effluvium results. This is most complained of at hay-making anil harvest time, when the manure collectors are less regular in their visits. The storage vessels are not removed, simply emptied, and the receiving vessels, mostly of wood, and the carts themselves, are offensive at the commencement of the day's work—the nuisance naturally being greatest in hot weather, both at the time of emptying the trade receptacles, and during past the earls through the streets, the tubs being usually covered with only. "Blood. —With blood may be grouped the other refuse matters from slaughter-houses, and with regard to these matters I am able to report comparative absence of cause for complaint—as a result of bye-law conceived and fairly carried out under substantial penalty for default. The various matters are stored in impermeable covered receptacles, in which, as a rule, they are, as they ought to be, removed from the premises, double sets of receptacles being provided. " Bones may be mentioned here, though not named in the Board's letter, The nuisance from these is great, especially in hot weather, and it may exist on every batcher's premises. Bones, from which the flesh 48 has been stripped, are stored usually in uncovered receptacles awaiting the periodical call of the collecting vehicle. The vehicles themselves are offensive, and as they load up they become every hour more objectionable to smell and sight, as they make their fetid progress through the streets. " Kitchen Stuff. —Under this head I include waste fat, bones, hare and rabbit skins, &c., all of which find their way to ' Marine Stores.' Skins are generally removed before they become very offensive, but even in regard to these there is by no means freedom from complaint. Bones and fat are generally offensive in warm weather, being often allowed to accumulate in considerable quantities, pending the periodica] call of the collecting vehicle. These matters are stored in open wooden tubs, which are emptied direct into the vehicle, or into receptacles, all of which are usually offensive, empty or full. Bones go to bone boilers, fat to the fat melters and soap boilers, and naturally the collectors do not call without hope of receiving an adequate quantity, making it worth their while. Hones are conveyed out of the parish, and a good deal of fat probably, but within the boundaries there are two melting establishments, which demonstrate the difficulty —even under good bye-laws fairly carried out—of preventing nuisance in the conduct of a naturally 'offensive' business. "Other Offensive Substances. —Greengrocers' refuse is not seldom the cause of complaint, arising largely out of the difficulty of getting it removed—such refuse, moreover, being naturally most abundant in summer, when it more speedily decomposes. It is often put into dungpits, where, under the influence of heat, it ferments, and soon becomes offensive, adding considerably to the nuisance arising in the removal of stable manure. " Cowshed Refute. —The dung from cowsheds, to which sometimes sour grains are added, is a cause of complaint, being removed in filthy vehicles, which are often leaky, and allow of dropping in the streets. Under the operation of the Board's Regulations for Cowsheds, the refuse is removed with greater frequency than formerly, but cow-dung in its passage through the streets is almost always objectionable. " Stable Manure is frequently allowed to remain too long in the receptacles, and when these are underground covered pits, the nuisance in removal —ill the time of collection, and in the progress of the vehicles through the streets—is very great, and is a frequent cause of complaint. The nuisance varies widely in different localities, according to the use made of straw as litter. In gentlemen's stables, the straw is changed frequently, and when the used litter is stored in iron cages, on a paved and drained surface, there is practically no nuisance in storage or removal. Hut people less favourably circumstanced use the litter day after day until it becomes fairly rotten before being deposited in the 'dung-pit' ; and then, naturally, the nuisance is great —in the pit itself, in the act of collection, ami in conveyance through the streets : greatest also in hot weather (when, moreover, it is difficult often to get it removed), and in proportion to the time of detention. Of late years peat moss has come into use as litter (sawdust, also, to some extent ). and in the act of collection, this is extremely offensive from disengagement of ammonia There is, however, little nuisance while the moss is undisturbed, or in conveyance through the streets. "Much of the nuisance (as already intimated) in regard to offensive substances of animal origin, occurs at the time of collection and in conveyance through the streets, with which, so far as I know, we have no 49 power to deal; but efforts have been constantly made to minimise cause for complaint by promoting removal before the substances in question have become offensive from decomposition." After some further observations in regard to the action taken by the Vestry to prevent or abate nuisance, the report concluded as follows:— "There can, I think, be no doubt that the representations made to the Board 'that the existing provisions in the Nuisance Removal Acts, and in the Local Management Acts, bearing upon the matter, do not enable the Local Sanitary Authority to deal authoritatively and effectively with nuisance'arising from the storage, the collection, and the removal of offensive substances, are well founded, and that additional powers arc necessary. The Board are satisfied that ' serious nuisance does arise' from the source in question, and I trust they will come to the conclusion, at which your Vestry long since arrived, that the matter can be dealt with effectively only by the bye-laws, entailing an adequate and fixed penalty for offence—bye-laws made by the Board, under their existing powers, or under fresh powers to be obtained from Parliament; bye-laws, the carrying out of which should be entrusted to the Local Sanitary Authorities. Such bye-laws with respect to offensive substances of animal origin should make provision with regard : — "(1) To storage vessels, which should be of metal, impervious and covered. "(2) To removal in iron tank vans (but it would be better to provide for the removal of the storage vessels themselves). "(3) To time of daily removal (in the evening) ; and "(4) To measures for disposal of the refuse. "It is open to consideration whether the duty of removing all offensive substances should not be devolved upon the Sanitary Authority, at the reasonable cost of the producers thereof." The report was approved by the Vestry, and the Board were informed on 12th December, 1887 — "That nuisance is experienced ... in the storage and in the collection of offensive material and in its conveyance through the streets . . . and is aggravated by the objectionable character and condition of the vehicles used for conveying the offensive material." The steps taken by the Vestry for preventing the nuisance were described —proceedings having been taken under the Nuisances Removal Acts, the Sanitary Act, 1866, and the Slaughter-houses (Metropolis) Act, 1874. The Nuisances Removal Acts were deemed insufficient for dealing adequately with the matter, as " there is no penalty for the offence of committing a nuisance, and it is not always easy to satisfy the justices of the reality of the nuisance." The Sanitary Act had proved insufficient to secure periodical removal of manure, " owing to the reluctance of the justices to inflict adequate penalties for default," i.e., breach of the regulations requiring periodical removal: the Vestry, moreover, " have no power to remove the refuse at the cost of the owner, nor without his consent." 50 It was stated that— "The provisions of the Slaughter-houses Act, under which the dealing with offensive material of certain trades is regulated by bye-laws, are adequate as far as they go, to the purpose of preventing nuisance, and it was 'the success of the Board's Regulations made under the provisions of the Act' which suggested to the Vestry ' the course most likely to succeed in preventing nuisance in connection with the storage, the collection and the conveyance of offensive material through the streets, viz., by the creation of bye-laws to regulate the trades which involve the production of refuse of an offensive matter.'" The Vestry directed ray report on the subject to be sent to the Board for their " further information," and as " containing a fuller exposition of their views on the important questions " dealt with in their circular letter. In the Annual Report for 1888 the subject was further referred to as follows :— "The Board's existence having been threatened by the introduction of the London Government Bill (in 1888), no legislation was initiated . . . the Special Purposes Committee indeed made no report on the subject." It was further remarked that " the materials collected are available for the use of the County Council, whose attention will probably be given to it in connection with the subject of by-laws,"—which could be made under Section 202 of the Metropolis Management Act, 1855. In 1889 the Vestry forwarded to the Count Council the Special Reports on " Sanitary, Nuisances Removal, and other cognate Acts " referred to above, " believing that legislation framed upon the lines of the reports would be conducive to the interests of public health in the Metropolis." Shortly afterwards a circular letter was received from the Council enquiring whether the Vestry had made bye-laws in pursuance of section 202 for the purposes indicated therein— including " works of cleansing and of removing and disposing of refuse " r —to which the reply given was that "no such bye-laws had been made by the Vestry for the reason that the Vestry have no power to make such bye-laws": the power to make such bye-laws, originally vested in the Metropolitan Board of Works, "now vests in the London County Council only." Incidentally, it may be mentioned that the County Council in 1901 passed Drainage bye-laws under the provisions of the section — 45 years after the Act came into force, and 16 Tears after attention had been called in these reports to the need for such bye-laws ; and in 1893 they gave effect to the provisions of section 16 of the Public Health (London) Act, 1891, by framing bye-laws as to prevention of nuisances, etc. —sub-section (2) (a) dealing with the removal of offensive matter. The bye-law (1) then framed was in 1902 superseded by a new one which, among other things, provided for the removal of peat-moss stable manure and cow-house manure, 51 under conditions designed to prevent nuisance in the transit through streets of these offensive forms of refuse. It rests now with the County Council to complete the good work done since the question was taken up tentatively, and by way of enquiry only, by their predecessors in 1887 ; and it is to be hoped that they will receive the assistance of the sanitary authorities in regard to any legislation they may promote, in the form of the suggested clauses contained in the circular letter which furnished occasion for the above resume, or otherwise. I have the honour to be, Sir, and Gentlemen, Your most Obedient Servant, T. ORME DUDFIELD, Public Health Department, Medical Officer of Health. Town Hall, Kensington, W. April 3rd, 1903. TABLE 52 Cases of Infectious Disease notified in the several Metropolitan Boroughs in the Four Weeks ended Saturday, 28th March, 1903. Name of Borough. Population, 1901. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Membranous Croup. Cholera. Totals. West. Kensington ... 33 13 6 ... ... ... 10 ... ... 62 176,628 Paddington ... 19 3 ... ... 9 1 ... 39 143,976 7 ... Hammersmith ... 32 21 3 ... ... ... 12 ... ... 68 112,239 Fulham 56 16 1 ... 4 13 ... ... 90 137,289 ... ... Chelsea 2 8 14 ... ... ... ... ... ... 27 73,842 3 City of Westminster 36 18 7 ... 1 6 ... ... 68 183,011 ... ... North. ... 33 1 ... ... 1 7 2 ... 57 133,301 St. Marylebone 13 Hampstead ... 18 10 1 ... ... ... 2 ... ... 31 81,942 St. Pancras ... 64 48 5 ... ... 20 ... ... 138 235,317 1 Islington ... 66 37 4 ... 1 1 16 1 ... 126 334,991 Stoke Newington ... 5 2 1 ... ... ... 1 ... ... 9 51,247 Hackney ... 49 57 4 ... ... 1 21 1 ... 133 219,272 Central. Holborn ... 10 4 1 ... ... ... 8 ... ... 23 59,405 Finsbury 1 9 3 ... ... 2 12 1 ... 33 101,463 5 City of London ... 9 1 ... ... ... ... ... ... 10 26,923 ... East. Shoreditch ... 18 8 2 ... ... 1 15 1 ... 45 118,637 Bethnal Green ... 17 25 2 ... ... ... 19 ... ... 129,680 63 Stepney 3 45 9 1 ... 22 2 ... 138 298,600 55 1 Poplar ... 22 23 5 ... ... ... 9 3 ... 62 168,822 South. Southwark 43 39 7 ... ... ... 12 ... ... 101 206,180 ... Bermondsey 50 13 2 ... 1 12 ... ... 83 130,760 2 3 Lambeth ... 58 34 ... ... ... 12 2 113 301,895 7 ... Battersea ... 50 16 5 ... ... ... 20 ... ... 91 169,907 Wandsworth ... 69 6 ... ... ... 14 1 142 232,034 52 ... Camberwell 1 67 7 ... ... ... 11 ... ... 114 259,339 28 Deptford ... 40 34 3 ... ... ... 10 1 ... 88 110,398 Greenwich ... 14 11 3 ... ... ... ... ... 32 95,770 4 Lewisham ... 40 22 ... ... ... 8 ... ... 71 127,495 1 Woolwich ... 12 12 3 ... ... ... 3 ... ... 30 117,178 Port of London 1 ... 1 4 ... ... ... ... ... ... 6 Grand Totals 10 990 641 107 3 1 14 311 16 ... 2,093 ; I Statement by the Medical Officer of Health of the principal items of the Work of the Sanitary Inspectors during the four weeks ended 28th March, 1903. DESCRIPTION OF WORK. Sanitary District. No. 1. No. 4. No. 7. No. 9. No. 10. Total. No. 3. No. 6. No. 8. No. 5. No. 2. Inspection of Houses. 183 126 Number inspected from January 5th to February 28th 305 171 172 108 105 142 171 122 1605 Number inspected during the four weeks 82 92 78 118 111 19 20 73 78 57 728 Inspected on Complaint 31 17 14 40 31 19 20 16 51 28 267 House-to-House Inspections 51 75 64 78 80 ... ... 57 27 29 461 60 57 64 ... ... 2 3 44 65 14 309 Registered Houses inspected January 5th to February 28th „ „ inspected during the four weeks 6 24 42 1 22 4 ... 19 27 ... 145 Registered Houses (rooms furnished) inspected from Jan. 5th to Feb. 28th 5 59 ... ... ... ... ... ... ... ... 64 „ „ „ „ inspected during the four weeks 4 ... 36 ... ... 2 ... ... ... 42 ... Re-inspections of Houses. .. ... ... ... : ... ... 467 399 401 309 379 252 250 322 336 211 3326 Number re-inspected from January 5th to February 28th Number re-inspected during the four weeks 223 267 267 121 131 63 86 169 219 103 1649 Inspections of Dairies, Milkshops, etc. (No. in Borough, 275) 23 1 10 15 16 1 6 22 2 96 ... Inspections of Bakehouses. (No. in Borough, 114) ... 2 9 ... ... ... ... ... ... 1 12 Inspections of Mews. (No. in Borough. 177) 30 26 26 39 55 28 66 49 34 377 24 10 Cases of Infectious Disease visited 7 7 5 8 3 2 6 3 5 56 „ „ re-visited ... 1 1 2 1 1 3 2 ... 11 ... „ „ removed 5 10 2 5 8 3 2 4 1 4 44 5 11 4 3 10 5 2 7 3 4 54 Houses disinfected Sanitary Notices issued 79 63 83 22 40 17 2 13 13 14 346 In respect of Registered Houses 3 15 42 ... 4 1 ... 8 4 80 3 „ other Premises 76 48 41 22 36 16 2 5 9 11 266 Summonses issued ... ... ... ... ... ... ... ... ... ... ... Sanitary Works completed (Including cases, 14 in number, in which the drainage portion of the work ordered was supervised by the Borough Engineer.) 143 116 52 18 38 71 21 104 8 19 590 TABLE 54 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 28th March, 1903. Description of Work. North Kensington. South Kensington. r Dressmakers. Laundries. Total. Dressmakers. Laundries. Miscellaneous. Total. Total whole Borough. Miscellaneous. 1 Total number of Houses visited 4 86 52 142 58 2 18 78 220 2 Workshops and Workplaces—Newly discovered and registered ... ... 2 5 ... 2 7 9 2 3 „ Workrooms therein measured ... ... 2 11 ... 1 12 14 2 4 „ Number of Inspections of 4 60 27 91 39 1 7 47 138 5 „ Number of Re-inspections of ... 26 19 1 ... 20 46 26 ... 6 Workrooms—Number of Inspections of 4 262 27 293 71 3 7 81 374 7 „ Found to be overcrowded ... ... ... ... ... ... ... ... ... 8 „ Found to be insufficiently ventilated ... 2 ... ... 2 2 ... ... ... 9 „ Found to be in a dirty condition 1 10 11 ... ... 2 13 2 ... 10 „ Cards distributed shewing number of persons permitted in each room ... ... 1 12 ... 2 14 15 1 11 Houses visited for Inquiry, at which no female hands were employed* ... 1 ... 1 2 10 8 8 ... 12 Statutory notices and writ tin intimations issued ... 18 4 ... ... 4 22 18 ... 13 Nuisances reported to the Medical Officer of Health and entered in Complaint Book ... ... ... ... ... ... ... ... ... * 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. 55 MEASLES; A "DANGEROUS INFECTIOUS DISEASE." In 1898 the Public Health Committee of the County Council having received from the School Board for London a communication urging the desirability of including measles in the term " dangerous infectious disease," expressed a desire " before coming to any decision in the matter" to "learn the views of the London Sanitary Authorities," and to be informed if they " would be in favour of the extension to measles of the provisions contained in the Public Health (London) Act, 1891, relating to notification, etc., of infectious disease." The replies of the Vestries, etc., having shown a " considerable divergence of opinion," the matter fell through, but in a further communication, in 1900, the same Committee thought it desirable to consult the Councils of the Metropolitan Boroughs " with a view to ascertain whether they were in favour of the extension to measles of the provisions contained in any or all of certain sections of the Act, it being expressly observed that " these sections do not relate to the question of notification." It is to be presumed that the general trend of the replies was favourable to the proposal, as the County Council have made an Order (which, having been approved by the Local Government Board, came into force on the Ist April), that the sections of the Act, cited below, with respect to dangerous infectious diseases, shall apply in the Administrative County to measles. The Order has been advertised and a copy sent to each medical man residing or practising in London, in accordance with the requirements of section 56. The following sections are now applicable to measles in common with other dangerous infectious diseases : — Section 62 relates to infections rubbish cast into ashpits without previous disinfection. Section 63 relates to the letting of a bouse or paw of a house in which infected persons have been residing, without having the house or room and infected articles therein disinfected. Section 64 relates to the letting for hire or showing for that purpose any house or part of a house, and the making of false statements as to the fact of there being, or within six weeks previously having been, therein, any person suffering from any dangerous infectious disease. Section 65 relates to a person ceasing to occupy a house in which any person has within six weeks previously been suffering from any 56 dangerous infectious disease, without disinfection, or notice to the owner, or making a false answer to questioning on the subject. Section 68 relates to the exposure of infected persons and things in any street, public place, shop, or inn. Section 69 prohibits an infected person carrying on business. Section 70 prohibits conveyance of an infected person in a public conveyance. Section 72 prohibits retention of an infected dead body in a room used as a dwelling place, sleeping place, or workroom, in certain cases. Section 73 prohibits the body of a person dying of infectious disease in hospital, &c., being removed therefrom excepting to a mortuary or for burial. Section 74 requires disinfection of any public conveyance after being used for carrying an infected corpse. For each of the offences dealt with in the foregoing sections a penalty is prescribed. The sections have been in force since the beginning of 1592, in reaped to notifiable diseases, named in section 55 (8), but the offences specified appear to have been rare- rarely heard of certainly, and probably it will not be otherwise now that measles is added to the list. But the main significance of the Order is in connexion with sections 60 and 61, which provide for the cleansing and disinfecting of infected premises and articles therein, a course which will certainly involve, at times, but for limited periods only, considerable labour and no little expense to the sanitary authority. Measles becomes epidemic about every second or third year, continues with variable severity for a time, and then dies down. In some years the deaths are relatively few. Thus, in Kensington, they were but 29, 18, 33, 33 and 24 in the years 1891, 1893, 1895, 1897 and 1899 respectively; in other years the deaths are numerous—e.g., 109, 108, 173, 120 and 98 in the years 1892, 1894, 1896, 1898, and 1900. The average number in the ten years 1892-1901 was 79 ; those from scarlet fever, diphtheria, and enteric fever were 26, 57, and 17 respectively. The deaths from scarlet fever exceeded 30 on three occasions only in the ten years—the maximum number was 59; the maximum from diphtheria was 89, 23 being the highest number recorded from enteric fever. There is no very wide variation in the annual number of deaths from notifiable diseases, or in the prevalence of them (as shown by notifications), and no difficulty has been, at any time, experienced in regard to disinfection. With measles it will be otherwise, for in consecutive periods of a few weeks the cases may range from practically 57 zero to thousands. I take 1896, the year of maximum fatality during the past decennium, for an illustration. During the first four-weekly period there were only three deaths. In the second, the number rose to 17; in the following five periods there were 20, 32, 45, 24, and 19 respectively: total, 157 in 24 weeks. During the remainder of the year only thirteen deaths were registered, including seven in the eighth four-weekly period. The case-mortality of measles may he taken at, say, 4 per cent.* On this basis there were some 3,925 cases of the disease in 24 weeks, and 400 in 28 weeks. The greatest number of deaths was in the fifth four-weekly period —45, corresponding to some 1,125 eases. It must be obvious that disinfection —if it could be carried out universally, would, with so many eases in so short a period, involve a heavy strain; probably, however, by far the greater proportion of the cases would remain unknown. Heads of families too often make light of measles and rarely seek the help of the sanitary authority. What will happen consequent to the steps taken by the County Council in making known the provisions of the Order remains to be seen. With a view to arrive at an approximate estimate of cases, I have studied the subject in the light of the mortal statistics for 1902. The deaths were 93 (11 above the corrected decennial average): 86 in the first half-year, 7 in the second. They occurred ill 92 houses. Seventy-seven of the deaths belonged to North Kensington ; in St. Charles Ward, 26; Golborne, 13; Norland, 25; Pembridge, 13 ; and 16 to South Kensington; in Holland Ward, 6 ; Earl's Court, 1; Queen's Gate, I; Redcliffe, 5; Brompton, 3. The deaths were spread over 61 streets; there was one in each of 40 streets ; there were two each in 13 streets, viz. : —Albion-place, Bomore-road, Blenheim-crescent, Clarendon-road, Finborough-road, Fowell-street, St. George's-road, Kenley-street, Lancaster-road, Latimer-road, Portland-road, Testerton-street, and Western-terrace; three each in two streets- Appleford-road and Peel-street (two of these in Campden-houses) ; four in each of tour streets, viz., Hurstway-street, Southam-street, Snarsgate-street and Treverton-street; five in one street, Walmer-road. In nine cases only was measles alone the certified cause of death : the fatal end was usually brought about by some intercurrent disease —of the respiratory system in 66 cases; the nervous system in 5; both systems in 11 ; diarrhoea in 1. * As will be shown later, the case-mortality at Edinburgh in ten years 1880-81» (30,000 cases) was only 3.1 per cent. 58 Eighty-nine of the deaths were of children under five years of age, including 21 under one year; the remaining four were of children aged five, six (two deaths), and eight years. Assuming the case-mortality to be 4 per cent, the cases would have been 2,325; 2,150 in the first half, 175 in the second. Of the notifiable diseases after which disinfection has been carried out hitherto there were 734 cases only: 403 in the first half-year, 331 in the second. Presumably all cases of small-pox, scarlet-fever, diphtheria, enteric fever, etc., were notified ; but of measles-cases no information was forthcoming in respect to the great majority. The deaths occurred, as already stated, in 92 houses, and I heard of 182 other houses in which the disease was alleged to have occurred. For the bulk of information in respect to these I was indebted to the head teachers of Board Schools acting under official instructions. The cases in children attending school were 173 : 63 other children were excluded on account of disease in the family or the house, children not being permitted to attend school from an infected house. Assuming the accuracy of the figures,* we should have had to disinfect 274 houses (267 in four months. January to April, and 7 in the remaining 8 months), whilst, on an average of three eases to a bouse, about 500 houses would have gone without disinfection. It may be anticipated that the publicity given to the Order will lead to disclosure of a larger proportion of the infected houses. At the present time the disease is in abeyance in the Borough. Measles is infectious from the onset of illness. It takes two or three weeks to incubate, and so the first case in the family may recover before a second child falls ill. Should disinfection be done on recovery of the first case in hope of preventing a second? the probability being that a second child (and others if there be more than one susceptible) will be incubating the disease at the date of disinfection. It is always probable that the disease will spread to all the families in a tenemented house; parents as a rule not being in dread of measles; indeed they commonly prefer that their children should have the malady all together, and so get the trouble over. The same feeling, or a sense of the inevitability of measles, often causes parents in the house generally, to be indifferent to the risk of infection, especially if the first case should be of a benign description. Not seldom, moreover, the disease will spread in a tenemented house whatever care be taken by the heads of families. * It is noteworthy that on April 1st, the day the Order came into force, two cases in one house were reported by a head teacher : the children were found to be suffering from chicken-pox. 59 Theoretically the proper course would be to disinfect after a first case —though it will generally be ineffectual to prevent spread—and after the last, when, the fire having gone out for want of fuel, it matters not whether disinfection be done or not. A question will soon arise as to the extent to which disinfection should be carried out ? whether of infected rooms and contents only, or also by removal of infected articles to the disinfecting station ? and as to when it should be done ? The subject, it will be seen, is not free from difficulties! The subjoined table shows the number of houses in which disinfection would have been required, had the Order been in force in 1902, upon the basis of the known number of infected houses. Number of Houses in which Disinfection would have been required in 1902. Population. No. of Houses requiring Disinfection. Total Houses. Locality. Once. Twice. Thrice. 177,500 13 2 274* The Borough 259 Sub-districts :— 128,660 225 13 2 240 Kensington Town Brompton 48,840 34 - 34 - Parliamentary Divisions: — North Kensington 91.510 168 12 2 182 South Kensington 91 1 92 85,990 - Wards :— St. Charles 22,060 2 56 47 7 Golborne 26,440 43 1 44 - Norland 23,580 29 1 - 30 Pembridge 19,430 39 3 - 42 Holland 20,500 49 - 50 1 Earl's Court 18,140 20 - 20 - Queen's Gate 14,340 8 - - 8 Redcliffe 18,790 11 - - 11 Brompton 14,220 13 - - 13 * Cases having occurred, at long intervals, twice in 13 houses and thrice in two houses, the actual number of disinfections of houses would have been 291. The Question of Notification. 60 The Question of Notification of Measles. —The County Council's Order has, by many medical men, been taken to imply that measles is now notifiable—which it is not. The responsibility thrown upon the Council, great as that may be, will be much less than it would have been had the Order made the disease compulsorily notifiable. Suggestions to add measles to the notifiable list have been made. A proposal to this effect was made in 1891 by the late Vestry of St. Margaret and St. John Westminster, but the Local Government Hoard declined to make an exception with respect to a single district. The said Vestry having sought the aid of the other Sanitary Authorities, I looked into the question, and in the Annual Report for 1891 (pp. 97-106) stated the conclusions at which I had arrived largely based on the experience of Edinburgh in the years 1880-89, as set out in a pamphlet by Dr. Harvey Littlejohn.* When I wrote the report there was no evidence that notification had lessened the prevalence of the disease, or (isolation being rarely available) reduced the mortality. I was and am of opinion that without extensive hospital accommodation there is little practical utility in notification. But, as I said in 1891, isolation would be of "the highest value to individual sufferers by removing them from homes too often wholly unfit for the treatment of a disease apt, under insanitary conditions, to assume an unfavourable type, and to kill by complications which might be averted could the sufferers be placed where they would obtain pure air and suitable diet, with medical attendance and nursing." At Edinburgh 30,000 cases were notified in the ten years 1880-1889 (at a cost in fees of £3,500), the maximum number of notifications (5,833) having been recorded in 1886: 5,220 of them in 21 weeks. The average annual rate of mortality was 3.1 per cent., ranging from 5.9 in 1880, when 3,216 cased were notified, to 1.5 in 1881, on 634 cases. Comparison of the dumber of notifications in two periods of six years —1880-1892—showed no reduction in the second. In the four years, 1886-89, the admissions to hospital were at the rate of 5.5 per cent, on the 15,102 notifications. The proportionate mortality in hospital cases was 4.70 in 1890 and 1.34 in 1891 ; and in home-treated cases 5.06 and 3.22 in the two years respectively. * "Ten years of Notification of Measles in Edinburgh." †In 1888 the late Vestry of Battersea addressed a request to the Asylums Board that, as measles is "a dangerous infectious disease of a febrile character," they should take such steps as they should consider advisable with a view to arrangements being made for the reception of sufferers therefrom into their hospitals. The Board replied that they had no legal power to admit cases of Measles. 61 With respect to the use made of notification, it appeared that an inspector called and got the names of the sick children, and the schools attended by them, saw what means of isolation (if any) existed, warned the parents about keeping the children at home, told them what precautions to use, and to send to him when the house was ready for disinfection, if disinfection were desired. Endeavours were made to get a first case in a street, in a crowded quarter of the town, into hospital: but the procedure of removing first cases could not be systematically carried out. owing chiefly to want of accommodation; no compulsion was attempted. It was felt strongly that it was only by dealing firmly with first cases, removing them, keeping the other children from school and disinfecting thoroughly, that there was any chance of preventing the biennial epidemics to which the city had been subject. As to disinfection, it was only in those cases where the bedding had been removed that fumigation of the room was done: it was therefore not done generally, as after scarlet fever, etc.. but always where specially desired. The conclusions arrived at by Dr. Harvey Littlejohn (in 1891, for I have mi later information)* were that "no practical benefit had (then) resulted from notification so far as the mitigation of the disease was concerned," and that "in a Large town with a susceptible population, and hospital accommodation necessarily limited when compared with the requirements of an outbreak of measles, notification as a means of checking the disease is practically useless." It is well to emphasize this point, for not improbably the recent Order may suggest the issue of one making measles notifiable, to which I should not object were a reasonable amount of hospital accommodation provided for suitable cases; for as I wrote in the report for 1891 (p. 104) :— "Whatever opinion may be formed as to the policy of making measles a notifiable disease, there can be no doubt that it would be wise to make provision to secure the removal of the sufferers to hospital, compulsorily if necessary, when the home surroundings are of such a nature as to militate against recovery, seeing there can be no doubt that with insanitary conditions—want of space, of pure air, of proper food and nursing—the disease assumes a virulent (suppressed) type leading to the pulmonary and other complications which are so commonly the immediate causes of death." Death from measles is very rare in the families of the well-todo : in this borough there were no such deaths in 1902. The fatal cases were with very few exceptions in the families of the labouring * Since this report was written I have read in the British Medical Journal that measles is not now notified in Edinburgh. 62 and poorer classes, and the rate of mortality may be said to be generally in proportion as the sanitary and home surroundings are defective and unwholesome. The Council will, I am sure, desire to make the best of the new Order, and to do what can be done to mitigate the fatality of this "dangerous infectious disease": to this end I beg to suggest reference of the report and the subject generally to the Public Health Committee for consideration.