No. XI., 1903. The Royal Borough of Kensington. REPORT OF THE MEDICAL OFFICER OF HEALTH For the four weeks, October 11th to November 7th, 1903; being the 41st, 42nd,4Srd, and 44th Weeks of the Registration Year, 1903. To the Mayor, Aldermen and Councillors of the Borough Council, Sir, and Gentlemen 1. I have to report that 270 births (males 152, females 118), and 184 deaths (males 84, Females 100), were registered in the four weeks ended November 7th. Alter making due allowance for increase of population, the births were 10, and the deaths 6 below the numbers registered in the corresponding weeks in the previous ten years. The births were equivalent in an annual rate of 19.7 per 1,000 persons living, or 1.7 per 1,000 below the decennial average (20.4). The deaths were equivalent to an annual rate of 13.4 per 1,000, or 1.5 per 1,000 below the decennial average (14.9). The rate in the successive weeks was 11.7, 12.6, 12.3, and 17.5. The death-rate in the Metropolis was 15.6 per 1,000; 2.2 above the rate in Kensington, and 1.8 below the decennial average ( 17.4). Fifty-two of the deaths of Kensington parishioners were of children under 5 years of age, including 38 under one year. Fifty-three persons died at 60 and upwards. Thirty-two deaths were caused by the diseases of the respiratory organs, including bronchitis 13, and pneumonia 12. The deaths from phthisis were 18, from diseases of the heart 18, and S50—0 1210—500—11-03 from tubercular or scrofulous diseases of children under 5 rears of age, 5. 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:- Locality. Population. Births in the four weeks Birth Rate. Deaths in the four weeks Death Rate 178,000 270 19.7 The Borough 184 13.4 Sub-districts:— Kensington Town 129,020 224 22.6 153 15.4 Brompton 48,980 46 12.2 31 8.2 Parliamentary Divisions: — North Kensington 91,770 198 28.0 119 16.9 South Kensington 86,230 72 10.9 65 9.8 Wards:- St. Charles 22,120 58 34.1 31 18.2 59 26,520 28.9 27 13.2 Golborne 23,650 45 Norland 24.7 39 21.4 19,480 36 Pembridge 24.0 22 14.7 Holland 21 20,560 19 12.0 13.3 8.6 Earl's Court 18,190 17 12.1 12 Queen's Gate 14,380 4 3.6 9 8.1 13.8 13 9.0 Redcliffe 18,840 20 14,260 12 10.9 10 Brompton 9.1 2. —Zymotic Diseases. -The deaths from the principal diseases of the zymotic class were 14, and 10 below the corrected decennial average number. In the Metropolis, as a whole, the deaths from these diseases were 575, and 129 below the corrected average. Measles.- There was no death from measles,as compared with 5, 2, and 2, in the three preceding four-weekly periods respectively, In the Metropolis, as a whole, the deaths from this cause were 68. and 39 below the corrected average. This disease appears to be becoming prevalent in the borough, but to be at present, of a mild type. Whooping-Cough. - There was one death from whooping. cough, as compared with 2, 0, and 1, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 40, and 30 below the corrected average, Diarrhœa. — The deaths from diarrhœa were 8 (all of infante under one year of age), as compared with 13, 35, and 22, in the three preceding four-weekly periods respectively. In the Metropolis, as a whole, the deaths from this cause were 319, and 154 above the corrected average. Of, these deaths, 294 wire of children under five years of age, including 235 under one year. The mortality from this disease continues to be unduly high having regard to the period of the year. Fever. — Six cases of enteric fever were recorded (4 in North Kensington, and 2 in South Kensington), of which 4 (3 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 0, 1, and 1, in the three preceding fourweekly periods. In the Metropolis, as a whole, the deaths from this cause were 56, and 25 below the corrected average. There were 279 eases in the Asylums Board Hospitals On the 7th inst., as compared with 148, 190 and 278, on August 15th, September 12th, and October 10th ; and 154 cases were admitted in the four weeks, as compared with 87, 122, and 196, in the three preceding Four-weekly periods. The notifications of case were 294, as compared with 159, 236, and 348, in the three preceding four-weekly periods. Scarlet Fever.- Twenty four cases of scarlet fever were recorded (16 in North Kensington and 8 in South Kensington), of which 18 (14 from North Kensington and 4 from South Kensington) were removed to hospital. There were three deaths from this cause (two of them in hospital), two of South Kensington persons and one of a North Kensington person, 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 33 (and 35 below the corrected average), as compared with 31, 29, and 23, in the three preceding four-weekly periods. There were 1854 cases in the Asylums Board and London Fever Hospitals on the 7th iust., as compared with 1,758, 1,772, and 1,881, on August 15th, September 12th, and October 10th; and 840 cases were admitted to the Asylums Board Hospitals in the four weeks, as compared with 897, 865, and 1,029, in the three preceding Fourweekly periods. The notifications of cases were 969,as compared with 1,022, 936, and 1,133, in the three preceding four-weekly periods. Diphtheria. — Seven cases of diphtheria were recorded (5 in North Kensington and 2 in South Kensington), all of which were removed to hospital. There was one death from this cause (in hospital) of a North Kensington person, as compared with 2, 4, and 1, in the three preceding four-weekly periods. In the Metropolis, as a whole, the deaths from this cause were 59 (and 150 below the corrected average), as compared with 45, 48, and 47, in the three preceding four-weekly periods. There were 782 cases in the Asylums Board Hospitals on the 7th instant, as compared with 810,665, and 700, on August 15th, September 12th, and October lOth; and 484 cases were admitted in the four weeks, as compared with 457, 387, and 481, in the three preceding four-weekly periods. The notifications of cases were 596, as compared with 550, 462, and 588, in the three preceding four-weekly periods. Small-pox.- Forty-five cases of small-pox were notified in London (1, 24, 14, and 6, in the successive weeks), as compared with 14, 11, 10,39,56,55, 50, 34, 40, and 14 in the ten preceding four-weekly periods. The contributory boroughs are shown in the table at page 183. No death was registered during the four weeks. The total deaths from this cause during the 44 weeks of the current year to November 7th, were 10, the notifications of cases, 368. On the 7th instant there were 43 cases in hospital, compared with 17 on October 10th. 3.—Deaths in Public Institutions.- Thirty-eight deaths of parishioners were registered at the Borough Infirmary, and 26 at out-lying public institutions, etc. 4.—Deaths of Non-Parishioners. — There were 56 deaths in the Borough of persons who were not parishioners; viz., 3 at the Brompton Consumption Hospital, 45 at the St. Marylebone Infirmary, Notting Hill; 7 at St. Luke's House, Pembridge-square, and one at the Jubilee Hospital. These eases are excluded from our statistics. 5. — Notifications of Infectious Disease in the Metropolis. — I append (page 183) 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 Hoard, as the Act directs), 2328 in number; including small-pox, 45, scarlet fever, 969, diphtheria and membranous croup, 611, and enteric fever, 290. The cases notified in the three preceding Four-weekly periods were 2124, 2014, and 2465, respectively. The Kensington notifications, 57 in number, were Localised as follows:- Scarlet Fever. Diphtheria. Enteric Fever. puerperal Fever Erysipelas. Total. Sub-Districts. Kensington Town 18 7 4 2 15 46 Brompton 6 - 2 - 3 11 Parliamentary Divisions. North Kensington 5 11 38 16 4 2 8 2 2 - 7 19 South Kensington Wards. St. Charles 4 1 - 1 - 3 9 Golborne 7 2 1 2 12 Norland - 2 2 1 4 9 Pembridge 5 - 1 - 2 8 Holland 1 - 2 2 5 Earl's Court 2 - 1 - - - - - 3 Queen's Gate - 1 2 3 Redcliffe 2 2 4 Brompton 2 - - - - 1 - 1 4 6. Inquests.— The cause of death in 13 cases, including 6 from violence, was returned by coroners. The cause of death in 4 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 November 7th, are appended to this report (vide pages 184 and 185). SANATORIA FOR PERSONS SUFFERING FROM CONSUMPTION. In October, 1900, at a Conference of Metropolitan Poor Law Authorities held to consider the question of "Open-air treatment of Phthisis," at which 26 out of the 32 Boards of Guardians were represented by 77 delegates, it was unanimously resolved — "That the time had come when provision should be made for the treatment by this method of the sick poor of the metropolis," and it was decided to " bring the matter to the consideration of the Local Government Board with the view to the necessary steps being taken by that Board for the carrying out of the proposal." A deputation was appointed to wait npon the President to present the resolution, it being understood that the Asylums Board would be designated as the proper body to act as Hospital Authority. A communication was sent to the Board in due course, but beyond stating that the matter would receive attention, together with applications of a similar nature which had been received from other public bodies, the Board took no action. In the early part of 1902 many Public Health and Poor Law Authorities, in communications to the Asylums Board, signified their desire that the Board should provide accommodation for the isolation and treatment of persons suffering from consumption. The several communications were referred to the General Purposes Committee in July, and on 29th November the Committee presented a report on the subject, as follows: — "We have given due consideration to the whole question, but having regard to the important issues involved, and to the fact that there is not yet a general consensus of opinion amongst the Metropolitan Authorities in favour of the Metropolitan Asylums Board undertaking the treatment of consumptive patients, we have deferred consideration of the matter for twelve months." The report was adopted. The action of the Borough Council. — This question had been dealt with in my eleventh report (November 6th), wherein a recommendation was made that some of the disused small-pox hospitals should be utilised as Sanatoria for Consumption. The epidemic was at an end, and for much of the hospital accommodation, so lavishly provided for sufferers from small-pox, there was no longer any need. The Council referred my report to the Public Health Committee, and on December 4th it was sent, with letters commendatory, to the Local Government Board and the Metropolitan Asylums Board. The report was sent also to the Public Health and Poor Law Authorities, many of which endorsed the Council's views in communications addressed to the Local Government Board and the Managers. The National Association for the Prevention of Consumption did likewise.* The Hospital Saturday Fund † are understood to be favourable to the principle of utilising the empty small-pox hospitals as proposed; a principle which, moreover, has been commended, on more than one ccasion, by the Secretary of the Hospital Sunday Fund, than whom, probably, there is no one more competent to speak with authority on the subject. But nothing came of the effort; and the Asylums Board, on three subsequent occasions, declined to re-open the matter, having rejected motions by Managers desirous of promoting an earlier enquiry. During the present month the matter will come up again, automatically, for consideration by the General Purposes Committee, which comprises the entire body of Managers, whose decision will be awaited with keen interest. Action of the Society of Medical Officers of Health. - The subject of Prevention of Tuberculosis has for some time been engaging the attention of the Incorporated Society of Medical Officers of Health, the several Branches of which were invited, recently, to express their views on certain points connected therewith, and especially on the question "Whether it is desirable to utilise existing Isolation Hospital accommodation, where practicable, for the isolation of phthisis ?" This particular question was fully considered by the Metropolitan Branch of the Society on the 23rd ult., and a resolution thereon was adopted as follows: — "The Metropolitan Branch of the Incorporated Society of Medical Officers of Health, noting the intention of the Metropolitan Asylums Board to give almost immediate consideration to the question whether they should undertake the treatment of persons suffering from consumption, desire to express their opinion that, by reason of * The letters addressed by the Council to the Local Government Board, the Asylums Board, and the National Association are printed in my annual report for 1902 (pages 51-53), as also the letter which the Association addressed to the two Boards. † It may be mentioned that this Fund decided, in May last, to make an independent effort to increase the accommodation for persons suffering from tuberculosis, in London and its vicinity, and a committee of representatives of organizations of workers, &c., has been Formed with a view of considering the advisability of providing Sanatoria within easy reach of the Metropolis, for the reception of tuberculosis patients on terms that would be within the means of the working classes.- (The Times Report.) practical experience in regard to provision of hospitals, and the treatment of the infectious sick, the Board are eminently qualified for the discharge of this duty, the effective performance of which, by any competent authority, could not fail to be attended with great advantages in the interests of public health." The Branch, moreover, having considered my proposal to utilise Gore Farm Hospitals for this purpose, adopted a further resolution, as follows:— "That the above resolution be transmitted to the Board with an expression of the hope of the Branch that —should the Managers decide to undertake the treatment of consumptive patients-they may be pleased to take into consideration the question, whether the Gore Farm Hospitals, which have ceased to be reckoned as small-pox hospitals, would be suitable for the purpose, seeing that the said hospitals could be brought into use at an early date, and that the utilisation of them would save an otherwise necessarily large expenditure by the provision of hospitals specially erected for the purpose." Both resolutions having been unanimously adopted, I though! it well to communicate them to the Medical Officers of Health who were unable to be present at the meeting, all of whom have signified agreement therewith, excepting two: in one case, inability to do so was frankly based on an acknowledgment of incompetency to form opinion, the officer not having considered the matter, nor had an opportunity of examining the question. A communication embodying the, resolutions, addressed to the Asylums Board by the Hon. Secretary of the Branch, has been referred to the General Purposes Committee, at whose meeting, on November 23rd, consideration the reference of July, 1902, will be resumed. The King's Sanatorium.- Public interest in the general question has been Stimulated during the present month in connexion with the laying of the foundation stone, by the King, of a Sanatorium which his Majesty has been graciously pleased to honour by calling it after his own name. This noble institution, it may he hoped, will Serve as a monument of the King's concern lor the welfare of his people, until tuberculosis shall have ceased to he the greatest of all the scourges of the human race. The Sanatorium is intended for the reception of 112 sufferers from phthisis, all but twelve "belonging to a class above the very poorteachers, governesses, and members of other ill-paid professions, clerks, shop-assistants, and the like, for whom no provision in sickness of this kind exists "- at present. The site, 151 acres in extent, on the southern slope of Easebourne Hill, in the Haslemere district of the county of Surrey, in the midst of beautiful scenery, would seem to lack nothing necessary to the realisation of the purpose for which it has been selected —whether regard be had to altitude (500 feet), shelter, soil, vegetation, etc. The sick wards will run east to west, and be comprised on two The proposal to provide for a limited number of patients of the wealthier classes, was a happy inspiration; for admission to such an institution is pretty sure to be an object of desire to well-to-do sufferers, whose ample contributions will constitute a welcome addition to the interest of the endowment fund which, together with the cost of the site and buildings, is the gift of one man, to whom the continual remembrance of the benefits to suffering humanity procured by his princely generosity should "make music in his soul at midnight." The Gore Farm Hospitals cannot compete with the King's Sanatorium in respect to beauty, or suitability of construction, but with some necessary modifications and additions, of no very costly sort —already £320,000 has been expended on site, buildings, etc. — they would provide all that is necessary for the purpose. The site, larger even than that at Haslemere, open and beautiful in itself, is not Less charming in its surroundings. The two hospitals, Upper and Lower, are distinct, each being perfectly equipped in all respect and ready for immediate use; the one, moreover, being almost invisible from the other. The Upper hospital, constructed mainly on two floors, and of brickwork, under the supervision of the late Sir Douglas Galton, and the present Chairman of the Board, is perhaps the more important of the two. and may be thought the most suitable for patients of the classes for whose service the King's Sanatorium is designed. The Lower hospital,comprised of single-floor wards, would serve well for the chargeable poor, to whom it would afford a welcome change from the wards of London infirmaries, or the more dreary surroundings of the Workhouse. All the wards of both hospitals are well lighted and well ventilated. The Upper hospital furnished accommodation for over 1,000 small-pox patients, allowing to each but little less cubic space of air than will be given to the patients in the King's Sanatorium. The same may be said of the Lower hospital which, designed for the reception of some 850 small-pox patients, has not received one, and, it is to be hoped, never will. The floor space in both hospitals is ample. The general lie of the wards of the Upper hospital is north and south, that of the Lower hospital north-east and south-west. The Upper hospital stands on a plateau —about 280 feet above ordnance datum, the elevation of the site of the Lower hospital being between 100 and 200 feet. In connection with both hospitals there is abundant space for open-air shelters, gardens, graded walks, etc. The grounds adjacent to both of the hospitals are well-wooded, with chestnuts, oaks, silver birches, etc.; and in the summer are carpeted with wild flowers and beautified by shrubs. Gore Farm is only two miles distant from Dartford; and therefore, not too far from the Metropolis—the Managers' Motor Ambulance could easily perform the double journey in one day—but far enough away to be out of the soot-area and London fogs, a matter of no little consideration in dealing with a disease whose most fatal incidence is upon the respiratory system. The locality is bracing, the air pure, the site dry, the chalk coming to within a little distance of the surface over most of the estate ; the water supply is good and assured, the drainage satisfactory. The hospitals are well sheltered from north and east winds; and it may be taken as reliable evidence of the healthiness of site and buildings that in the year 1900 of 3,220 convalescents treated in the Upper hospital not one died. The Need of Metropolitan Sanatoria. —At the Conference of Poor Law Authorities in 1900, Dr. Downes, Poor Lew Medical Inspector to the Local Government Board, informed the delegates that, in July of that year, there were 1,562 consumptive patients in Metropolitan institutions— lnfirmaries and Workhouses —of whom 1,000 could be moved to a sanatorium, or sanatoria, within 50 miles of London, and of the total number 400 were in the initial stage of the dis ease. How many non-chargeable sufferers there may be in the Metropolis for whom no adequate provision exists, or can be provided excepting by a central authority, such as the Asylums Board, it is not possible to say. But they are a great host as may be inferred from the fact that in 1902, the deaths from phthisis in registration London numbered 7,621, those from all the diseases now admissible to the Managers' hospitals being 3,643, including 1,314 from smallpox, a disease rarely epidemic, and which during the current year, to date, has been the cause of only ten deaths. The Alternative Use of Gore Farm. — The hospitals when not required for small-pox patients, have been utilised for fever and diphtheria convalescents. But that was at a time when the accommodation for sufferers from these diseases was less than at present. The Managers now have 5,250 beds at their disposal in the Town Hospitals, and the Northern Convalescent Hospital at Winchmore Hill; a number which will be increased to over 6,000 on the completion of the Southern Convalescent Hospital at Carshalton. That fine site of 300 acres, moreover, would, if necessary, allow of the provision of a much larger number of beds than the 800 now in course of being provided. It is, of course, possible that even this large total might not suffice for the needs of a great epidemic of scarlet-fever; it is rare, however, to have two zymotic diseases epidemically prevalent at the same time; and as Gore Farm, intended originally for convalescents from small-pox, has, in the abeyance of that disease, been used for convalescent fever patients, so, in case of emergency, the bulk of the beds at the Joyce Green small-pox hospitals, might be utilised for a like purpose, should Gore Farm become a Sanatorium. Are the Hospitals likely to be wanted for Small-pox. — I have been asked, What about small-pox, should there be a serious epidemic? This question, I think, need not trouble us, for at Joyce Green, and lands adjacent to the pier and landing stage at Long Reach, there are, or soon will be, upwards of 2,000 beds, in three hospitals—provided at a cost of half a million sterling— and abundant spaces for more, if needed, the estate comprising more than 300 acres. But never since 1871, my first year of office; have there been so many as 2,000 patients under treatment at any one time; and since 1886, when the plan of removing sufferers from small-pox out of London—initiated on my recommendation in 1881 —was perfected, the largest number of patients in hospital, at any one time, was 1,600, in 1902, the next highest total being 593 in 1893. The Nati onal Aspect of the Movement. — The work, by whatsoever body or bodies performed, is clearly one of National importance, and if evidence were wanting of the beneficial results likely to accrue from it, reference might be made to the experience of Prussia. In that country all workers are required to insure their lives; and the Insurance Companies have found it worth their while to establish Sanatoria for sufferers from consumption— to the extent of 7,000 beds. The average duration of stay in hospital of each patient is three months, some 30,000 cases being admitted in the year. The time spent in hospital is devoted not merely to treatment, but also to educative work, the sufferers being taught how to manage themselves and carry on their "cure" after leaving. It is stated, on authority, that 87.7 per cent, of the cases are cured, or improved in health: 67.3 per cent. of them so as to be fully restored to work; another 7.1 per cent, becoming fully capable of work, other than that of their previous occupation, and that 14.6 per cent. become capable of partially resuming work; whilst only 11.0 percent. leave the hospitals in a state so as not to be able to earn their living. These statistics were published in The Times, 21st October, in an article on "Industrial Conditions in Germany." The Legal Aspect of the Case. It having been asked, whether the Managers could give effect to my views under existing circumstances? I have no hesitation in saying that, as regards the chargeable poor, they possess the power —subject to the approval of the Local Government Board—under section 5 of the Metropolitan Poor Act, 1867, which authorises them to provide Asylums for "reception and relief of the sick, insane, or infirm, or other class or classes of the poor, chargeable in unions and parishes in the Metropolis." The Case as to Non-chargeable Persons. As respects the nonchargeable poor, presumably legislation would be necessary, as it was held to be (in 1889) to enable the Managers to undertake the treatment of persons suffering from diphtheria —an extension of their work which the late Vestry were largely instrumental in bringing about. A similar one-Clause Bill, I think, would meet with little, if any, opposition in Parliament, if introduced, as it presumably would be, by the President of the Local Government Board. The Medico-Legal Status of Consumption. In connexion with the question of legality, the Council may be reminded that the Local Government Board, in a communication to the National Association for the Prevention of Consumption,* made it clear that phthisis comes within the definition of an "infectious disease." and that provision may be made for persons suffering therefrom under the Isolation Hospitals Act, 1893; an Act "for enabling county councils" (other than the London County Council) "to promote the establishment of hospitals for the reception of Patients suffering from Infectious Diseases." The Board stated that the provisions of the Act "may be applied to any other infectious diseases" than those that are notifiable, in like manner "as if a county council were a local anthority under the Act relating to the notification of infectious disease." And that, "although pulmonary tuberculosis is not one of these diseases, the provisions of the Act may, under section 26, be applied to that disease," by an order of the County Council, which, however, "requires the approval" of the Board. It may be assumed, therefore, that the Board would be prepared to give their approval should the Managers desire authority for undertaking the care of persons suffering from Consumption. In this connexion it may be mentioned that the President of the Board is in hearty sympathy with efforts to provide Sanatoria, and that the Board have, on more than our occasion, sanctioned such provision being made for the chargeable poor. The duty in this regard, therefore, which the Managers are invited to assume, is thus seen to be cognate to the work they have, since 1870, performed, in respect to other infectious diseases, with so * The Board's letter was summarised in The Times, 23rd May last. much success, and with manifest advantage to the public health interests of London. The Act referred to does not apply to the Metropolis, for the simple reason that, long before it was passed, the powers which it confers on County Councils, other than the London County Council, had been exercised by the Metropolitan Asylums Board. The Question of Local Hospitals. — In passing, it may be mentioned that the Sanitary Authorities might, singly, or in any degree of combination, provide hospitals for the inhabitants of their several districts ( Public Health (London) Act. 1891, section 75); but no action has hitherto been taken to exercise this power. Some of the South Eastern Borough Councils did attempt to form a combination, but it fell through; and I fear that it would be found impracticable to make any arrangement of the sort which would prove permanent or ent irely satisfactory. The Need of a Central Authority.- The work is one that can be carried out, effectively, only by a Metropolitan Authority, as the Local Government Board plainly intimated to the promoters of the Conference of 1900, held at their suggestion. Were hospitals provided, by a single Sanitary Authority, or a combination of Authorities, it is more than likely that persons suffering from consumption would flock to the district in the hope of getting admitted: surely an undesirable effect of what could not be described, otherwise, than as a legal and justifiable course of proceeding, were it reasonably practicable. The desiderated "General Consensus of Opinion" Attained. — It has long been believed that the Asylums Board are willing to take up the work, and are only waiting for evidence of a "general consensus of opinion on the part of the Metropolitan Authorities" in favour of their so doing. In their annual report for 1902, after referring to the "diversity of opinion" amongst the Boards of Guardians, as to the desirability of the Board undertaking the treatment of the tubercular disease "Lupus," they went on to state that "there was a nearer approach to unanimity on the part of the Boards of Guardians, as well as on the part of the Sanitary Authorities of the Metropolis, on the suggestion that the Board should provide Sanatoria for Consumption." Is not the "consensus of opinion" now "general" enough ? Reference has already been made to the unanimity of the Conference of Guardians. May it not suffice, then, that Public Health Authorities such as those of the boroughs of St. Pancras, St. Marylebone, Lambeth. Poplar. Shoreditch, Battersea, Finsbury, Fulham, Stepney, Stoke Newington, Kensington; and Boards of Guardians such as those of Paddington, Chelsea, Hammersmith, Holborn, Poplar, Step- ney, Wandsworth, and Clapham, and Kensington, endorse the views of the Council, and desire the Board to undertake the duty proposed to them? Only two Borough Councils expressed dissent to the proposal, and one Board of Guardians. A considerable number of other Authorities—Poor Law and Public Health—decided to take no action, but cannot be deemed unfriendly to the movement, some of them having expressed approval of the principle; whilst other Sanitary and Poor Law Authorities, who did not honour the Council by replying to their letter, may be regarded as, at the least, not hostile to the proposal. And, lastly, it will be remembered that the Medical Officers of Health of the City and County of London, competent judges, surely, are all but unanimous in their desire that the Managers should become the Authority for providing the needed Sanatoria. It will be a great and notable day for London should the Asylums Board avail themselves of this superb opportunity of adding to the benefits they have already, in so many ways, conferred upon the inhabitants of London. PROPOSED EXTENSION OF THE AMBULANCE SERVICE. In the first report for the current year (page 5), it was stated that for non-infectious sick persons (other than the chargeable poor), and private lunacy cases needing to be removed, from home, or school, or place of business, to a hospital, nursing home, asylum, or any other place, and able to pay a moderate fee for such service, no adequate provision exists in the Metropolis. I further stated, that in my opinion, no other public authority was so well fitted to make the necessary provision for dealing with such cases, as the Metropolitan Asylums Board, who, at their several ambulance stations, have an abundant "plant" and staff available for the purpose. In the second report (page 33) it was stated that the subject had been considered at a meeting of the Board on the 7th March, in connexion with a notice of motion referring it to the General Purposes Committee to consider and report on the question of the "desirability and practicability, or otherwise, of extending the operations of the Managers' ambulance service so as to include the transport of medical and surgical and lunacy cases; and, if considered desirable and practicable, to suggest what steps should be taken to place the Board's ambulances at the service of the public and upon what terms." The motion was adopted. The General Purposes Committee (on 16th March) requested the Ambulance Committee to submit to them a report upon the whole question. The report of the Ambulance Committee, dated 2nd November, records the steps taken by them to ascertain the views of the 60 Metropolitan Public Health and Poor Law Authorities, and shows that 33 of these bodies will support an application by the Asylums Board to the Local Government Board for the necessary legal authority for the Asylums Board to use their ambulance carriages for the conveyance of non-infectious cases: only 16 of these bodies are averse to the proposal. The Committee, moreover, wrote to the secretaries of 33 London hospitals enquiring whether they considered it would be of advantage to the public if the Asylums Board were empowered to place ambulance carriages at the service of the public at moderate charges? With one exception the replies were emphatically in favour of the proposal. The Committee state that it is "generally recognised that a public ambulance service for the conveyance of non-infectious cases is very much wanted in London," and that in their opinion "the Asylums Board is in the best position of any public body to provide the service required." "Economy and efficiency," they say. "must result from all the ambulance arrangements of London being under the control of one central authority of great experience in such matters," —a view which surely will be generally accepted—and "the Board can carry out the work more economically than any other body because there is so much of its existing service which can be utilised for the purposes in view-such as its extensive telephone system, and its clerical staff"; it being possible, moreover, to reserve a certain number of ambulance carriages exclusively for non-infectious work." Already, during the current year, the Mead Station vehicles have conveyed over 1,000 non-infectious cases —infants and children — to the Managers' Asylums, and the work is still going on. It has been ascertained that, on an average of five years, the daily admissions to the asylums under the charge of the County Council, and those of the Managers, is twelve; and as the vehicles of the Mead Station are sufficient to effect at least 50 separate removals a day, the Committee believes that there would be "an ample margin for surgical eases and medical cases,* sufficient to meet all probable demands." "On the grounds of economy and efficiency," therefore, the Committee think that "it is advisable for the Asylums Board to undertake the proposed work," and that "it is practicable for them to do so immediately the necessary legal authority can be obtained." * The reference to the Committee did not include street accident cases The report was before the General Purposes Committee on the 9th inst., and in submitting it for the information of the Managers, they recommended them to adopt the following resolution in regard thereto, viz.:— "That, in the opinion of the Managers, it is desirable and practicable to extend the operations of the ambulance service so as to include the transport of medical cases, surgical cases (other than cases of street accidents), and persons of unsound mind; and that, upon the neecssary legal authority being obtained for the Managers by the Local Government Board, the work be Immediately undertaken, the cost of the proposed service being covered by a charge of 7s. 6d. for each single journey by a one-horse ambulance within the Metropolitan area." The report of the Committee came before the Managers at the meeting held on the 14th November, and after some discussion was referred back for farther consideration and report. It will be remembered that, as stated in my first report, this year (page 6), this question was raised in a report by the Medical Officer of the London County Council, to which was prefixed a prefatory note, by Sir William J. Collins, Chairman of the Ambulance Sub- Committee of the General Purposes Committee. We may be certain that the question, thus raised, has come to stay, and that if the Asylums Board do not deal with it. the County Council will-with, we cannot doubt, the energy manifested by them in all matters affecting the welfare of the citizens of London, and with their customary success. THE HOUSING OF THE WORKING CLASSES. With further reference to this subject, dealt with in the preceding report, we learn from the reply to a question put to the Chairman of the Housing of the Working Classes Committee of the London County Council, (November 10th), that the Council own 4.363 tenement, providing for 22.222 persons, the total rental, in 1902, being £81,000. It would be interesting to know what these dwellings and the sites have cost. The work accomplished- extending over many years —is no doubt excellent; but how Little it is! having regard to the fact that the population of the Metropolis increases by over 40,000 every year. At the same meeting the Committee reported the receipt of "official representations" from Medical Officers of Health declaring insanitary certain areas in the boroughs of Hampstead and Holborn, and recommended that in neither case should "improvement schemes" be made under Part 1 of the Housing Act. The areas proposed to be dealt with are small, and the report of the Committee justifies their decision. The Council, evidently, are careful, and well may be, in regard to proposals For "Improvement Schemes" under Part 1, having regard to the costliness of such schemes in the past, and the modest results at tained under t hem. Reference is made in the same report, to "Schemes for the clearance of (six) Insanitary Areas," involving the displacement of 4,714 persons, the estimated net cost of the clearances being £524,000, say £ 111 per head displaced, or £ 92 for each person proposed to be provided for on t he sites. It appears moreover that- From 1st April to November 4, 1903, housing has been provided for 3,399 persons, at an "estimated cost of works and plans," of £177,481, or upwards of £52 per head; that- Works in course of construction, to provide for 12,061 persons, are estimated to cost, For buildings and plans, £416,626, or £34 10s. per head; and that — Works are about to be commenced to provide for 38,131 persons, at an estimated cost, of buildings and plans, of £1,698,202, or £44 10s. per head. The principal work is on the White Hart Lane estate, 33,778 persons, at a cost of £1,486,818; and this, presumably, will be ultimately remunerative. Works, for which preliminary plans are in course of preparation, to provide for 12,904 persons, are estimated to cost £577,101, or £ 44 14s. per head. The principal work is the provision of cottages on Old Oak Common Lane estate for 9,200 persons, at a cost of £400,000; and this also, presumably, will be ultimately remunerative. PROSPECTIVE SANITARY LEGISLATION. The Public Health Committee of the London County Council, some time since, made certain proposals for legislation in the Session of 1904 which have been adopted by the Council, and are well deserving of consideration by the Metropolitan Sanitary Authorities. The first proposal relates to "the purification or destruction of articles of clothing (including bedding) which are in a filthy, dangerous or unwholesome condition." Sections 60 and 61 of the Public Health (London) Act. 189l, enable the Sanitary Authority to require the disinfection of premises and articles which have been exposed to infection by any dangerous infectious disease, and the Cleansing of Persons Act. 1897, empowers the same authority to allow the use, free of charge, of their disinfecting apparatus, for cleansing persons and articles infected with vermin; and also to provide buildings and appliances for the purpose of carrying out the Act. There is, however, no power to deal with articles of bed or body clothing which are in a filthy, dangerous, or unwholesome condition, and the Committee thought that it would be very desirable if Sanitary Authorities were enabled to require such articles to be cleansed or destroyed. They accordingly have advised the County Council to promote Legislation with this object, and suggested a clause for the purpose. With this proposal the Council will be in Sympathy, as during several years the Sanitary Authority of the Borough have been making efforts to obtain the sanction of the Local Government Board to a by-law, applicable to the case of furnished rooms in registered houses, for this purpose. The second proposal relates to "the cleansing of rooms infested with vermin." The Committee say that in the administration of the Common Lodging Houses Acts they have been successful to a extent in freeing common lodging-houses in London from vermin, and most people, probably, will think with them that it is desirable that some attempt should be made to compel owners of premises which are infested with vermin to take steps to cleanse them. The proposed legislation is designed to enable Sanitary Authorities to require the owners of premises to strip the walls and cleanse any room or rooms infested with vermin. It would be an advantage, doubtless, to have direct legislative power for this purpose, which, however, is largely achieved in this Borough by the service of notices, commonly under the by-laws for registered houses, to cleanse vermin-infested rooms. The third proposal relates to "urinals opening on to streets and so placed as to be a nuisance or offensive to public decency." Sanitary authorities possess power, under the Public Health (London) Act, 1891, sec. 2(1) (b), to deal, as nuisances, with urinals which are so foul, Or in such a state as to be a nuisance or injurious or dangerous to health; and Section 45 (2) prohibits the erection of sanitary conveniences (which term includes urinals), in or accessible from any street, without t he consent in writing of the sanitary authority. The Committee state that their attention has been frequently called to cases in which urinals opening on to streets have been so constructed as to be offensive to public decency-such urinals having been generally erected before the passing of the Act. There appears to be no power, at present, to deal effectively with such eases, and the committee recommend promotion of legislation to enable the Sanitary Authority, by notice, to require the owner to remove any such urinal. or otherwise to reconstruct the same, in such a manner, and with such materials, as may be required to abate the nuisance and remove the offence against public decency. In this connection the Council may be reminded of the effort made in 1888 to improve the condition of the urinals connected with publichouses in the Borough; efforts which were less effective than might have been desired owing to the want of such powers as the County Council now propose to acquire for Sanitary Authorities. The fourth proposal, relating to "the paving of stables," deals with a matter of very considerable interest from the public health point of view. The Committee state that they have had frequent complaints of nuisances caused from manure at stables, and they think it would be of assistance in removing causes of complaint, if the Sanitary Authorities were enabled to require such stables to be properly paved with some impervious material. They are of opinion that the matter could best be dealt with if the County Council were enabled to make by-laws on the subject, which should be enforced by the Sanitary Authorities. With this view there will probably be general agreement. But power to make such by-laws might, with advantage, be extended so as to deal with the ceiling, as well as the flooring, of stables, and also with the means of access to dwellingrooms over stables, so as to bring about the removal of insanitary conditions which lead to pollution of the air, and which max properly be regarded as dangerous to the health of the persons who are obliged to live in such rooms. This subject has, for some time, been engaging my attention, with a view to ascertain whether, under existing powers, something may not be done to improve the sanitary condition of stables by excluding filth-polluted air from dwelling rooms placed over them. The fifth proposal relates to the "removal of fixed dust receptacles, after moveable receptacles have been provided." This proposal arises out of a resolution passed by the conference of representatives of the Sanitary Authorities at the County Hall, in 1900, expressive of the opinion that "fixed ash-pits should be abolished and moveable receptacles provided in their place." At present there is no power to abolish an existing fixed receptacle, if it be not a nuisance. But all new "ash-pit" are required by t he by-law of the County Council to be of the moveable sort, and of the prescribed material and dimensions. As a general rule it is the dilapidated condition of the original fixed receptacle which leads to the issue of a notice to provide a moveable ash-pit, the remains of the fixed receptacle being, as a rule, simultaneously demolished. The by-law referred to, which came into force in 1893, is not retro- spective, and "does nut enable the Sanitary Authority to require the removal of an old brick or other fixed ash-pit," unless it is in such a condition as to be a nuisance. The Committee allege that "these old fixed receptacles often become filled with refuse and give rise to recurring nuisances," and therefore the Sanitary Authority should hare power to require their demolition in all cases in which moveable receptacles shall have been provided-a course certainly desirable. The sixth proposal relates to "the inspection of premises where food is prepared for sale," and in connection therewith reference is made to a recent illustration of the difficulties which beset the sanitary inspector when the occupier of premises takes it into his head, for whatever reason, to refuse admittance to that official. The Committee advise that the power of entry should he enlarged, so as to enable the Sanitary Authority to examine premises where food is prepared for sale, and so to "require the removal of conditions which are likely to give rise to contamination." The Committee reported, in 1902, on kitchens of hotels and restaurants-"a matter which has recently excited considerable public attention," and think that the powers they suggest "would be very useful to Sanitary Authorities in this connexion." This was shown in a report by one of the County Council's Assistant Medical Officers of Health, after an enquiry, made in 1898, us to "the circumstances under which certain articles of food are prepared for sale in London," which pointed to the desirability of giving Sanitary Authorities power to "require the removal of conditions exposing food to the risk of contamination." "Such powers have already been given in the case of milk, and certain provisions, with a similar object, and directed against the contamination of bread, have been in force for a number of years." The Committee remark that "there is no reason why provisions which are necessary in the case of bakehouses should not be necessary with regard to any place where food is prepared for sale"—a remark which leads me to observe that the provisions for securing bread against contamination are insufficient, and that the County Council would do well to include in their proposed Bill a provision to enable them to frame by-laws to regulate the, construction of bakehouses, and the conduct of the business of a baker. The seventh proposal relates to "the payment to sanitary authorities of penalties imposed on ice-cream vendors and manufacturers." These penalties are now payable to the police, but the Committee think it only just that the authority which takes proceedings should receive the fine. The eighth proposal relates to the "sorting and sifting by hand of house refuse" —a disgusting pracitice in which women are sometimes employed —"under most objectionable and insanitary conditions." The County Council have decided to "promote legislation with the object of altogether prohibiting the sorting and sifting of refuse by hand in London." The Committee concluded their report by summarising the several proposals, and recommended — (a) That application be made in the next Session of Parliament for powers— 1. Enabling Sanitary Authorities to require the cleansing or destruction of articles of clothing which are in a filthy, dangerous, or unwholesome condition. 2. Enabling Sanitary Authorities to require the owners of premises to Strip the walls, and cleanse any room or rooms infested with vermin, and enabling owners to recover the cost of the work from tenants in certain cases. 3. Enabling Sanitary Authorities to require the reconstruction or removal of urinals or other conveniences opening on to streets, and constructed before the passing of the Public Health (London) Act, 1891, and so placed as to be a nuisance, or offensive to public decency. 4. Enabling the Council to make by-laws, to be enforced by Sanitary Authorities, requiring the paving of stables with impervious material. 5. Enabling Sanitary Authorities to require the removal of fixed dust receptacles after moveable receptacles have been provided. 6. Enabling Sanitary Authorities to examine premises on which food is prepared for sale, and to require the removal of conditions likely to give rise to contamination. 7. Amending Part VIII. of the London County Council (General Powers) Act, 1902, so as to make penalties against ice-cream manufacturers and vendors payable to the Met ropolitan Borough Councils. 8. Prohibiting the sorting and sifting of house refuse, by hand, in London. (b) That a copy of their report be sent to each of the Metropolitan Borough Councils, with an expression of the Council's hope that they will support the proposals contained therein. It is to be anticipated that the Borough Councils will generally approve and support the proposals which, as they affect the whole of the Metropolis, can be most conveniently dealt with in a Bill promoted by the County Council. The several recommendations have been embodied in clauses which will form part of the County Council's General Powers Bill, 1904. I have the honour to be, Sir, and Gentlemen, You most Obedient Servant, T. ORME DUDFIELD, Medical Officer r of Health. Public Health Department, Town Hall, Kensington, W. November 16th, 1903. Cases of Infectious Disease notified in the several Metropolitan Boroughs in the Four Weeks ended Saturday, 7th November, 1903. Name of Borough. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Membranous Croup. Cholera. Totals. ... 24 7 6 ... ... 2 18 ... ... 57 Kensington 1 44 18 8 ... ... ... 15 1 87 Paddington ... Hammersmith ... 9 6 ... ... 1 6 1 ... 49 26 Fulham ... 18 18 7 ... ... ... 3 ... ... 46 Chelsea ... 11 7 3 ... ... 2 6 ... ... 29 City of Westminster 6 22 15 6 ... ... ... 15 ... ... 64 St. Marylebone 1 31 20 6 ... 1 2 16 1 ... 78 7 2 ... ... ... 3 ... ... 19 Hampstead 1 6 St. Pancras 3 66 42 8 ... ... ... 16 ... ... 135 Islington 1 68 26 19 ... 1 24 ... ... 139 ... Stoke Newington ... 4 ... 9 ... ... ... 3 ... ... 16 Hackney ... 68 28 31 ... 4 26 3 ... 161 1 Holborn ... 4 1 6 ... ... ... 9 ... ... Finsbury ... 12 6 9 ... ... ... 13 ... ... 40 City of London ... ... 4 ... ... ... 1 ... ... 6 1 ... 32 15 ... 1 1 12 ... ... 75 Shoreditch 14 Bethnal Green ... 53 18 10 ... ... 1 21 1 ... 104 Stepney 2 88 48 23 ... ... ... 43 ... ... 204 Poplar ... 44 55 15 ... ... 1 10 ... ... 18 32 29 22 ... ... ... 20 1 ... 122 Southwark Bermondsey 1 22 8 12 ... ... 1 16 1 ... 61 Lambeth 4 45 52 16 ... ... 2 24 ... ... Battersea ... 32 30 13 ... ... ... 9 3 ... Wandsworth 4 42 43 8 ... ... 2 9 1 ... Camberwell 3 51 26 10 ... 1 ... 21 ... ... 112 Deptford ... 34 24 ... ... ... ... 12 ... ... Greenwich ... 15 14 7 ... ... ... ... ... 4 Lewisham ... 37 17 4 ... ... 2 9 1 ... 70 Woolwich ... 37 14 3 ... ... ... 3 1 ... 58 Port of London ... ... ... 2 ... ... ... ... ... ... 2 Grand Totals 45 969 596 290 ... 4 22 387 15 ... 2,328 [TABLE. Re-inspections of Houses. Number re=inspected from January 5th to October 10th Number re-inspected during the four weeks Inspections of Dairies, Milkshops, etc. (No. in Borough, 283) Inspections of Bakehouses. (No. in Borough, 111) Inspections of Mews. (No. in Borough, 177) Cases of Infectious Disease visited „ „ re-visited „ „ removed Houses disinfected Sanitary Notices issued In respect of Registered Houses „ other Premises Summonses issued Sanitary Works completed Including cases, 15 in number, in which the drainage portion of the work ordered was supervised by the Borough Engineer.) 2150 109 25 1 35 8 ... 6 7 29 ... 29 ... 55 1830 205 ... 57 82 7 1 4 5 73 46 27 1 157 2139 211 6 7 49 10 2 3 6 73 39 34 ... 33 1248 169 15 13 41 7 ... 4 7 28 ... 28 ... 8 1401 93 18 25 57 19 ... 8 14 23 ... 23 2 19 1825 231 22 20 24 4 1 3 6 38 ... 38 ... 48 1170 94 1 29 21 3 ... 3 4 44 40 4 ... 107 1329 158 1 33 73 3 1 1 2 19 12 7 ... 24 1646 151 1 1 20 4 2 3 5 20 6 14 ... 61 973 94 ... 49 23 3 ... 1 2 12 ... 12 1 12 15711 1515 89 235 425 68 7 36 58 359 143 216 4 524 184 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 7th November, 1903. Description of Work. North Kensington. South Kensington. Dressmakers. Laundries. Miscellaneous. Total. Dressmakers. Laundries. Miscellaneous. Total. Total number of Houses visited 40 65 41 146 111 3 36 150 Workshops and Workplaces—Newly discovered and registered 2 ... 1 3 4 ... ... 4 „ Workrooms therein measured 6 ... 1 7 20 ... 6 26 „ Number of Inspections of 33 32 39 104 87 3 22 112 „ Number of Re-inspections of 7 9 ... 16 22 ... ... 22 Workrooms—Number of Inspections of 40 136 39 215 159 7 58 224 „ Found to be overcrowded 1 ... ... 1 2 ... ... 2 „ Found to be insufficiently ventilated 3 ... ... 3 6 ... 1 7 „ Found to be in a dirty condition ... 18 ... 18 2 1 3 ... „ Cards distributed shewing number of persons permitted in each room 4 ... ... 4 28 ... 6 34 Houses visited for Inquiry, at which no female hands were employed* 2 3 4 3 ... 6 9 9 Statutory notices and written intimations Issued 1 14 ... 15 5 ... 1 Nuisances reported to the Medical Officer of Health and entered in Complaint Book ... ... 1 1 1 ... ... 1 * 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.