KEN 14 THE ANNUAL REPORT on the HEALTH, SANITARY CONDITION, etc., etc., OF THE ROYAL BOROUGH OF KENSINGTON FOR THE YEAR 1905 BY T. ORME DUDFIELD, M.D. Medical Officer of Health. LONDON: VAIL & Co., PRINTERS, FARRINGDON ROAD, E.C. A Foreword.—The year 1905 completed half-a-century of Sanitary administration in London by popularly elected local authorities : between 1856-1900 by the late Vestries: between 1901-1905 by the Metropolitan Borough Councils. This fact lends additional interest to the statistical Tables relative to Kensington, set out in Appendix II., pp. 129-131, which show (inter alia)— That- during the fifty years the population of the Royal Borough increased by 122,000, viz., from 57,000 to 179,000; That comparing the last quinquennial period (1901-1905) with the first (1856-1860) the birth rate has fallen from an average of 30.7 per 1,000 persons living, to 19.7—a decrease of 11.0 per 1,000, partly accounted for by the disproportion in the relative numbers of the two sexes ; That the general death-rate has fallen 6.6, viz., from 21.0 to 14.4 per 1,000, and That the death-rate from the principal diseases of the zymotic class has fallen 2.0, viz., from 3.5 to 1.5 per 1,000. It may be added that since 1871 the population has increased by 58,000; whilst, comparing the first with the last quinquennial period, there has been a decrease of 11.7 per 1,000 in the birth-rate; of 4.5 per 1,000 in the general death-rate, and of 1.46 per 1,000 in the zymotic death-rate. The infantile mortality rate, i.e., the proportion of deaths under one year of age to 1,000 registered births, which averaged 159 in the quinquennium 1871-1875, was 148 in the last five years, a decrease of 11 per 1,000 : but it is far too high. The greatly reduced mortality from infectious diseases in the last 35 years is largely attributable to— (1) The provision of adequate and free hospital accommodation under a single authority, to which facile admission is obtainable without loss of social status; (2) The removal of sufferers from small-pox to hospitals without London; (3) The establishment of admirable land and river ambulance services, and (4) The compulsory notification of infectious disease. As regards the future the immediate objects to be aimed at seem to be, mainly, the following— (1) Compulsory notification, and sanatorium provision for persons suffering from Consumption ; (2) Transference of administration of the Vaccination Act to the Public Health authorities, and compulsory re-vaccination at school-age ; (3) Reduction of child mortality— (a) By appointment of Health Visitors, establishment of Creches, and provision of pure milk supply, (b) By exclusion from Public Elementary schools of children under five years of age, and institution of Day Nurseries, or Nursery schools, under medical supervision. (4) Establishment of a comprehensive Metropolitan Ambulance Service. The Royal Borough of Kensington. REPORT of the MEDICAL OFFICER OF HEALTH For the Year 1905. To the Mayor, Aldermen, and Councillors of the Borough Council. Sir, and Gentlemen, The vital and mortal statistics in this report relate to the registration year, a period of fifty-two weeks, January 1st to December 30th, 1905. For the purposes of the report the population of the Royal Borough is assumed to have numbered 179,000 at the middle of the year; the estimated population of the sub-districts, parliamentary divisions, etc., is set out in the table at page 5. The estimate of population of the borough is based on the subjoined summary table which shows the Age and Sex-Distribution of the people as ascertained at the census of 1901. Population at all Ages, March 31st, 1901. Under Five Years. 5 to 15. 15 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 to 75. 75 to 85. 85 to 95. 95 and upwards. All Ages. Females 107,544 7,092 13,305 24,769 23,482 15,377 10,953 6,985 3,818 1,515 243 5 107,544 Females Males 69,084 7,056 12,595 13,461 11,491 9,440 7,220 4,586 2,306 820 107 2 69,084 Males Excess of Females 38,460 36 710 11,308 11,991 5,937 3,733 2,399 1,512 695 136 3 38,460 Excess of Females Total of both sexes 176,628 14,148 25,900 38,230 34,973 24,817 18,173 11,571 6,124 2,335 350 7 176,628 Total of both sexes The enumerated population comprised 38,349 Families or Separate Occupiers (an increase of 2,396 on the number, 35,953, in 1891); 28,770 in the Town sub-district, 9,579 in Brompton. The tenements of less than five rooms, 20,052 in 1891, and 55.8 per cent, of total tenements, were 21,115 in 1901, and 55.1 per cent, of the entire number. In these tenements there were housed 73,425 persons (compared with 70,718 in 1891), or 40 per cent. of the population: the relative per centage in 1891 was 42.5. Number and Population of Tenements of Less than Five Rooms in 1901. Tenements of — Number. Population. One Room 5,695 11,334 Two Rooms 7,776 27,800 Three ,, 4,757 20,210 Four „ 2,887 14,081 It thus appears that 6.41 per cent. of the parishioners lived in one-room tenements, compared with 8.2 per cent. in 1891; 15.73 per cent. in two-room tenements (15.6 in 1891); 10.81 per cent. in three-room tenements (10.9 in 1891); and 7.97 per cent. In four-room tenements (7.8 in 1891). 4 POPULATION AND RATEABLE VALUE. The subjoined statement exhibits the growth of population during the nineteenth century:— The Year. Population. 1801 8,556 1811 10,886 1821 14,428 1831 20,902 1841 26,834 1851 44,053 1861 70,108 1871 120,299 1881 163,151 1891 170,071 1901 176,628 1905 179,000 The development of the Borough during the last 83 years is evidenced by the subjoined statement, showing the increase in rateable value. The present total is about one-sixteenth of that of the Administrative County of London. Rateable Value of Property. The Year. £75,916 1823 93,897 1833 142,772 1843 257,103 1853 444,030 1863 975,046 1873 1,711,495 1883 2,037,221 1893 £2,335,567 (October) 1905 The following table, brought up to date, exhibits the growth of the borough since the Metropolis Local Management Act came into operation just half a century ago, in 1856:— 1856. 1905. Increase in 50 years. Population 57,000 179,000 122,000 Number of Inhabited Houses 7,600 23,000 15,400 Rateable Value of Property £308,000 £2,335,567 £2,027,567 The increase in all respects within the last thirty-five years, 1871-1905, the period over which my official experience extends, has been very considerable, as the subjoined figures show:— 1871. 1905. Increase in 35 years. Population 121,000 179,000 58,000 Number of Inhabited Houses 15,735 23,000 7,265 Rateable Value £935,720 £2,335,567 £1,399,847 It thus appears that the population in 1905 was more than twenty times as large as in the first year of the nineteenth century, and the rateable of property more than thirty times as great as in 1823, the first year in respect to which I possess information. Since 1856, the rateable value has increased more than seven-fold, the increase in the last 35 years being more than four times the total in 1856; since which date the population and the number of inhabited houses have increased more than three-fold. 5 AREA OF THE BOROUGH. The Borough comprises an area of 2.291.1 statute acres, an addition of 101.1 acres having accrued from the changes in boundaries brought about by the London Government Act, 1899. Of this addition all but 1.8 acres belongs to the Town sub-district, the area of which (including 3.8 acres of inland water) is 1,596.3 acres ; the area of Brompton being 694.8 acres. The acreage of the wards is not given in the census report. REGISTRATION DISTRICT AND SUB-DISTRICTS. The " Kensington " Registration District (No. 1 B in the Registrar-General's list) comprises two sub-districts, respectively named Kensington Town (hereinafter for brevity referred to as Town) and Brompton. The Town sub-district comprises all that portion of the Borough north of Kensington High-street and Kensington-road, together with a large area south of that main thoroughfare, the dividing line running, from west to east, along Pembroke-road, Stratfordroad, and south of the workhouse, through Cornwall-gardens to Queen's-gate-place, and thence northwards so as to include Queen's-gate (west side). The remainder of the Borough, south of the line indicated, forms the sub-district of Brompton. The Parliamentary Divisions are two in number; North Kensington and South Kensington—High-street, Notting-hill, and Holland-park-avenue forming the line of demarcation. The Wards are nine in number, of which four—Golborne, St. Charles, Norland, and Pembridge are in (and constitute) the Parliamentary Division of North Kensington ; and five— Holland, Earl's Court, Queen's Gate, Brompton, and Redcliffe, are in (and constitute) the Parliamentary Division of South Kensington. POPULATION AND INHABITED HOUSES IN 1905. The population of the borough, estimated at the middle of the year, was 179,000. It comprised 70,010 males and 108,990 females: excess of females, 38,980. In the Town sub-district (estimated population 129,740), the males numbered about 54,160, the females, 75,580; excess of females, 21,420. In the Brompton sub-district (estimated population 49,260), there were about 15,850 males and 33,410 females: excess of females 17,560. This population of 179,000 persons, was in occupation of about 23,000 houses ; equal to 7.8 persons to a house. For the purposes of this report, the population of the borough, the sub-districts,.the parliamentary divisions, and the wards, will be taken to be as follows The Borough 179,000 Sub-districts:— Kensington Town 129,740 Brompto 49,260 Parliamentary Divisions:— North Kensington 92,290 South Kensington 86,710 Wards :— [St. Charles 22,240 North kensington Golborne 26,670 norland 23,790 pembridge 19,590 South Kensington Holland 20,680 19,590 Earl's Court 18,290 queen's Gate 14,460 Redeliffe 18,940 Brompton 14,340 6 MARRIAGES AND MARRIAGE RATE. The marriages in the year were 1,574, compared with 1,703, 1,623 and 1,672 in the three preceding years respectively. Of these marriages there were celebrated— By the Church (64.9 per cent. of total marriages) 1,022 At Roman Catholic places of worship 149 At other Nonconformist places of worship 61 At the Jewish Synagogue 11 At the Superintendent-Registrar's Office 331 1574 The subjoined table shows:— Marriage-Rate in Ten Years 1895-1904, and in 1905, in Kensington, London, and England and Wales. YEAR. Kensington. London. England and Wales. No. of Marriages. Marriage Rate. Marriage Rate. Marriage Rate. 1895 1,455 17·2 17·1 15·0 1896 1,706 20·1 18·0 15·8 1897 1,681 19·7 18·5 16·0 1898 1,648 19·2 18·8 16·2 1899 1,693 19·6 18·6 16·4 1900 1,543 17·8 18·0 15·9 1901 1,651 18·7 17·6 15·9 1902 1,703 19·2 17·8 15·8 1903 1,623 18·2 17·4 15·6 1904 1,672 18·7 17·0 15·2 Average 1895-1904 1,637 18·8 17·9 15·8 1905 1,574 17·6 16·9 15·3 BIRTHS AND BIRTH RATE. The births registered were 3,458;* viz., males, 1,760, and females, 1,698: in the Town sub-district (which includes the Borough Infirmary), 2,949, and in the Brompton sub-district, 509. The male births were to the female births in the proportion of 1,036 to 1,000. The births were 242 below the corrected decennial average (3,700). They were 10 more than in the year 1904, but fewer by 583 than the number in 1872 (4,041), when the population (127,600) was 51,400 less than in 1905 ; 157 of them were of illegitimate children. The birth-rate, which of late years has always been considerably below that of London, has been declining since 1868, in which year it was 33.1 per 1,000 persons living. In 1905 it was 19.3 per 1,000, and 1.3 below the decennial average (20.6). The rate in the sub-districts was:—Town, 22.7, Brompton, 10.3 per 1,000. • Exclusive of 121 registered without the Borough, at Queen Charlotte's Lying-in-Hospital. 7 The births in North Kensington, i.e., the part of the Borough north of Holland Park Avenue and High Street, Notting Hill, were 2,481; the birth-rate 26.9 per 1,000 living, and 0.2 below the metropolitan rate. The births in South Kensington, i.e., the part of the borough south of the streets named, were 977 ; the birth-rate 11.3, and 15.8 per 1,000 below the metropolitan rate. The birth-rate in the several wards—after distribution of the births at the borough infirmary— was as follows:— North Kensington— St. Charles 604 births = 27.2 Golborne 891 births = 33.4 Norland 628 births = 26.4 Pembridge 358 births = 18.3 South Kensington— per 1,000 persons living. Holland 276 births = 13.3 Earl's Court 234 births = 12.8 Queen's Gate 121 births = 8.4 Redcliffe 231 birth = 12.2 Brompton 115 births = 8.0 The births exceeded the deaths by 951: in the Town sub-district they were 978 more in number than the deaths, whilst in the Brompton sub-district the deaths exceeded the births to the number of 27. In North Kensington the births exceeded the deaths by 916 ; in South Kensington to the number of 35 only. The excess of births over deaths in the several wards was as follows:— (St. Charles 236 south Holland 36 North Golborne 417 Kensington. Queen's Gate 2 Kensington. Norland 153 Earls Court 16 Pembridge 110 The deaths exceeded the births by 7 in Redcliffe Ward, and by 12 in Brompton Ward. The registered births of illegitimate children in the borough as a whole were 157—one more than in 1904. Of these births 145 were registered in the Town sub-district, which includes the workhouse, at which institution out of 121 live births (males 59, females 62) 76 were illegitimate. In the borough generally the illegitimate births formed 45 per cent. of total births as compared with rates of 4.6, 4.2, and 4.5 in the preceding three years. The subjoined table shows the quarterly number of births of males and females in the borough, and in each of the sub-districts:— Kensington Town. Brompton. The Borough. Males. Females. Total. Males. Females. Total. ./ 1st Quarter 394 406 800 46 69 115 915 2nd „ 384 340 724 67 70 137 861 3rd ,, 371 355 726 85 55 140 866 4th „ 354 345 699 59 58 117 816 1,503 1,446 2,949 257 252 509 3,458 Illegitimate Births 15 19 34 3 1 4 38 23 10 33 - 2 2 35 22 15 37 3 1 4 41 20 21 41 1 1 2 43 80 65 145 7 5 12 157 8 The following table shows the population, the number of births, and the birth-rate for each of the ten years, 1895-1904:— The Year. Population. Total Births. Males. Females. Birth-rate per 1.000 1895 169,300 3,621 1,861 1,760 21·4 1896 170,000 3,717 1,943 1,774 21·4 1897 170,700 3,683 1,839 1,844 21·6 1898 172,000 3,633 1,830 1,803 21·1 1899 172,400 3,590 1,798 1,792 20·8 1900 173,000 3,586 1,770 1,816 20·7 1901 177,000 3,602 1,840 1,762 20·4 1902 177,500 3,488 1,743 1,745 19·3 1903 178,000 3,565 1,826 1,789 20.0 1904 178,500 3,448 1,719 1,729 19·8 Totals 85,933 18,169 17,764 Average 20·6 Excess of male births in the ten years 405 Birth-rate in the Metropolis, and in Kensington, and in certain Districts of the Borough, during the thirteen four-weekly periods ended December 30th, 1905, and in the Registration Year, 1905. Four Weeks ended Metropolis. Borough. Sub-Districts. Parliamentary Divisions. Wards. Kensington Town. Brompton. North. South. St. Charles. Golborne. Norland. Pembridge. Holland. Earl's Court. Queen's Gate. Redcliffe. ton./ January 28 28·6 20·4 25·4 7·1 30·4 9·7 28·6 42·9 29·0 17·3 16·3 7·8 5·4 11·0 5·4 February 25 28·3 20·9 25·1 10·0 30·1 11·1 29·2 39·5 28·4 20·5 13·2 16·3 8·1 8·2 8·2 March 25 28·2 19·1 22·6 9·8 27·8 9·9 26·3 38·0 27·3 15·9 12·6 8·5 5·3 13·0 8·2 April 22 26·4 18·1 20·2 12·4 22·8 13·0 22·8 29·2 17·5 20·6 15·6 13·5 10·8 16·5 7·3 May 20 28·7 20·9 24·7 10·8 28·7 12·6 28·1 30·7 30·0 25·2 17·0 16·3 9·0 10·3 8·2 June 17 25·8 18·8 21·8 10·8 25·1 12·1 30·4 28·3 25·1 14·6 15·7 12·8 6·3 16·5 6·3 July 15 27·4 20·1 22·8 12·9 26·5 13·3 24·0 33·6 23·5 23·2 11·3 18·5 14·4 13·0 9·1 August 12 26·9 19·8 23·1 11·1 27·2 12·0 27·5 28·3 30·0 21·9 13·2 13·5 9·9 13·0 9·1 September 9 27·1 20·2 22·5 13·9 27·3 12·6 25·7 35·1 27·9 17·9 9·4 16·3 9·0 15·8 11·8 October 7 25·9 18·4 22·4 7·9 26·1 10·3 26·3 35·1 24·0 15·9 17·0 10·0 7·2 7·6 8·2 November 4 26·7 19·1 21·8 11·9 25·6 12·1 28·6 30·7 27·9 12·6 11·3 12·1 12·6 16·5 7·3 December 2 26·2 17·8 21·5 7·9 26·2 8·8 22·8 29·7 32·2 17·9 8·8 13·5 6·3 6·9 8·2 December 30 25·1 17·4 21·1 7·7 25·6 8·7 32·7 33·1 20·2 13·9 12·6 7·1 4·5 10·3 7·3 Birth-rate for the year 1905 27·0 19·3 22·7 10·3 26·9 11·3 27·2 33·4 26·4 18·3 13·3 12·8 8·4 12·2 8·0 Table A, Appendix II. (page 129) gives the number of births and the birth-rate for each of the fifty years, 1856-1905. DEATHS AND DEATH-RATE. The registered deaths, inclusive of 324 of parishioners at outlying public institutions, etc., but exclusive of 673 of non-parishioners at public institutions, etc., within the borough, were '2,507 (males 1,242, females 1,265), and 295 below the corrected decennial average (2,802). Of these deaths, 1,971 were registered in the Town sub-district and 536 in Brompton. 9 The death-rate, which in the preceding three years had been 15.2, 13.8 and 14.2 per 1,000 respectively, was 14.0* in 1905. It was 1.6 below the decennial average (15.6) and 1.1 below the rate in the Metropolis, as a whole, 15.1. The rate in the sub-districts was : Town 15.2, Brompton 10.9 per 1,000, as compared with 15.8 and 10.1, respectively, in 1904. The deaths in North Kensington were 1,565, and the death-rate 17.0 per 1,000. The deaths in South Kensington were 942, and the death-rate 10.9 per 1,000. The sex-rate was, males 17.7, females 11.6 per 1,000. Localised Death-rates.—For many years the death-rate of localised portions of the borough, including the sanitary districts, has been given in these reports. The rate as regarded the sub-districts and parliamentary divisions, was calculated on the basis of the population of those areas enumerated at quinquennial census periods, corrected yearly for increase, and was closely approximate to the true rate. But as regarded the sanitary districts, only an estimated population and an estimated rate could be given ; the continuity of the statistics, moreover, was always liable to be disturbed upon any change in the number of the said districts; and four changes had been made within a few years. Having, in 1901, received from the Registrar-General a statement of the population of the nine wards comprised in the borough, and regard being had to the improbability of any change in their number, and to the fact that the population of the wards will be ascertainable at censal periods, it was thought that the value of these localised statistics would be enhanced by adopting the ward, in place of the sanitary district, as the unit for calculation of the death-rate, and this was done. The ward-rate is set out below; the rate in each of the thirteen four weekly periods in the table at page 13. North Kensington: St. Charles 368 deaths = 16.5 Golborne 474 deaths = 17.8 Norland 475 deaths = 20.0 Pembridge 248 deaths = 12. 7 South Kensington : per 1,000 persons living. Holland 240 deaths = 11.6 Earl's Court 218 deaths = 11.9 Queen's Gate 119 deaths = 8.2 Redcliffe 238 deaths = 12.6 Brompton 127 deaths = 8.9 The Corrected or True Death-rate.—The death-rate, 14.0 per 1,000, as calculated above, is a crude or uncorrected one, not taking cognizance of the relative number of the sexes, nor of the age-composition of the population. Correction for these data involves addition to, or subtraction from, the "recorded death-rate," as compared with the "standard death-rate." The necessity for such correction is obvious, having regard to the great excess of females in the population, and to the lower death rate in the female sex as compared with the rate in the male sex. That excess in 1905 was approximately 38,980. The deaths among the 70,010 males were 1,242 and those among the 108,990 females 1,265. The crude death-rate in the male sex was 17.7 as compared with the rate of 11.6 in the female sex. It is, obvious, therefore, that if the numbers of the sexes had been equal, the death-rate would have been higher than the recorded rate. The Registrar-General, in his annual summary, gives the " factor for correction for sex and age-distribution " in each of the Metropolitan Boroughs. Corrected after the manner indicated, the death-rate of Kensington in 1905 becomes, instead of 14.0, one of 15.1 per 1,000 ; and the rate for London, as a whole, 15.85 instead of 15.1. The "true" death-rate is that which shows the mortality per 1,000 living of each sex at different age-periods, and this is shown in the table on page 10. * This is the crude death-rate. The rate corrected for age and sex-distribution was 15. 09 per 1,000. The " true deathrate '' is set out in the table at page 10. The " standard " death-rate signifies the death-rate at all ages, calculated on the hypothesis that the rates for each sex at each of twelve age-periods in each town were the same as in England and Wales, during the 10 years 1891-1900, the rate at all ages in England and Wales during that period having been 18 21 per 1,000. 10 The True Death-rate of Kensington, 1905. Age-Period. Population. Deaths. Death-rate. Both Sexes. Males. Females. Both Sexes. Males. Females. Both Sexes. Males. Females. Under five years of age 14,337 7,149 7,188 757 423 334 52·8 59·2 46·5 Five and under 15 26,244 12,763 13,481 68 33 35 2·6 2·6 2·6 Fifteen and under 25 38,742 13,641 25,101 93 46 47 2·4 3·4 1·8 Twenty-five and under 35 35,443 11,645 23,798 137 74 63 3·9 6·4 2·6 Thirty-five and under 45 25,148 9,567 15,581 176 91 85 7·0 9·5 5·5 Forty-five and under 55 18,415 7,315 11,100 247 131 116 13·4 17·9 10·5 Fifty-five and under 65 11,726 4,646 7,080 336 170 166 28·7 36·6 23·4 Sixty-five and under 75 6,205 2,335 3,870 337 143 194 54·3 61·2 50·1 Seventy-five and upwards 2,740 949 1,791 356 131 225 129·9 138·0 125·6 Totals 179,000 70,010 108,990 2,507 1,242 1,265 14·0 17·7 11·6 The subjoined table shows the quarterly number of deaths of males and females in the borough, and in each of the sub-districts:— Kensington Town. Brompton. The Borough. Males. Females. Total Males. Females. Total. Total. 1st quarter 281 311 592 65 84 149 741 2nd „ 232 236 468 74 70 144 612 3rd „ 218 192 410 52 56 108 518 4th ,, 258 243 501 62 73 135 636 989 982 1,971 253 283 536 2,507 The Births were, of Males 1,760 The Deaths were, of Males 1,242 ,, Females 1,698 „ Females 1,265 Total Births 3,458 Total Deaths 2,507 Deduct- 2,507 Deaths Shows 951 excess of Births over Deaths. During the ten years April 1st, 1891, to March 31st, 1901, the inter-censal period, 31,794 deaths were registered in the borough. Table A, Appendix II. (page 129) gives the number of deaths and the death-rate for each of the fifty years 1856-1905. For further details, see also Tables 6 and 7, Appendix I., pages 110-111. INFANTILE MORTALITY. The infantile mortality, or the proportion of deaths under one year of age to registered births, is an important factor in vital statistics. The deaths under one year, which in the three preceding years had been 515, 510, and 503, respectively, were 498 in 1905, being equivalent to 144 per 1,000 births; and 18 below this decimal average. The deaths under one year in the Town sub-district (442) were equivalent to 150 per 1,000 births, those in Brompton (56) to 110 per 1,000. 11 The infantile deaths in North Kensington, after distribution of the deaths at the Borough Infirmary, were 395, or 159 per 1,000 births ; those in South Kensington 103, or 105 per 1,000. In the several wards the rate was as follows:— North Kensiugton— 8t. Charles 95 deaths = 157 Golborne 138 deaths = 149 Norland 125 deaths = 199 Pembridge 42 deaths = 117 South Kensington— per 1,000 registered births. Holland 24 deaths = 87 Earl'8's Court 25 deaths = 107 Queen's Gate* 14 deaths = 116 Redcliffe 21 deaths = 91 Brompton 14 deaths = 122 The infantile mortality rate in the Metropolis, usually below that of Kensington, was 129, as compared with an average proportion of 153 per 1,000 in the preceding ten years. The lowest rates in the Metropolitan Boroughs were: St. Marylebonet 88, Lewisham and Holborn 92, and Hampstead 94; the highest rates : Bethnal Green 151, Poplar 153 and Shoreditch 167. The rate in seven boroughs was higher, and in twenty-one boroughs lower than in Kensington. In England and Wales the rate was 128, the lowest yet recorded, and 22 per 1,000 below the mean proportion in the ten years 1895-1904. In the 76 great towns of England and Wales (including London) the rate averaged 140 per 1,000, ranging from 66 in Hornsey, 80 in Handsworth (Staffs.) and 83 in Bournemouth, to 193 in Merthyr Tydfil, 195 in Hanley and 200 in Rhondda. The rate in Rural England was 113 per 1,000. Infantile Mortality Rate. year. The Borough. Kensington Town. Brompton. London. Deaths under 1 year. Deaths per 1,000 births. Deaths under 1 year. Deaths per 1,000 births. Deaths under 1 year. Deaths per 1,000 births. Deaths under 1 year per 1,000 births. 1895 624 172 552 181 72 118 166 1896 656 176 578 186 78 127 162 1897 609 166 531 169 78 142 159 1898 655 180 593 212 62 112 167 1899 642 179 574 188 68 125 167 1900 641 179 581 192 60 106 160 1901 581 161 506 166 75 135 149 1902 515 148 449 152 66 124 141 1903 510 143 461 152 49 92 131 1904 503 146 451 154 52 101 146 Average 1895-1904 594 165 528 175 66 118 153 1905 498 144 442 150 56 110 129 • There were 19 deaths in the ward, but five of them occurred at the Borough Infirmary, the previous residence of the mothers not being known, and presumablv not having been in this ward. The low rate in St. Marylebone is due to the presence of Queen Charlotte's Lying-in Hospital, at which, some 120 births to Kensington mothers alone were registered during the year. 12 Table A, Appendix II. (page 129) gives the number of deaths under one year in Kensington, and the proportion to 1,000 registered births (the " infantile mortality rate "), for each of the thirty-five years, 1871-1905, during my tenure of office. The deaths of children over one year and under five years of age were 259 ; the deaths under five years, therefore, were 757, compared with 790, 768 and 756 in the preceding three years, being equal to 219 per 1,000 deaths ; the relative proportion in London, as a whole, being 196. The deaths of illegitimate children under five years of age, 67, 79 and 63, in the preceding three years respectively, were 94 in 1905, of which 84 were registered in the Town sub-district, and 10 in Brompton. These deaths were equal to 59.9 per cent. on the 157 births registered as illegitimate. Of the 94 children 25 only survived the first year of life. Senile Mortality.—At sixty years of age and upwards,.there were 873 deaths, as compared with 956, 803 and 883 in the preceding three years respectively. These deaths were equivalent to 348 per 1,000 deaths at all ages. The relative proportion in all London was 291 per 1,000. District Rates of Mortality.—The table at page 13 shows (inter alia) the death-rate in the sub-districts, the parliamentary divisions, and the wards, for the year, and also for each of the thirteen four-weekly periods covered by the monthly reports. As usual the rate was far higher in the Town sub-district (15.2 per 1,000) than in the Brompton sub-district (10.9), and the same observation applies to the parliamentary division of North Kensington (17.0), compared with the southern division of the borough (10.9). In three of the wards in North Kensington, viz., St. Charles (16.5), Golborne, (17.8) and Norland (20.0), the death-rate exceeded that of the borough as a whole (14.0 per 1,000). The rate in Pembridge Ward (12.7) and in each of the wards in South Kensington was more or less largely below the rate for the borough as a whole. In the Notting-dale " special area " (estimated population 4,000) comprised in Norland Ward, the death-rate was 32.0 per 1,000, compared with 20 0 in the ward as a whole. The zymotic death-rate was 3'7 per 1,000 persons living, and more than double that of the borough as a whole (1.38). The deaths at all ages were 9 more than the births; the deaths of children under one year of age being in the proportion of 345 per 1,000 registered births. The main facts with respect to vital and mortal statistics of this distressful area, in 1905, which generally are of a more favourable character than in any one of the preceding eight years, are summarised below. "NOTTING-DALE" SPECIAL AREA. vital and mortal statistics, 1905. {The corresponding statistics for the preceding nine years are added for comparison.) Population 1905. 1904. 1903. 1902. 1901. 1900. 1899. 1898. 1897. 1896. (Estimated) 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 Births 119 113 136 98 112 113 120 117 130 118 Birth-rate 29·7 28·2 34·0 24·5 28·0 28·2 30·0 29·3 32·5 29·5 per 1,000 persons living. Deaths 128 145 159 185 194 163 236 182 223 187 Death-rate 32·0 36·2 39·7 45·5 48·5 40·7 59·0 45·5 55·7 46·8 per 1,000 persons living. Infantile Mortality. Deaths under one year of age 41 31 46 41 46 54 61 49 56 51 Death-rate 345 274 338 427 411 478 508 419 431 432 per 1,000 registered births. Zymotic Diseases. Deaths from the Seven Principal 15 13 13 14 37 18 12 22 25 30 Death-rate 3·7 3·2 3·2 3·5 9·2 4·5 3·0 5·5 6·3 7·5 per 1,000 persons living. Causes of Death.—In 9 cases Diarrhea; in 3 cases Whooping Cough; in 2 cases Measles, and in 1 case Enteric Fever. There was no death from scarlet fever or diphtheria. The general deathrate was the lowest on record. 13 Among the principal causes of death were—diseases of the nervous system, 5 deaths; diseases of the respiratory system, 28 deaths; diseases of the circulatory system, 13 deaths ; other visceral diseases, 9 deaths; tubercular diseases, 28 deaths, including 19 from consumption (= 4.7 per 1,000 persons living); wasting diseases of infants, 5 deaths; cancer, 6 deaths, and violence, 4 deaths. Three deaths of infants prematurely born were registered, and 5 deaths from old age. Inquests were held in 13 cases. The annual Death-rate per 1,000 persons living, in the thirteen successive four-weekly periods, was:— (1) 39.0 (2) 45.5 (3) 85.7 (4) 29.2 (5) 26.0 (6) 35.7 (7) 29.2 (8) 32.5 (9) 35.7 (10) 16.2 (11) 35.7 (12) 19.5 (18) 35.7 Fifty-eight of the deaths occurred at the homes of the deceased persons, 65 at the Borough Infirmary (nearly an eighth of the total deaths at this Institution—553) and 5 at other Public Institutions ; 23 of the deaths were of persons who had previously resided at common lodginghouses in the Area; but only one of these deaths took place at a common lodging-house. The deaths comprised 67 of males and 61 of females. The ages at death were—under five years of age, 57 (including 41 under one year) ; between 5 and 20 years, 6 deaths; between 20 and 60 years, 43 deaths; at 60 years and upwards, 22 deaths. The deaths were connected with streets as follows : Bangor Street, 38 deaths; Crescent Street, 22 deaths; St. Katharine's Road, 42 deaths; Kenley Street, 10 deaths; Sirdar Road, 16 deaths. Death-rate in the Metropolis, and in Kensington, and in Localized Districts of the Borough, in each of the thirteen four weekly periods ended December 30th, 1905, and in the Registration Year, 1905. Four Weeks ended. Metropolis. Borough. Sub-Districts. Parliamentary Divisions. Wards. Kensington Town. Brompton. North. South. St. Charles. Golborne. Norland. Pembridge. Holland. Earl's Court. Queen's Gate Redcliffe. Bromp ton. January 28 17·5 16·3 18·8 9·8 19·4 13·0 16·9 20·0 25·1 14·6 19·0 16·3 7·2 12·3 7·2 February 25 17·0 16·8 17·6 14·5 19·0 14·4 18·1 18·5 21·9 17·3 15·1 9·2 16·2 17·8 13·6 March 25 16·3 16·6 18·7 11·1 20·8 12·1 22·2 22·9 21·3 15·9 14·5 15·6 9·0 15·1 3·6 April 22 15·5 16·1 17·2 13·2 19·0 13·0 15·2 23·9 21·3 13·9 16·3 16·3 7·2 13·0 10·0 May 20 14·8 13·3 14·0 11·8 15·4 11·1 15·2 16·6 20·2 8·0 14·5 11·4 4·5 13·3 10·9 June 17 14·1 13·1 13·7 11·6 15·8 10·3 15·8 17·5 18·0 10·6 8·2 10·7 9·0 12·3 11·8 July 15 11·7 10·5 10·9 9·5 12·1 8·8 6·4 12·2 19·1 9·9 8·2 5·0 9·0 13·7 8·2 August 12 15·0 12·5 14·2 7·9 17·0 7·6 13·4 18·5 21·9 13·3 8·2 5·0 5·4 10·9 8·2 September 9 16·7 13·5 14·6 10·6 17·6 9·1 16·9 15·6 22·4 15·3 6·3 14·2 4·5 8·9 11·8 October 7 13·4 11·0 12·0 8·2 13·9 7·8 17·5 14·1 10·4 13·9 8·8 10·6 5·4 6·9 6·8 November 4 15·8 13·5 13·9 12·4 15·4 11·5 19·9 14·6 16·4 10·0 9·4 11·4 11·7 15·1 10·0 December 2 17·9 15·4 17·2 10·6 18·9 11·7 24·0 19·0 21·9 9·3 13·2 16·3 6·3 13·0 7·2 December 30 18·2 13·4 14·3 10·8 16·1 10·5 13·4 17·5 19·7 12·6 9·4 12·8 11·7 11·7 6·3 Death rate for the Year 1905 15·1 14·0 15·2 10·9 17·0 10·9 16·5 17·8 20·0 12·7 11·6 11·9 8·2 12·6 8·9 14 SUMMARY OF VITAL AND MORTAL STATISTICS. In the table at page 15, the principal vital and mortal statistics of the year have been arranged in thirteen four-weekly periods corresponding to the dates of the monthly reports. The birth-rate was 19.3 per 1,000; the death-rate 14.0 per 1,000. There were, as usual, considerable fluctuations in the rate at different periods of the year, ranging between the minimum (10.5) in the seventh four-weekly period, ended July 15th, and the maximum (16.8) in the second four-weekly period, ended February 25th. The rate in five of the periods was above, and in eight below, the average for the year. The deaths in the first half of the year (1,353) were 199 more than those in the second half (1,154); the death-rate in the two half-years being 15.1 and 12.9 respectively. The deaths from the principal diseases of the zymotic class were 247—three more than in 1904, and 70 below the decennial average ; 108 of them occured in the first half of the year, 139 in the second. Whooping cough was the prevalent and most fatal disease in the first half; the deaths in the first twenty-four weeks numbering 51 out of a total of 60 in the year. Seventy-four of the 90 deaths (mostly infantile) from diarrhoea occurred in the second half of the year ; 64 of them in twelve weeks, July 16th to October 7th. The deaths from diseases of the respiratory organs (537) were more by 21 than in 1904. Diseases of the heart were the causes of 209 deaths, compared with 212 in the preceding year. Phthisis was fatal to 199 persons against 226 in 1904; other tubercular diseases claimed 74 victims, compared with 116 in the preceding year. COMPARATIVE VITAL AND MORTAL STATISTICS. London.—The birth-rate, 27.1 per 1,000 (2.2 below the decennial average), was the lowest on record. The rate has been declining for many years, never having been below 30 per 1,000 prior to 1898: the highest rate during my tenure of office, 35.9 per 1,000, was recorded in 1876. The death-rate was 15.1 per 1,000 (1.5 per 1,000 below that in 1904), and 2.7 below the average of the preceding four years 1901-4. Small-pox, the cause ot '242,1,3000, 13 and '25 deaths, respectively, in 1901,1902,1903,and 1904, was fatal to 10 persons in 1905. Scarlet-fever was the cause of 549 deaths, compared with 365 in 1904, and a decennial average of 595. Diphtheria was the cause of 553 deaths ; 176 fewer than in 1904, and 1,166 below the decennial average, 1,719. Enteric-fever shows the smallest number of deaths on record, 243 or less than half the decennial average, 596. The four diseases above-named, commonly spoken of as the " dangerous infectious diseases," were the causes of 1,355 deaths : the deaths from the other three principal diseases of the zymotic class totalled 6,632 being 1,785 above the decennial average; viz., measles 1,715 (average 2,495), whooping-cough 1,507 (average 1,941), and diarrhoea 3,410 (average 3,981). Kensington.—The birth-rate, 19.3 per 1,000, and the lowest on record, was the same as the rate in 1904, and 1.3 below the decennial average. Having regard to the disproportion in the number of the sexes a high birth-rate is not possible ; but the fall from the maximum during my tenure of office, viz., 31.7 in 1872, is unduly great. The death-rate, 14.0 per 1,000; was 0.2 below that in 1904, and 1.6 below the decennial average; the infantile mortality-rate, 144, compared with 162 in the ten years 1895-1904. Scarlet-fever was the cause of 21 deaths, diphtheria of 9, and enteric-fever of 13; total 43 in a population of 179,000 ; a surprisingly small number. The deaths from scarlet-fever, diphtheria and interic-fever were 2 above, and 36 and 2, respectively, below the decennial averages. The deaths from the remaining three of the principal diseases of the zymotic class were 204 : viz., measles 54 [average 77), whooping-cough 60 (average 51), and diarrhoea 90 (average 107). The table at page 20 shows the number of deaths in the several Wards of the Borough from the principal diseases of the zymotic class. The mean temperature of the air at Greenwich during the year was 49.9 Fahrenheit and 0.5 above the means of the preceding 50 years: the means of the four quarters being 41.8, 53.2, 60.9 and 42.6, respectively. 15 Summary of Vital and Mortal Statistics of the Royal Borough of Kensington, 1905. During the Four Weeks ended Births. Deaths. Death-rate. Deaths at Ages. Deaths from Zymotic Diseases. Deaths from Diseases of Respiratory System Deaths from Phthisis. Deaths from Heart Disease. Deaths under Five from Tubercular Disease Mean Temperature. Kensington. London. 1905. Decennial Average. 1905. Decennial Average. 0—1 1—5 60 and upwards. Totals. Small-pox. Measles. Scarlet Fever. Diphtheria. WhoopingCough. Enteric Fever. Typhus Fever. Simple continued Fever. Diarrhœa. Totals. Bronchitis. Pneumonia January 28 281 225 16·3 17·8 17·5 20·2 38 17 98 8 ... 1 ... 1 4 1 ... ... 1 77 36 28 12 22 3 38·0° February 25 *288 231 16·8 17·6 17·0 20·7 38 19 83 18 ... 1 2 1 10 1 ... ... 3 54 26 18 20 19 6 42·4° March 25 263 229 16·6 19·4 16·3 21·6 54 18 81 16 ... ... 1 1 10 2 ... ... 2 59 27 27 17 12 7 43·9° April 22 249 222 16·1 16·3 15·5 18·7 31 33 89 12 ... 2 1 1 7 ... ... ... 1 54 23 24 15 18 4 45·8° May 20 288 183 13·3 14·4 14·8 16·7 38 23 60 21 ... 3 2 2 10 1 ... ... 3 38 13 21 16 11 4 51·2° June 17 259 181 13·1 13·1 14·1 15·3 37 24 65 26 ... 8 1 ... 10 2 ... ... 5 30 11 16 10 19 1 56·8° July 15 277 145 10·5 13·1 11·7 15·0 26 17 50 16 ... 7 2 1 1 ... ... ... 5 17 5 9 7 17 2 64·3° August 12 273 172 12·5 16·1 15·0 19·3 46 24 48 30 ... 3 2 1 4 2 ... ... 18 21 7 11 16 9 3 63·5° September 9 278 186 13·5 14·2 16·7 18·6 68 14 50 48 ... 8 2 ... ... 1 ... ... 37 16 6 5 8 9 1 60·0° October 7 254 151 11·0 12·9 13·4 16·4 28 9 51 16 ... 6 1 ... ... ... ... ... 9 22 6 12 20 12 3 52·6° November 4 263 186 13·5 14·5 15·3 17·0 25 32 60 18 ... 9 4 ... 3 ... ... ... 2 42 14 26 13 21 6 44·6° December 2 245 212 15·4 16·0 17·9 18·4 35 12 81 10 ... 4 1 1 1 1 ... ... 2 53 27 21 19 24 5 40·9° ,, 30 †240 184 13·4 17·3 18·2 19·4 34 17 57 8 ... 2 2 ... ... 2 ... ... 2 54 29 21 26 16 6 40·8° Totals 3,458 2,507 14·0 15·6 ‡15·1 18·3 498 259 873 247 ... 54 21 9 60 13 ... ... 90 537 230 239 199 209 51 49·9° * Maximum number during the year, and so throughout the table. Minimum number during the year, and so throughout the table. This rate, 15.1, is arrived at after excluding deaths of non Londoners. The thirteen four weekly ratio as given in the Weekly Returns are equivalent to 15 .6 per 1,000. 16 Death-rate in England and Wales and in London and in other Large Towns.— The death-rate in England and Wales in 1905, was 15.2 per 1000 ; 1.0 below that of 1904; 2.0 below the average rate in the preceding ten years, and the lowest yet recorded. The rate in London, as already stated, was 15.1 per 1,000 of the estimated population, 1.5 below the corresponding rate in 1904; 3.2 below the average rate in the 10 years 1895-1904, and the lowest on record. The subjoined table shows the annual death-rate per 1,000 persons living in each of the last eleven years, in Kensington, in London, and in England and Wales. 1905 1904. 1903. 1902. 1901. 1900. 1899. 1898. 1897. 1896. 1895. Kensington 14·0 14·2 13·8 15·2 15·0 15·6 17·5 16·3 15·6 16·7 16·4 London 15·1 16·6 15·7 17·7 17·6 18·8 19·8 18·7 18·2 18·6 19·8 West Districts 14·9 15·5 14·6 16·7 15·7 17·6 19·0 17·0 16·1 17·6 18·5 North „ 14·3 15·4 14·4 16·1 15·9 16·9 18·1 16·9 16·6 17·1 18·2 Central „ 19·4 20·2 19·0 21·2 20·8 21·5 22·5 22·1 21·8 21·2 23·8 East „ 18·4 19·5 18·6 20·0 20·7 22·1 23·0 21·7 21·2 21·3 23·4 South „ 14·2 15·3 14·2 16·1 16·6 17·7 18·5 17·7 17·2 17·5 18·3 England and Wales 15·2 16·2 15·4 16·3 16·9 18·2 18·2 17·5 17·4 17·0 18·7 Greater London.—The death-rate in " Greater London"—which is co-extensive with the " Metropolitan" and "City" Police Districts, the population of which at the middle of the year was 7,010,172 (viz. 4,684,794 in Inner or Registration London and 2,325,378 in the Outer Ring) was 144 per 1,000, as compared with 16.4, 14.5 and 15.5 severally in the preceding three years. In the County of London the mortality was at the rate of 15.1 per 1,000, whilst in the Outer Ring it did not exceed 11.8. Infantile mortality in Greater London was equal to 123 per 1000 births, as compared with 135, 126 and 143, severally, in the preceding three years. Last year infantile mortality was equal to 129 per 1,000 in the County of London and to 108 in the Outer Ring. Other Large Towns.—The crude death-rate in the seventy-six large towns, including London (population 15,609,377), was 15.7 per 1,000, the rates in the preceding three years having been 17.4, 16.3 and 17.2. The death-rates of Edinburgh, Glasgow, Dublin and Belfast were severally 16.2, 17.9, 21.3 and 20.1. These rates are calculated without reference to differences between one town and another with regard to the age and sex-distribution of their respective populations. But the sex and age composition of the several populations having been ascertained at the census of 1901, suitable factors have been calculated for correcting the recorded death-rates in the large towns in order to render them fairly comparable with one another; and in his Annual Summary the Registrar-General (page vi.) furnishes a table showing the recorded and corrected death-rates per 1,000 persons living, in each of the 76 towns in 1905. Colonial and Foreign Cities.—The authorities of a large number of the principal cities supply returns of mortality to the Registrar-General. The highest death-rates recorded in 1905, were, Trieste 28T, Moscow 27.9, and St. Petersburg 25.0 ; the lowest, Sydney 11.0, The Hague 13.7, and Amsterdam 13.8. Indian Cities.—The death-rate was 34.4 per 1,000 in Calcutta, 58.7 in Madras, and 48.6 in Bombay. ASSIGNED CAUSES OF DEATH. The Registrar-General issued, in 1902, a "New List of Causes of Death, as used in the Annual Reports for England and Wales, together with " Suggestions to Medical Practitioners respecting Certificates of Causes of Death," in which it is stated to be " highly desirable that Medical Practitioners should use only those terms which are recognised by the Royal College of Physicians of London."* This List takes the place of the one used in these reports for many years as Table III., and since 1900 as Table VIII. It comprises the "General Diseases," i.e., those in which the whole body may be said to suffer, and the " Local Diseases," of various systems and organs, set out in Table VIII., at page 112, in which the first twenty diseases are those formerly described as " Specific, Febrile or Zymotic Diseases chief among them being the nine " Principal Zymotic Diseases;"three of which were formerly associated under the generic term " Fever," which comprises Typhus-fever, Enteric-fever, and Simple continued fever (Pyrexia). * The Registrar-General placed at my disposal a sufficient number of copies of the New List to enable me to forward one to each registered medical practitioner in the Borough, which was done in October, 1902. 17 The Tables numbered I. to V. are required by the Local Government Board to be used in the Annual Report of the Medical Officer of Health. TABLE I. For Whole District. Year. 1 Population estimated to Middle of each Year. 2 Births. Deaths under One Year of Age. Deaths at all Ages. Total. Deaths in Public Institutions. 9 Deaths of Nonresidents registered in District. 10 Deaths of Residents registered beyond District. 11 Deaths at all Ages. Nett. Number. s Rate.* 4 Number. 5 Rate per 1,000 Births registered 6 Number. 7 Rate.* 8 Number. 12 Rate.* 13 1895 169,300 3,621 21·4 624 172 3,065 18·1 1,062 625 308 2,748 16·2 1896 170,000 3,717 21·4 656 176 3,158 18·6 1,065 620 353 2,891 16·7 1897 170,700 3,683 21·6 609 165 3,025 17·7 1,164 691 333 2,667 15·6 1898 172,000 3,633 21·1 655 180 3,151 18·8 1,123 639 286 2,798 16·3 1899 172,400 3,590 20·8 642 179 3,422 19·8 1,320 722 821 3,021 17·5 1900 173,000 8,586 20·7 641 179 3,087 17·7 1,132 672 283 2,698 15·6 1901 177,000 8,602 20·4 581 161 2,964 16·7 1,108 635 321 2,650 15·0 1902 177,500 3,488 19·3 515 148 3,112 17·2 1,182 681 315 2,746 15·2 1903 178,000 3,565 20·0 510 143 2,803 15·7 1,094 666 318 2,455 13·8 1904 178,500 3,448 19·8 503 146 2,911 16·3 1,089 710 339 2,540 14·2 Averages for years 1895-1904. 173,840 3,593 20·6 594 165 3,070 17·6 1,134 666 318 2,721 15·6 1905 179,000 3,458 19·3 498 144 2,856 15·9 1,222 673 324 2,507 14·0 * Rates calculated per 1,000 of estimated population. Note.—The deaths included in columns 7 and 9 of this Table are all those registered during the year within the Borough. The Deaths included in column 12 are the number in column 7, corrected by the subtraction of the number in column 10, and the addition of the number in column 11. The term " non-residents " in column 10, means persons brought into the Borough on account of illness and dying there. The term " residents " in column 11, means persons taken out of the Borough on account of illness and dying thereout. Area of Borough in acres 2,291 Total population at all ages 179,000 No. (approximate) of inhabited houses 23,000 Average number of persons per house 7.8 INSTITUTIONS WITHIN KENSINGTON RECEIVING SICK AND INFIRM PERSONS FROM OUTSIDE THE BOROUGH. 1. St. Marylebone Infirmary, North Kensington. 2. The Hospital for Consumption and Diseases of the Chest, Brompton. 3. St. Joseph's House, Notting Hill. 4. St. Luke's House, Pembridge Square. 5. Queen's Jubilee Hospital, Richmond Road, South Kensington. For Institutions outside Kensington at which Sick, Insane and Infirm Persons from the Borough died, see page 32. 18 TABLE II. Names of Localities. Kensington. Kensington Town. Brompton. Year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. 1895 169,300 3,621 2,748 624 121,280 3,052 2,231 552 48,020 569 517 72 1896 170,000 3,717 2,891 656 121,840 3,101 2,344 578 48,160 616 547 78 1897 170,700 3,688 2,667 609 122,400 3,133 2,169 531 48,300 550 498 78 1898 172,000 3,633 2,798 655 123,600 3,078 2,302 593 48,400 555 496 62 1899 172,400 3,590 3,021 642 123,900 3,046 2,455 574 48,500 544 566 68 1900 173,000 3,586 2.698 641 124,300 3,021 2,193 581 48,700 565 505 60 1901 177,000 3,602 2,650 581 128,300 3,046 2,192 506 48,700 556 458 75 1902 177,500 3,488 2,746 515 128,660 2,956 2,243 449 48,840 532 503 66 1903 178,000 3,565 2,455 510 129,020 3,033 1,998 461 48,980 532 457 49 1904 178,500 3,448 2,540 503 129,380 2,934 2,045 451 49,120 514 495 52 Averages of years 1895-1904 173,840 3,593 2,721 594 125,268 3,040 2,217 528 48,572 553 504 66 1905 179,000 3,458 2,507 489 129,740 2,949 1,971 442 49,260 509 536 56 Note.—Deaths of residents occurring outside the Borough are included in the table; those of non-residents occurring in the Borough are excluded. Deaths of residents occurring in public institutions are allotted to the respective sub-districts according to the previous addresses of the deceased. TABLE IV* Causes of, and Ages at, Death during the Year 1905. Causes of Death. Deaths in whole District at subjoined ages. Deaths in Localities (at all ages). Total Deaths whether of Residents or non "Residents" in Public Institutions in the District. All Ages. Under 1 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65 65 and upwards Kensington Town. Brompton. Small-pox ... ... ... ... ... ... ... ... ... ... Measles 54 18 41 ... ... ... ... 52 2 26 Scarlet Fever 21 1 14 5 ... 1 ... 14 7 ... Whooping-Cough 60 24 33 3 ... • •• ... 54 6 7 Diphtheria, Membranous Croup 9 ... 7 2 ... ... ... 6 3 1 Croup ... ... ... ... ... ... ... ... ... ... Fever Typhus ... ... ... ... ... ... ... ... ... ... Enteric 13 ... ... 3 2 8 ... 9 4 ... Other continued ... ... ... ... ... ... ... ... ... ... Epidemic Influenza 49 3 ... 1 .. 21 24 36 13 3 Cholera ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... Diarrhœa 90 65 15 ... 1 4 5 86 4 13 Enteritis 32 21 5 ... ... 3 3 26 6 3 Puerperal Fever 3 ... ... ... ... 3 ... 2 1 2 Erysipelas 7 2 ... ... ... 4 1 7 ... 4 Other septic diseases 10 1 ... ... 8 4 2 9 1 4 Phthisis 199 ... 4 5 23 159 8 166 33 262 Other tubercular diseases 74 23 28 9 6 7 1 59 15 49 Cancer, Malignant disease 172 ... ... ... ... 115 57 123 49 93 Bronchitis 230 43 14 ... ... 63 110 192 38 176 Pneumonia 239 57 61 4 12 59 46 195 44 56 Pleurisy 11 ... 1 ... ... 5 5 8 3 5 Other diseases of Respiratory Organ 57 4 4 2 ... 28 19 48 9 23 Alcoholism 10 ... ... ... ... 9 1 6 4 5 Cirrhosis of Liver 19 1 ... ... ... 14 4 11 8 6 Venereal Diseases 22 18 1 ... 1 2 ... 21 1 18 Premature Birth 72 72 ... ... ... ... ... 58 14 4 Diseases and Accidents of Parturition 4 ... ... ... 3 1 ... 2 2 1 Heart Diseases 209 1 2 7 6 86 107 153 56 83 Accidents 78 16 6 6 4 35 11 57 21 24 Suicides 22 ... ... ... 3 18 1 14 8 2 All other causes 741 133 23 21 29 247 288 557 184 352 All causes 2,507 498 259 68 93 896 693 1,971 536 1,222 Note.—Deaths of residents occurring outside the Borough are included in the Table; those of non-residents occurring in the Borough are excluded, with the exception of the last column. * Table III, " Cases of Infectious Disease notified," will be found at page 37 and Table V., "Infantile Mortality," at page 56. 19 Deaths of residents occurring in public institutions are allotted to the respective sub-districts according to the addresses of the deceased as given by the registrars, and, in addition, are classified, under the heading Public Institutions, with those of non-residents. The subjoined table, being a summary of Table VIII. in Appendix I., page 112 (Table III. in annual reports prior to 1900), shows the number of deaths from diseases comprised in the " New List of Causes of Death," as used in the Annual Reports of the Registrar-General for England and Wales, referred to in the following pages; to which I have added the deaths from violence, and certain diseases comprised in the old classification under the heading Ill-defined and Not Specified Causes, e.g., Debility, Atrophy, Inanition, terms which find no place in the New List. No. of Deaths. GENERAL DISEASES 1,049 LOCAL DISEASES— Diseases of Nervous System 123 Diseases of Organs of Special Sense 4 Diseases of Heart 209 Diseases of Blood-vessels 125 Diseases of Respiratory Organs 537 Diseases of Digestive System 168 Diseases of Lymphatio System 8 Diseases of Urinary System 99 Diseases of Generative System 10 Accidents of Childbirth 4 Diseases of Locomotive System 6 Diseases of Integumentary System 4 1 ,292 DEATHS FROM VIOLENCE— Accident or Negligence 78 Homicide... — Suicide 22 100 ILL-DEFINED AND NOT SPECIFIED CAUSES 66 Total 2,507 GENERAL DISEASES. The Deaths from the " Principal diseases of the Zymotic Class " were 247, and 70 below the corrected decennial average (317). These deaths, of which 221 belong to the Town sub-district and 26 to Brompton, were equivalent to 138 per 1,000 persons living (T70 in the Town sub-district and 0.53 in Brompton) as compared with 1.37 in 1904, the decennial average being 1.77. The rate in the Metropolis, as a whole, was 1.70 per 1,000 (2.15 in 1904); the decennial average being 2.46. The subjoined table snows the number of deaths from the several diseases occurring in the sub-districts and at outlying public institutions, etc. Disease. Sub-Districts. In Hospital. Total Deaths. Decennial Average. Town. Brompton. Town. Brompton. Uncorrected. Corrected for increase of Population. Small-pox ... ... ... ... ... 1·3 1·3 Measles 52 2 ... ... 54 75·2 77·4 Scarlet Fever ... ... 14 7 21 18·7 19·3 Diphtheria 4 1 2 2 9 43·7 45·0 Whooping-cough 52 5 2 1 60 49·3 50·8 Typhus Fever ... ... ... ... ... 0·3 0·3 Enteric Fever 3 2 6 2 13 14·7 15·1 Simple-Continued Fever ... ... ... ... ... 0·4 0·4 Diarrhœa 77 4 9 ... 90 104·0 107·1 188 14 33 12 247 307·6 316·7 20 Distribution of the deaths from the Principal Zymotic Diseases during the year 1905:— Smallpox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Enteric Fever. Continued Fever. Diarrhœa. Total. Sub-districts— Kensington Town ... 52 14 6 54 9 ... 86 221 Brompton ... 2 7 3 6 4 ... 4 26 parliamentary Divisions— North Kensington ... 46 14 4 43 7 ... 82 196 South Kensington ... 8 7 5 17 6 ... 8 51 Wards— North Kensington St. Charles ... 17 7 2 7 1 ... 22 56 Golborne ... 12 4 2 19 3 ... 32 72 Norland ... 10 2 ... 14 2 ... 21 49 Pembridge ... 7 1 ... 3 1 ... 7 19 South Kensington Holland ... 4 ... 2 6 2 ... 1 15 Earl's Court ... 1 3 ... 4 ... ... ... 8 Queen's Gate ... 2 ... 2 4 ... ... 3 11 Redcliffe ... 1 3 ... 1 3 ... 3 11 Brompton ... ... 1 1 2 1 ... 1 6 District Zymotic Rate.—The deaths from these diseases in North Kensington were 196 and the rate 2.12 per 1,000 persons living. In South Kensington the deaths were 51, and the rate 0.59 per 1,000. The rate in the several wards was as follows:— North Kensington— St. Charles 56 deaths, = 2.5 Golborne 72 deaths, = 2.7 Norland 49 deaths, = 2.l Pembridge 19 deaths, = 1.0 South Kensington— per 1,000 persons living. Holland 15 deaths, = 0.7 Earl's Court 8 deaths, =0. 4 Queen's Gate 11 deaths, = 0.7 Redcliffe 11 deaths, = 0.6 Brompton 6 deaths, = 0.4 The table at page 15 exhibits the distribution of the deaths in the Borough, as a whole, from the several diseases, as recorded in the thirteen four-weekly reports. In Appendix II., statistical information is given in Tables B, C and D, pages 130 and 131, showing the number of deaths from the several diseases during the fifty years, 1856-1905; viz., in Table B, the annual number of deaths from each disease and the death-rate therefrom ; in Table C, the number of deaths grouped in quinquennial periods; in Table D, the rate per 1,000 of the population, in quinquennial periods, of the four notifiable diseases (small-pox, scarlet fever, diphtheria and "fever"), and the three non-notifiable diseases—measles, whooping-cough and diarrhoea. In England and Wales the deaths from these diseases were at the rate of 1.52 per 1,000 persons living, against 1.64, 1.46 and 1.94, respectively, in the preceding three years. In the seventy-six great towns, including London, the average rate was 1.88. The following table shows the rate of mortality per 1,000 persons living from the principal zymotic diseases in Kensington and London, and in England and Wales, in 1905:— Small pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhœa. Kensington 0·00 0·30 0·12 0·05 0·34 0·07 0·50 London 0·00 0·37 0·12 0·12 0·32 00·5 0·72 England and Wales 0·00 0·32 0·11 0·16 0·25 0·09 0·59 21 SMALL-POX. This disease was non-existent in the Borough throughout the year. The corrected decennial average number of deaths from this cause was 1.3. The deaths in London, as a whole, were 10. Eight of the deaths occurred in hospital, to which 53 cases were admitted. The cases notified were 74, compared with 417, and 492 in the preceding two years. The contributory boroughs are set out in the table at page 35. MEASLES. This disease was the cause of 54 deaths, compared with 93, 34, and 67, in the three preceding years ; 52 and 2 in the Town and the Brompton sub-districts respectively ; the corrected decennial average number being 77. The four-weekly tale of deaths is set out in the table at page 15. The deaths from this cause in London, as a whole, were 1,715, and approximately 780 below the corrected decennial average (2,495) : the rate of mortality was 0.37 per 1,000 persons living. The lady sanitary inspectors commenced, in June, a systematic visitation of cases of measles reported by school teachers—to the number of 479 in the seven months. Other 138 cases were met with in the houses visited, making a total of 617 : 588 of the cases were in North Kensington, 509 of them in three wards; viz., in St. Charles Ward 114, Golborne 270, and Norland 125. Four hundred and sixty-four of the sufferers were under five years of age (including 50 under one year) and 127 between 5 and 7 years. All of the 54 deaths were of children below five years of age ; viz., under one year, 13 ; between 1 and 2 years, 25 ; and in the following three years of age, 6, 4, and 6, respectively. The object of the visitation was two-fold ; to impress on mothers the danger of the disease if neglected, and to carry out the requirements of the County Council's order with respect to disinfection. In only a small proportion of the cases was a doctor in attendance, and few precautions appeared to be taken to prevent spread of the disease. Some mothers, indeed, expressed desire for all of the children to get it and " have it over." The disinfections carried out were few compared with the number of cases; but in many houses several children, often in more than one family, were ill, simultaneously or successively, and disinfection could not be carried out until after recovery of the last case. A Leaflet calling attention to the serious nature of the disease, and the danger incurred through neglect of proper care of the little sufferers, was distributed at every known infected house. SCARLET FEVER. The notifications of scarlet fever were 332, compared with 372, 320, and in the preceding three years: 186 in North Kensington and 146 in South Kensington. The deaths were 21 (a case-mortality of 6.3 per cent.) and 2 above the corrected decennial average (19). Fourteen belonged to the Town sub-district, and 7 to Brompton. All of them occurred at outlying public institutions, to which 301 cases were removed. The rate of mortality was 0.12 of the population. The deaths in the preceding three years were 21, 14, and 5, respectively. A group of ten cases may be cited as an illustration of a not uncommon mode of spread of the disease. The first case, which ended fatally, was notified, on August 1st, at a house in Kramer Mews. Four cases, in one family, were notified at a house in Richmond Road on the 9th, and suspicion having been directed to a second house in Kramer Mews, it was ascertained that four children thereat, all in one family, had the disease; but not being " ill," were allowed to be, and were seen, in the street. These children were the source of infection to the other five cases, and to a fifth member of their own family subsequently. All of the cases were removed to hospital. The mother of the four children in Kramer Mews was away from home ill. The father, a coal-carman, always away from home from early morning till late in the evening, professed ignorance of the nature of what appeared to him to be a trifling ailment of the children; and there was no ground for questioning his good faith. These children who when first seen, were " peeling," had visited at the house whence the first case had been removed, and had played in the street with the first mentioned group of children. The information as to scarlet-fever mortality in the borough in the fifty years—1856-1905 —set out in Appendix II. (Tables B, C, D, pages 130 and 131) shows the great reduction in the fatality of this disease in recent years. The deaths in London, as a whole, were 549, compared with 563, 362, and 365, in the preceding three years, the corrected decennial average being 595. Of the 549 deaths 538 (98 per cent.) took place in public institutions. The case-mortality was 3.1 per cent.; the mortality-rate 0.12 per 1,000 of the population. 22 Scarlet Fever was more than usually prevalent in London throughout the second half of the year; and consequent on the rise in admissions, as well as in view of the situation as regards patients' accommodation, the Hospitals Committee of the Asylums Board gave instructions, in July, for the Upper Hospital at Gore Farm to be opened for convalescing cases. The ordinary accommodation at their disposal was less than the normal, the South-Eastern hospital (488 beds) being in course of reconstruction and the new Southern Convalescent Hospital (800 beds) not being ready for occupation, although the contract time had expired. The notifications were 19,467, compared with 18,258, 12,536, and 13,439, in the preceding three years. The mortality-rate was 2.8 per cent, on cases notified, compared with 3.1, 2.9, and 2.7 in the preceding three years. The admissions to hospital were 17,230, compared with 14,883, 10,580, and 11,401, in the preceding three years, or about 88.5 per cent, on cases notified, At the close of the year there were 3,446 cases remaining in hospital, compared with 2,327, 1,632, and 2,386, at the corresponding period in the preceding three years. The subjoined table shows the degree of prevalence of scarlet fever in the Borough, and in London, as a whole, as indicated by the number of notifications, and of deaths, in thirteen successive four-weekly periods, as set out in my reports:— Scarlet Fever in 1905. Report for four weeks ended No. of Notifications. No. of cases admitted to Hospitals. No. of Deaths. No. of cases in Hospital at the end of the period Kensington London. Kensington. London. Kensington. London. January 28 19 972 13 857 — 39 2,096 February 25 16 1,087 12 954 2 41 1,987 March 25 32 1,233 28 1,129 1 50 2,034 April 22 15 1,181 12 1,089 1 40 2,128 May 20 35 1,253 32 1,128 2 34 2,211 June 17 36 1,365 33 1,224 1 30 2,356 July 15 27 1,460 25 1,369 2 37 2,520 August 12 34 1,464 36 1,377 2 39 2,670 September 9 21 1,683 21 1,574 2 38 2,982 October 7 31 2,184 29 2,051 1 38 3,789 November 4 21 2,212 19 2,061 4 55 4,200 December 2 32 1,984 28 1,764 1 45 4,021 December 30 13 1,389 13 1,286 2 63 3,446 332 19,467 301 17,863 21 549 For the sake of comparison, I subjoin the corresponding table for 1904, taken from the report for that year. Scarlet Fever in 1904. Report for four weeks ended No. of Notifications. No. of cases admitted to Hospitals. No. of Deaths. No. of cases in Hospital at the end of the period. Kensington. London. Kensington. London. Kensington. London. January 30 23 819 21 744 — 39 1,651 February 27 18 696 17 624 — 21 1,587 March 26 19 774 16 666 — 17 1,585 April 23 15 751 12 676 1 25 1,543 May 21 28 1,023 25 888 — 25 1,630 June 18 25 924 20 800 — 25 1,630 July 16 23 1,070 18 951 — 27 1,698 August 13 26 931 22 832 — 23 1,763 September 10 11 1,037 11 961 1 21 1,816 October 8 22 1,580 19 1,430 — 30 2,341 November 5 24 1,557 23 1,365 1 38 2,782 December 3 12 1,192 10 1,062 1 41 2,625 December 31 16 1,081 11 948 1 33 2,386 262 13,435 225 11,947 5 365 Note. Correction has not been made in the two tables for errors in diagnosis, either with respect to notifications, or admissions to hospital. The notifications are collated from the weekly returns of the Asylums Board ; the admissions to, and numbers in, the hospitals, and the deaths in London, from the weekly returns of the Registrar-General. 23 The following tables exhibit certain particulars of interest with respect to scarlet fever prevalence, &c., during 1905, and the preceding ten years, 1895-1904:— Scarlet Fever in Kensington, 1895-1905. Year. Cases notified. Case rate per 1,000 of population. Deaths. Death rate per 1,000 of population. mor/tality per cent 1895 525 3·10 27 0·16 5·1 1896 1,011 5·95 39 0·23 3·9 1897 749 4·33 29 0·17 3·9 1898 474 2·75 23 0·13 4·8 1899 443 2·57 10 0·06 2·2 1900 367 2·12 4 0·02 1·4 1901 475 2·68 15 0·08 3·2 1902 372 2·09 21 0·12 5·6 1903 330 1·85 14 0·08 4·2 1904 262 1·47 5 0·03 1·9 1905 332 1·85 21 0·12 6·3 Scarlet Fever Cases Recorded in Kensington in 1905, and in the Preceding Ten Years, in Thirteen Four-Weekly Periods. The Year. Weeks. 1-4. Weeks. 5-8. Weeks. 9—12. Weeks. 13-16. Weeks. 17-20. Weeks 21—24. Weeks. 25—28. Weeks 29—32. Weeks. 33-36. Weeks. 37—40. Weeks. 41-44. Weeks. 45-48. Weeks. 49—52. Total. 1905 19 16 32 15 35 36 27 34 21 31 21 32 13 332 1904 23 18 19 15 28 25 23 26 11 22 24 12 16 262 1903 18 12 32 31 27 17 37 46 28 21 24 17 20 330 1902 36 31 27 30 33 21 32 20 26 35 37 18 26* 372 1901 26 19 22 18 31 32 45 56 46 48 52 43 37 475 1900 32 26 28 28 20 22 32 21 23 25 41 31 35 364 1899 26 20 20 27 26 38 40 47 35 47 42 55 22 445 1898 34 40 34 39 31 31 40 45 38 31 33 38 34 468 1897 43 32 40 28 33 58 68 51 55 133 88 84 34 747 1896 79 90 57 45 37 68 93 94 92 84 104 91 77* 1011 1895 20 22 20 23 22 33 39 40 24 63 91 62 66 525 Average 1895-1904 33·7 31·0 29·9 28·4 28·8 34·5 44·9 44·6 37·8 50·9 53·6 45·1 36·7 500† * Return comprises five weeks. †Without correction for increase in population. 24 Statistics of Scarlet Fever in Kensington in 1905, and in the Preceding Ten Years. The Year. No. of Recorded Cases. Total Number of Recorded Cases Percentage of Removals to total Recorded Cases. Deaths. Total Deaths. Percentage of Deaths. Percentage of Deaths to Recorded Cases. Deaths in London from Scarlet Fever. Treated at Home. Removed to Hospital. At Home. In Hospitals. At Home. In Hospitals. 1905 31 301 332 91 - 21 21 — 100 6·3 549 1904 37 225 262 86 - 5 5 - 100 1·9 365 1903 53 277 330 84 2 12 14 14 86 4·2 362 1902 61 311 372 84 2 19 21 10 90 5·6 563 1901 92 383 475 81 4 11 15 27 73 3·2 584 1900 74 290 364 79 — 4 4 — 100 1·4 361 1899 101 344 445 77 2 8 10 20 80 2·2 398 1898 117 361 478 76 1 22 23 3·4 95·6 4·8 583 1897 188 561 749 75 3 26 29 10·3 89·7 3·9 780 1896 248 763 1011 75 7 32 39 18 82 3·9 942 1895 167 358 525 68 12 15 27 44 56 5·1 829 DIPHTHERIA. The cases notified as diphtheria (including membranous croup, classified by the RegistrarGeneral as diphtheria) were 125; compared with 184, 160, and 186, in the preceding three years; 58 in North Kensington, and 67 in South Kensington. The deaths were 9 (a case-mortality of 7.2 per cent.), and 36 below the corrected decennial average (45); 6 in the Town sub-district, and 3 in Brompton. Four of the deaths took place in hospitals, to which 100 cases were removed—a case-mortality of 4.0 per cent. Seven of the deaths were of children under five years of age. The mortality rate was 0 05 per 1,000 of the population. Detailed information in regard to diphtheria mortality in the borough—1856-1905—is set out in Appendix II., Tables B, C, and D pp. 130 and 131. The deaths in London, as a whole, were 553, and considerably less than a third of the corrected decennial average number (1,719), compared with 1,181, 752, and 729, in the three preceding years. The mortality rate was 012 per 1,000 of the population. The notifications were 6,489 in number, compared with 10,735, 7,727, and 7,224, in the three preceding years. The cases admitted to hospital were 4,180, compared with 8,086, 5,113, and 4,739, in the preceding three years; and the deaths in hospital 348, a case-mortality of 8.3 per cent. At the close of the year there were 701 cases under treatment in the hospitals, compared with 927, 739, and 807, at the corresponding period in the preceding three years. 25 The subjoined table, based on the thirteen four-weekly reports, set out certain particulars with regard to diphtheria, in Kensington, and in London as a whole:— Diphtheria in 1905. Report for four weeks ended No. of Notifications. Kensington. London. No. of cases admitted to Hospital. Kensington. London. No. of Deaths. Kensington. London. No. of cases in Hospital at the end of the period. January 28 13 570 11 463 1 51 840 February 25 11 567 9 476 1 53 841 March 25 3 488 1 380 1 50 807 April 22 13 469 11 375 1 41 731 May 20 11 445 10 344 2 39 686 June 17 11 443 8 398 ... 31 719 July 15 11 562 8 478 1 30 764 August 12 9 436 6 390 1 35 706 September 9 4 409 5 359 ... 31 686 October 7 8 568 7 487 ... 42 775 November 4 10 558 5 449 ... 40 804 December 2 17 489 15 407 1 43 725 December 30 4 485 4 404 ... 67 701 125 6,489 100 5,410 9 553 Note.—Correction has not been made in the above table for errors in diagnosis, either with respect to notifications or admissions to hospitals. The following table gives particulars with respect to diphtheria in North and South Kensington respectively. Set out in Report for Four weeks ended. Total Cases Recorded. Cases Recorded in North Kensington.* Cases Recorded in South Kensington.* Cases removed to Hospital from— Deaths (4 in Hospital). North Kensington. South Kensington. North Kensington. South Kensington. January 28 13 7 6 6 5 1 ... February 25 11 7 4 6 3 1 • •• March 25 3 2 1 ... 1 1 • • • April 22 13 7 6 7 4 1 ... May 20 11 2 9 2 8 ... 2 June 17 12 5 7 5 3 ... ... July 15 9 6 3 5 3 ... 1 August 12 9 4 5 4 2 ... 1 September 9 5 3 2 3 2 ... • •• October 7 8 5 3 4 3 ... ... November 4 10 5 5 4 1 ... ... December 2 17 5 12 5 10 ... 1 ,, 30 4 ... 4 ... 4 ... ... 125 58 67 51 49 4 5 *North Kensington and South Kensington are the districts to the north and the south of the centre of Notting-hill High-street, and Holland-park-avenue, respectively. 26 Diphtheria in Kensington, 1895-1905. Year. Cases Notified. Case rate per 1,000 of population. Deaths. Death rate per 1,000 of population. Case Mortality per cent. 1895 378 2.23 89 0.53 23.5 1896 371 2.18 72 0.42 19.4 1897 332 1.94 82 0.48 24.7 1898 222 1.29 26 0.15 11.7 1899 257 1.49 42 0.24 16.3 1900 332 1.92 27 0.16 8.1 1901 250 1.41 38 0.21 15.2 1902 184 1.04 20 0.11 10.9 1903 158 0.90 24 0.13 15.2 1904 186 1.04 17 0.09 9.1 1905 125 0.70 9 0.05 7.2 WHOOPING-COUGH. Whooping-cough was the cause of 60 deaths, compared with 21, 90, and 19, in the preceding three years; 54 in the Town sub-district, and 6 in Brompton; the corrected decennial average being 51. Fifty-seven of the deaths were of children under five years of age, including 24 under one year. The mortality rate was 0.34 per 1,000 of the population. The four-weekly tale of deaths is set out in the table at page 15. The lady sanitary inspectors commenced, in June, a systematic visitation of cases of whooping-cough reported by school teachers, to the number of 43; other 24 cases having been found in the houses visited making a total of 67 in the seven months. All but three of the cases were in three wards in North Kensington; viz., in St. Charles 31, in Golborne 18, and in Norland 15. Thirty-nine of the sufferers were under five years of age; (5 under one year) and 28 between 5 and 14 years. All but three of these deaths were of children under five years of age; 24, 18, and 7, in the first, second and third years, respectively. Between three and five there were 8 deaths, and 3 between five and seven. Of the 60 deaths during the year, 50 had occurred before the inspectors began their new work. It was made apparent that mothers attached little importance to the disease, a doctor seldom being called in. The inspectors' visits were well received, and it may be hoped that the oral advice given will have served a useful purpose, supported as it was by distribution of a Leaflet calling attention to the serious nature of the disease, and the danger incurred through neglect of proper care of the little sufferers. The deaths in London, as a whole, were 1,507, and 434 below the corrected decennial average (1,941). The mortality rate was 0.36 per 1,000 of the population. FEVER. The notified cases of Enteric Fever were forty-nine in number, compared with 80, 61, and 46, in the preceding three years. The deaths were 13 (2 below the corrected decennial average), 9 of them belonging to the Town sub-district. Eight of the deaths took place in hospitals, to which 40 cases were removed. The deaths from this cause in the preceding three years were 19, 9, and 6 respectively. The mortality rate was 0.07 per 1,000 of the population. In a few of the cases there was ground for suspicion that the illness had been caused by the eating of shellfish—oysters in two instances. 27 Enteric Fever in Kensington, 1895-1905. Year. Cases Notified. Case rate per 1,000 of population. Deaths. Death rate per 1,000 of population. Case Mortality per cent. 1895 99 0.58 15 0.08 15.1 1896 94 0.55 15 0.08 16.0 1897 117 0.69 21 0.12 18.0 1898 104 0.60 12 0.07 11.5 1899 107 0.62 23 0.13 21.5 1900 104 0.60 16 0.09 15.4 1901 97 0.55 11 0.06 11.3 1902 80 0.45 19 0.11 23.7 1903 61 0.34 9 0.05 14.8 1904 46 0.26 6 0.03 13.0 1905 49 0.27 13 0.07 26.5 The deaths in London, as a whole, were 243 (the lowest number on record), and 353 below the corrected decennial average (596). The notifications were 1,549 (1,902 in 1904): the admissions to hospitals 587 (compared with 1,806,967, and 750, in the preceding three years), and the deaths therein 82. At the close of the year there remained 78 cases under treatment, against 210, 246, and 159, at the corresponding period of the preceding three years. The mortality rate was 0.05 per 1,000 of the population. No case of Typhus Fever was notified in the Borough; and 9 cases only in London, as a whole, there being no death from this cause. No death occurred in the Borough from simple continued fever (Pyrexia); two cases were notified. The deaths and notifications in London, as a whole from this cause, were 3 and 14 respectively. DIARRHŒA. Diarrhoea was the cause of 90 deaths, compared with 78, 97, and 128, in the preceding three years; 86 in the Town sub-district and 4 in Brompton; the corrected decennial average being 107. The deaths under one year, 65, were in the proportion of 18.8 per 1,000 births. The mortality rate was 0.50 per 1,000 of the population. The deaths in London, as a whole, were 3,410, and 571 below the corrected decennial average (3,981): 3,145 of the deaths were of children under five years of age, including 2,642 of infants under one year. The mortality rate was 0.72 per 1,000 of the population. Of the 3,356 deaths 2,125 were certified Epidemic Diarrhœa, or Infective Enteritis, and 1,285 Diarrhœa, Dysentery. INFLUENZA. Forty-nine deaths were registered from influenza, as compared with 68, 41, and 50, in the three preceding years; 36 in the Town sub-district, and 13 in Brompton. The deaths in London, as a whole, from this cause were 689, against 1,073, 644, and 709, in the preceding three years. 28 OTHER GENERAL DISEASES. Syphilis was the cause of 22 deaths, 21 of them in the Town sub-district. Puerperal Diseases caused three deaths—between 25 and 45 years of age—two of them in the Town sub-district. Four deaths were registered as having occurred from accidents connected with childbirth. The deaths registered as having been caused by diseases and accidents associated with parturition (seven in all), were equal to 2.0 per 1,000 live births, compared with rates of 2.9, 2.2, and 3.5 per 1,000 in the three preceding years respectively. Erysipelas was the cause of seven deaths, all of them in the Town sub-district. The notifications of Erysipelas were 157 in number. Tuberculosis in its various forms was the cause of 273 deaths, as compared with 310, 285, and 342, in the three preceding years; 225 in the Town sub-district, and 48 in Brompton; 55 of them under five years of age. Tubercular Phthisis (Pulmonary Tuberculosis) was the certified cause of 153 deaths (128 and 25 in the Town and Brompton sub-districts respectively), and "phthisis" of 46: total 199, or l.ll per 1,000 of the population. Tubercular Meningitis was the cause of 27 deaths; Tubercular Peritonitis of 7; and General Tuberculosis of 25. The deaths from Tubercular Diseases were, proportionately to population, not so numerous in Brompton as in the Town sub-district. The total deaths were in the proportion of 1.5 per 1,000 of the population. Further information on the subject of Tuberculosis will be found at pp. 40 and 54. Deaths and Death Rate from Phthisis and other Tuberculous Diseases in 1905. District. Phthisis. Other Tuberculous diseases. Total. No. of deaths Rate. No. of deaths. Rate No. of deaths. Rate. Kensington Town 166 1.28 59 0.45 225 1.73 Brompton 33 0.67 15 0.30 48 0.97 The Borough 199 1.11 74 0.41 273 1.52 London 6,809 1.45 2,514 0.52 9,323 1.97 Tuberculosis in Kensington, 1895-1905. Year. Deaths from Phthisis per 100,000 persons living. Deaths from other Tuberculous Diseases per 100,000 persons. Total deaths from Tuberculosis per 100,000 persons living. 1895 149.4 57.3 206.7 1896 140.2 46.3 206.5 1897 140.6 58.6 199.2 1898 126.2 67.4 193.6 1899 128.2 56.8 185.0 1900 121.4 55.5 176.9 1901 132.5 45.3 177.8 1902 123.9 50.7 174.6 1903 119.1 41.0 160.1 1904 126.6 65.0 191.6 1905 111.2 41.3 152.5 29 The deaths from Tubercular Diseases in London, as a whole, were 9,323. Of these deaths, 6,809 were due to Phthisis. The death-rate from Phthisis in London, in 1905, per 1,000 persons living, was 1.45 against 1.64, 1.60, and 1.67, in the preceding three years, and a decennial average of 1.69. Phthisis mortality ranged from 0.83 per 1000 persons living in Hampstead; 0.85 in Lewisham, and 0.96 in Paddington; to 1.96 in Shoreditch, 2.02 in Finsbury, 2.04 in Bethnal Green, 2.13 in Southwark, and 2.84 in Holborn. Alcoholism, Delirium Tremens, was the cause of 10 deaths; six in the Kensington Town sub-district, and 4 in Brompton. The deaths in London, as a whole, were 498. It is probable that if all the deaths due, directly or indirectly, to the immoderate use of intoxicating liquors were correctly certified, alcoholism would occupy a more prominent position in the bills of mortality; many deaths due to the misuse of alcohol are certified, and necessarily classified, to visceral and degenerative diseases caused or aggravated by drink. Rheumatic Fever, Acute Rheumatism, was the cause of 5 deaths, four of them in the Town sub-district. Malignant Disease, Cancer, was accountable for 172 deaths; 123 in the Town sub-district and 49 in Brompton. Carcinoma was the registered cause in 77 cases, Sarcoma in 6, and Malignant Disease, Cancer, in 89. Cancer would appear to be on the increase in the country generally; possibly, however, some portion of the apparent increase in the number of deaths classified to this cause, may be due to greater accuracy in diagnosis. The deaths in Kensington in the ten preceding years were 136, 173, 168,193, 169, 152, 185, 155, 187, and 174, respectively. The deaths in 1905 were equal to 9.6 per ten thousand of the population, and to 6.9 per cent. of all deaths registered. Deaths from Malignant Disease are usually more numerous, proportionately to population, in the Brompton sub-district than in the Town sub-district, cancer being quite as prevalent, probably more prevalent, amongst well-to-do people, than in the poorer classes. The parts of the body most commonly affected are the viscera or internal organs; in women, the uterus and the breast; the disease, moreover, being for the most part one of later life. Thus 156 of the deaths took place at ages above forty-five, and 13 between thirty-five and forty-five years. In London, as a whole, the deaths from Malignant Disease, Cancer, were 4,675. Premature Birth was the cause of 72 deaths; 58 in the Town sub-district and 14 in Brompton; Old Age (Spenile decay) of 92; 73, and 19, in the two sub-districts respectively; including 9 between 65 and 75 years, 46 between 75 and 85, and 34 at 85 years and upwards. LOCAL DISEASES. Nervous System.—The deaths from the diseases of this system were 123; 98 in the Town sub-district and 25 in Brompton—as compared with 146, 123, and 108, in the three preceding years: 30 of them occurred under five years of age. Eighteen of the deaths were due to Convulsions (an objectionable term), and 28 to diseases which, not being named specifically in the "New List," are classified to "Other Diseases" of the System. The number of deaths from the several other diseases are set out in Table VIII., page 112. Circulatory System. — The deaths from Diseases of the Heart were 209; 153 in the Town sub-district and 56 in Brompton—as compared with 251, 196, and 212, in the three preceding years. The larger proportion of the deaths, 105, were registerd from "Syncope, Heart Disease (not specfied)* Valvular Disease was accountable for 62 deaths, Angina Pectoris for 5, Dilatation of Heart for 20, and Fatty Degeneration for 14. Diseases of Blood Vessels were the causes of 125 deaths; 93 in the Town sub-district and 32 in Brompton, including 70 from Cerebral Hemorrhage, Embolism, Thrombosis; and 29 from Apoplexy, Hemiplegia, conditions which generally connote cerebral hemorrhage. * A considerable number of deaths are certified as due to "Failure of the Heart," in persons dying in old age. These deaths are classified to " Old Age" in Table viii., page 112. 30 Respiratory System.—The diseases of the Respiratory organs (phthisis being excluded), were accountable for 537 deaths (21 more than in 1904, and 21.4 per cent. on total deaths); 443 in the Town sub-district and 94 in Brompton—as compared with 626, 482, and 516, in the three preceding years. The principal causes were Bronchitis 230 deaths, and Pneumonia, in one or other of its forms, 239 deaths. The deaths under five years of age were 184, or 34.3 per cent. of the total number, as compared with 31.8, 38.1, and 30.6, per cent. in the three preceding years; and at 55 and upwards, 252, or 46.9 per cent., against 44.9, 43.1, and 47.9, in the three preceding years. Bronchitis and Pneumonia were accountable for 469 deaths (including 175 under five years of age), of which 82 were registered in the Brompton sub-district. Digestive System.—The diseases of the Digestive System were accountable for 163 deaths; 114 and 49 in the Town and Brompton sub-districts, respectively; 42 of them under five years of age. The chief causes were Cirrhosis of the Liver 19 deaths, Other Diseases of the Liver and Gall Bladder 26 deaths, Intestinal Obstruction 20, Enteritis 26, Gastric Ulcer 9, and Appendicitis 17. Urinary System.— Ninety-nine deaths were due to diseases of the urinary system; 69 and 30 in the Town and Brompton sub-districts respectively; Chronic Bright's Disease (Albuminuria), being the cause of 65 deaths, Bladder and Prostate Disease of 16, and Other Diseases of the Urinary System, of 16. DEATHS FROM VIOLENCE. One hundred deaths, including 22 under five years of age, and 16 under one year, were caused by violence; 71 belong to the Town sub-district, and 29 to Brompton. Accident or Negligence occasioned 78 deaths; 57 in the Town sub-district, and 21 in Brompton; 22 of them under five years of age, and 16 under one year. Fractures and Contusions were responsible for 40 deaths, Burn, Scald, for 8, and Suffocation for 14—of which 11 were of infants under one year. Suicide accounted for 22 deaths; 14 and 8 in the Town and Brompton sub-districts respectively; from Gun Shot Wounds 1, Cut, Stab 1, Poison 7, Drowning 2, Hanging 5 and otherwise 6. Ill-defined and Not specified Causes of death were returned in 66 cases; 56 in the Town subdistrict and 10 in Brompton: 62 were certified due to Debility, Atrophy, Inanition, 60 of them of infants under one year. DEATHS AT PUBLIC INSTITUTIONS. The only large public institution in which we are directly interested is the Poor-law infirmary located in the Town sub-district. There are several public institutions, at which the deaths are mainly of non-parishioners; viz., St. Marylebone Infirmary, St. Luke's House for the dying, Pembridge Square, the Jubilee Hospital at Brompton, the Brompton Consumption Hospital, and St. Joseph's House, Portobello Road, Notting Hill, a Roman Catholic Home for aged poor persons of both sexes. The deaths of non-parishioners at St. Marylebone Infirmary (508), at the Brompton Consumption Hospital (56) at St. Luke's House (52), at the Jubilee Hospital (16), at Kensington Children's Hospital, Church Street (2), and at St. Joseph's House (21) are excluded from our statistics. The deaths of parishioners registered at the Infirmary and Workhouse (553), at the Consumption Hospital (2), at St. Marylebone Infirmary (1), at the Jubilee Hospital (1), at Kensington Children's Hospital (5), at St. Luke's House (3), at St. Joseph's House (2) and at outlying public institutions (296), aggregate 863; or 34.4 per cent. of total deaths. 31 Kensington Deaths in Public Institutions, 1895-1905. Year. Total Deaths in Borough. Deaths in Public Institutions. Proportion per cent. of Deaths in Public Institutions to Total Deaths. 1895 2,748 762 27.7 1896 2,891 817 28.3 1897 2,667 839 31.5 1898 2,798 782 27.9 1899 3,021 942 31.2 1900 2,698 764 28.3 1901 2,650 801 30.2 1902 2,746 832 30.3 1903 2,455 772 31.4 1904 2,540 784 30.9 Average, 1895-1904 2,721 809 29.8 1905 2,507 863 34.4 The percentage proportion of deaths in public institutions in the Metropolis in 1905 was 37.5; viz., 19.3 in workhouses and workhouse infirmaries; 1.5 in Metropolitan Asylums Board Hospitals; 13.6 in other hospitals, and 3.1 in public lunatic and imbecile asylums. The Registrar-General in his Annual Summary states that "about one in every five deaths occurred in a workhouse or workhouse infirmary, one in every 68 in a Metropolitan Asylums Board Hospital, one in every 7 in some other hospital, and one in every 33 in a public lunatic or imbecile asylum." The increase in the number of deaths in public institutions has been great and continuous for many years. The Borough Infirmary.— I am indebted to Dr. H. Percy Potter, the medical superintendent, for the statistics of mortality at this important institution. The deaths, the causes of which are set out in the table below, were 552, compared with 528, 460, and 471, in the three preceding years respectively, and were equal to 22 per cent., or more than one-fifth of all the deaths recorded in the borough. The quarterly numbers were 134, 122, 129, and 167; 301 deaths, therefore, occurred in the first and fourth or colder quarters, and 251 in the second and third or warmer quarters of the year. The deaths included 287 of males and 265 of females. The ages at death were:—Under one year, 72 (compared with 61, 65, and 36, in the three preceding years respectively); between one and sixty, 270 (compared with 254, 218, and 237, in the three preceding years), and at sixty and upwards, 210 (compared with 213, 177, and 198, in the three preceding years). SUMMARY OF CAUSES OF DEATH, 1905. DISEASES. Under 1 year. Between 1 year and 60 years. At 60 years and upwards. Total. Nervous System, Diseases of 1 29 17 47 Circulatory System, Diseases of 2 22 60 84 Respiratory System, Diseases of 9 53 57 119 Digestive System, Diseases of 3 13 19 35 Urinary and Generative Systems, Diseases of - 13 7 20 Tubercular Diseases (including Marasmus) 22 89 12 123 Cancer - 16 15 31 Measles 6 17 - 23 Influenza - 3 - 3 Gangrene - 1 8 9 Various other Diseases 24 14 9 47 Premature Birth 5 - - 5 Senile Decay - - 6 6 72 270 210 552 32 Twelve inquests were held: in each of six cases a verdict of "natural death" was returned; the other six deaths were caused by accidents of various descriptions. Outlying Public Institutions.—The deaths of parishioners at public institutions, etc., without the borough, which in the three preceding years had numbered 315, 318, and 339, respectively, were 324 in 1905. All of these deaths are included in the borough statistics. The deaths occurred at the several institutions as follows:— St. Mary's Hospital 79 St. George's Hospital 27 West London Hospital 14 Charing Cross Hospital 7 St. Thomas's Hospital 5 Middlesex Hospital 3 St. Bartholomew's Hospital 3 King's College Hospital 1 Guy's Hospital 1 London Hospital 1 M.A.B. Western Hospital 35 North Western Hospital 1 Brompton Hospital (South Wing) 4 Cancer Hospital, Chelsea 2 Children's Hospital, Paddington 14 Victoria Hospital for Children 4 Children's Hospital, Great Ormonde Street 2 North — Eastern Children's Hospital 2 Chelsea Hospital for Women 2 Queen Charlotte's Hospital 2 Home Hospital, Fitzroy Square 1 National Hospital 1 St. Saviour's Hospital 1 Friedenheim 2 Hostel of St. John and St. Elizabeth 1 St. Peter's Home 1 St. Thomas's Home 1 Home for Sick Children, Sydenham 1 Paddington Workhouse 1 Fulham Infirmary 1 Banstead Asylum 16 Horton Asylum 9 Hanwell Asylum 18 Norwood Asylum 7 Colney Hatch Asylum 6 Cane Hill Asylum 5 Leavesden Asylum 6 Claybury Asylum 2 Caterham Asylum 1 Dartford Asylum 1 Tooting Bee Asylum 1 Camberwell House Asylum 4 Friern Barnet Asylum 2 Metropolitan Benefit Asylum, Balls Pond Road 1 Middlesex County Asylum, Wandsworth 1 Epileptic Colony, Epsom 1 United Service Club 1 296 Other 28 deaths occurred without the borough; viz., by drowning, two of males and one of a female in the Thames, and two of males in the Grand Junction Canal; two of males and one of a female at railway stations; five of males in the street; and eight of males, and seven of females on private premises. Deaths from diseases of the zymotic class occurred at public institutions without the borough as follows:—Western Hospital 31 (scarlet fever 21, diphtheria 4, enteric fever 6); Children's Hospital, Paddington 3 (diarrhœa 2, whooping-cough 1); St. Mary's Hospital 2 (diarrhœa); Victoria Hospital for Children 2 (enteric fever 1, whooping-cough 1); North-Eastern Children's Hospital 2 (diarrhœa); West London Hospital 1 (diarrhœa); Children's Hospital, Great Ormonde Street 1 (whoopingcough); Horton Asylum 1 (diarrhœa); Hanwell Asylum 1 (diarrhœa). One death from enteric fever took place at a private house in Paddington. UNCERTIFIED DEATHS. There was not one death in the borough that was not "certified," either by a registered medical practitioner or by a coroner. In England and Wales the deaths not certified were 1.6 per cent. of totals deaths; the proportion in London was 0.2. The subject of uncertified deaths was considered, in the Session of 1893, by a Select Committee of the House of Commons, appointed "to inquire into the sufficiency of the existing law as to the disposal of the dead for securing an accurate record of the causes of death in all cases, and especially for detecting them when death may have been due to poison, violence or criminal neglect." The recommendations of the Committee were summed up in ten paragraphs, of which the first two were as follows:— 33 "(1) That in no case should a death be registered without production of a certificate of the cause of death, signed by a registered medical practitioner, or by a coroner after inquest. "(2) That in each sanitary district a registered medical practitioner should be appointed as public medical certifier of the cause of death in cases in which a certificate from a medical practitioner in attendance is not forthcoming." No action has been taken, so far, to give effect to the recommendations. INQUESTS. Two hundred and seventeen inquests were held on parishioners, including 48 at places without the borough, mostly at public institutions to which the deceased persons had been removed for treatment. The cause of death is stated to have been ascertained by post mortem examination in 133 cases. Forty-five inquests were held on the bodies of non-parishioners who had died in Kensington. All of the inquests in the borough were held at the coroner's court at the Town Hall. The causes of death may be classified as follows:— Deaths caused by disease 117 Deaths caused by violence (100), viz.:— Accidental 78 Suicidal 22 100 Total 217 Of the 22 suicidal deaths, 8 belong to the Brompton sub-district and 14 to the Town subdistrict. The inquests on Kensington parishioners were in the proportion of 8.7 per cent. on total deaths, the rate in the Metropolis being 9.9 per cent.; in England and Wales the rate was 6.8 per cent. The relative percentages in 1904 were 8.010, 9.6 and 6.5, respectively. The deaths from violence (100) were equal to 0.56 per 1,000 of the population in Kensington; the corresponding rates were 0.65 per 1,000 in London, as a whole, and 0.57 per 1,000 in England and Wales. NOTIFICATION OF INFECTIOUS DISEASE. The tables at pp. 34-38 show (1) the number of notifications of all the scheduled diseases in London in the 16 years, 1890-1905; (2) the ages at notification in 1905, (3) the cases notified in the several Metropolitan boroughs, (4) the relative prevalence of the several diseases at different periods of the year in Kensington and in London, (5) the notifications in Kensington, and in the several divisions thereof, in 1905, and (6) the notifications, gross and proportional numbers, and percentages of removals to hospital in Kensington in the years 1895-1905 inclusive. The Kensington notifications in 1905, 669—487 in the Town sub-district, and 182 in Brrompton, were the lowest number on record save in the preceding year, when they were 651, exclusive of 271 of chicken-pox, a disease not notifiable in 1905. The notifications in the ten years and other particulars are set out in the table, at page 38. Table XII. (Appendix 1, page 112) shows the streets, etc., where cases of the scheduled diseases occured; Table XIII. (page 121) the streets with which deaths from these causes were connected. The cases notified in London were 32,880. 34 The notifications in London of each of the diseases during the sixteen years, 1890-1905, are set out in the subjoined table. Year. Small-pox. Chicken-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever Erysipelas. Croup. Cholera. Relapsing Fever. Total. 1890 60 ... 15,330 5,870 2,877 35 237 206 4,598 550 25 7 29,795 1891 114 ... 11,398 5,907 3,372 27 152 221 4,764 505 23 39 26,522 1892 423 ... 27,096 7,791 2,465 20 147 347 6,934 565 54 7 45,849 1893 2,813 ... 36,901 13,026 3,663 22 205 397 9,700 668 86 4 67,485 1894 1,192 ... 18,440 10,655 3,360 21 162 253 6,080 535 21 2 40,721 1895 978 ... 19,757 10,772 3,506 14 105 236 5,660 451 29 3 41,511 1896 225 ... 25,638 13,361 3,189 6 102 278 6,438 446 13 3 49,699 1897 105 ... 22,876 12,811 3,113 4 65 264 5,801 388 38 1 45,466 1898 35 ... 16,917 11,561 3,032 17 55 250 5,180 310 23 — 37,380 1899 29 ... 18,112 13,363 4,460 14 69 329 5,615 338 15 — 42,344 1900 87 ... 13,812 11,788 4,309 7 73 237 4,776 210 5 — 35,304 1901 1,702 ... 18,387 11,967 3,193 20 48 250 4,604 187 3 — 40,361 1902 7,794 25,708 18,246 10,542 3,405 4 48 313 5,537 192 1 — 71,790 1903 417 ... 12,536 7,571 2,337 22 40 231 4,376 156 — — 27,686 1904 492 10,940 13,435 7,079 1,902 3 28 274 4,952 145 1 — 39,251 1905 74 ... 19,467 6,365 1,549 9 14 291 4,987 124 — — 32,880 The Ages at notification of certain of the diseases, in 1905 were as follows:— Age. Small-pox. Scarlet Fever Diphtheria. Enteric Fever. Erysipelas. Puerperal Fever. 0—1 year 3 264 179 2 205 - 1—5 5 6,178 2,570 72 215 - 5— 8 8,232 2,066 211 181 - 10— 7 2,811 682 199 226 - 15— 4 833 284 207 269 9 20— 8 524 246 220 302 80 25— 23 489 301 328 655 147 35— 9 94 104 199 869 55 45— 5 23 36 86 876 1 55— - 12 8 23 638 - 65 and upwards 2 1 5 5 535 - Age not stated - - 1 - 1 - 35 Cases of Infectious Disease notified in the several Metropolitan Boroughs in the Fifty-two Weeks ended Saturday, 30th December, 1905. Name of Borough. Small-pox. Scarlet Fever. Diphtheria. Enteric Fever. Typhus Fever. Other Continued Fevers. Puerperal Fever. Erysipelas. Membranous Croup. Cholera. Totals. Population. 1901. West. Kensington ... 332 124 49 ... 2 4 157 1 ... 669 176,628 Paddington 2 279 92 45 ... ... 7 138 6 ... 569 143,976 Hammersmith ... 359 240 42 ... ... 12 124 2 ... 779 112,239 Fulham ... 780 285 56 ... ... 24 145 1 ... 1,291 137,289 Chelsea ... 228 52 16 ... ... 10 78 ... ... 384 73,842 City of Westminster 2 368 121 41 ... ... 12 124 ... ... 668 183,011 North. St. Marylebone ... 278 130 46 ... ... 6 162 1 ... 623 133,301 Hampstead ... 180 66 18 ... 1 2 44 ... ... 311 81,942 St. Pancras 3 987 283 71 1 1 10 228 4 ... 1,588 235,317 Islington 3 1,200 352 100 ... ... 25 252 ... ... 1,932 334,991 Stoke Newington 1 178 75 10 ... ... 1 28 4 ... 297 51,247 Hackney 4 1,066 373 165 1 1 8 291 12 ... 1,921 219,272 Central. Holborn 1 157 46 21 ... 1 2 36 ... ... 264 59,405 Finsbury 1 479 140 46 ... ... 6 115 1 788 101,463 City of London ... 76 15 3 ... ... ... 25 1 ... 120 26,923 East. Shoreditch 2 792 178 36 ... 2 9 140 3 ... 1,162 118,637 Bethnal Green 4 794 295 61 ... 2 6 204 10 ... 1,376 129,680 Stepney 13 1,846 631 127 7 ... 15 520 8 3,167 298,600 Poplar ... 992 484 71 ... ... 8 209 8 1,772 168,822 South. Southwark ... 776 288 73 ... ... 11 296 15 ... 1,459 206,180 Bermondsey ... 752 167 41 ... ... 8 161 ... ... 1,129 130,760 Lambeth ... 1,025 446 78 ... 2 12 294 11 ... 1,868 301,895 Battersea ... 848 190 33 ... ... 16 177 4 ... 1,268 169,907 Wandsworth 1 1,490 349 99 ... 1 18 254 2 ... 2,214 232,034 Camberwell 13 1,222 234 62 ... ... 23 345 13 ... 1,912 259,339 Deptford 2 609 142 34 ... ... 7 153 6 ... 953 110,398 Greenwich 4 283 143 27 ... ... 6 92 4 ... 559 95,770 Lewisham 9 572 150 38 ... ... 11 109 7 ... 896 127,495 Woolwich 7 516 274 26 ... 1 12 83 ... ... 919 117,178 Port of London 2 3 ... 14 ... ... ... 3 ... ... 22 Grand Totals 74 19,467 6,365 1,549 9 14 291 4,987 124 ... 32,880 The figures in this and the following table, collated from the Asylums Board's weekly returns differ slightly from the revised returns issued by the Registrar-General as shown in the table at foot of page 34. showing the number of Cases of Infectious Disease Notified in Kensington, and in London, in 1905 Arranged in four-weekly periods. kensington. o. 3 c w 3 ■C a, >. H 12 11 8 13 11 11 11 9 4 8 10 17 4 124 1 8 2 1 10 8 5 5 1 3 5 2 8 49 t CD Ut "rt 3 a, 14 13 14 5 6 8 13 7 12 19 17 17 12 157 a. 3 'j o -E u o H 47 43 51 35 62 63 56 56 39 62 53 70 82 669 london. X O Cu *rt B cn 4 5 24 12 11 9 5 3 74 37 TABLE III. (Required by the Local Government Board to be used in the Annual Report of the Medical Officer of Health.) Cases of Infectious Disease notified during the Year, 1905. Notifiable Disease. Cases Notified in Kensington. Total Cases Notified in each Sub-District. Number of Cases removed to Hospital from each Sub-District. At all Ages. At Ages—Years Kensington Town. Brompton. Kensington Town. Brompton. Under 1 1 to 5. 5 to 15. 15 to 25. 25 to 65. 65 and upwards Small-Pox ... ... ... ... ... ... ... ... ... ... ... Chicken-Pox ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... Diphtheria 124 3 38 50 21 12 ... 85 39 70 30 Membranous croup 1 ... 1 ... ... ... ... 1 ... ... ... Erysipelas 157 6 4 9 12 101 25 136 21 3 1 Scarlet fever 332 1 95 185 27 24 ... 220 112 201 100 Typhus fever ... ... ... ... ... ... ... ... ... ... ... Enteric fever 49 ... ... 13 10 26 ... 41 8 34 6 Relapsing fever ... ... ... ... ... ... ... ... ... ... ... Continued fever 2 ... 1 ... ... 1 ... 1 1 1 1 Puerperal fever 4 ... ... ... ... 4 ... 3 1 1 ... Plague ... ... ... ... ... ... ... ... ... ... ... Totals 669 10 139 257 70 168 25 487 182 310 138 Table showing the Notifications, in 1905, in the Borough, the Sub-Districts, the Parliamentary Divisions, and the Wards. Area. Scarlet Fever. Diphtheria. Enteric Fever. Continued Fever Puerperal Fever. Erysipelas. Croup. Totals. Population. Notifications per 1,000 of the population. The Borough 332 124 49 2 4 157 1 669 179,000 3.7 Sub-Districts— Kensington Town 220 85 41 1 3 136 1 487 129,740 3.8 Brompton 112 39 8 1 1 21 ... 182 49,260 3.7 Parliamentary Divisions— North Kensington 186 57 29 ... 3 107 1 383 92,290 4.1 South Kensington 146 67 20 2 1 50 ... 286 86,710 3.3 Wards— North K. St. Charles 56 20 3 ... ... 24 ... 103 22,240 4.6 Golborne 78 22 8 ... 1 43 1 153 26,670 5.7 Norland 37 9 8 ... 2 22 ... 78 23,790 3.3 Pembridge 15 6 10 ... ... 18 ... 49 19,590 2.5 South K. Holland 16 19 11 1 ... 13 ... 60 20,680 2.9 Earl's Court 42 11 ... ... ... 10 ... 63 18,290 3.4 Queen's Gate 12 11 1 ... ... 13 ... 37 14,460 2.6 Redcliffe 51 16 5 ... 1 10 ... 83 18.940 4.4 Brompton 25 10 3 1 ... 4 ... 43 14,340 3.0 38 Table showing Number of Notifications in Kensington—gross and per 1,000 of the Population in 1895-1905, and percentage of notified cases removed to Hospital. Year. No. of Notifications Received. Notifications per 1,000 of the Population. Percentage of Cases removed to Hospital. 1895 1,289 7.6 51.7 1896 1,781 10.5 59.6 1897 1,457 8.5 59.6 1898 1,004 5.8 60.3 1899 1,046 6.1 58.8 1900 986 5.7 67.1 1901 1,025 5.8 67.0 1902 939 5.3 64.2 1903 738 4.1 61.2 1904 651 3.6 64.5 Average of ten years, 1895-1904 1,092 6.3 61.4 1905 669 3.7 67.0 Note.— The notifications of chicken pox have been deleted in the foregoing table. They numbered 669 in 1902 and 271 in 1904. 39 TABLE VI. Comparison of Prevalence of Sickness and Death from Infectious Diseases in 1905 and the Preceding Ten Years. (Rates calculated per 1,000 persons on the population estimated to the middle of each year.) Year. Small-pox. Erysipelas. Diphtheria and Membranous Croup. Scarlet Fever. Typhus Fever. Enteric and Continued Fever. Puerperal Fever. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. 1895 0.05 0.00 1.59 0.05 2.23 0.53 3.10 0.16 0.00 0.00 0.61 0.09 0.04 0.02 1896 0.07 0.00 1.63 0.02 2.18 0.42 5.95 0.23 0.00 0.00 0.59 0.09 0.05 0.04 1897 0.00 0.00 1.39 0.05 1.94 0.48 4.33 0.17 0.00 0.00 0.74 0.13 0.09 0.03 1898 0.00 0.00 1.05 0.04 1.29 0.15 2.75 0.13 0.05 0.01 0.63 0.07 0.06 0.03 1899 0.00 0.00 1.22 0.05 1.49 0.24 2.57 0.06 0.00 0.00 0.72 0.13 0.06 0.03 1900 0.03 0.00 0.92 0.05 1.92 0.16 2.12 0.02 0.00 0.00 0.66 0.09 0.05 0.03 1901 0.08 0.00 0.95 0.03 1.41 0.21 2.68 0.08 0.00 0.00 0.59 0.06 0.05 0.01 1902 0.53 0.06 1.06 0.03 1.04 0.11 2.09 0.12 0.00 0.00 0.47 0.11 0.08 0.03 1903 0.03 0.00 0.99 0.03 0.90 0.13 1.85 0.08 0.00 0.00 0.35 0.05 0.02 0.01 1904 0.01 0.00 0.78 0.02 1.04 0.09 1.47 0.03 0.00 0.00 0.27 0.04 0.06 0.03 1905 0.00 0.00 0.88 0.04 0.70 0.05 1.85 0.12 0.00 0. 00 0.28 0. 07 0.02 0.02 * This Table is recommended for use by the Society of Medical Officers of Health, as a record of " the frequency and mortality of infectious diseases in the whole district for a series of years. 40 CEREBRO-SPINAL FEVER ("SPOTTED FEVER"). The Local Government Board, on 24th August, addressed a circular letter to Sanitary Authorities throughout the Kingdom with reference to this disease, in which it was stated that, so far as they had been able to ascertain, there was no ground for the apprehension that the disease had newly extended to, or had been developing in, this country; it having recently been somewhat extensively prevalent in Central Europe and in America. The Board thought it probable that cerebro-spinal fever was, at that time, "not more prevalent in this country than it had been from time to time during the past quarter of a century." Nevertheless they considered that Sanitary Authorities should be on the alert to detect the presence of the disease in their districts, and to this end the Board had issued a Memorandum, prepared by their Medical Officer, dealing generally with the characteristic symptoms of the disease, and especially with its minor and anomalous manifestations. The Board described the steps it would be desirable to take in the event of the discovery in any district of groups of cases of illness which might possibly be of the nature of cerebro-spinal fever, and stated that in such an event, they would be prepared to render the Sanitary Authority such advice or assistance as in the circumstances might appear to be necessary; and in the event of the Sanitary Authority desiring that the dieease should be made compulsorily notifiable in their district, the Board would be prepared to consider an application for their approval to a resolution of the Authority for a temporary extension of the provisions of law to the disease. It may be mentioned that I received a notice of the occurrence of a case of what was thought to be cerebro-spinal fever in a young man. The patient was removed to hospital. A post-mortem examination clearly proved that the illness was not of the nature supposed. But disinfection had been done, and all other necessary measures of precaution were adopted. THE PREVENTION OF CONSUMPTION. The assemblage at Paris of the seventh international congress on tuberculosis, naturally recalled the Congress held in London in 1901, and the great stimulus it gave to efforts for combating this, the greatest scourge of the human race in the occidental world. The Council appointed two delegates to represent them at the Congress, whose report, and certain other communications, were referred to the Public Health Committee. The report of the Committee (printed in my annual report for 1901—page 39) set out certain of the recommendations of the Congress, to wit— Voluntary notification of cases of consumption attended with tuberculous expectoration—the main agent for the conveyance of tuberculosis from man to man; The supply to consumptives, by hospitals and dispensaries, of pocket spittoons, with a view to the suppression of the dangerous habit of indiscriminate spitting; The supply to consumptives, by these institutions, of printed instructions with regard to the prevention of consumption; The provision of sanatoria as an indispensable part of the measures necessary for the diminution of tuberculosis; and The provision of anti-tubercular dispensaries, as the best means of checking tubercular disease among the industrial and indigent classes. Premising that time would be required for giving effect to the recommendations, the Committee, as regarded action that might be taken by the Council, recommended (inter alia)— 1. (a) The adoption of a system of voluntary notification by medical men of cases of sumption attended with tuberculous expectoration ; (b) Payment to medical men of the customary fee for notification of such cases, and (c) An arrangement for bacteriological examination of expectoration suspected to be tuberculous. 2. The further circulation of the Council's leaflet on "The Prevention of Consumption." 3. Disinfection of houses after the occurrence of fatal cases of consumption, and after the removal of consumptives, and 4. An appeal to the Local Government Board to give effect to the recommendation of the Conference of delegates of the Metropolitan Poor Law Authorities (October, 1900) for the provision of Sanatoria. 41 The report stated, as "evidence of the importance of the subject, that in Kensington, consumption alone—apart from all other diseases of the tubercular class—destroys, year by year, very many more lives than small-pox, scarlet fever, diphtheria, and 'fever' combined'': the fact being that the deaths from these diseases in the three years, 1898-1900, aggregated 183 only, whereas those from consumption were 210 in 1900 alone. The report having been unanimously adopted by the Council, (13th November, 1901), was sent forthwith to medical practitioners, together with the Council's leaflet on "The Prevention of Consumption," and an explanatory letter (printed in the Annual Report of the Medical Officer of Health for 1901, page 41) setting out the scheme, which provided for voluntary notification; for bacteriological examination of sputa, and for disinfection after deaths, and upon change of abode of persons suffering, from consumption. The scheme was put into operation at the beginning of 1902. The recommendations of the Committee have been carried out as fully as practicable, and it may be interesting to show now, after an interval of four years, with what results, With respect to— Bacteriological Examination of Sputa, there is nothing to report, save failure; only one application for this important aid to diagnosis having been received during the four years 1902-5, although it was intimated in the explanatory letter— "That the Council have entered into an arrangement with the Jenner (now Lister) Institute for the examination of expectoration suspected to be tuberculous, and will when necessary defray the cost of such examination." It is probable, however, that medical men may have submitted specimens for examination to private assocications or individuals who undertake work of this description. Disinfection.—Eleven hundred and fifty rooms in private houses were known to be infected during the four years, but only in 611 cases (531 per cent.) was disinfection done; in 494 cases (43 per cent.), 138, 112, 129, and 115 in the consecutive years, by the Council's officer, and in 117 cases by, or under the direction of, medical practioners. In 539 cases (57 per cent.) the premises were not disinfected, proffered assistance having been refused on the ground that disinfection was deemed unnecessary (in 194 cases), or on the ground of anticipated inconvenience (345 cases). Whatever difference of opinion there may be in regard to other precautionary measures for the prevention of consumption, there is none as to the desirability of disinfection,* which was carried out in little more than a moiety of the cases; it being open to the parties interested to accept or decline—for whatever reason or none—the offered services of the Council's staff. This fact points to the necessity for making disinfection compulsory, which could be effected by an order, under Section 58 of the Public Health (London) Act, 1891, applying to consumption the provisions of Section 60 [ss. (1) and (2)], which provides for the cleansing and disinfecting of infected premises and articles therein. These provisions have been extended to another non-notifiable disease, measles, which proved fatal in the metropolis, last year, to only 1,714 persons (1,641 of them tinder five years of age), whereas the deaths from consumption were 6,662; including 2,871 between 20 and 40 years of age, and 2,559 between 40 and 60. Thus, 5,430, or 81.5 per cent., were of persons at the working period of life, whose deaths (each life being valued at £200) involved a loss to the community of more than a million sterling. Notification.—During the four years 1902-5, cases to the number of 1,494 were investigated, of which 889 (59.5 per cent.) were notified; the remaining 605 (40.5 per cent.) being cases the occurrence of which became known only after registration of death (517) or otherwise (88). Of the 889 cases notified (247, 221, 203 and 218 in the four years consecutively) 766 (86 per cent.) belonged to North Kensinton, and 123 (14 per cent.) to South Kensington; in three of the northern wards there were 692 cases (St. Charles 104, Golborne, 187, Norland, 401) or 78 per cent. of total notifications; and in the remaining six wards 197, or 22 per cent. Between the ages 20-40 years there were 366 notifications; and between 40-60 years 393. At all other ages the * The Conference of delegates of the Borough Councils held at the County Hall, Spring Gardens, "On the Administration of the Public Health (London) Act, 1891," (July, 1904) unanimously adopted a resolution in connection with " Precautionary Measures against Phthisis "—"That the sanitary authority should disinfect the premises in which a person suffering from phthisis has died, or from which such a patient has removed or has been removed." 42 tions were 130 only. Thus 85 per cent. of the cases (and 81 per cent. of the 879 deaths also) occurred during the most useful, the working, period of life—a fact the economic importance of which needs no insistence. It is a significant fact, pointing to the relative inefficiency of the voluntary system, that only 38 notifications (14, 5, 8, and 11 in the four years) were received from other than Poor Law Medical Officers who reported 851 cases; 809 in their official capacity (217, 205, 185, and 202 in the four years); and 42 (16, 11, 10, and 5) private cases. The deaths totalled 879: 226, 219, 235, and 199 in the four years respectively. Granting the necessity for disinfection, it becomes obvious that steps should be taken to obtain the earliest possible information of the occurrence of consumption. The International Congress of 1901, in view of the fact that— "The voluntary notification of cases of phthisis attended with tuberculous expectoration, and the increased preventive action which it has rendered practicable, has been attended by a promising measure of success," were of opinion that "the extension of notification should be encouraged in all districts in which efficient sanitary administration renders it possible to adopt the consequential measures"— of which disinfection is one of the most important. The Council adopted voluntary notification in 1901, and since the beginning of 1902 the "consequential measures" have been carried out as completely as practicable in regard to cases notified; which constitute, probably, scarcely more than a fourth of the total cases that exist in the Royal Borough in any given year. It is a question whether the Council should rest satisfied with this result, or should take steps to obtain complete information by promoting a measure for securing compulsory notification ? That benefit would accrue therefrom, there can be no doubt; but consumption (pulmonary phthisis) stands on a plane different from the dangerous infectious diseases named in Section 55 of the Public Health (London) Act, 1891, to which, for the purpose of securing disinfection, among other things, measles was added in 1903, by an order of the London County Council. In regard to consumption, the system would have to be modified, to obtain from it the maximum of good with the minimum of inconvenience to individuals. How this might be effected is a question too wide to be dealt with here. The subject was discussed in the "Milroy" Lectures* (1903) on The Causes, Prevalence and Control of Pulmonary Tuberculosis, the view expressed being that if notification were made obligatory, consumption should be placed "in an entirely separate category" from other dangerous infectious diseases—small-pox, scarlet fever, diphtheria, etc. The suggestion was thrown out, moreover, that in the first instance, it might be well to "limit notification to cases of "pulmonary tuberculosis in which the condition and environment of the patient are such that "danger to the public is likely to accrue"—for example, in "the cases of patients occupying "tenement houses or other places where the first principles of cleanliness are not observed, and "where the people live much in common, with tendency to overcrowding." This view is in harmony with the opinion of Professor Koch (expressed at the Congress of 1901), that notification of consumption is necessary only in cases, that, "owing to their domestic conditions, are sources of dan"ger to the people about them "—a limitation, by the way, which would deprive all but the poorest classes of the benefit of the "consequential measures" now put into operation by the sanitary authority, with manifest advantage, in cases voluntarily notified. I am in entire agreement with the Milroy Lecturer that "the future depends very largely upon the discretion with which the knowledge acquired by notification is utilised." It may be mentioned that compulsory notification powers given to Sheffield in 1903, were extended, by Improvement Acts, to Bolton and Rathmines during the Session of 1904, in each case until 1910 only. In the Metropolis, the County Council, or any Sanitary Authority, may, by an order, under Section 56 (1) of the Public Health Act, secure compulsory notification; but an order has no validity until it has been approved by the Local Government Board; and whether such approval would be given is more than doubtful. THE SANATORIUM QUESTION. The Congress of 1901 affirmed "the provision of sanatoria to be an indispensable part of "the measures necessary for the diminution of tuberculosis." This was the view also of the Conference of Delegates of the London Boards of Guardians held, at the suggestion of the Local Government Board, in 1900, when a deputation was appointed to wait upon the Board to present * By Dr. H. Timbrel! Bulstrode, Inspector, Medical Department, H.M. Local Government Board. The lectures, delivered before the Royal College of Physicians, were published in The Lancet. 43 the resolution, unanimously adopted, affirming the necessity for the "open-air" treatment of Consumption. It was the view, moreover, of the Conference of Delegates of the Metropolitan Borough Councils,* held at the County Hall in July, 1904. The Delegates, at both Conferences, concurred with the opinion expressed by the Local Government Board, prior to the first Conference, that the provision of sanatoria was a matter which, "if dealt with at all, should be dealt with by a Metropolitan Authority"—the Authority indicated at both Conferences being the Metropolitan Asylums Board. In the interval between the two Conferences, the Asylums Board were requested by many of the Public Health and Poor Law Authorities to assume the function of Sanatorium Authority—mainly at the instance of the Councils of the boroughs of Chelsea, Bermondsey, and Kensington.† The National Association for the Prevention of Consumption cordially endorsed the proposal, which received the unanimous support of the Metropolitan Medical Officers of Health. The (then) President of the Local Government Board, moreover, was known to be a convinced believer in the. "open-air" treatment, which he had done somewhat to foster by favouring the provision of sanatoria by Boards of Guardians. The Metropolitan Asylums Board have taken theoretical interest in the question for a long time. In 1901 they would have undertaken the treatment of the tubercular disease LUPUS, had the consensus of opinion of the Boards of Guardians in regard to the matter been more general; and in November, 1902, they manifested willingness to entertain favourably the request that they should become the Sanatorium Authority for London—on assurance being forthcoming that there was a "general consensus of opinion among the local authorities" in support of the proposal. The Managers, moreover, have conceded the principle involved in the proposal, by establishing at East Cliff, Margate, and at Rustington, near Littlehampton, Seaside Homes for Children, for the treatment of surgical and medical cases of Tuberculosis, respectively. It was hoped, and expected, therefore, that, the desired "general consensus of opinion" having been attained, the Managers—when consideration of the subject, after twelve months' postponement, was resumed in November, 1903—would have applied to the Local Government Board for the necessary powers. But, whilst recognising the "vital and far reaching importance of the pro"posal to the community at large," they resolved to take no further steps in regard to it without an "authoritative expression of opinion by the Chief Health Authority of the country, the Local Government Board." This decision was communicated to the Local Government Board, and to the local authorities, in December, 1903. The Board have not yet announced their views, having, in fact, informed the Managers, in June last, that they were "obtaining information on the whole subject," and were not then" in a position to express an opinion on the question as to whether the Managers should undertake the new duties suggested." Such being the present state of affairs, it becomes an interesting question whether there are any indications as to the nature of the "opinion" likely to be expressed by the Board? I think there are, and that they are of a hopeful tendency. In support of this view reference may be made to the Board's suggestion for the holding of the Poor Law Conference in 1900. In 1903 the Board informed the National Association for the Prevention of Consumption that the Isolation Hospitals Act, 1893, which enables County Councils (other than the London County Council) to take measures for promoting the provision, by groups of sanitary authorities, of hospitals for infectious diseases, was applicable to phthisis (consumption), though this disease is not named in that enactment; and in July, 1905, the Board informed the Bath Union Board of Guardians—who had consulted them "with reference to the detention in the workhouse of paupers suffering from phthisis",—that, "if the advanced phthisis from which a workhouse inmate is "suffering is 'pulmonary tuberculosis' with expectoration," it may be regarded as an infectious disease within the meaning of Section 22 of the Statute 30 and 31, Vict. c. 106—so that, in other words, the person might be detained as if he were suffering from one of the infectious diseases admissible to the hospitals of the Metropolitan Asylums Board. The Board, moreover, entertain favourably applications by Boards of Guardians for sanction to expenditure on provision of separate accommodation for consumptives in Poor Law institutions, and on sanatoria. Reference may also be made to certain unofficial expressions of opinion on the Sanatorium question by the Board's Medical Inspectors. Thus, at the Poor Law Conference in 1900, Dr. Downes, the Chief Inspector for Poor Law purposes, expressed the view that, if sanatoria should be established without the Metropolis—and he was favourable to it being done—they should be * "On the Administration of the Public Health (London) Act, 1891." † A list of the authorities assenting, and dissenting, approving the principle, or neutral, was given in the report of the General Purposes Committee of the Asylums Board, dated 23rd November, 1903. 44 available not only for the chargeable poor but also "for that class above the very poor who were not able to pay for sanatorium treatment." Cases not likely to recover should, he said, be sent to places where facilities could be given for friends to visit them. Provision of this sort now exists, some two thousand beds having been set apart for this hopeless class of sufferers at the Metropolitan Poor Law infirmaries.* Again, Dr. Bulstrode, who is known to be "obtaining information" for the Local Government Board, spoke in his Milroy Lectures (1903) with no uncertain sound on the question. Sanatoriums, "as curative agents," are described by him as "almost indispensable." "In the matter of prevention" they are "likely to curtail the prevalence of the disease by aiding educa"tion, and by reducing the number of advanced cases"; and "no one who has studied the work"ing of them" can doubt that they are "of great value in a curative sense." The sanatorium question is "not so much one of the infectivity or communicability of phthisis, as one of inability to do much good to a poor patient in his insanitary home and surroundings." The infectivity is "proportional to bad home influences—scant accommodation and insanitary conditions—productive of low vitality of the host of the tubercle bacillus": "in unwholesome circumstances and "prolonged exposure, pulmonary tuberculosis asssumes a higher infective power than it manifests "in the relatively healthy conditions of a hospital for consumption." Again, the facts as to "cured " tuberculosis as seen in the post mortem room, "show how much good may be done in "aiding the healing process by sanatoriums, and by better conditions of living." Should the foregoing views meet with acceptance at Whitehall—and they are based on information obtained—a great victory will have been won in the fight against tuberculosis. On the relation of tuberculosis to poverty, Dr. Bulstrode states that "the effects of poverty" cannot be dissociated from "those of the conditions with which poverty is almost invariably allied, "and of which they are but the expressions." Consumption is, in truth, a disease of the poor. Evidence of this is given in the table (at page 54) of the status of sufferers, whose cases or deaths formed the subject of investigation by the Council's officers last year. It is worthy of note, in this connection, that in the four years 1902-5, of 879 deaths from consumption in Kensington, 357 (40.6 per cent.) took place at the Borough infirmary, to which not a few respectable men and women, impoverished by illness, drifted against their will, as their only remaining place of refuge. With regard to the economic side of the question, the British Medical Journal (September 23rd, 1905) is responsible for the statement that the average amount of the sick pay of one of the great Friendly Societies to a consumptive member, is three times as great as in the case of any person dying from another disease. Dr. Bulstrode, moreover, cites Dr. Herrmann Biggs, the leader of the Sanitary Authorities of New York, as being responsible for estimates of annual loss to the United States of America from the ravages of the tubercle bacillus, at £66,000,000; the value of lives lost in the City of New York † alone, with addition of loss by enforced idleness prior to death, being estimated at £4,600,000—compared with an expenditure of £100,000 on preventive measures. What all this means has been expressed in another way by Dr. Hay ward, who, the Milroy Lecturer states, has calculated that "if there had been no "phthisis, the average length of life for each individual born, would have been increased by two 'and a half years." Be this as it may, there can be no doubt that if the same care were taken to prevent and cure tuberculosis, as is taken to control and treat scarlet fever, etc., consumption would soon become a far less prolific contributory to the roll of mortality. It is not to be thought for a moment that sanatorium treatment alone is going to extirpate tuberculosis—there is a great field for the work of Sanitary Authorities, as has often been pointed out in these reports—but that hospital treatment and isolation would do much towards this end there can be no question. And, after all that has been said and written since the establishment of the National Association, in 1899, no one, I think, can doubt that the Local Government Board and the Asylums Board would confer a lasting benefit on the inhabitants of this Metropolis by acceding to the prayer of the "Memorial" presented to the Managers by the great representative deputation in April last, of which an account follows. * Particulars ot this accommodation are given at page 48. † The population of New York is 3,500,000, that of London being at least a million greater. 45 DEPUTATION TO THE METROPOLITAN ASYLUMS BOARD. The paper on The Need, of Sanatoria for Persons Suffering from Consumption* read at a meeting of the Couucil of the Charity Organisation Society in October, 1904, gave rise to a discussion in which the Chairman of the Council of the National Association for the Prevention of Consumption, the President of the Society of Medical Officers of Health, the Secretary of the Metropolitan Hospital Sunday Fund, the Secretary of the Metropolitan Hospital Saturday Fund, and the Chairman (also an ex-Chairman) of the Works Committee of the Metropolitan Asylums Board, took part. On the motion of Sir William Broadbent, the paper and the discussion upon it were referred to the Administrative Committee with an instruction to report thereon to the Council at some subsequent meeting. The Administrative Committee convened a Conference for consideration of the reference to which, amongst others, the MedicAl Officers of Health and the Medical Superintendents of the Poor Law Infirmaries were invited. The Conference, held in January, 1905, (Sir William Broadbent being in the chair), unanimously passed resolutions as follows:— 1. "That it is of urgent importance that further and more complete public provision be made for cases of phthisis. 2. "That it is desirable that provision be made by the Metropolitan Asylums Board for persons suffering from phthisis who are, or may from time to time become, chargeable to the poor rates. 3. "That the Council of the Charity Organisation Society approach the following Societies, amongst others, with a view to these or similar resolutions being submitted to the Local Government Board, jointly; viz., the Society of Medical Officers of Health, the National Association for the Prevention of Consumption, the National Health Society, and the Royal Sanitary Institute." The Secretary of the Society subsequently enquired of each of the societies named, whether they would co-operate with the Charity Organisation Society with a view to the submission of the resolutions to the Local Government Board, or otherwise? pointing out that they "do not "deal with the large number of phthisical cases which are to be found outside the poor-law;" the Conference having been of opinion that " it would be best to deal with the question of poor"law cases only in the first instance." The Society of Medical Officers of Health (Metropolitan Branch) thought the better course would be to approach the Metropolitan Asylums Board, and resolved to organise a representative deputation to wait upon the Managers in support of the prayer of a Memorial which I was requested to draft, in which it was shown— 1. That between 7,000 and 8,000 persons (of whom the large majority are adults in the prime of life) die every year in London from pulmonary phthisis (consumption), the mortality in the male sex being some 40 per cent. greater than in the female sex; and that a much larger number of persons (also chiefly adults) suffer from ill-health arising from the same disease. 2. That great loss accrues to the community from these deaths, and this morbidity, from pulmonary phthisis (consumption), and many deaths, and much illness and suffering might be prevented, were hospitals provided for the treatment of this disease. 3. That persons suffering from pulmonary phthisis (consumption) may be divided, roughly, into two classes; (1) Those in the primary stage of the disease, which is curable and not specially infectious; and (2) Those in the chronic stage of the disease, which is incurable and very infectious. 4. That for those in the primary stage of the disease, hospitals are required wherein the patients may be treated with a view to cure; and for those in the chronic stage, refuges wherein the patients may be isolated so as to be prevented from spreading the disease to others. 5. That the existing provision of hospitals for pulmonary phthisis (consumption) in London is totally inadequate; and that, in connection with such provision as there is, great difficulty (and consequent delay) is experienced in obtaining admittance thereto ; more especially when, as usually is the case, the "letter" system prevails, rendering it necessary for patients not only to have to wait long for their turn, and so lose the advantage of special and valuable treatment in the early stage of the disease, but also to find that, when admitted, they are rarely kept in hospital long enough to obtain a cure. * The paper was printed in my annual report for 1904, page 35. 46 6. That the pressing need for the moment is the provision of a hospital, or hospitals, in the country for the treatment of persons in the acute and curable stage of the disease. 7. That, having regard to the provision now made, or which could be made, in separate wards, at the various Poor Law infirmaries, the chronic cases might, for the present at any rate, be kept in town, where they could be visited by their friends. 8. That the need for Sanatoria arises from the fact that it is practically impossible to treat poor persons in their own homes, or in Poor Law Infirmaries in London, with any reasonable hope of cure. 9. That the great bulk of the cases occur amongst the poor, and the poorest classes of the people, who are unable to make any contribution towards the expenses incident to sanatorium treatment. [In 1899 (the only year for which reliable statistics* are available) a third of the deaths in London from pulmonary phthisis (consumption) occurred in Poor Law Institutions. Many of the sufferers might have been cured could they have obtained sanatorium treatment at the beginning of their illnesses, and a large amount of poverty and charge on the rates have been thereby avoided. It is well known that many persons reduced by consumption to a state of poverty, drift into the workhouse, and become a permanent charge upon the rates, often leaving widows and orphans in a state of destitution; whereas many such persons might be cured if sanatorium treatment were made available for them in the early stages of the disease.] 10. That whilst the deaths in London in 1904 from the diseases admissible to the Board's Hospitals (small-pox, scarlet fever, diphtheria and fever) aggregated only 1,415, of which 1,094 were due to scarlet fever and diphtheria (70 per cent. of them being death's of children under the age of five years),† the deaths from pulmonary phthisis (consumption) alone, and exclusive of all other tubercular diseases, were 7,738 || in number, and of these a vast proportion were deaths of adult men and women (men more especially) in the prime of life. 11. That the money value to the community of the lives lost every year from this preventable and curable diseases is enormous, and immensely transcends any possible cost to the rates by sanatorium provision. Your Memorialists having given all these points consideration, and believing that it would be in the best interests of the community, earnestly pray the Managers to take necessary steps, as they may think desirable, forthwith; and respectfully suggest the following:— 1. That an Order of the Local Government Board be obtained to make section 5 of the Metropolitan Poor Act, 1867, applicable to the case of "poor persons" suffering from pulmonary phthisis (consumption); and if necessary— 2. That an Act be obtained to make the provisions of section 80 of the Public Health (London) Act, 1891, applicable to pulmonary phthisis (consumption) as if such disease were therein mentioned as well as "fever, or small-pox, or diphtheria." The Deputation was received by the Board on the 15th April, 1905. It comprised representatives of— (1) The National Association for the Prevention of Consumption and other forms of Tuberculosis (Sir William Broadbent, Chairman of the Council, and Mr Malcolm Morris, F.R.C.S., Treasurer of the Association). (2) The Royal Institute of Public Health (Dr. Roberts and Dr. Millson). (3) The Royal Sanitary Institute (Mr. W. Whitaker, F.R.S., Chairman of the Council, and Professor Kenwood). (4) The National Health Society (Dr. J. Edward Squire, C.B., Physician to Mount Vernon Consumption Hospital). (5) Sir Edmund Hay Currie, Secretary of the Metropolitan Hospital Sunday Fund. * The statistics were obtained by Dr. Downes, Medical Inspector of the Local Government Board for Poor Law purposes, and were communicated by him to the Conference of Poor Law Authorities, in 1900. † The deaths from these diseases of persons over 20 years of age, were 21 only. || Of the 7,738 deaths 897 (12 per cent.) were of persons under 20 years of age, and 645 (8 per cent. )of persons aged 60 years and upwards. The deaths between 20 and 60 years of age were 6,196, and 80 per cent. of the total number. 47 (6) Mr. W. G. Bunn, Secretary of the Metropolitan Hospital Saturday Fund, and (7) The Society of Medical Officers of Health (represented by the President of the Metropolitan Branch, Dr. Roberts; the President of the Society, Dr. J. F. J. Sykes; the Hon. Secretary, Dr. Priestley; the Editor of Public Health, the organ of the Society, Dr. F. J. Allan, and Dr. T. Orme Dudfield). A transcript of a shorthand note of the speeches made on the occasion, by the Council's Medical Officer of Health, on behalf of the Society of Medical Officers of Health, the originators of the movement, and by Sir William Broadbent, Sir Edmund Currie and Mr. W. G. Bunn, was circulated by the Managers,* together with the sympathetic reply to the Deputation by Mr. A. C. Scovell, J.P., the Chairman of the Board. The Memorial was referred for consideration and report to the General Purposes Committee, who forthwith took steps to ascertain the views of the local authorities concerned with Public Health and Poor Law administration; and in October published an "abstract of observations" received from "(a) City and Borough Councils, (b) Metropolitan Boards of Guardians . . . upon the proposals contained in the Memorial." The Council, and other Borough Councils had, previously, taken steps to elicit the views of the local authorities. Summarising the views of these bodies thus ascertained, prior to April, 1905, and adding information supplied since October, 1905,—premising, moreover, that a few of the authorities favourable to the principle that the Asylums Board should be the Sanatorium Authority, express the opinion that the maintenance of sanatoria should be a charge on the Imperial revenue, and not on the local rates—the result of the several inquiries may be stated as follows:— Of the 29 Public Health Authorities, the following have, at one time or another, since 1902, expressed themselves favourable to the principle of the open-air treatment of consumption, and the appointment of the Asylums Board as Sanatorium Authority; but with certain qualifications in two or three instances, especially as to the incidence of chargeability:—Battersea, Bermondsey, Bethnal Green, Chelsea, Deptford, Finsbury, Fulham, Greenwich, Hackney, Hampstead, Islington, Kensington, Lambeth, Lewisham, City of London, St. Marylebone, St. Pancras, Poplar, Shoreditch, Southwark, Stepney, Stoke Newington, Wandsworth, City of Westminster, and Woolwich. It must be added that in more than one instance the same local authorities have at different times expressed divergent views on the subject. In the Asylums Board Abstract, the Councils of Bermondsey and Chelsea are stated to have " taken no action " upon the Managers' application for their views—this, presumably, because they had already urged the Board to assume the position of Sanatorium Authority, and had taken steps to obtain the support of the other authorities for their representations to the Board and the Local Government Board. So far as I have been able to ascertain, the Borough Councils of Camberwell and Paddington alone, appear to be unfavourable to the principle; the Hammersmith Council express no opinion either way. Of the Boards of Guardians, 31 in number, 16 have, at one time or another, expressed views favourable to the principle of sanatorium treatment, and the appointment of the Asylums Board as Sanatorium Authority; viz., those of Chelsea, Clapham, St. George, Hanover Square, Hackney, Hammersmith, Holborn, Islington, Kensington, Lambeth, City of London, Paddington, St. Pancras, Poplar, Southwark, Stepney, and Wandsworth. The Hampstead and St. Marylebone Boards "offer no observations." The Fulham Guardians "have no data for forming an opinion"; those of Whitechapel are waiting for an expression of the views of the Local Government Board. The following Boards appear to be not favourable to the principle: — Bermondsey, Bethnal Green (on account of the cost), Camberwell, St. Giles and St. George, Greenwich, Lewisham, Strand, Westminster, and Woolwich. The less degree of unanimity amongst the Poor-law authorities is not difficult of explanation. The General Purposes Committee had invited the observations of those bodies not only on "the principle involved" in the prayer of the Memorial, but also with regard to the provision they had made for treatment of consumptives—a matter dealt with in my sixth monthly report, 1905, wherein it was shown that since the Poor Law Conference of October, 1900, a * By the courtesy of the Board I was enabled to send a copy of the transcript to the Members of the Council. But in No. 4 report (pages 53-67) I had already submitted a resume of the proceedings at the deputation. 48 large amount of accommodation for the chargeable poor suffering from consumption had been provided by the Metropolitan Boards of Guardians. With a view to ascertaining the extent of this accommodation, I had made inquiry (in June) of the medical superintendents of the 27 Poor-law infirmaries, as to what accommodation had been " provided in separate wards " for— (a) Cases of consumption in the early and hopeful stage, and (b) Chronic cases beyond hope of recovery. Replies were received from all but three of these institutions—Hackney, St. George Hanover Square, and Woolwich, which may be summarised as follows:— No special accommodation has been provided at five infirmaries — Chelsea, Mile End, Paddington, St. George-in-the-East, and Whitechapel. Special accommodation, amount not stated, is provided at four infirmaries—City of London, Hampstead, Lewisham, and Wandsworth. St. Marylebone was about to open three special wards. In the remaining fourteen infirmaries, accommodation has been provided as follows— Bermondsey 84 beds. Bethnal Green 120 beds. Central London Sick Asylum 35 beds (at Hendon). Fulham 80 beds. Greenwich 23 beds. Holborn 96 beds, and a separate ward for cases in the early stage of the disease. Islington 120 beds, and others in open-air galleries. Kensington 90 beds. Lambeth 92 beds. Poplar and Stepney Sick Asylum district 28 beds. St. Giles, Camberwell 200 beds. St. Pancras 24 beds for early cases; an indefinite number for chronic cases. Shoreditch 43 beds. Southwark 170 beds. a total of 1,205 beds in fourteen, or about a moiety, of these institutions* It may be remembered that in July, 1900, it was ascertained by the Medical Inspector (for Poor Law purposes) of the Local Government Board, that there were in the Metropolitan infirmaries and workhouses 1,562 cases of tuberculosis, including about 260 extra-Metropolitan cases. So that provision now exists for chargeable persons suffering from consumption adequate to the present demand, so far as mere numbers go. As regards non-chargeable sufferers, it may be mentioned that three voluntary hospitals, for consumption and diseases of the chest, in the Metropolis, contain 630 beds; viz., Brompton Hospital, 321; City of London Hospital, 164 beds, and Mount Vernon Hospital, 145 — irrespective of the country branch at Northwood.† 100. And this, apparently, is all, or nearly all, the public provision for a more or less curable disease from which there are probably some 31,000 sufferers (including about 11,000 "chargeable" poor) in a population approaching five millions; compared with 10,000 beds in the general hospitals of the Metropolis, and a like number for infectious diseases in the hospitals of the Asylums Board, including those now in course of construction or re-construction. The General Purposes Committee of the Asylums Board were possessed of all the foregoing information when, in February of the present year, they gave final consideration to the prayer of the Memorial presented by the representative deputation ten months previously, on which they reported as follows:— "On the 15th April, 1905, we were instructed to consider and report to the Board upon the memorial which the Managers then received from the Metropolitan Branch of the Incorporated Society of Medical Officers of Health, and in which they were urged to provide hospital accommodation for the treatment and isolation of patients suffering from pulmonary phthisis. * The Guardians of Bethnal Green, Fulham, Lambeth and Paddington occasionally send suitable (i.e. hopeful) cases to extra-Metropclitan sanatoria for treatment † Not only is the accommodation totally inadequate, but it is also extremely difficult of access under the system of subscribers' letters; the patients who are fortunate enough to get letters having to "wait their turn"—so long, in some instances, as to deprive them of all but the hope of being cured. 49 " In this memorial it was proposed— "'(a) That an Order of the Local Government Board be obtained to make Section "5 of the Metropolitan Poor Act, 1867, applicable to the case of 'poor persons' " suffering from pulmonary phthisis (consumption); and, if necessary, "'(6) That an Act be obtained to make the provisions of Section 80 of the Public "Health (London) Act, 1891, applicable to pulmonary phthisis (consumption), as if such " disease were therein mentioned as well as ' fever or smallpox or diphtheria.' "With the object of ascertaining, in the first instance, the views of the Local Government Board, of the several Metropolitan City and Borough Councils, Boards of Guardians, and Sick Asylum Districts, and of the administrative bodies of the hospitals for consumptives at Brompton and Victoria Park and in the City Road, upon this most important subject, we gave directions at our meeting on the 8th May last, for a copy of the memorial, together with a copy of the speeches delivered in support thereof by Dr. T. Orme Dudfield, Sir William Broadbent, Bart., Sir Edmund Hay Currie, and others, to be forwarded to these authorities. We at the same time directed that the Boards of Guardians should also be asked to inform the Managers what steps (if any) they had taken to deal with tuberculous cases in their infirmaries, and with what results. "The Local Government Board have since replied, in a letter dated 27th June last, to the effect that whilst they were then 'obtaining information on the whole subject,' they were not 'in a position to express an opinion on the question as to whether the Managers should undertake the new duties suggested.' "In the absence of any authoritative expression of opinion by the Local Government Board, and as the result of our consideration of the question in all its bearings, we recommend— "' That the Managers do forward to the Local Government Board a copy of the "memorial addressed to the Managers by the Metropolitan Branch of the Incorporated "Society of Medical Officers of Health on the 15th April, 1905. . . on the subject "of the provision of hospital accom modation for the treatment and isolation of patients " suffering from pulmonary phthisis; "'That the Local Government Board be further informed that, having regard to "the uncertainty which prevails as to the probable number of patients who would come "under the scheme referred to in the memorial, and to the great prospective cost to "the ratepayers of the Metropolis, the Managers will be glad to receive the judgment " of the Local Government Board upon the prayer of the memorial referred to.' " The report was adopted. It need hardly be pointed out that, after all the efforts made during the last four years, the matter has advanced not a whit beyond the stage attained in November, 1903, when the Managers, having been urged by many influential authorities, including the Metropolitan Branch of the Society of Medical Officers of Health, to undertake the treatment of persons suffering from consumption, passed a resolution to the effect— "That the matter is one of such vital and far reaching importance to the community at large, and the proposal one which, if adopted by the Managers, would entail so considerable an extension of their duties and responsibilities, and so large an increase in their expenditure, as to call for some authoritative expression of opinion by the chief health authority of the country, viz., the Local Government Board, before the Managers are asked to take any definite action in the matter, or to make any further enquiries in regard thereto. .” It is now obvious that nothing in the way of initiative is to be expected from the Managers: it remains, therefore, to be seen what action the Local Government Board under the new President, will take in regard to this matter, so vital to the interests of the community, and especially of the working classes. 50 Life in a Sanatorium.— In the report for 1904, reference was made to the intention of the Governors of the Brompton Hospital to establish a country branch and sanatorium, at Frimley, for the open-air treatment of consumption. The institution was formally opened by the Prince of Wales in June, 1905. An account of the system of treatment practised, was given in the Times of June 19th. The main features were said to be open air and sufficient food. The aim is to educate patients into a condition of real bodily vigour and capacity for work; and they are put through a graduated course of exercise adjusted to their physical condition. There is a strict routine for the day, which is so ordered and enforced that the sanatorium is a "school of manners, health, and industry, not less than a cure-place for consumption." The resident medical officer attaches great importance to the disciplinary element, and the soundness of his method is attested by the men—male patients, only, so far have been admitted At first they find it strange, but they fall into it, and feeling the improvement in themselves, they get to like it. They approve, alike, the place, the treatment, and the life. The lowest grade of exertion is walking at a slow pace; this is followed by carrying baskets, then by active work on the grounds, digging, planting, rolling, mowing, and making paths and roads. The hours are—get up and bath at 7, breakfast at 8-15, work out-of-doors from 10 to 10-45, then a quarter of an hour for lunch, and work again till 11.55. This is followed by an interval of absolute rest on beds till 12-45 ; then dinner, washing-up, and rest; work again from 2-50 to 4-15, tea at 4-45 ; after tea temperatures are taken, then patients can go into the woods, write letters, or play games; supper at 7-15; 8 to 8-30 reading room and concert hall; prayers, bed; lights out at 9 p.m. The men remain at work in the open air for the allotted time regardless of weather; if it is wet they wear goloshes, and change their clothes when they come in. The report goes on to say that "a good many of the men were engaged in work involving considerable muscular exertion, but they performed it with ease, and looked well and sturdy." It is found that the work interests them, and draws their minds away from themselves. They make their own beds, lay the meals, and wash up. The bill of fare is varied every day, and the food provided is excellent. A man can say he has no appetite, or if too much is put on his plate he can bring the plate up; but what he accepts he must finish. Most of the patients are quite young men, and in an early stage of consumption, but there are also some convalescents who are recovering, after treatment in hospital, from more severe forms of the disease. If one might express an opinion on this interesting experiment, it would be that the "system" of treatment is not calculated to suit the temperament of the generality of the "pauper" class; and if a conjecture might be permitted, it is that some, at least, of the more intelligent of the patients, coming to like the life and the work, will find it to their interest to pursue it for the remainder of their days, and go "back to the land." NOTIFICATION OF CONSUMPTION, 1905. Towards the close of 1901, the Council resolved, upon the recommendation of the Public Health Committee, to make pulmonary phthisis (consumption) voluntarily notifiable by medical practitioners as from the commencement of 1902; and, subsequently, with a view to the utilisation of the information thus obtained, the Committee authorised n.e to employ the services of the lady inspectors in an inquiry into the circumstances of the cases notified; and, generally, to give effect to the recommendations of their Sub-Committee, whose report is printed in the Minutes of the Council's proceedings for 13th November, 1901 (pages 19 and 20). The work thus inaugurated is still going on, and in submitting the report of the lady inspectors for 1905, I desire to express my appreciation of their services. I have only to add that to secure coherence to the inquiry, information is obtained in each case notified under the subjoined headings. Case or Phthisis. Ward Sanitary District No. of Case Date of notification. Probable source of infection. Date of death, if case not notified. Number of rooms occupied. Patient's name. Boom occupied by patient. , age. How many sleep in patient's bedroom. „ sex. Has, or had patient a separate bed. „ occupation. Sauitary condition of habitation. Present address and length of residence. Sanitary condition of room. Previous residences— Light. Ventilation. Sputa, how treated. Duration of illness. Disinfection done by on Number in family. Cleansing done by on Any other cases in family, now or formerly ? Remarks:— 51 The Inspectors' report is as follows:— During the year 1905, we enquired into all cases of pulmonary phthisis (consumption) voluntarily notified by medical practitioners; 218 in number (compared with 203 in 1904) of which 62 proved fatal. We made enquiries also with regard to 29 deaths of persons whose illness had been notified in previous years, and of 108 deaths of persons whose illness had not been notified. The cases investigated during the year were thus 355 (males 223, females 132); the number of visits paid being 487. Home or other Accommodation of the Sick Person or Family. Number of Rooms Occupied. 1 2 3 4 or more. Homeless Persons in the Infirmary. Common Lodginghouse Cases. No Information obtainable. Total Cases. Number of cases of illness 110 69 37 33 32 39* 35 355 One hundred and ninety-seven of the 218 notifications, and 139 of the 199 deaths, were of persons belonging to North Kensington; 181 of the notifications were from three wards:— St. Charles (35), Golborne (57), Norland (89); and 123 of the deaths (32, 37 and 54 respectively) belonged to the same wards, the population of which is a little under 73,000. The proportion of deaths from phthisis at the Workhouse Infirmary to deaths from this cause in the Borough, as a whole, was as usual large; 78 out of 199; males 47 and females 31. Sixty-four of these deaths were of North Kensington persons and 14 of South Kensington persons. The notified cases were 126; males 87, females 39; 107 of North Kensington persons and 19 of South Kensington persons. Eighty-one cases were notified by district medical officers, the majority of which were subsequently removed to the Infirmary. Eleven cases only (10 of them in North Kensington), were notified by other than Poor Law Medical Officers. Notified cases residing at home (averaging 50 in number) were kept under observation, being visited as frequently as practicable. Disinfection after the death of a sufferer, or after removal of a patient from one abode to another, was offered and usually accepted, but the refusals were more than in previous years; objections being made of the resultant "inconvenience," and that " disinfection is not compulsory." We noted continued improvement in the ventilation of sick rooms by open windows; an increased appreciation of the value of fresh air to phthisical persons, and of the danger arising from indiscriminate spitting. In a large majority of cases, the disease was in an advanced state when notified, the sufferers continuing to work for the support of their families, and having refused to see a doctor till absolutely compelled. The longer we work the more are we impressed with the need of a sanatorium to which the sufferers could be removed in the early stage of the disease, which, however, cannot be brought about without provision being made for the support of the families during the period devoted to isolation. I am indebted to Dr. Potter for an interesting account of the work at the Infirmary in relation to the treatment of tuberculosis in 1905. The male patients admitted were 156, of whom 28 were admitted for the second time, 5 for the third time, and 2 for the fourth time. Sixty female patients were admitted, 7 of them for the second time. No active phthisical cases among adults are now treated in the general wards of the Infirmary or in the workhouse. But children are treated in the general wards. The Guardians have set apart for the treatment of tuberculous cases 90 beds in the Infirmary ; 63 for males and 27 for females. A very creditable record indeed. * These 39 persons had resided at 17 common lodging-houses; 17 (7, 5 and 5) in three of them Most if not all of them were removed to the Borough Infirmary. 52 Tables illustrative of the Lady Inspectors' work amongst consumptives in the four years, are subjoined. Attention may be drawn to the table (at p. 54); which bears eloquent testimony to the fact that consumption is a disease of the poor. Of the 355 cases investigated in 1905, only twelve were of persons in a more or less well-to-do position—all of them died—the remainder belonging to classes of the population able to contribute, the great bulk of them obviously nothing, and the rest but little, if anything, towards the cost of sanatorium treatment. Voluntary Notification of Consumption in Kensington in the four years 1902-3-4-5. Number of Cases notified. 1902. 1903. 1904. 1905. Total. The Bobough 247 221 203 218 889 Sub-Districts— Kensington Town 288 206 190 210 844 Brompion 9 15 18 8 45 Parliamentary Divisions— North Kensington 218 182 169 197 766 South Kensington 29 89 84 21 123 Wards— North K. St. Charles 25 19 25 85 104 Golborne 47 46 87 57 187 Norland 117 100 95 89 401 Pembridge 29 17 12 16 74 South K. Holland 12 13 14 8 47 Earl's Court 5 6 4 8 18 Queen's Gate 4 12 6 4 26 Kedcliffe 4 4 5 4 17 Brompton 4 4 5 2 15 The Year. AGE AT NOTIFICATION. 0-5. 5-10. 10-20. 20 40. 40-60 60 and upwards. Total. 1902 2 2 7 117 109 10 247 1903 — 1 8 81 111 20 221 1904 2 4 10 72 96 19 203 1905 1 1 11 96 77 82 218 Totals 5 8 36 366 393 81 889 Deaths in Kensington after notification of Consumption, and otherwise, in the four years, 1902-3-4-5. 1902. 1908. 1904. 1905. Total. The Borough 226 219 235 199 879 Sub-Districts— Kensington Town 176 197 208 166 747 Brompton 50 22 27 33 132 Parliamentary Divisions— North Kensington 160 151 164 189 614 South Kensington 66 68 71 60 265 Wards— North K. St. Charles 19 26 38 82 115 Golborne 58 41 42 87 173 Norland 66 66 62 54 248 Pembridge 22 18 22 16 78 South K. Holland 12 27 28 21 88 Earl's Court 14 5 19 10 48 Queen's Gate 12 16 4 5 37 R°edcliffe 18 11 10 15 54 Brompton 10 9 10 9 88 53 Age at Death from Consumption in the four years 1902-3-4-5. The Year. 0-5. 5-10. 10-20. 20-40 40 60 60 and upwards. Total. 1902 6 4 7 93 94 22 226 1903 4 6 16 83 94 16 219 1904 9 4 24 91 90 17 235 1905 5 2 10 90 75 17 199 Totals 24 16 57 357 353 72 879 Disinfections after Consumption carried out by the Council's officer in four years, 1902-3-4-5. 1902. 1903. 1904. 1905. Total. Notifications and Deaths. Disinfections. Notifications and Deaths. Disinfections. Notifications and Deaths. Disinfections Notifications and Deaths. Disinfections. Notifications and Deaths. Disinfections. The Borough 394 138 374 112 371 129 355 115 1,494 494 Sub-Districts— Kensington Town 339 117 340 90 332 110 318 96 1,329 413 Brompton 55 21 84 22 39 19 37 19 165 81 Parliamentary Divisions— North Kensington 309 102 276 78 280 86 283 85 1,148 851 Soutb Kensington 85 36 98 34 91 43 72 80 346 143 Wards — North K. St. Charles 41 13 36 14 53 23 52 24 182 74 Golborne 78 38 73 17 66 31 77 33 294 119 Norland 153 85 138 82 129 22 127 22 547 111 Pembridge 37 16 29 15 32 10 27 6 125 47 South K. Holland 20 9 34 9 83 21 25 11 112 50 Earl's Court 16 9 11 6 22 8 11 3 60 26 Queen's Gate 16 28 2 10 1 9 4 63 7 Redcliffe 19 14 14 9 12 6 18 10 63 39 Brompton 14 4 11 8 14 7 9 2 48 21 Number of Rooms disinfected, and not disinfected; (total infected rooms 1,150) in the four years, 1902-3-4-5. 1902. 1903. 1904. 1905. Total. By Council's Disinfecting Officer 138 112 129 115 494 By or under the direction of the Doctor attending the case 24 48 18 27 117 Disinfection refused 195 128 103 113 539 54 Occupation or Status (so far as could be ascertained) of persons whose illness was notified (218 cases), and of deceased persons who illness had not been notified (137 cases):— Males— No. of Cases. Artizan 34 Labourer 30 Cabman, coachman, stableman, etc. 17 Shopman, hawker 12 Porter 7 Handy-man, railway employe, clerk (4 each) 12 Butler, waiter; 5 Errand-boy 3 Tailor, potman, scavenger, postman, messenger, marine engineer, (2 each) 12 Common lodging-house keeper (deputy), licensed victualler, milkcarrier, sailor, tobacconist, street musician, cab-repairer, watchmaker, builder, shoe-black, laundryman, gardener, racing tipster, scaffolder, silk hat maker, farrier, warehouseman, packer, and a "cripple" (1 each) 19 Child of artizan, labourer 6 Tramps 3 Persons of the more prosperous classes* (all of whom died) 5 165 Females (of whom 55 were married) — Laundress 16 Domestic servant 15 Dressmaker, tailoress, milliner 10 Charwoman 3 Child of artizan, labourer, licensed victualler, postmaster, cabman 13 Wife or widow of artizan (17), of labourer (13), of small tradesman (5), of coachman, stableman, navvy, potman, hawker, packer, carriage cleaner, caretaker, upholsterer, flower-seller, general dealer, and of a " cripple " (1 each) 47 Persons of the more prosperous classest (all of whom died) 5 109 274 (Males 29, females 13); Cases not known at addresses given to the relieving officer 42 (Males 29, females 10) ; Cases from common lodging-houses: occupation (if any), unknown 39 Total 355 * Malfs described as of independent means (2), and as company director, solicitor, naval officer (1 eacb). † Females described as of independent means (1), and as wife of gentleman (2), daughter of a rranufacturer, and of an accountant (1 each). 55 INFANTILE MORTALITY. No subject connected with the health interests of the community has received more attention than this during the last few years. Several of the Metropolitan Borough Councils have shown their desire to safeguard infant life by appointing Lady Sanitary Inspectors, some of whom are partially occupied, as Health Visitors, in advising poor women, as soon as practicable aften-their confinement, with regard to the feeding, and the care, generally, of their babies And recently the Local Government Board have manifested their interest in the question by requiring the Metropolitan Medical Officers of Health to include in their annual reports a new table of the stated causes of deaths of infants under one year of age. This table (set out at page (56) is of great interest, and when the returns shall have been summarised for the whole of London, the information cannot fail to be of much value. I have supplied a further table, showing the number of deaths, in the several calendar months, from the diseases named in the Board's table, to which I have added (in italics) a few other diseases, which, in the official table are included under the .eading " other causes." Of the 498 deaths, under one year, in 1905, the quarterly numbers were 142, 105, 148 and 10-3. March and August were specially fatal to infant life; 136 deaths (59 and 77 in the two months respectively) having been registered. Diarrhoeal diseases head the list, being the causes of 90 deaths; but it is interesting to note that, although nearly a third of the deaths from all causes occurred within the first four weeks of life, there was not one death at that ageperiod from diarrhoea—a fact explicable by the general practice among poor women of suckling their babies during the puerperal month when they are detained in their homes. Prematurity was accountable for 72 deaths; 64 of them within four weeks of birth, and 47 in the first week. Atrophy, debility, marasmus—terms often synonymous with tuberculosis, and usually connoting improper feeding and want of maternal care, were the causes of 60 deaths—23 of them in the first four weeks. To tuberculous diseases 23 deaths were attributed, to bronchitis 43, and to pneumonia 57. Three babies only were " overlayed," but 13 perished from other forms of "accidental" violence, as suffocation, want of attention at birth, etc. The illegitimate births during the year were 157 = 4.54 per cent. on total births; the deaths of illegitimate children 69 = 14 per cent. on all deaths under one year, and 44 per cent. on the births registered as illegitimate. Inquests were held in 23 cases. This question of infantile mortality has received much of my attention during the last few years, especially since 1902, when, with the approval of the Public Health Committee, a special enquiry was made by the Lady Inspectors, the results of which were set out in the annual report for that year (page 60). The particulars exhibited were; the number of deaths, of male and female infants, in the several wards, in each of the first four weeks of life, and in each subsequent month under one year of age; the causes of death, the position in life of the male parent, and in illegitimate cases, the status of the mother — the particulars thus corresponding pretty closely with those required by the table now prescribed for use by the Local Government Board. Table. 56 TABLE V. INFANTILE MORTALITY DURING THE YEAR 1905. Deaths from stated Causes, in Weeks and Months, under One Year of Age. Cause of Death. Under 1 week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under One Year. Common Infectious Diseases Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... — Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... — Measles ... ... ... ... ... ... ... 1 ... 1 2 ... ... 2 3 1 13 Scarlet Fever ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 Diphtheria: Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... — Whooping-cough ... ... ... ... ... ... 3 2 ... ... 1 5 4 2 3 4 24 Diarrhœal Diseases Diarrhoea, all forms ... ... ... ... ... 7 7 6 9 5 7 10 2 4 6 2 65 Enteritis (not Tuberculous) ... 1 1 1 3 ... ... 5 1 ... 2 1 ... ... 1 2 15 Gastritis, Gastrointestinal Catarrh ... ... ... ... ... ... 1 ... 1 ... 1 1 ... ... ... ... 4 Gastro-enteritis* ... 1 ... 1 2 1 ... 1 1 ... ... ... 1 ... ... 6 Wasting Diseases. Premature Birth 47 5 7 5 64 4 3 1 ... ... ... ... ... ... ... 72 Atelectasis 10 1 ... 11 ... ... ... ... ... ... ... ... ... ... 11 Congenital Defects 4 1 1 ... 7 2 ... ... 2 1 ... ... ... ... ... 12 Injury at Birth 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 Want of Breast-milk Atrophy, Debility, ... ... ... ... 1 1 1 ... ... ... ... ... ... ... S Marasmus 9 5 5 4 23 12 10 5 ... 3 5 1 ... ... ... 1 60 Indigestion ... ... 1 1 ... 1 1 1 ... ... ... ... ... ... ... 4 Tuberculous Diseases Tuberculous Meningitis ... . . . ... ... ... 3 ... ... 1 1 ... ... 1 1 ... 7 Tuberculous Peritonitis. Tabes Mesenterica ... ... ... ... ... 2 ... 2 2 ... ... ... ... ... ... 1 7 Other Tuberculous Diseases ... ... ... 1 1 ... 1 1 1 1 ... 1 1 ... 2 ... 9 Erysipelas ... 1 ... ... 1 ... 1 ... ... ... ... ... ... ... ... ... 2 Syphilis ... 1 ... 2 4 2 3 ... 2 1 ... 1 ... ... 1 ... 18 Rickets ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... 2 Meningitis (not Tuberculous) .. ... ... ... ... ... ... 2 ... ... ... 1 ... ... 1 2 ... 6 Convulsions 5 2 2 ... 9 2 ... 1 ... ... 2 1 ... ... 1 ... 16 Bronchitis ... ... 3 2 5 6 2 3 4 4 1 3 2 2 8 3 43 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... — Pneumonia ... 1 3 1 5 4 ... 5 2 2 3 8 9 4 2 13 57 Other Lung Diseases ... ... ... 1 1 1 ... 1 1 ... ... ... ... ... ... ... 4 Suffocation, overlaying ... 1 ... ... 1 . . . ... 2 ... ... ... ... ... ... ... ... 3 Violent Deaths, other 7 ... 2 ... 9 1 ... ... 1 1 ... 1 ... ... ... ... 13 Dentition ... ... ... ... ... . . . ... ... ... 2 ... ... 1 1 1 ... 5 Other causes 1 2 ... 1 4 2 ... 8 2 ... ... 1 ... 2 1 ... 15 84 22 25 21 152 47 38 46 30 24 26 36 21 19 32 27 498 * The diseases printed in italics are not named in the official table, but are grouped therein under the heading "other causes." 57 TABLE VA. INFANTILE MORTALITY. Causes of Death of Infants under one year of age, grouped in monthly periods. Cause of Death. January. February. March. April. May. June. July. August. September. October. November. Decemher. Totals. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... — Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... — Measles ... ... ... ... 3 2 ... ... 1 ... 3 2 13 Scarlet Fever ... ... ... ... ... ... ... ... 1 ... ... ... 1 Diphtheria ... ... ... ... ... ... ... ... ... ... ... — Whooping-cough 1 3 7 3 3 3 2 2 ... ... ... ... 24 Diarrhoea ... 2 1 2 1 3 8 32 12 3 ... 1 65 Enteritis 1 ... 1 1 1 2 1 3 2 1 2 ... 15 Gastritis, Gastro-Intestinal Catarrh ... ... ... 1 1 1 ... ... ... ... ... 1 4 Gastro-enteritis* 1 ... ... ... 1 1 ... 2 1 ... ... ... 6 Premature Birth 7 3 7 3 5 4 7 14 8 3 5 6 72 Atelectasis 1 2 ... 1 3 1 ... ... 1 1 1 ... 11 Congenital defects 4 2 ... ... 2 ... 2 ... ... 1 1 ... 12 Injury at birth ... ... ... ... ... ... ... ... 1 ... ... ... 1 Want of breast milk ... ... 2 ... ... ... 1 ... ... ... ... 3 Atrophy. Debility, Marasmus 4 3 13 4 5 3 6 7 5 5 4 1 60 Indigestion ... ... 2 1 1 ... ... ... ... ... ... ... 4 Tuberculous Meningitis 2 2 ... ... ... ... 2 ... ... ... 1 7 Tuberculous Peritonitis, Tabes Mesenterica ... 2 1 1 ... ... ... ... 1 1 ... 1 7 Other Tuberculous Diseases 1 ... 2 1 ... 1 1 ... ... ... 2 1 9 Erysipelas 1 ... ... ... ... 1 ... ... ... ... ... ... 2 Syphilis 1 1 1 2 3 .. 2 4 ... 2 1 1 18 Rickets ... 1 1 ... ... ... ... - . . ... ... ... 2 Meningitis ... ... 2 ... 1 ... ... 1 . ■. 2 ... ... 6 Convulsions 1 3 3 ... ... 3 1 1 2 1 1 16 Bronchitis 4 4 5 4 8 2 ... 1 4 6 10 43 Laryngitis ... ... ... ... ... ... ... ... ...... ... ... ... Pneumonia 10 6 8 6 6 1 1 2 4 6 7 57 Other Diseases of Lungs 1 ... 1 1 ... ... ... ... ... ... ... 1 4 Suffocation, overlaying ... ... ... ... ... ... 1 ... ... 2 ... ... 3 Other violent deaths 3 ... 1 ... 1 3 1 2 ... ... 2 ... 13 Dentition 2 1 ... 1 ... ... ... ... ... ... 1 ... 5 Other causes 1 2 1 2 1 1 2 2 ... 1 1 1 15 46 37 59 34 41 30 37 77 36 31 35 35 498 * The diseases printed in italics are not named in the official table, but are grouped under the heading " other causes." 58 The subjoined list shows to what a preponderant extent the deaths of infants under one year of age occur among the less well-to-do classes of the population. STATUS OR OCCUPATION OF MALE PARENTS OF DECEASED INFANTS. Labourer 127 Lamplighter, Platelayer, Ball-Furnisher, Insurance Agent, Stenographer, Miner, Masseur, Licensed Victualler, Contractor (1 each) 24 Artizan 77 Coachman, Cabman, Carman 47 Housekeeper, Stableman 15 Tradesman (in small way of business) 19 Foundlings 3 Shop Assistant 15 Costermonger, Flower-seller, Hawker 14 Persons of the more prosperous classes: — Porter 12 Merchant, Solicitor (4 each) 8 Clerk 10 Commercial Traveller 3 Milk-Carrier 6 Gentleman, Tailor's Manager (2 each) 4 Flat, Hotel Porter 4 Civil Engineer, Stock and Share Dealer, Alkali Manufacturer, Hotel Manager, Lieut.-Colonel, Dentist, Member of Stock Exchange (1 each) 7 Omnibus Conductor 4 Soldier, Laundryman (3 each) 6 Photographer, Guard, Journeyman Baker, Police-Constable, Seaman, Gardener, Waiter, Caretaker, Watchman, Pavement Artist, Engineer, Warehouseman (2 each) 24 Status or Occupation of Mothers of deceased Illegitimate Infants: — Domestic Servant 39 Charwoman 12 Engine-driver, Butterman, Barman, Fencing-master, Bargeman, Cellarman, Potman, Marine Engineer, Sorter, Timekeeper, Wigmaker, Postman, Chimney-sweep, Musician, Scavenger, Laundress 10 Barmaid, Flower-seller, Tailoress (2 each) 6 Dressmaker, and " no occupation " (1 each) 2 Total 498 THE CARE OF INFANTS: APPOINTMENT OF A HEALTH VISITOR. In 1900, I recommended the appointment of women to assist in sanitary administration by the performance of duties analogous to those discharged by "Health Visitors" at Manchester, Birmingham, etc., some account of which was set out in my annual report for that year. The Sanitary Committee of the late Vestry reported sympathetically on the subject, as being "deserving of the careful attention of Sanitary Authorities;" but they felt that, having regard to the Vestry's "waning existence," it was "undesirable that any new office should then be created." Nevertheless, at the meeting of the Vestry (18th July), on consideration of the Committee's report, there was a strong expression of opinion that action should be taken, forthwith, in the direction recommended by me: ultimately, however, a motion to that effect was negatived. In the first monthly report in 1904, I renewed the proposal when dealing with the question of Infantile Mortality, and the report was referred to the Public Health Committee, for whose information I drew up a further report which was printed at page 48 in the annual report for 1904, The specific recommendation made to the Public Health Committee was, that three Health Visitors, with the status of Sanitary Inspector, should be appointed; and the sub-committee reported in favour of this proposal; but ultimately the Public Health Committee presented a report as follows: — "We have had before us, pursuant to the reference by the Council of the 16th February last, the appendix to the report of the Medical Officer of Health, dated 4th February, 1904, under the heading 'Infantile Diarrhoeal Mortality in 1903,' together with a memorandum on the subject subsequently prepared by that officer ; and having carefully considered as to the steps which should be taken to reduce, as far as possible, the high rate of infantile mortality which does undoubtedly exist in parts of Kensington, we are of opinion that it ia desirable, temporarily to appoint a properly qualified woman to act in the capacity of ' Health Visitor,' at a salary not exceeding £2 per week, and to circulate leaflets for the guidance of mothers with regard to the feeding, clothing, &c., of young children, and the management of the home." The report was adopted by the Council 20th December, 1904, and in March, 1905, Miss Gauntlett was appointed to the position of Health Visitor, for the purpose of visiting poor mothers to advise them with regard to the feeding and the care generally of their babies, and to distribute a leaflet, prepared by the sub-committee, approved by the Public Health Committee and adopted by the Council, containing "advice for the guidance of Mothers on the Feeding and Care of their Babies." 59 Each case visited was recorded on a form showing particulars as follows— Ward Reference No REPORT ON THE CASE OF— Name Living at Born Registeieii Sex Head of Family, Name of. Condensed Milk, Brand of? Whole? Separated? „ „ Occupation of. Feeding bottle, type of? Children in Family, No. of. Weaning, age at? Rooms occupied; No. and position of. Doctor or midwife; Attended by? „ condition of. Mother goes out to work as— Bedding, condition of. How many days in week? Feeding, method of— How long per day? Suckled? Child, how cared for during day? Milk (fresh whole), how much daily? Infantile deaths in family? Remarks:— Visit, date of first- Condition of child at birth? Age at— Any illnesses? Re-visits— If child dies— Cause of death. Date of death. Alive at the end of first year? I have pleasure in submitting an account of the Health Visitor's work for the nine months, April to December, during which period 1,624 mothers were interviewed at home; 1,420 in North Kensington and 204 in South Kensington, and 502 were re-visited, making a total of 2,126 visits.* In addition to these visits to the homes of the poor, Miss Gauntlett, at my request, and by permission of the medical superintendent, has for some time past paid a weekly visit to mothers in the maternity ward at the Workhouse Infirmary, and has thus had numerous opportunities for giving simple instruction regarding the care and feeding of infants, and for finding out the destination of the mothers with a view to subsequent visitation, should circumstances permit. Of the mothers visited, 245 were confessedly engaged in work which took them away from home on several days in each week: 84 of them as charwomen, etc., and 165 as laundresses; the babies meantime being left in the charge of relatives, lodgers, neighbours (often aged and decrepid), or young children, not a few of them more or less incompetent for the duty. Many infants are taken from home for this purpose, and in the case of laundry employees are fetched away in the evening, often at late hours and in all weathers: hence many an illness—bronchitis, pneumonia, etc., the most common causes of infantile deaths. "A distressing element of the work" (the Health Visitor reports)" is the poverty which during the lying-in period reduces many a mother to a state of destitution, rendering it impossible for her properly to nourish her infant in the natural way .... I think I must have seen quite 50 mothers who, I have every reason to believe, were in a state of dire need, with their babies of a few days old lying beside them."† * During the first quarter of the year the lady sanitary inspectors visited babies to the number of 491: 413 in North Kensington and 78 in South Kensington : 126 re-visits were paid—108 in North Kensington and 18 in South Kensington. In all, 2,115 babies were visited. The births registered during the year numbered 3,458. † In an earlier report, the Health Visitor, commenting on the connection between destitution and infantile mortality, referred to " the malnutrition of the nursing mother as a principal cause of the malnutrition of the infant. Thus it happens that when the mothers get up and about, the little milk they had disappears, or becomes almost valueless as food for their offspring, Unable to provide cow's milk, or other good substitute, the infant is fed with bread as a supplementary article of diet, and sometimes as the sole article, malnutrition, disease often, and sometimes death, being the result. Appeals to the relieving officer for out-relief in such cases, unless the district medical officer is in attendance, result in the offer of the ' House,' of which the mothers of families are unwilling to avail themselves. Illustrative cases of the kind could be given–but, of course, I have to depend on the statements of the sufferers which I have no means of verifying. There is, however, no question of the extreme want from which the mothers I have in my mind suffered; and with the ' reduction of infantile mortality' as my point of view, I find it hard to be able to do nothing to relieve their distress." Commenting on this report I observed—" Here is a noble field for benevolence, which many ladies in the Royal Borough would be only too glad to exercise towards their destitute sisters in their time of trial, were it possible to bring rich and poor together—by some system providing for the distribution of relief, if only the want could be made known, and judicious almoners found." 60 The report supplies information with respect to babies suckled by the mothers, and with respect to the mode of feeding in cases brought up, wholly or in part, by hand—a matter in regard to which almost invincible ignorance appears to be but too commonly displayed: the more intelligent mothers, even, in many instances, concluding that the breast milk " does not 'satisfy' the child." have recourse to boiled bread and other starchy articles of diet, until instructed as to the unsuitability of such food for young babies. Many homes seen dirty on a first visit, were found in a better condition on a second call. Neglect of babies, not often observed, was usually accounted for by the habits of the mothers. The visits of the Health Visitor, with rare exceptions, were cordially welcomed; especially by young mothers, who listened, intelligently and gratefully, to oral advice, and profited by the directions contained in the Council's leaflet on "The Care of Infants." One of the most satisfactory results was the diminished use of the long tube b.ottle, and the substitution therefor of the tubeless bottle, although the latter is more expensive. Nuisances observed were duly reported and abated; and altogether much good work was done which, it may be hoped, will bear fruit in due season. The one thing to be regretted is the inability of a single visitor to accomplish all that could be wished. Systematic re-visitation would greatly enhance the value of the work. Applications were received from the Kensington Health Society, the Board of Guardians, and others, for the services of the health visitor, for giving lectures on the care of infants, etc., to district visitors and workers amongst the poor, and "talks" to mothers' meetings, and also to thriftless women at the workhouse. The Public Health Committee gave sympathetic consideration to the said applications, but felt it incumbent on them, in view of the amount of work devolving upon that officer, to lay down, as a rule, that she could not be permitted to give her services for the said purposes. Appended is a short summary of the work of the Health Visitor— Summary of Visits Paid to Babies in the several Wards, etc. W ard. St. Charles. Golborne. Norland. Pembridge. Holland. Earl's Court. Queen's Gate Redcliffe. Brompton. Total No. of primary visits to houses 326 583 864 147 93 47 9 39 16 1,624 No. of re-visits 137 185 113 20 31 6 2 4 4 502 Babies suckled at time of visit 227 445 263 104 67 31 7 21 11 1,176 Babies improperly fed 29 45 27 15 10 6 ... 7 8 142 No. of unhealthy babies seen 44 82 57 28 8 6 1 9 2 237 No. of mothers who go out to work 67 72 67 11 14 1 1 ... ... 233 No. of dirty homes 10 15 16 4 2 ... ... ... ... 47 PARTICULARS OF BIRTHS. The efforts of Sanitary Authorities for bringing about a reduction of the high rate of infantile mortality—i.e., the proportion of deaths under one year of age to registered births, were, until recently, rendered almost nugatory through want of information of the occurrence of births. Medical Officers of Health had long been desirous of obtaining such information through the sub-district registrars, who for many years had supplied them with particulars of deaths. But it was not until November, 1904, that these officers were authorised to supply information. As was stated in the twelfth report for that year, the Local Government Board had then intimated that "after comunication with the Registrar-General, they had approved of an arrangement for the supply to local authorities, by registrars of births and deaths, of particulars as to births within their sub-districts." Since the beginning of last year every possible effort has been made in this 61 Borough to utilise the information thus obtained. The work, in the first instance, was entrusted to the Lady Inspectors, who in the first quarter of the year, paid primary visits to 491 infants, mostly in the northern parts of the borough. The value of the information supplied by the registrars is by no means inconsiderable; but, as stated in the report adverted to, " registration being, as a rule, long delayed,* particulars as to births of infants who die within the first month of life, do not usually reach the Medical Officer of Health much, if any, sooner than particulars as to their deaths." Evidence to this effect was given in the report: it will suffice here to state that of the deaths of infants, in the year 1902, 35 per cent. occurred within the first four weeks after birth, a period within which scarcely more than 20 per cent. of births are registered. Such being the state of the case, it is obvious that the value of the particulars of births the registrars are authorised to supply, would, as I said, be " greatly enhanced could registration be made compulsory within, say, seven days." At the date of the report a sub-committee had been appointed by the Public Health Committee to consider the recommendation I had made for the appointment of female "Health Visitors," and it was stated that in the event of the Council deciding to make such appointments, "efforts would be made to obtain information at the earliest practicable date after the birth of children to the poorest classes—through the agency of medical men, registered midwives, district visitors and others." Soon after the appointment of the Health Visitor, a scheme was set on foot for obtaining information of births through district visitors who, obviously, could be approached only through the beneficed clergy, to each of whom I wrote as follows:— " Infantile Mortality—I am desirous of obtaining early information of births occurring in the poorer parts of the Borough, with a view to visitation of the mothers by the Council's Lady Health Visitor, shortly after their confinement; and should be greatly obliged if, through the agency of district visitors, or otherwise, you could assist me in the matter. " The object in view is to reduce, if possible, the present excessive amount of infantile mortality, i.e., the proportion of deaths under one year of age to registered births. " To show the importance of the matter, I may mention that about one-third of the births are registered after the age of six weeks, whilst one-third of the deaths of infants under one year of age, occur within the first month of life. From this it follows that few babies can be visited within the period when the danger to life is greatest, their existence being unknown to the sanitary authority. "I should be pleased to send forms for report on receiving names and addresses of district visitors or others willing to supply the desired information." The one clergyman who replied to the letter intimated that he had called a meeting of his fourteen district visitors, who had promised their assistance. Forms for the report of births were forwarded to the several ladies, from one of whom I received particulars of three births. A letter was also addressed to the certified midwives residing and practising in Kensington, whose names and addresses were supplied to me by the Medical Officer of Health to the County Council, the local supervising authority under The Midwives Act, 1902. The letter ran as follows: — "The Council have appointed a Lady Health Visitor to visit poor mothers shortly after their confinement, in the hope of bringing about a reduction of the present high rate of infantile mortality. "I may mention that I receive, every Monday, particulars of births registered in the Borough in the preceding week; but, unfortunately, about a third of the births are not registered until six weeks and upwards after their occurrence, whereas a third of the deaths of babies under one year of age take place within a month after birth. "The work of the Health Visitor would be of greatly increased value if she were enabled, by receiving early information of a live birth, to visit the mother within a few days after her confinement. "You would be doing good service to poor women and their babies, and I should be much obliged, if you would kindly report to me the births which occur in your practice in Kensington. " Should you be willing to do this, I shall be happy to send you forms for the purpose." * Births should be registered within 42 days, and may be registered without fee within three months. 62 I am pleased to state that this appeal met with success, and gladly express my obligations to the ten midwives who, in a period of sixteen weeks, reported 356 births soon after their occurrence. In almost every instance the mother was visited within a few days after her confinement ; and (as also in other cases, visited at later periods upon receipt of the registrars' returns) oral advice was supplemented by the printed card, drawn up for the purpose, entitled " Advice for the Guidance of Mothers on the Feeding and Care of their Babies The births registered within the four months during which the system was in operation numbered 1,068, and more than one-third of the mothers were visited within the month. Valuable, however, as the midwives' returns were, the information supplied by them was far from being as complete as could be desired; I did not see, moreover, how it could be increased. Happily the County Council took action which may lead to important developments. Believing that it would be of " assistance to them as the Local Supervising Authority under the Midwives Act, 1902, if complete returns of births occurring in the practice of midwives in London could be obtained," the Medical Officer of Health was directed to ask the several midwives to furnish him with a weekly list of the births attended by them, on forms provided for the purpose. The suggestion had been made to the County Council that it would be advantageous for the Metropolitan Medical Officers of Health " to receive information with regard to births occurring in the practice of midwives, in order that advice may be given, by the officers of the Sanitary Authority, to mothers, on the feeding and care of infants, in those cases where such advice would appear advisable." And such information has since been supplied, in the form of a weekly list of births, to the Medical Officers of Health of the several Metropolitan Boroughs by the County Medical Officer. During the first sixteen weeks I received 376 notices of births compared with the 356 received from midwives direct during the preceding 16 weeks. The advantage of the arrangement consists in the early date at which information of births reaches the Medical Officer of Health in midwives' cases, compared with information supplied by the registrars. This is well illustrated in the two tables below, showing that in the first four weeks under the new arrangement, information of births was received from midwives in 111 cases (out of 116) within 14 days after their occurrence, whilst of registered births information was received in 12 cases only out of 242 within a corresponding limit of time. Thus it follows that the Health Visitor is able to visit the majority of mothers within a fortnight of their confinement in midwives' cases, whereas in the case of registered births, the visit is not possible in a tenth of the cases within that limit of time, when advice is of the greatest value, and is most acceptable. Too often, when the visit is made in cases reported by the registrars, the mothers will have resumed their usual occupations which take them from their babies during the daytime, and so be away from home and not seen. Notices of Births received from the Medical Officer of Health of the London County Council in the four weeks, November 5th to December 3rd, 1905. Age of Infants at Date of Receipt of Notice. In Days 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total Cases. No. of Births 11 8 19 13 16 18 17 11 1 2 3 1 — 1 116 The shortest period between the occurrence, and the notification, of a birth was 5 days, the longest 18 days, whilst of the 116 births reported, very few had been registered within the period of 18 days. Births registered in the four weeks, November nth to December gth, 1905. Age at Registration, in Weeks. Weeks. -1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 At ages above 13 weeks. Total. Births 3 9 18 16 25 74 65 26 2 5 1 ... 1 2 242 63 Of the 242 births, 41 only were registered within four weeks, 140 within six weeks, and 100 between the sixth and thirteenth weeks. In connection with this subject, I pointed out in the eleventh monthly report, that in the interests of public health the law (Births and Deaths Registration Act) should, if practicable, be amended, so as to ensure registration of births within a much shorter period than six weeks; and I recommended that the Local Government Board be approached on the subject. The report was referred to the Public Health Committee who expressed the view "that the law relating to the registration of births might, with advantage, be amended, and that the time limit for such registration should be reduced to 21 days as in Scotland"; and they accordingly recommended: "(a) That representations be addressed to the Local Government Board urging that Board to promote legislation in the direction indicated; and (b) That a circular communication be addressed to the Metropolitan Borough Councils inviting their co-operation in the matter." The report was adopted by the Council, and as the result a large proportion of the Public Health and Poor Law Authorities addressed communications to the Local Government Board in support of the Council's request for an amendment of the Registration Act. CRECHES - DAY NURSERIES (OR NURSERY SCHOOLS). In the tenth monthly report, 1902, when dealing with the subject of infantile mortality, I expressed the hope that, "by a combined effort on the part of the Sanitary Authority and philanthropic agencies, means might be adopted" for providing creches" for the care, during work hours, of the infants of poor women compelled to earn their living by labour away from home." In July, 1904, I brought the subject to the notice of the conference of delegates of the Metropolitan Borough Councils, convened by the County Council, and held at the County Hall. The resolution adopted by the conference was: — "That, having regard to the decli ning birth-rate and the large infantile mortality-rate of the Metropolis, it is desirable that the Metropolitan Borough Councils should be empowered, at their discretion, to establish creches for the reception of young children during the hours their mothers are employed in work away from home, and to make reasonable charges for the accommodation so provided, and for the food of the children; and that the London County Council be requested to insert in their General Powers Bill for the Session of 1905, a clause to confer such power upon the said Borough Councils." There would now appear to be a probability of action being taken, ere long, in the desired direction, the Public Control Committee of the County Council, after much consideration of the subject, having, in July, submitted to the Council a report "as to Creches or Day Nurseries," based upon an enquiry made by the Chief Officer of the Department by the instruction of the Committee. The report furnishes particulars of the present crlche accommodation in the County of London, and in the United Kingdom, together with information obtained, by desire of the Committee, by the Secretary of State for Foreign Affairs, relative to the organisation and working of similar institutions in many large towns on the Continent. The Committee stated that there were, irregularly distributed throughout London, about 55 creches, managed by private bodies or individ uals, receiving, daily, an average of 1,183 infants. But the selection of the districts in which these institutions have been established, has depended, not so much on local needs, as upon the existence of philanthropic organisations therein; some of the largest, poorest, and most densely populated districts being either totally unprovided for, or having inadequate provision. It would be difficult, the Committee observe, to estimate the benefit that would be afforded to the infant life of such districts by a properly organised system of creche accommodation, or the extent to which such a system would affect the rate of infant mortality. The general conditions of life amongst the poor compel the mother to work for her living, and infants are often left where they cannot be properly cared for, or are frequently placed out to nurse under unsatisfactory conditions, and without due provision being made for their nourishment. The advantages claimed for the proposed system are summarised by the Committee as follows: (i.) The crbche is usually healthier and cleaner than the child's home; the treatment is more enlightened, and the method of feeding better adapted to the child's tender age. (ii.) At the creche the child is taught cleanliness and good habits, becomes stronger and healthier, and is given a better chance in life, (iii.) Crfohes are under medical supervision, and the promptitude with which a case of sickness is treated, often prevents more serious consequences, (iv.) The mother is required to bring the child clean; better methods of feeding are learned; and the cleanliness and discipline of the creche insensibly react to the advantage of the home. 64 The success which has attended the efforts of philanthropic bodies to meet the difficultiesof the poor in this matter, may, the Committee 'think, be taken as showing the need for creche accommodation; but more and better organised means are necessary to grapple successfully with the problem. This is being realized by certain local authorities; and already one authority on the outskirts of London (Acton) has endeavoured to obtain Parliamentary powers, to establish a creche, whilst several of the more important corporations in the country are considering the question. The Committee call attention to the fact that the Inter-Departmental Committee on Physical Deterioration, in their report, made a recommendation to the effect that, whenever it was thought desirable, owing to the employment of married women in factories, or for other reasons, to establish municipal creches, girls over 14 might be made to attend occasionally, and that the teaching of infant management to such girls should be eligible for aid from the grant for public education. Public money could not be more usefully expended! The Committee recommended, (a) That the standing order (No. 1G1), limiting the period for considering applications to Parliament, be suspended, so far as may be necessary to enable the Council to consider their recommendations with regard to the provision and maintenance of creches in the County of London; (b) That notice be given, by public advertisement, of the intention of the Council to consider, at its meeting to be held on August 1st, 1905, a proposal that it shall take the necessary measures for promoting, in the next session of Parliament, legislation to enable the metropolitan borough councils: (i) to provide and maintain crhhes; and (ii.) to contribute towards the maintenance of criches established by voluntary effort in the county of London, and to defray, out of the county fund, the costs and expenses of so doing. But at the meeting of the County Council held on 25th July, the report was withdrawn by the Committee, and will not therefore form the subject of an application to Parliament during the current Session. In connection with the suggested provision of creches, the Education Committee gave consideration to the desirability of not permitting children under five years of age to attend school, and it is expected that they will soon be in a position to report on the subject. CHILD MORTALITY AND SCHOOL ATTENDANCE. The Board of Education decided, last year, to relieve local education authorities from the obligation to provide school places for children under the age of five years, the age at which compulsory attendance begins, and it is staled that the number of such authorities who have decided that in future children under five shall not be admitted to elementary schools, is already considerable: some few authorities have elected to exclude children under four only. In connection with the question of the provision of creches, referred to in the preceding section, the London Education Committee are still considering the desirability of availing themselves of this power of exclusion. The subject received considerable attention in the House of Commons, in the debate on the Education vote, on the first of August, the date at which the decision of the Board of Education became operative. Sir William Anson, then Vice-President of the Board, stated that:— "There are a great many reasons why children under the age of five should be excluded from schools; their work is of small educational value, their attendance is accompanied very often by considerable risk to health; in tolerably well-to-do families they are are almost always better at home, and in very poor families they ought to be provided for by crtcke and public nursery, but not by public elementary school." He further stated that " very interesting reports of women inspectors who were specially asked to report upon the condition of infant schools, and to inform the Board what educational value attached to them, had been obtained." The reports, which are " very strong and decided," have since been published. The decision of the Board should be heartily welcomed by sanitary authorities, and it is to be hoped that in the result there will be a material reduction in child mortality — especially from such diseases as measles and whooping-cough, which are spread to no inconsiderable 65 tent by infant schools. These diseases were the causes of some 24,000 deaths yearly in the decennium 1893-1902; of which, as respects measles, 94 per cent. were those of children under five years old, whilst as respects whooping-cough, not fewer than 97 per cent. of the total deaths occurred among children under five. The deaths from all causes under that age in the Royal Borough, in the decennium 1894-1903, were more than a third of the total mortality, and equivalent to about one-fourth of the registered births. It remains to be seen what further action the Board of Education under the present Government will take in the matter. Should the practice of exclusion become general, the need of a substitute for the infant school for children under five would be imperative. Without such provision the exclusion of children at the age-period 3—5 years would be of doubtful advantage, and would assuredly lose much of its value as a measure for diminishing mortality in early childhood. Possibly authority may be given to sanitary authorities to provide municipal creches. But the Lambeth Borough Council, having asked the London County Council (Education Committee) " to consider the advisability of all children under five years of age being excluded from the Public Elementary Schools "—a course which would lead to a large reduction in the education grant—further suggested," That in the event of such children being excluded, the expenses connected with the provision and upkeep of the necessary criches and infants' nurseries be provided out of Imperial taxation and not out of local rates." The scholars below five years of age under instruction in England and Wales, are some 588,000 in number, the amount of the annual Grant for them being about nine hundred thousand pounds. Ill-nourished. Scholars.—It is notorious that insufficiently fed children are unable to profit by the " education" received in elementary schools, and strenuous efforts are being made to secure for these unfortunates at least one good meal a day. It is not improbable that, ere long, legal provision will bte made to secure this boon, desirable as much in the interests of the community as in those of the little sufferers. The London Education Committee are moving in the matter, and feeding many children. The scheme outlined in one of their reports last year, proposed that the food dressed in the cooking centres be utilised, as far as possible, in arranging for dinners at certain named schools, the expenditure incurred to be recovered from parents or from charitable funds. The Committee however do not desire to interfere with the work of charitable institutions, but rather to organise existing agencies and work in harmony with them. The Laws of Health.—It is interesting to note that the Board of Education in the new Code of 1905, called attention to the teaching of the laws of health, and circulated a syllabus on the subject, worked out on the lines suggested by Sir Michael Foster, M.D., and Dr. Hutchinson. The Vice-President expressed the opinion, which surely will be generally accepted, that the said syllabus " is one of the most practical and useful of the sort which has yet been issued by the department, or any other authority in charge of these matters." In my first annual report, for 1871, I asked, When will this teaching form an integral part of the education of children in the Public Elementary Schools? The London Education Committee, it is understood, are taking steps to secure, by proper technical training, a body of competent persons for teaching the subject. MILK DEPOTS (LONDON) BILL. A Bill so intituled, was introduced last Session by Mr. T. Lough* (supported by Sir Charles Dilke among others), its object being to legalise action already taken by some of the Metropolitan Borough Councils, and to authorise the others to take similar action, by establishing depots for the sale of pure and sterilised milk for the use of infants. In the Memorandum prefixed to the Bill it was stated that the expenditure thus involved had been very small; but that "in the absence of legal power to carry on the depots "it had been surcharged by the Local Government Board auditor. The Board had, however, each year, remitted the surcharge at Battersea, and had intimated that they would do so in the case of Lambeth. It was the object of the Bill to remove that difficulty, and to confer power upon such Councils as might wish to adopt the proposed Act, to maintain milk depots free from the fear of surcharge. There were three operative clauses. The first to give power to the Council to establish milk depots; the second providing that the expenses should be paid out of the general rate, and the third defining a milk depot to mean" an establishment for the purification, improvement, preservation, sterilization, and sale of milk and cream." The Bill did not become law. * Now Parliamentary Secretary to the Board of Education. 66 It will be remembered that upon the consideration of my tenth report for 1902, dealing with the auestion of infantile mortality, referred by the Council to the Public Health Committee, the Committee reported in favour of the proposal to establish a milk depot, as follows:— "We are of opinion that it would be a desirable thing to establish in the Borough a municipal supply of sterilised and humanised milk, for the feeding of children of the poorer classes, in the hope that it might tend to the diminution of the excessive mortality which does, without doubt, exist in a certain portion of North Kensington and they recommended— "That the Council do endorse the opinion above expressed, and that it be referred back to the Committee to consider and report as to what steps should be taken to give effect to the proposal." The report was not adopted by the Council, possibly on the ground that they did not possess legal power to establish a depot. It is to be desired that such discretionary power should be possessed by sanitary authorities, as a means whereby the evil of an excessive rate of infantile mortality may be combated. MIDWIVES ACT. The London County Council forwarded to the Council an extract from a report of their Midwives Act Committee, and asked to be informed whether the Council would be prepared to render any assistance under Section 77 of the Public Health (London) Act, 1891, where medical practitioners are summoned by midwives in cases of difficulty or emergency, and are unable to obtain payment of their fees ? I put myself in communication with the Clerk to the Guardians, who informed me that the Board were proposing, in cases of proved emergency and destitution, to apply to those cases the powers, conferred upon them by the provisions of the Poor Law Amendment Act, 1848, "to pay for any medical or other assistance which shall be rendered to any poor person on the happening of any accident, bodily casuality or sudden illness, although no order shall have been given for the same by them or any of their officers."* The Public Health Committee, therefore, were of opinion that no action was necessary on the part of the Council. It may be mentioned that the County Council in their General Powers Bill now before Parliament, are seeking power to pay fees for medical assistance in such cases of emergency. VACCINATION. The table at page 68 is a return respecting vaccination in Kensington in 1905, for which I am indebted to Mr. King, the vaccination officer. It shows that out of 3,466 infants born, whose births were returned in the "Birth List Sheets" (col. 2), during the year, 3,268 were successfully vaccinated, and that 14 were returned as "insusceptible of vaccination." In 7 cases vaccination was postponed by medical certificate; 317 infants died unvaccinated; in 20 cases infants were removed to other districts, the vaccination officers of which were duly notified of the fact; whilst 156 cases, from "removal to places out of the parish, unknown, or which cannot be reached, and cases not having been found," were unaccounted for. These cases are, with those of "conscientious objectors" (37, against 46, 23 and 25 in the preceding three years respectively), equivalent to a "loss" (i.e. cases not finally accounted for) of 5.8 per cent., as compared with the number of births returned in the Birth List Sheets ; the loss in the preceding ten years having been 8.4, 9.0, 10.7, 10.1, 12.7, 8.1, 6.8, 7.6, 61 and 5.8 per cent. The returns compare favourably with those for the Metropolis as a whole. * The Local Government Board had expressed the view that the case of a medical practiticner who may have been summoned by a midwife in a case of difficulty or emergency, might conceivably come within the section, and the Guardians might then, if they wished, pay for the medical assistance required. 67 The actual figures, showing loss, both for the Metropolis and the rest of England during the twenty years 1883-1902, as set out in the report of the Local Government Board for 1903-4, are as follows:— Metropolis. Cases lost. Rest of England. Cases lost. Metropolis. Cases lost. f Rest of England. Cases lost. 1883 0.5 per cent. 4.9 per cent. 1898 18.2 per cent. 15.7 per cent. 1884 6.8 ,, 5.3 ,, 1894 20.6 19.0 ,, 1885 7.0 ,, 5.5 ,, 1895 24.9 „ 19.8 ,, 1886 7.8 ,, 6.1 ,, 1896 26.4 ,, 22.3 ,, 1887 9.0 ,, 6.7 ,, 1897 29.1 ,, 21.6 ,, 1888 10.3 ,, 8.2 ,, 1898 88.0 ,, 19.6 ,, 1889 11.6 ,, 9.6 ,, 1399 27.7 ,, 15.4 ,, 1890 13.9 ,, 10.9 ,, 1900 25.8 ,, 18.9 ,, 1891 16.4 ,, 12.9 ,, 1901 24.1* „ 11.2 ,, 1892 18.4 ,, 14.8 ,, 1902 21.3 „ 10.0 ,, These figures show the great increase in annual "loss," from 1883 onward to 1898, and indicate that the new Act, which came into operation in 1899, has brought about a considerable increase in the number of primary vaccinations. The cost to the country has been great; but the Act has justified the policy of the Local Government Board in introducing it. The Board, in their annual report for 1901-2, referring to the vaccination returns for 1899, observed that "the increased acceptance of primary vaccination"—at a time precedent to the last epidemic of small-pox—is to be "referred to the altered conditions under which, consequent upon the Vaccination Act, 1898, and their regulations made thereunder, vaccination is now performed, and the increased facilities which now exist for its performance." One of the most potent influences tending to the increase in the number of vaccinations in normal years, is the provision made for the use of glycerinated calf-lymph, which has cut the ground from under the feet of those who objected to vaccination because of the possibility of enthetic disease being conveyed in humanized lymph. In a communication with which the vaccination officer favoured me recently, the opinion was expressed that the continuing decrease in the number of births might be "partly due to nonregistration." He occasionally discovers " children born in this and other Boroughs, whose births have not been registered by the parents, either from ignorance of the Registration Act, or from intentional withholding of information in order to evade the Vaccination Act." He thinks "it would do some good if notices were posted in conspicuous positions—churches, chapels, etc., calling attention to the penalties for neglecting to register, and for falsely registering, the births of children." He "traced 15 cases in Kensington, and 11 of other boroughs, in one year, which had not been registered ; parents alleging in some cases that they had acted in ignorance, and admitting, in others, their purpose to evade the Vaccination Act." This, he believes, " would not happen if the person attending at a birth, were held responsible for giving information to the Registrar of Births. Should a child's birth be not registered (he adds) it is improbable that it will be vaccinated; and the same remark applies with respect to false registration, which in Kensington alone, he thinks amounts to about five per cent., and is " likely to continue, as no proceedings are ever taken on discovery." These views correspond generally with those of the late vaccination officer who was of opinion that " false registration, i.e. fictitious addresses entered in the birth list sheets, largely accounts for the ' loss'; the children cannot be traced." [Table. * This is the percentage for the Metropolis as a whole, In several of the unions the percentages of cases not finally accounted for in 1901, were exceedingly high: for instance, in Mile End Old Town 65 8, in Bethnal Green 51.8, in Poplar 48.7, in Shoreditch 44.4, and in Stepney 43 9. 68 Vaccination Officer's Return respecting the Vaccination of Children whose Births were Registered in 1904.* (Vide page 60.) DATE. Registration Sub-Districts comprised in Vaccination Officer's District Number of Births returned in Birth List Sheets. Number of these Births duly entered in Columns 1, 2, 4, and 5 of the Vaccination Register (Birth List Sheets), viz. : Number of these Births which are not entered in the Vaccination Register, on account, (as shown by Report Book) of Column I. Successfully Vaccinated. Column II. Column V. Dead, Unvaccinated. Postponement by Medical Certificate. Removed to other Districts and notified to Vaccination Officers of the Districts. Removal to places unknown, or which cannot be reached, and cases not having been found. Total Number of Certificates of Successful Vaccinations received during each of the Calendar Years. Insusceptible of Vaccination. Certificate of Conscientious Objection. 1904. 1905* 1904. 1 2 3 4 6 7 8 9 10 12 13 1st January to 31st Dec. Kensington Town 2,951 2,471 9 36 279 6 16 130 3,268 3,135* Brompton 515 438 5 1 38 1 4 26 Total 3,466 2,909 14 37 317 7 20 156 3,268 3,135 * The complete Return for 1905 will not be due until February, 1907. It may be mentioned that, last year, 245 children born in other Boroughs were successfully vaccinated in Kensington, raising the total to 3,380. Legal proceedings were taken in six cases for default/ 69 THE BOARD OF AGRICULTURE AND THE SALE OF FOOD AND DRUGS ACT, 1899. The Public Health Committee, on 3rd October, instructed the Public Analyst and myself to report, jointly, with reference to a circular letter from the Board of Agriculture, in which it was "suggested that in the absence of any special circumstances indicating the commission of fraud," the local authority might, in the first instance (i.e., before taking proceedings under the Sale of Food and Drugs Acts, 1875 to 1899) call the attention of the vendor of milk to the adverse report of the public Analyst, and afford him an opportunity of submitting any explanation he might desire to offer on the subject. The joint report was as follows— "The issue of the said circular letter of the 29th December, 1901, to which attention is drawn in a further circular letter, dated 16th March, 1905, was due to ' numerous representations' received by the Board ' from dairy farmers and others complaining of the institution of proceedings in cases in which, as alleged, the deficiency of milk-fat or milksolids, as compared with the limits laid down in the Sale of Milk Regulations, 1901, was due to accidental causes, and not to any fraudulent action on the part of the vendor.' "In the 1901 circular letter, the Board expressed the opinion that, 'if the explanation were one which the Local Authority felt able to accept, they might, in the exercise of their discretion, refrain from the institution of proceedings, or withdraw any summons which it might have been necessary to take out, in order to avoid the failure of proceedings.' It is stated in the circular letter of March 1905, that ' the experience of the past three years has confirmed the propriety of the views expressed by the Board on the subject,— practically in condemnation of their own regulations—and that they would be glad to learn that (the Council) have made arrangements to proceed on the lines suggested; and if not, that the matter will be further considered at an early date.' "In the year ended June 30th, 1905, 204 samples of milk were collected for analysis in the Borough, and we are not aware that the collection of any of them was governed by the presence of ' special circumstances indicating the (probability of the) commission of fraud.' Of the said samples, irrespective of nine described as of ' inferior quality,' thirteen were adulterated; that is, generally, were found to be deficient in milk-fat or nonfatty milk-solids. We are not aware that in regard to any of these thirteen cases, there were 'special circumstances indicating the commission of fraud;' and had the Council adopted the advice tendered by the Board in 1901, every one of the vendors might have been afforded an opportunity of submitting any explanation he might have desired to offer for the condition of the impugned samples. "It must be pointed out that the Milk Regulations were framed by the Board, and that the standards are minimum standards. The Board, in fact, in the 1901 circular letter, state that ' the limits below which a presumption is raised that the milk is not genuine were necessarily fixed at figures lower than those which were usually afforded by genuine milk' ; and they further state that ' the evidence given before the Milk Regulations Committee tended to show that the practice of fraudulently mixing separated milk with new milk has become increasingly prevalent'—a statement, which, so far as we know, not having been controverted, makes the Board's recommendation all the more inexplicable. "The Board in the 1901 circular letter, said it was very desirable that farmers and dairymen, and all other cowkeepers, should have samples of the milk of their cows tested, from time to time, so as to enable them to guard against the effects of seasonal and other variations in the quantity of milk-fat contained in the milk. If this course were adopted —and producers know when to expect 'seasonal and other variations,' and how to correct them—it is not likely that genuine milk would be vended of a quality below the official standard. The Board, themselves, moreover, are ' satisfied that if the keepers of cows would, from time to time, test the quality of their milk for themselves, any legitimate ground of complaint on the part of the producers as to the administration of the law, so far as the adulteration of milk is concerned, would speedily be removed.' "The course recommended by the Board does not appear to us to have been conceived in the public interests, and we do not feel justified in recommending it for adoption by the Council." The Committee took no action in the matter. 70 THE METROPOLITAN ASYLUMS BOARD. L nder the provisions of the (now repealed) Sanitary Act, 1866, the local sanitary authority was endowed with power to provide, for the use of the inhabitants of their district, hospitals for the reception of the sick; a provision re-enacted in section 75 of the Public Health (London) Act, 1891. But, excepting in a few districts, and for limited periods in time of emergency; e.g., when small-pox was epidemic, this power was not exercised, notwithstanding official pressure brought to bear to induce sanitary authorities to erect local hospitals. The late Vestry originated opposition to the establishment of such hospitals; and no one now doubts that the policy of that body was wise, and fruitful of benefit to the entire Metropolis. In 1867 the Metropolitan Poor Act brought the Asylums Board into existence, and this body set to work forthwith to provide infectious disease hospitals, nominally for paupers only. As a matter of fact, however, and despite the disabilities attaching, in theory, to the use of the hospitals, they were largely used from the beginning by non-paupers; and in course of time legislation secured to the-inhabitants of the Metropolis all of the advantages contended for by the late Vestry, at my instance, from 1877 onwards. The hospitals are now free to all, no disability attaching to the use of them. The Managers have carried out their work admirably, and having created for London an unequalled hospital service, fulfil the duties originally devolved upon the local sanitary authorities; duties which those authorities would undoubtedly have had to perform but for the creation of the Board; and the subsequent legislation which has so enhanced their power as to leave little to be desired. The Annual Report of the Board for 1904 (that for 1905 not having been issued yet) is a document of great interest to Public Health and Poor Law Authorities—and to all ratepayers—by reason of the importance of the duties devolved upon the Managers, and the magnitude of their expenditure, which amounted to £1,196,795; viz., £1,002,198 on current aocount (including for Asylums, £211,224; Hospitals, £344,451; Ambulance Service, £36,053—Land, £23,378, River, £12,675—Children's Homes and Schools, £53,875; Training Ship, £17,711General Expenses," £338,777); and £194,597 on loan account; the total amount borrowed to Michaelmas, 1904, for land, buildings, fittings and furniture, being £5,332,125 ; the amount outstanding at that date being £3,544,592. The precepts levied by the Managers on the constituent parishes and unions of the district for the year, work out at 6d in the £, the same as the average for the preceding five years. The Institutions administered by the Board comprise 15 hospitals for infectious disease; a land ambulance service (8 stations, 171 ambulance and other vehicles), a river ambulance service (3 wharves and 5 steamboats), 5 asylums for imbeciles; a training ship; 2 schools for children with ringworm; 2 schools for children with ophthalmia; 3 sea-side homes for children; 5 homes for defective children, and 3 homes for children remanded by magistrates; making with the central stores and central needle-room, and the offices of the Board, a total of 49 institutions; one hospital for convalescing fever patients, and one asylum for imbeciles, being in course of construction. The Board's property comprises an area of 1,507 acres. The following statistical and other items are extracted mainly from the reports of the several Committees of the Board: — Infectious Diseases.—The particulars under this heading are summarised as follows: — Notifications. Admissions to hospitals. Death-rates, 1904. (i.) Scarlet fever 13,439* ll,155† 8.37 (ii.) Diphtheria 7,073 4,687 10.08 (iii.) Enteric fever 1,896 750 14.58 (iv.) Typhus fever 3 3 — (v.) Smallpox 489* 449 601 Ambulance Work.—Land Service.—Infectious patients removed to or from home to hospital : fever, 18,468; small-pox, 494; other infectious removals, 10,999. Conveyance of Imbeciles and other persons, 1,273; Total removals, 31,798; Mileage run by vehicles, 250,352. River Service.—Patients conveyed down the river to the smallpox hospitals, 437; other passengers conveyed to and from the hospitals, including recovered patients, 1,219; Total passengers, 1,656: Miles run by steamboats, 11,604. * Metropolitan cases only. † Including extra-Metrcpolitan cases. 71 Asylums.—Patients admitted, 770; discharged or transferred to other places, 94; died, 555: remaining, 6,642. Children's Homes and Schools.—Children admitted, 4,706; discharged, 4,344; died, 21: remaining, 1,501. Training Ship " Exmouth."—Boys admitted, 294; discharges to Royal Navy, 103; to mercantile marine, 105; to army, 17; other discharges, 30; died, 2: remaining, 560. Number of persons in the various institutions on the last day of the year: Permanent staff, 4,636; Temporary staff, 413; Inmates, 12,028: Total, 17,077. The area of the District served by the Board is 121 square miles, having a population, estimated to middle of 1904, of 4,648,950. The following items may be deemed of interest: — Expenditure on land and buildings for 18 hospitals for infectious diseases, to October, 1904, amounted to £8,882,010, including £229,400 on the Western Hospital (452 beds) to which Kensington cases are removed, and £380,054 on the Gore Farm Hospitals (1,814 beds), which were not used for infect ious diseases during the year. The "direct" and "common" charges in connexion with the hospitals for the year, amounted to £344,451. The fever hospitals, irrespective of Gore Farm, provide accommodation for 4,981 patients, which will be increased by 1,288 beds when the South-Eastern Hospital, and the Southern Convalescent Hospital, shall have been completed. For small-pox, provision has been made for 2,040 patients. On two seaside Homes for Children suffering from tuberculous diseases, about £46,000 has been expended. Ambulance Service.—The land Ambulance Stations have cost £96,292 (for land, £7,272; for buildings, £89,020); the River Service, £114,074, (for land, £22,329; for steamers, £40,988, and for 3 wharves, £73,086), a total expenditure of £210,366. The expenditure on the service during the year (£36,053) is a "common charge" on the rates. Use of the Hospitals, etc.—It is made evident throughout the report, that the Public Health Authorities avail themselves fully of the facilities provided for the isolation of infectious patients. But the Managers express regret for the failure of the Boards of Guardians to " make full use of the homes and schools." Attention is called to the " interesting experiment of receiving, at the Millfield Home, Rustington, near Littlehampton, children in the early stages of pulmonary tuberculosis. "The Children's Committee" have every reason to be satisfied with the results achieved there," and yet," notwithstanding the clamour for the public provision of special treatment for consumptives, a considerable number of vacancies remain unfilled at the home." The "clamour," it need hardly be said, is not made by the authorities responsible for the public health, but who have no control over the admittance of sufferers to this Home, or to the East Cliff Home at Margate,* the only exibting public institutions, other than workhouses and parochial infirmaries, available for Metropolitan consumptives, and these of the pauper class only. With regard to non-chargeable pufferers, the Committee for General Purposes report that " although more than twelve months have elapsed since the Managers asked the Local Government Board for an authoritative expression of their opinion upon the proposal of Metropolitan local authorities that the Managers should establish sanatoria for the treatment of consumptive patients, no reply to the Clerk's letter of the 4th December, 1903, has yet (January 1st, 1905) been received from the Local Government Board." * This Home is mainly for children suffering from surgical forms of tuberculous disease, especially spinal, hip and other joint cases "which derive altogether exceptional benefit from a maximum of fresh air and sunlight." The Home is equipped fo dealing with several hundred cases annually.—(Report for 1904 of the Medical Officer.) 72 Ambulance Service.—The Managers express regret for being unable to report the acquisition of legal power to utilise their ambulance service for the conveyance of persons requiring removal, other than those suffering from infectious disease—their application to the Local Government Board to obtain for them the desired power, having been made as far back as November, 1903. " The experience of another year (they say) offers further proof of the pressing need felt in London for an efficient public ambulance service for cases not provided for by the Public Health (London) Act, 1891." Cases of Mistaken Diagnosis.—The Statistical Committee report that "no fewer than 1,993 patients, or a percentage on the total admissions of 10-7, were, after admission at the fever hospitals, found not to be suffering from the diseases mentioned in the medical certificates upon which they were removed to hospital . . . The percentage on the total scarlet fever cases was 6-7; diphtheria cases, 161; and enteric fever cases, 25.9." The percentages of cases of mistaken diagnosis do not differ materially from those recorded in previous years, and the subject would scarcely call for notice, but for the broad statement made by one of the Managers, that the cases in question ought never to have been sent to the Board's hospitals. This statement involves a reflection on the medical profession which is alike undeserved, and calculated to deter practitioners from sending patients to hospital until the diagnosis is quite certain, thus leading to detention of sufferers in the crowded homes of the poor, at the imminent risk of spread of disease. The doctor has to act upon his judgment; and in my opinion he does well for the interests of the public in acting quickly. There appears to be no evidence of injury to the individuals whose illnesses were wrongly diagnosed, and if doubt as to the nature of an illness should exist in the hospital receiving room, the patient would be placed in an isolation ward. The certifying practitioner has but a few minutes, it may be, in which to make his diagnosis; the hospital doctor days, or even weeks. The best evidence of the difficulty of ensuring universal correctness, is supplied by an interesting "Note" by the Medical Superintendent of the South-Eastern Hospital, "on the number of cases admitted in whom the diagnosis was doubtful in the receiving room." During the year 1903, he states, 1,286 patients were admitted with a certificate of scarlet fever or diphtheria. Of 735 cases certified as scarlet fever, 538 cases were diagnosed (only one incorrectly) scarlet fever in the receiving room; whilst the diagnosis in the receiving room was "doubtful" in 197 instances. Of these 197 cases, 158 were " ultimately " diagnosed scarlet fever, and 39 were "ultimately" diagnosed other diseases. Of 551 cases certified diphtheria, 317 were diagnosed (only two incorrectly) diphtheria, in the receiving room, whilst the diagnosis in the receiving room was "doubtful" in 234 cases. Of these 234 cases, 154 were " ultimately " diagnosed diphtheria, and 80 were "ultimately" diagnosed other diseases. This interesting statement arose out of an inquiry to ascertain the probable requirements for isolation of "doubtful" cases at the South-Eastern Hospital, then about to be reconstructed; and the conclusion come to by the Medical Superintendent was, that " in order to isolate every case which appears doubtful in the admission room, if the above figures are taken as a guide, we shall require to isolate 27 per cent. of the cases certified to have scarlet fever, and 42 per cent. of those certified to have diphtheria." As already stated, the "errors" in diagnosis by certifying practitioners, in respect of scarlet fever, amounted to no more than 6.7 per cent., and in respect of diphtheria, to no more than 161 per cent. This question of mistaken diagnosis was brought to the attention of the Borough Councils by the Holborn Borough Council in a letter in which they called attention to an alleged expenditure, amounting, according to their estimate, to about £60,000, which, they said, had been occasioned by the admission during the last five years into the Asylums Board's Hospitals, of some 10,000 cases of mistaken diagnosis. A conference between the Board and the several Metropolitan Borough Councils to consider the subject was suggested. The letter adverted to was referred by the Managers to the Hospitals Committee, who in their report, after dealing with the question of the extra cost to which the Board had been put by the admission of such cases—which they estimated at £3,200 per annum, in the last five years, as against the estimate of £12,000 per annum made by the Holborn Borough Council—remarked that— "It is undeniable that in the early stages of many cases of infectious disorder, there could be no absolute certainty of diagnosis, and that to detain at home every patient until such certainty is attained, must frequently result in the spread of infection, the prevention of which is the primary object of the Board's hospitals. It must therefore be always 73 wiser to remove a doubtful case than to have it outside, with the danger of infecting others, which, if done, would of necessity increase the number of admissions, and thus cause a very considerable expenditure of the rates. "In the Commitee's opinion" the Managers would be going quite beyond the scope of their functions if they took any step which would have the effect of discouraging medical practitioners from freely exercising their judgment in seeking for their patients admission to the Board's Hospitals." The Committee did "not see that any useful purpose would be served by a conference such as had been suggested," and could "not recommend the Managers to take any part therein." The report was adopted, and there was no conference. The views expressed by the Hospitals Committee seem to me judicious, and will, I am persuaded, commend themselves alike to the sanitary authorities and the medical profession. Ambulance Arrangements.—Kensington patients are removed to hospital by the staff at the Western Station, which adjoins the Western Hospital, Seagrave Road, Fulham, S.W In the early part of 1900, the Managers, on removing to their new offices, Victoria Embankment (corner o( Carmelite Street, E.C.), arranged for the reception there of applications for the removal of the sick to hospital between the hours of 9 in the morning and 11 in the evening, on all days of the year; so that it is now necessary to apply at the ambulance stations between 11 in the evening and 9 in the morning, only. It cannot be too widely known that the sick are admitted on application, the sole condition being the presentation of a certificate signed by a registered medical practitioner, as evidence of the nature of the disease and the fitness of the patient for removal. The application may be made by anyone, personally, or by letter, or by telegraph, or by telephone. The telegraphic address is "Asylums Board London"; the telephone numbers are 2461 "Holborn," and 7181 " Central." HOSPITAL ACCOMMODATION It is an accepted axiom that provision for the isolation of infectious disease should be made at the rate of not less than one bed for each thousand of the population. The subject, as regards the Metropolis, was dealt with by the Royal Commission in 1881-2, who, in their Report (1882) recommended, that the provision of hospitals should be extended so as to provide 5,100 beds; viz.: 3,000 nominally for " fever," and 2,100* for small-pox. Diphtheria cases were not at that time admissible to the hospitals. The population of London in 1882, was a little over 3,860,000; consequently the recommendation of the Commissioners went, to the extent of 1,240 beds (at the least), beyond the theoretical requirements of the day. But they desired, doubtless, that provision should be made for probable requirements for a lengthened period in advance, and the amount of accommodation advised, is even now in excess of the standard, the estimated population being under 4,700,000. Circumstances, however, not then anticipated, have led to largely increased demands on the resources of the Asylums Board ; not only by the sanitary authorities, but also by private medical practitioners and others. Among these circumstances may be mentioned the depauperization of medical relief in the hospitals, and the opening of the several institutions to all classes of the people (measures advocated in these reports many years before they formed the subject of legislation); the admission of patients, on whatever form of application, subject only to the production of a medical certificate; gratuitous treatment; the popularity of the hospitals themselves; and the increasing recognition by the public of the advantages accruing from the isolation of the infectious sick. Compulsory notification, moreover, has been very effective; for now that the sanitary authorities become acquainted with, practically, all cases of infectious disease, they are able to secure the admittance to hospital of numbers of cases, of which in pre-notification days they would probably never have heard. I am indebted to Mr. Duncombe Mann, Clerk to the Metropolitan Asylums Board, for the subjoined statement, showing the existing and projected accommodation. The ordinary provision for small-pox was to be 2,100 beds, but capable of being increased on an emergency to 2,700 74 Return showing the permanent Fever Hospital Accommodation, existing and in course of provision: — (1) Accommodation for Acute Cases— Beds. Eastern Hospital 362 North-Eastern Hospital 596 North-Western Hospital 460 Western Hospital 452 South-Western Hospital 345 Fountain Hospital 402 Grove Hosp'ital 518 South-Eastern Hospital (will be ready in June, 1906) 486 Park Hospital 548 Brook Hospital 560 (2) Convalescent Hospital Accommodation— Northern Hospital (at Winchmore Hill) 738 Gore Farm (Upper) Hospital 964 „ (Lower) „ 850 Southern Hospital (in course of provision) at Carshalton 800 8,281 For Smallpox Patients : — Long Reach Hospital 300 Orchard Hospital 800 Joyce Green Hospital 940 Total 2,040 It is thus seen that the accommodation far exceeds the theoretical requirement of one bed for each thousand of the population. On that scale London would require not more than 4,700 beds; it has, or soon will have, more than 10,000. METROPOLITAN AMBULANCE SERVICE. This question, to which much consideration has been given in these reports* since 1903, entered upon a new phase in 1905, the London County Council having decided to apply to Parliament for power to establish a street accident service. The subject was brought up in a report of the General Purposes Committee, dated 3rd July, embodying a scheme which contemplated the establishment of a principal ambulance station and seven district stations, in positions within approximately a two-mile radius of Charing Cross—two miles apart; and each to serve an area with a radius of about a mile. A service would thus have been provided for that part of the county within a radius of three miles of Charing Cross, comprising the districts where accidents most frequently occur, and to which the Committee thought it desirable to confine the service until experience should have been gained as to the working of it. The stations were to be furnished with motor ambulances worked by electricity; and connected with each station there was to be a number of call-posts, similar to those in use in the fire-brigade service, and situated about a mile from each other within the three-mile circle. The estimates of the cost of the scheme showed a capital outlay of £13,000, and an annual charge of £9,600 for maintenance. The Committee stated that the Metropolitan Police returns for 1903 give as the total number of street accidents 10,356 (of which 154 were fatal) within the Metropolitan Police area, which is much greater than the area of the County of London, but does not include the City. They assumed, however, that no more than 7,500 accidents of which the police have knowledge, occur in the course of the year within a three mile radius of * The question was dealt with in the second, third, sixth, seventh and thirteenth four-weekly reports, 1905. 75 Charing Cross. Detailed particulars of the scheme were given as regards the description of premises to be used for the stations, the kind of motor ambulance to be adopted, the stand-posts for the "calls" (not more than a quarter of a mile from any place within the area of the three mile radius), the staff required, and the cost of the service, the estimated capital cost and the annual cost. The recommendation made was— "That the scheme for the establishment of an ambulance service for London to deal with street accidents within a three mile radius of Charing Cross, and providing for (1) the erection and maintenance of a principal ambulance station and seven district stations, (2) motor ambulances worked by electricity, and (3) a method of giving calls by means of street call-posts fitted with telephones, be approved." The scheme was confessedly tentative, it not being proposed to embark on any heavy capital expenditure in connection with the erection or adaptation of buildings, which for the most part were to be rented, until experience should have been gained of the working of the scheme. The Finance Committee of the County Council reported adversely to the recommendation of the General Purposes Committee; their criticism of the scheme being "based purely on financial grounds, and without regard to the need of such a service or the merits of the scheme." But on 25th July, the Council adopted the report, and decided to apply to Parliament for powers to establish an ambulance service. Their general approval to the scheme, however, was qualified by an instruction to the Committee to report further upon the questions raised by the Finance Committee. Subsequently, the General Purposes Committee presented a further report, stating that they had "arrived at the conclusion that it is desirable that a less expensive scheme should be in the first instance established;" viz., two Stations, one north and one south of the river; the latter in Lambeth, near St. Thomas's Hospital; "near Charing Cross" being indicated as the site of the second station. The estimated cost of providing this service was stated to be £5,200 (including an initial outlay of £2,200); an amount which " must not be regarded as other than approximate," but which the Committee "believe" will "cover the cost of the initial expenditure for, and the equipment of, the two Stations, and the expenditure for the first year." The Finance Committee, in a report dated 13th December, observed, with reference to this proposal, that" there can be little doubt that, should the scheme be found successful, its extension must be anticipated." The formal recommendation of the General Purposes Committee was— "That an experimental scheme for the establishment of an ambulance service to deal with street accidents, and providing for (1) two ambulance Stations, (2) motor appliances and wheeled litters, and (3) a method of giving calls by means of street call-posts fitted with telephones, be approved." The recommendation was adopted, without discussion, at the meeting of the Council on December 19th, and clauses were inserted in the General Powers Bill for 1906, with a view to the Council obtaining the necessary authority. The scheme is obviously inadequate; but the Committee are not "without hope that the Council may receive the co-operation and assistance of various voluntary associations interested in the provision of an adequate ambulance service." Be this as it may, they think that the two stations, " together with one which (they) understand the City Corporation proposes to establish within the City of London, would render ambulance services available for the zone in which street accidents are most frequent." The City Scheme— Reference having been made to the City, it may be mentioned that the street ambulance question had for some time engaged the attention of the Corporation. It formed the subject of a report—" Horse Ambulance System in the City of London "—by the Commissioner of Police, to the Police Committee, dated 24th February, 1904. The Committee, on 30th March, 1905, in a report to the Court of Common Council, outlined a scheme for giving effect to the Commissioners views, and appended thereto the opinions of many distinguished medical and other authorities who had attended them as a deputation of the Metropolitan Street Ambulance 76 Association, and the St. John Ambulance Association. The Committee, in their report to the Court, "having due regard to the public interest, and to the practical scheme propounded," expressed the opinion that "it is most desirable that the Horse Ambulance System proposed by the Commissioner be adopted in its entirety"; and they recommended that "it should be referred back to them to give the necessary directions to carry out the scheme "—which provides for two ambulance stations, serving the western and eastern portions of the City respectively; cases from the western district to be conveyed to St. Bartholomew's Hospital, and those from the eastern district to Guy's, and the London Hospital. The hospital authorities warmly support the proposal. The report was agreed to, and referred to the Coal and Corn and Finance Committee to consider and report on the question of ways and means. The importance of the matter is unquestionable—the Committee stating that "the number of street accidents removed by the City Police to the Hospitals for the five years 1900-1904," aggregated 9,761; an average of nearly 2,000 yearly; " and of these only about one-half were removed on even hand-litters." Both schemes—that of the Council and that of the Corporation—contemplate assistance being rendered by senior hospital medical students, and nurses, accompanying the ambulances, the male attendants of which, moreover, would be qualified to render " first aid." Metropolitan Asylums Board Ambulance Service.—In the County Council scheme no reference was made to the Metropolitan Asylums Board, whose work should not be left out of consideration in any proposal for the establishment of a comprehensive Ambulance Service for London.* The County Council, desiring power not only to "provide and maintain" an ambulance service for street accidents, but also to "aid in providing and maintaining" such a service by other authorities, it becomes an interesting question (as I observed in the sixth report) " whether the * In the present state of the question, a brief history of the Board's Service may not be without interest:— The Managers derive their powers to provide ambulances for the conveyance to hospital of the infectious sick, from Section 16 of the Poor Law Act, 1879, which reads as follows:— "The Metropolitan Asylums Board may, from time to time, provide and maintain carriages suitable for the conveyance of persons suffering from any dangerous infectious disorder, and shall cause the same to be, from time to time, properly cleansed and disinfected, and may provide and maintain such buildings and horses, and employ such persons, and do such other things as are necessary or proper for the purposes of such conveyance. "All expenses incurred by the Metropolitan Asylums Board in the execution of this section, to such an extent as the Local Government Board may sanction, shall be paid out of the Metropolitan Common Poor Fund." The power thus conferred was not exercised until after the Royal Commission on Infectious Hospitals (1882) had expressed the view, in their "Practical Recommendations," that "the hospital authorities should have the entire control of the ambulances, by which all other modes of conveyance should be as far as possible superseded." The Managers thereupon lost no time in taking measures to give effect to this recommendation, which was accordant with the intention of the legislature and with the views of the Local Government Board. But the ambulances were used exclusively for the conveyance of patients to the hospitals of the Board. It not infrequently happened in those days, that public vehicles (cabs, etc.) were used for the conveyance of persons suffering from dangerous infectious disorders. Such use was not then unlawful, provided that the person hiring or using the vehicle gave notice of the condition of the sufferer to the owner or driver, who had the right of refusing to convey the sick person unless he should be indemnified for costs and expenses incurred by so doing ; viz., for disinfection, loss of time, etc. It was felt at this time, and the feeling constantly grew stronger, that conveyance of infectious cases by public vehicles should be prohibited by law; a proposition with which I concurred ; pointing out, however, that " provision should be made for the conveyance of all infectious cases, by the Managers or other constituted authority, in public ambulances." In December, 1884, I suggested, for the consideration of the Managers, "whether it would not be practicable to place their ambulances at the service of the medical profession, and medical officers of health, for the conveyance of such cases, with or without payment ? "The Managers replied that they were "not yet in a position to undertake the removal of any cases of infectious disease beyond those which were to be received into hospitals under their own control." Two or three years later, however, though they doubted whether they had " power to use their ambulances for other cases than those contemplated by the Poor Law Act of 1879," they had become willing to take steps for obtaining " the power to undertake the general removal of infectious cases in the metropolis." The Poor Law Act, 1889, Sec. 6, enabled the Managers to allow the use of their ambulances for the conveyance of persons suffering from any dangerous infectious disorder, to and from hospitals and places other than hospitals provided by themselves, and to make (if they thought fit) a reasonable charge for that use. On 30th November, 1889, effect was given to the new legislation by regulations prescribing the conditions on which the use of an ambulance could be obtained; provision, moreover, being made for the attendance of a nurse for a fee of half-a-crown per journey, the charge for the ambulance being five shillings; power to remit these charges, when deemed expedient, being reserved. Proposed Non-infectious Service.—In November, 1903, the Managers informed the Local Government Board of their willingness and ability to remove, to hospitals and elsewhere, urgent non-infectious cases—medical, surgical and insane— without cost to the indigent, but on payment of a moderate fee for the well-to-do. Hitherto, the Local Government Boardr have not taken steps to obtain from Parliament the necessary authority for the Managers, whose legal power extends only to the removal, to hospitals or other places, of persons suffering from " dangerous infectious diseases "—an expression which has been held to cover measles. Nevertheless, for some time past, the Managers' vehicles have been employed, occasionally, for the removal to hospitals of non-infectious cases; to the number of 1,439 in 1905, including 134 medical and surgical cases for. which a small fee was charged. 77 words cited in the recommendation" of the General Purposes Committee, "cover an intention by the Council to secure the co-operation of the Metropolitan Asylums Board,' which would necessitate an extended application to Parliament. Such co-operation, and the grant of power to the Managers to remove non-infectious, medical, surgical, and insane cases, would round off the system and endow the Metropolis with an ambulance service second to none. Not many persons, probably, are aware of the extent of the service provided by the Managers, particulars of which are set out in the subjoined table:— Name of Station. Number of Ambulance Carriages. Number of Omnibuses. Normal Provision. Single-bedded. Double-bedded Horses. Male Staff. Eastern 16 7 4 16 30 North-Western 11 5 2 20 20 Western 11 4 3 15 21 South-Western 9 4 3 16 19 South-Eastern 12 5 6 20 26 Brook 15 6 3 16 25 Mead 12 8 . 5 24 42 Tooting Bee — — — — — 66 84 26 127 183 Note.—The Tooting Bee station is unoccupied at present, and the Mead station is reserved for work in connection with the transport of non-infectious cases; such as imbecile patients to and from the Board's Asylums, and the Asylums of the London County Council, and of children to the Board's special schools—for sufferers from ringworm, ophthalmia, etc. Arrangements, it is stated, can be made at most of the stations for temporarily increasing the numbers of the male staff beyond the normal amount. There is accommodation for nurses at all of the stations, save the South-Western and Tooting Bee; but at present the nurses are drawn from the various fever hospitals. Infectious Removals.—At page 70 an account is given of the removals of sick and recovered cases by the Land Service, in 1904, to the number of nearly 30,000, which may be supplemented by the fact that the existing service, when in full work, can remove about 300 acute cases a day, to the town fever hospitals, besides transporting convalescing cases to the country hospitals. Traction.—At present horsed vehicles only are employed; but a motor ambulance (cost £550) has been on its trial, and promises to be quite successful.* With motor traction it is believed that the capacity of the service would be practically doubled, and that the Managers would be able, if required, to undertake the whole of the street-accident service, and non-infectious removals also, in addition to their infectious work. As it is, and with the horse service, they can place an ambulance in almost any part of London in about thirty minutes from the receipt of the call for it. Hospitals.—However good a street ambulance service may be, it depends for its utility upon the existence of hospital accommodation for the injured and sick, within a reasonable distance; and such accommodation, if regard be had to the general hospitals only, does not exist. The * The Ambulance Committee it may be mentioned are satisfied as to the suitability of motor traction for the purposes of the Board's ambulance service. The patients are in the vehicles much shorter times, and consequently suffer far less fatigue than in horse-drawn vehicles; and as much more work can be performed in a day by motors than by horses, the committee believe that the general adoption of motor traction would result in considerable economy. % 78 principal hospitals, as shown in the table at page 79, are only seventeen in number; thirteen of them being within the central section of the Metropolis—extending from the West London Hospital and St. Mary's Hospital in the west, to the London Hospital and Poplar Hospital in the east; and from University College Hospital and Royal Free Hospital in the north, to St. Thomas's Hospital and Guy's Hospital in the south. A map is wanted to show to what degree the hospitals provide for the needs of the districts within reasonable distance of them, and how extensive is the remaining area of London practically almost devoid of the necessary accommodation. Poor Law Sick Asylums and Infirmaries.—Within the last generation there has sprung up a new and admirable set of institutions—hospitals in everything but the name—the Poor Law Infirmaries and the Sick Asylums, which might be made available for the relief of the victims of dangerous street accidents. The position of these institutions—of which Kensington Infirmary, and St. Marylebone Infirmary, at Notting Hill, may be taken as types—is indicated in the table at page 79 ; and there can be no question as to their potential usefulness as adjuncts to the general hospitals. Even now they render occasional service; St. Marylebone Infirmary, for instance. admitting sufferers from severe accidents occurring in its vicinity in the northern portion of the Royal Borough. Most of the asylums and infirmaries, presumably, possess vehicles for conveyance of the sick, and few are without means for housing an ambulance—a remark which applies to the workhouses also, when these are not immediately connected to the infirmaries. Poor Law Ambulances.—The Poor Law Infirmaries being well spread over London, it has been suggested that, if it were in the power of the Asylums Board to organize the supply of ambulance carriages and litters, a complete service for accidents and non-infectious cases could be arranged in an inexpensive manner. The suggestion is certainly deserving of consideration; but nothing can be done—whether by the County Council, the Asylums Board, or the Local Authorities—without legislation, which would naturally be preceded by some authoritative inquiry on the entire question of a METROPOLITAN AMBULANCE SERVICE. But, seeing the brevity and simplicity of the legislation which brought the ambulance service of the Asylums Board into existence, it would seem there should be no insuperable difficulty in carrying a Bill to complete the ambulance service, as proposed, and so remove what has been described as " the reproach of London's municipal administration." The foregoing account of the ambulance service is compiled from several reports presented to the Council in 1905—notably from the thirteenth report, which was referred to the Public Health Committee, whose recommendations thereon, unanimously adopted by the Council, were as follows: (a) That a copy of the report of the Medical Officer of Health on " Metropolitan Ambulance Service " be sent to the members of Parliament for the borough, and that they be asked to call the attention of the House of Commons to the need of a Metropolitan Ambulance Service for sick and injured persons, and to raise the question as to the authority to which the provision of such a service should be entrusted. (6) That a petition be presented to each House of Parliament, calling attention to the public need of a Metropolitan Ambulance Service, and emphasizing the desirability of such service being provided and maintained by a single authority. (c) That a copy of the report be forwarded to each of the members of the Committee on the London County Council (General Powers) Bill, and to other members of Parliament likely to be interested in the question. (d) That a copy of the report be also forwarded to the Metropolitan Borough Councils, and that they be invited to take action in the matter. 79 METROPOLITAN GENERAL HOSPITALS, POOR LAW INFIRMARIES, Etc., AND AMBULANCE STATIONS. Postal District. Hospitals. Infirmaries and Sick Asylums. Ambulance Stations. Name. Locality. Beds. Name. Locality. Beds. Name. Locality. Ambulances. Single Bedded Double Bedded Total. N. North London Tottenham 120 Holborn Archway Road 625 Islington Highgate Hill 840 Gt. Northern Central Holloway Road 159 St. Pancras Dartmouth Park Hill, Highgate 540 Shoreditch Hoxton Street 515 N.E.. Metropolitan Kingsland Road 111 Bethnal Green Cambridge Road 669 Hackney Homerton 606 Mile End Bancroft Road 460 Eastern Brooksby's Walk Homerton 16 7 23 West Ham Leytomtone 741 Whitechapel Vallance Road.. 590 N.W. Hampstead Hampstead 184 North-Western Lawn Road, Hampstead 11 5 16 St. Pancras (South) Cook's Terrace, Pancras Road 400) E. London Mile End 820 City of London Bow Road 511 Poplar & Stepney Sick Asylum Bromley 820 Poplar Blackwall 100 St. the-East Raine Street 394 EC. St. Bartholomew's West Smithfield 744 W.C. Middlesex Berners Street 340 Central London Cleveland Street 264 Fulham Fulham Palace Road 500 St. Mary's Cambridge Place Paddington 360 Hammersmith Wood Lane, Shepherd s Bush 350 Kensington Marloes Road 667 West London Hammersmith Road 175 Paddington Harrow Road .. 284 St. Marylebone Notting Hill 744 W.C. King's Strand 221 Charing Cross Charing Cross 300 L.C.C. To be provided near Charing Cross ? ? ? University College Gower Street 288 Royal Free Gray s Inn Road 165 S.W. Westminster The Abbey 215 Chelsea Cale Street 423 Western* Seagrave Road, Fulham 11 4 15 St. George's Hanover Square Fulham Road 776 Mead* Wandsworth Bridge 12 3 15 St. George's Hyde Park Corner 356 Wandsworth St. John's Hill 661 South - Western† Tooting Beef Stockwell (Landor Road Tooting (unoccupied 9 4 13 ' S.E. Guy's.. St. Thomas's London Bridge Westminster 602 602 Bermondsey Lower Road 640 Greenwich Greenwich 538 South-Eastern New Cross Road 12 5 17 Lambeth Brook Street 622 Lewisham Lewisham 401 L.C.C. To be provided near St.Thomas's Hospital ? ? ? Camberwell Brunswick Square 819 Southwark East Dulwich Grove 786 Kent. Brook Shooter's Hill 15 6 21 Total Numbers. 17 5,678 29 16,370 8+2 86 34 120 * North of the River Thames †South of the River Thames. 80 THE HOUSING OF THE WORKING CLASSES. (Housing of the Working Classes Act, 1890, Part III.) The Council took an important step in 1904, in regard to this important question, by acquiring a considerable number of houses in Kenley Street, Notting Dale, in the exercise of their powers under Part III., and adapting them for occupation by persons of the poorer classes. The houses on the north side of the street are now in occupation; those on the south side have been demolished, and will be replaced by six blocks of flats—constituting an important public health improvement. It is intended, moreover, to erect single-roorp tenements on a site in Hesketh Place and Thomas Place, in " The Potteries." The Housing Problem.—The Royal Commission on London Traffic, when dealing with housing in relation to the traffic question, expressed the opinion that to re-house, " on site," people displaced in large numbers, from whatever cause, is too costly a proceeding ; while the re-housing in the suburbs, with quick and cheap transit, is not only practicable, but can be accomplished without any loss to the rates. In their view, a large proportion of workers in the overcrowded parts of London do not need to live near their work; and, when facilities for locomotion are afforded, the population not only take advantage of it, but are far more comfortable and healthy. In order to relieve overcrowding, they contend that means must be provided for taking the population in and out of London, in many directions, at rapid speed, frequent intervals, and cheap rates. I am in agreement with this view of the subject, having dealt with it on similar lines in the annual report for 1889, wherein it was pointed out that " the carrying out of Cross's Acts in London must needs be a costly procedure at all times, and probably much more so than schemes for migration; which, by lessening the excessive demand for lodgings, might lead to reduction in rents, and thus enable the poorer classes to obtain more and better accommodation." "By a large scheme for migration," I added, "overcrowding might be diminished, and with it preventible disease resulting from this, the most perilous of insanitary conditions." The model dwellings erected on the sites cleared under Cross's Act, it was stated," are not tenanted to any large extent by the poorest of the working classes, or by those displaced by the clearings. Clerks, and superior artizans able to command constant work, commonly occupy these healthy homes, and plenty others would doubtless be forthcoming were the accommodation greatly extended. These, however, are the classes for whom it might be practicable to provide out of London." The subject was further considered in the report for 1891 (" Migration as a Remedy for Overcrowding"), in which the need for a "service of cheap trains" for giving effect to the plan was emphasized. The hope was expressed that "care would be exercised to prevent the creation of slums outside London." The houses to be built "should not be too large, nor too crowded on space." Working men, moreover, "should be encouraged to become the owners of their cottage homes"; whilst travelling facilities "should be confined, so far as practicable, to bond fide workmen only, so that the suburbs may not be overrun by ' outcast London.'" It is to be hoped that the report of the Royal Commission may contribute towards the realization of these ideals; alike by commercial enterprise, and through the agency of the London County Council, who, under the Housing of the Working Classes Acts, are enabled to erect, purchase, or hire houses, without as well as within the Metropolis; and who have done, and are doing, much to facilitate migration, by promoting and providing cheap and rapid transit in London and to the suburbs. "Dwellings from Rubbish—Under this picturesque heading, an article appeared in a July issue of the Municipal Journal on the experimental erection by the Liverpool Corporation of workmen's dwellings, three storeys high, made from concrete composed of crushed clinker from refuse destructors, and Portland cement, reinforced with a little steel. The side-walls, the ceiling, and the floor of a room are moulded in single slabs of the size of the room, and transported ready for erection. The living rooms are fifteen feet by ten feet four inches; the bedrooms fifteen feet three inches by seven feet nine inches, with a height of ten feet: the slabs comprising 81 the room are dovetailed, bolted, and cemented together; the floor being covered with flooring boards embedded in a hot-pitch mixture and nailed to scantlings embedded in the concrete. It is claimed amongst other advantages of this type of buildings, that slabs of any size likely to be required for housing purposes can be safely manufactured, transported, and erected; that the strength of the slabs is ample, and that the method of jointing them has proved satisfactory; that the risk of fire is reduced to a minimum; that the houses are as nearly as possible vermin-proof, and (if not finished in plaster), can be washed down for cleansing, and that the buildings can be made attractive in appearance. It is estimated that houses constructed of this material may be erected at a cost some twenty-five per cent. less than that of brick buildings. It only remains to be said that the Liverpool scheme was carried out, after a local enquiry, with the approval of the Local Government Board, who granted the necssary borrowing powers. BY-LAWS FOR HOUSES LET IN LODGINGS. The Council's new by-laws having been allowed by the Local Government Board, came into operation 17th August. The former by-laws had worked satisfactorily for twenty years; but for reasons explained in previous reports, certain alterations in their provisions had become necessary. Exception may be taken to the seventh by-law, as it throws upon the occupier (described as the "landlord") of a house let in lodgings the duty of carrying out the annual work of cleansing. Often the "landlord" is a person in poor circumstances, who lets one or more rooms to help pay the rent. The obligation to cleanse falls on the right person in the case of a house let in tenements, he being the "landlord" in the usual acceptance of the expression, which, in the interpretation of terms, is defined as follows:— "'Landlord,' in relation to a house or part of a house which is let in lodgings or occupied by members of more than one family, means the person (whatever may be the nature or extent of his interest in the premises) by whom or on whose behalf such house or part of a house is let in lodgings, or for occupation by members of more than one family, or who for the time being receives, or is entitled to receive, the profits arising from such letting." The seventh by-law, providing for " Cleansing and Ventilation," prescribes that— "Subject to the provisions of these by-laws, the landlord of a lodging-house shall cause the walls and ceiling of every room, and of every common passage, landing, staircase, watercloset, washhouse, and other outhouse thereof, and, where necessary, the walls of the vard and area, to be thoroughly cleansed and well and sufficiently limewashed at least once in every year, between the first day of March and the first day of April, or at any other time, between the thirty-first day of March and the first day of August, which may be stated in a notice previously given by him to the Sanitary Authority. "Provided that the foregoing requirement with respect to the limewashing of the internal surface of the walls of rooms, staircases, and passages shall not apply in any case where the internal surface of any such wall is painted, or where the material of or with which such surface is constructed or covered is such as to render the limewashing thereof unsuitable or inexpedient, and where such surface is thoroughly cleansed and the paint or other covering is renewed, if the renewal thereof be necessary for the purpose of keeping the nremises in a clean and wholesome condition." The duty of carrying out the provisions of the by-law should fall on the person who lets the house to the occupier—viz., the " landlord " in the ordinary sense of the term. At present there are about 2,000 houses on the register, of which, in 1905, 7,757 inspections were made by the sanitary inspectors. 82 Common Lodging Houses.—The County Council in 1894, took over from the police the supervision of common lodging-houses, under the circumstances set out in my annual report for 1893 (p. 207). I am indebted to the Council's Medical Officer of Health for the subjoined return of the common lodging-houses in this borough, which are 24 in number, and contain accommodation for 711 persons. COMMON LODGING-HOUSES. Ward. Name of Keeper. Address of Common Lodging-House. No. of Lodgers, for which licensed, in 1905. Male. Female. Total. Golborne Madden, James 194, Kensal Road 75 ... 75 Norland Rusha, Alfred 18, Bangor Street ... 24 24 Do. 20, do. ... 45 45 ,, Reynolds, Charles 85, do. 26 ... 26 ,, Phillips, Thos. Jno. 5, do. 52 ... 52 ,, Do. 7, do. ,, Hankins, George 10, Crescent Street ... 25 25 ,, Do. 28, do. 54 ... 54 ,, Do. 30, do. ,, Do. 40, do. ... 25 25 ,, Rusha, Alfred 25, do. ... 57 57 ,, Do. 27, do. ,, Do. 81, do. 58 ... 58 ,, Do. 88, do. ,, Simpson, James 87, Mary Place 26 ... 26 ,, Do. 85. 'do. ,, Davis, Sagel 66, St. Ann's Road 66 ... 66 ,, Rusha, Alfred 84. Sirdar Road ... 58 58 ,, Do. 86, do. ,, Do. 88, do. 48 ... 48 ,, Do. 40, do. ,, Code, George 12, St. John's Place .... 48 48 Holland Redman, John 24, Peel Street 84 ... 84 ,, Do. 22, do. Seventeen of the common lodging-houses, with accommodation for 467 persons are comprised in the "Notting-dale" special area. THE WORK OF THE LADY INSPECTORS. (Factory and Workshop Act, 1901.) Subjoined will be found the report of the lady inspectors of workshops, workplaces, and laundries where women are employed, and the report of the chief sanitary inspector, comprising information which Section 132 requires to be set out in the annual report of the Medical Officer of Health. In connexion with the first-named report it may be mentioned that it was in Kensington that the services of women were first enlisted in the work of sanitary administration. The seed sown in 1893 has prospered, for already the Cities of London and Westminster and 20 of the other 27 Borough Councils have appointed women inspectors to the number of 34. It will be remembered that the conference of delegates of the Borough Councils, convened by the County 83 Council, and held in July, 1904, at the County Hall, on the Administration of the Public Health (London) Act, 1891, passed an unanimous resolution expressive of the opinion "that female inspectors should be employed in each borough." In 1901, a new duty was undertaken by the lady inspectors—inspection of the kitchens of restaurants and eating-houses, which may be regarded as "workplaces"—an expression not defined in the Act. The results of the inspection were summarised in my first monthly report for 1902, which came under the notice of the Public Health Committee of the County Council, who, in January of that year, had been instructed to "consider and report as to the best means to exercise periodical inspection of restaurants and eating-houses." The Committee expressed the opinion that it would be advisable for the Council to send a copy of their report, and to address a circular letter, to each of the Borough Councils (except Kensington), expressive of the Council's hope that they would cause the kitchens of hotels and restaurants in their districts to be inspected, and exercise their power under the Public Health (London) Act, 1891, for the removal of any insanitary conditions that might be found. This was done, and now such kitchens, in most of the districts, if not in all, are under supervision. The County Council, it may be mentioned, in their General Powers Bill, 1904, made an unsuccessful effort to obtain increased powers for the sanitary authorities in regard to places where food is stored or prepared for sale: such powers, we may be sure, will, sooner or later, be obtained. In 1902, the workshops in the Borough having become well-ordered, and requiring less frequent inspection, the Public Health Committee and the Council assented to my proposal to employ a portion of the time of the lady inspectors on another duty, of not less importance than those for the discharge of which they were primarily appointed—to wit, inquiries with respect to cases of pulmonary phthisis (consumption). In 1905, moreover, the inspectors began systematically to visit cases of measles and of whooping-cough. References to these several branches of their work will be found at pages 21 and 26. The report of the inspectors of their work under the Factory and Workshop Act, in 1905, is as follows: — "The number of workshops in the Royal Borough at which female labour is employed, at the end of 1905, was 907: viz., 428 (mostly laundries) in North Kensington, and 479 (mostly dressmakers, etc.), in South Kensington. During the year 78 new workshops were added to the register and 96 were removed therefrom; the net result being a decrease of 18, all in North Kensington. "The subjoined table summarises particulars of the workshops on the Register at the end of the year, in North Kensington and South Kensington respectively—Holland Park Avenue and High Street, Notting Hill, constituting the dividing line. Workshops, etc. North Kensington. South Kensington. Total for Whole Borough Dressmakers. Laundries. Miscellaneous Total. Dressmakers. Laundries. Miscellaneous. Total. No. on Register 67 278 83 428 331 14 124 479 907 No. of Rooms therein 101 812 112 1,025 635 16 174 825 1,850 "he number of persons employed varies with the period of the year, being, of course, greatest during the ' season': it exceeds 10,000. 84 The businesses carried on at the registered premises are set out in the subjoined list:— Trade or Business. North Kensington. South Kensington. Total in tha Borough. Art needlework 1 1 2 Blind-maker 2 2 Blouse-maker 2 8 5 Boot header 1 — 1 ,, closer 2 — 2 Cardboard box maker — 1 1 Corset maker 2 8 5 Cracker maker 1 — 1 Dressmaker and ladies' tailor 67 329 396 Dyer and cleaner 1 4 8 Eyelet hole finisher 1 — 1 Firewood manufacturer 1 — 1 Furrier 2 2 4 Hair wash manufacturer 1 — 1 Hosier — 1 1 Lamp shade maker 1 1 2 Laundries (workshop) 213 14 227 „ (factory) 65 — 65 Machinist — 1 1 Mantle maker — 4 4 Milliner 5 38 43 Outfitter — 2 2 Photographer 2 11 13 Printer — 2 2 Restaurant and dining room keeper 38 41 79 Silversmith — 1 1 Spice merchant 1 — 1 Tailor 15 4 19 Typist — 2 2 Upholsterer 1 11 12 Waistcoat maker 2 — 2 Wig maker — 1 1 Total 428 479 907 "The several premises were inspected by us more or less frequently according to the needs and circumstances of individual cases; all complaints, and they were not many, received immediate attention. At several workshops improvements of ventilation, a matter within the jurisdiction of the Council, were carried out upon our recommendations; and improvements in arrangements for warming likewise, though this is a matter which legally falls within the province of the factory inspectors. With regard to these and all matters connected with our duties under the Act, we gladly testify to the almost universal willingness of employers to conform to the requirements of the law, and also to the courtesy with which our visits and suggestions are received. "Overcrowding.—In upwards of thirty instances this ' nuisance ' was detected, and abated, upon service of written intimations, excepting in one instance, when proceedings had to be taken, a fine of £2, with costs, being inflicted. "Sanitary Conveniences for the two sexes appear to be now generally provided. In only one instance was it necessary to take proceedings under section 38 of the Public Health (London) Act, for default. A fine of £5, with costs, was inflicted. Subsequently the requirements of the section were complied with. "In no other instances did it become necessary to take cases into court, and we seldom had to ask for statutory notices, due attention being so generally given to the requirements endorsed on written intimation notices. "Outworkers.—The addresses of 22 outworkers working for firms in the Borough but residing elsewhere, were forwarded to the Medical Officers of Health of the respective Boroughs; whilst the addresses were received of 162 persons residing in the Borough but working for firms in other Boroughs. "The number of outworkers employed in connexion with Kensington workshops is small as compared with other Metropolitan Boroughs; and not very many of them are solely dependent on this occupation for a livelihood. As far as we could ascertain, about 50 employers, presumably employing outworkers, failed to send in the half-yearly list of names and addresses. But employment of outworkers is to some extent seasonal, and in the case of laundries, to no inconsiderable extent, is necessary only between the two dates, February 1st and August 1st, when the returns become due. 85 "Infectious Disease.—Cases of notifiable disease occurred at eighteen premises: erysipelas in 12 instances ; scarlet fever, in 4 ; and diphtheria, in 2. All the sufferers from scarlet fever and diptheria were removed to hospital. The necessary measures—including disinfection—were taken, and there was no spread of illness. The cases of erysipelas were mild, and required no special precautions. "Home Office.—Thirty-four cases were notified to the Home Office of failure to affix the required Abstract in workshops and five other complaints re overtime, etc., were forwarded. Twenty-five complaints were received from the Home Office of alleged insanitary conditions in workshops, all of which were at once investigated and where necessary remedied; nineteen reports thereon were forwarded to H.M. Inspectors. "The appended table summarises the work of the year under the Act so far as it is capable of being expressed in this form. North Kensington. South Kensington. Total for Borough. Dressmakers. Laundries. Miscellaneous Total Dressmakers Laundries. Miscellaneous Total. 1. Workshop inspections 53 340 189 532 871 24 164 1,059 1,591 2. „ re-inspections 9 141 19 169 177 19 196 392 561 8. Workroom inspections 78 1,796 161 2,035 1,459 66 181 1,706 3,741 4. Workrooms found overcrowded 8 2 — 5 81 — — 31 86 6. „ insufficiently ventilated 1 24 1 26 21 — 7 28 54 6. „ in a dirty condition 4 62 — 66 11 — — 11 77 7. „ measured; number of 11 9 4 24 104 — 10 114 138 8. Workshops, &c., reported to H.M. Inspector 4 — 1 5 25 — 4 29 34 9. Workshops, &c., reported by H.M. Inspector — — — — 15 — 1 16 — 10. Workshops, &c., newly discovered and registered 4 2 2 8 53 — 17 70 78 11. Workshops, &c., removed from register 16 49 7 72 15 1 8 24 96 12. Domestic workshops and workplaces inspected 90 98 18 206 97 6 2 105 311 18. Written intimations issued 1 50 1 52 51 — 5 56 108 14. Statutory notices issued — 13 — 18 3 — — 3 16 15. Sanitary defects remedied:— (a) Additional means of ventilation provided — 4 — 4 13 4 17 21 (6) Rooms cleansed and whitewashed 9 71 2 82 2 — — 2 84 (c) Yards, floors, roofs, &c., repaired — 28 — 28 — — — — 28 (d) Sanitary conveniences; defects remedied — 14 — 14 22 — 2 24 38 (c) Dustbins provided or repaired — 4 — 4 1 — — 1 5 (d ) Miscellaneous defects remedied — 8 — 8 7 — 2 9 17 16. Nuisances reported to Medical Officer of Health — 5 7 12 6 — 3 9 21 17. Workroom cards distributed; Number of 5 — 1 6 104 — 10 114 120 86 In addition to work under the Factory and Worshops Act, the inspectors kept under observation the public lavatories for women, three in number—at Talbot Road, Westbourne Grove, and Brompton Road, respectively, and the lavatory accommodation provided for women at 11 railway stations within the borough. WORKSHOPS WHERE MEN ARE EMPLOYED. Considerable improvement with regard to workshop inspection, generally, took place in 1902 consequent on the appointment of additional male inspectors, which permitted of men's workshops being brought under supervision. Men's workshops (i.e. workshops conducted on the system of not employing any woman, young person or child therein) are in a somewhat different position to those where women are employed, inasmuch as (inter alia) the sections in Part I. of the Act relating to temperature, thermometers, means of ventilation, drainage of floors, sanitary conveniences, etc., are not applicable to them. I have received from the Chief Sanitary Inspector the subjoined account of the adminis tration of the Act in relation to men's workshops, in 1905. "The businesses carried on at the workshops where men are employed, 756 in number, are set out in the subjoined list, compiled from the register, in which the trades are classified, columns being provided for the address, and the name, of the occupier, and a column for the " number of protected persons " employed at the date of inspection of the premises. Trade or Business. North Kensington. South Kensington. Borough. Baker 61 35 96 Basket Maker 8 — 8 Blacksmith 17 20 37 Bootmaker 71 39 110 Builder 54 48 102 Cabinet-maker and Joiner 23 20 43 Carver and Gilder 1 5 6 Coach-builder 31 8 39 Cycle Maker 9 11 20 Firewood Manufacturer 18 — 18 French Polisher 1 2 3 Marble Mason 6 2 8 Printer 3 3 6 Saddler 6 9 15 Tailor 44 18 62 Trunk Maker 6 6 12 Umbrella Maker 3 2 5 Undertaker 7 4 11 Upholsterer 11 6 17 Watchmaker 20 20 40 Wig Maker — 13 13 Sundry businesses 49 36 85 Total 449 307 756 87 The subjoined table, dealing with persons of both sexes employed at workshops, etc., is prescribed by the Local Government Board to be inserted in the annual report of the Medical Officer of Health. FACTORIES, WORKSHOPS, LAUNDRIES, WORKPLACES AND HOMEWORK. 1.—Inspection. Including Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) ... 81 12 — Workshops (including Workshop Laundries) 2843 281 3 Workplaces 446 41 — Homeworkers' Premises 249 2 — Total 3619 336 3 2.—Defects Found. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health (London) Act, 1891*:— Want of cleanliness 223 221 — — Want of ventilation 47 47 — — Overcrowding 36 36 — 1 Want of drainage of floors 6 6 — — Other Nuisances 109 109 — — Sanitary accommodation ( insufficient 4 4 — — unsuitable or defective ... 71 71 — — ( not separate for sexes 5 4 — 2 Offences under the Factory and Workshop Act:— — — — — Illegal occupation of underground bakehouse (S. 101) — — — — Breach of special sanitary requirements for bakehouses (SS. 97 to 100) 3 3 — — Failure as regards lists of outworkers (S. 107) 51 — — — Giving out work to be done in premises which are unwholesome (S. 108) — — — — (infected (S. 110) 5 5 — — Allowing wearing apparel to be made in premises infected by scarlet fever or small-pox (S. 109) — — — — Other Offences — — — — Total 560 506 — 3 • Including ttose specified inSections 2, 3, 7 and 8, of the Factory Act as remediable under the Public Health Act. 88 3.—Other Matters. Class. Number. Matters notified to H.M. Inspectors of Factories:— Failure to affix Abstract of the Factory and Workshop Act (s. 133) 84 Action taken in matters referred by H.M. Inspectors as remediable under the Public Health Acts, but not under the Factory Act (s. 5) 1 Notified by H.M. Inspectors 25 Reports (of action taken) sent to H.M. Inspectors 19 Other 5 Underground Bakehouses (s. 101):— Certificate granted during the year 1 In use at the end of the year 75 Homework:— Number of List of Outworkers (s. 107):— Lists. Outworkers. Lists received 44 408 Addresses of outworkers forwarded to other Authorities 299 received from other Authorities 197 Homework in unwholesome or infected premises :— Wearing Apparel; Other. Notices prohibiting homework in unwholesome premises (s. 108) — — Cases of infectious disease notified in homeworkers' premises 5 — Orders prohibiting homework in infected premises (s. 110) — — Workshops on the Register (s. 181) at the end of the year Important classes of workshops. such as; workshop bakehouses, may be enumerated here. Workshop Laundries 227 Workshop Bakehouses 94 Factory Bakehouses 2 Other Workshops 1,289 Total number of workshops on Register 1,612 89 BAKEHOUSES. The bakehouses in the Borough, 96 in number, of which 75 are underground, were periodically inspected during the year, with a view to enforcing compliance with the provisions of Sections 97 and 100 of the Factory and Workshop Act, 1901, which re-enacted and extended provisions contained in the several Acts repealed by the consolidating Act. PUBLIC HEALTH (LONDON) ACT, 1891. The need for amendments to this Act is recognised, and it was expected that the County Council would have introduced an amending Bill ere now. In February, 1899, a letter had been received by the late Vestry from the Public Health Committee of that body, desiring information as to amendments which in their opinion should be made. The communication was referred to a sub-committee of the Sanitary Committee, together with reports by the vestry clerk, the surveyor, and the medical officer of health; and also a communication from the Society of Medical Officers of Health, embodying suggestions for amendments and additions to the Act. The sub-committee made recommendations for amending section 2, and especially by a definition of "overcrowding,' corresponding to the provisions of the Council's second by-law for registered houses. They further proposed that section 5 should be amended, so as to enable the sanitary authority, upon obtaining a closing order, to evict the tenants. Other proposed amendments dealt with offensive trades (slaughter-houses and cow-houses) and dairies; with the disposal of refuse ; regulations as to waterclosets; unsound food ; notification of infectious disease; cleansing and disinfection of premises after infectious disease; isolation in hospital; exposure of infected persons, etc. Further additions to the provisions of the Act were suggested, especially with regard to the control of infectious disease. The report, subject to a slight variation in regard to proposed amendments to section 55 {notification of infectious disease), was approved by the committee, and submitted to the Vestry. Some of the amendments were adopted; others, and all but two of the proposed additions, were rejected. The somewhat barren result of the inquiry was communicated to the County Council. No proposals for legislation dealing with the points raised have so far been made. In 1904, however, the Council convened a Conference of delegates of the Metropolitan Asylums Board, and of the Metropolitan Borough Councils (twenty-five of which were represented), to consider " the administration of the Public Health (London) Act, 1891." The Conference was held at the County Hall, Spring Gardens. The resolutions adopted, 49 in number, were grouped under the following headings:— 1. Housing (1-13).—Houses Let in Lodgings, Underground Rooms, Water Supply, Factories and Workshops, Shops. 2. Food (14-25).—Premises where Food is prepared for sale, Abolition of Private Slaughter- liounes, Inspection of Meat killed in Private Slaughter-houses, Inspection of Slaughter-houses, Cow-houses, Dairies, Milk Shops and Milk Stores, Registration of Milk Shops, Sale of Milk, Municipal Milk Depots, Sale of Food and Druqs Acts, Cisterns. 3. Prevention of Disease (26-48).—Disinfection, Provision of Laundry, Provision of Permanent Shelter Accommodation, Precautionary Measures against Phthisis, Hospital Accommodation, Offensive Trades, House Refuse, Collection of frish Offal and other Offensive Trade Rifuse, Sanitary Inspection. 4. Miscellaneous (44-49).—Municipal Creches, Smoke Nuisances, Metropolitan Ambulance Service, etc. The County Council forwarded to the Metropolitan Borough Councils a transcript of the shorthand note of the proceedings at the Conference, and asked to be furnished with the views of those bodies on such of the resolutions as proposed legislation. I made a report to the Council (November 15th), expressing concurrence with the said resolutions, which dealt with the following subjects: — (a) The formulation of by-laws for the regulation of the structure of premises where food is prepared for sale, and the certification of the suitability of such premises by the Borough Councils. (b) The formulation of by-laws for the regulation by the Borough Councils of the conduct of the business carried on in premises where food is prepared for sale. (c) The acquisition of powers to enable the Borough Councils to refuse registration of premises as milk shops where, in their opinion, the premises are unfit. (d) The introduction of legislation providing for the penalising of persons selling filthy milk in London. (e) The acquisition of powers to enable the Borough Councils, at their discretion, to provide depots for the preparation and sale of sterilised and humanised milk for infants. 90 (f) The introduction of legislation for the repeal of the warranty sections of the sale of Food and Drugs Acts (Sections 25 of the Act of 1875 and 20 of the Act of 1899). (g) The acquisition of powers to enable the Borough Councils, at their discretion, to establish creches and to make reasonable charges for the accommodation and food provided thereat. (h) The amendment of the law so as to provide that disinfection shall be carried out without the intervention of a contractor, and to the satisfaction of the Medical Officer of Health. (i) The acquisition of powers to enable the Metropolitan Asylums Board to extend the operations of their ambulance service so as to include the transport of medical, surgical and mental cases. My report was referred to the Public Health Conmittee, who intimated that, whilst in general sympathy with the majority of the resolutions, they felt a little hesitancy in expressing an opinion thereon until they should have had before them the Bill which would, no doubt, be introduced into Parliament, embodying the various suggestions dealt with. The Committee therefore decided to defer the further consideration of the matter until such a measure had been formulated, and they recommended that a communication be addressed to the London County Council on these lines. The report was adopted by the Council. THE WORK OF THE SANITARY INSPECTORS. The Sanitary Inspecting Staff comprises a chief inspector, ten male inspectors, and two lady inspectors of workshops, workplaces and laundries where women are employed. The table at page 93 contains a summary of the work of the male inspectors (so far as it admits of tabulation) in their several districts; of which six are in North Kensington; i.e., north of High Street, Notting Hill, and Holland Park Avenue; and four in South Kensington, three of them to the south of Kensington High Street and Kensington Road; the remaining district lying between the main thoroughfares named. The work of the inspectors is carried out under the supervision of the Public Health Committee, the Council having conferred on that body authority to enforce the provisions of the Public Health (London) Act, 1891, the Housing of the Working Classes Acts, 18901903, and the Factory and Workshop Act, 1901, etc. Supervision of underground work—reconstruction and trapping of drains, etc., was, as from the beginning of the year, transferred from the Borough Engineer's department and placed under the Sanitary Inspectors, who during the year supervised the reconstruction of the drainage systems of 172 premises. A considerable number of drains were voluntarily reconstructed by the owners or occupiers of houses, after the deposit of plans for the approval of the Public Health Committee, particulars of which will be found in the Borough Engineer's report. The Sanitary Inspectors are charged with the further duty of collecti ng samples of food and drugs for analysis by the public analyst; the number of samples collected last year was 536. A sample of potable water, moreover, was collected, monthly, in each of the three districts formerly supplied by the Grand Junction, West Middlesex and Chelsea Water Companies. written Intimations of nuisances were served by the inspectors to the number of 2,134. As a result of these intimations, many works of sanitary amendment were carried out forthwith, thus realising the object of the legislature, and obviating, in many instances, the necessity for service of statutory notices. On the intimation form a red ink note authorises the person liable to abate a nuisance to make what, for convenience, may be called an "appeal" to the Committee, against the requirements of the sanitary inspector. Appeal, which is of rare occurrence, usually takes the form of an application for an extension of the time specified for carrying out works. Statutory Notices for the abatement of nuisances to the number of 471 were issued by direction of the Committee. Notices under the by-laws for houses let in lodgings, to the number of 1,155, were served. legal Proceedings.—In fifteen cases proceedings were instituted: in one instance, for an offence under the by-laws for registered houses, the fine inflicted being £5; in thirteen cases for non-compliance with the Council's notices, the fines inflicted, in five cases, amounting to £18 5s. Orders were made in three other cases, and in five cases the summonses were withdrawn, the required work having been executed. In one instance proceedings were instituted for the carrying of offensive matter through the streets, a fine of five shillings being inflicted. The fines in all amounted to £23 10s. 91 The subjoined table recommended for use by the Metropolitan Branch of the Society of Medical Officers of Health is inserted at the request of the Medical Officer of Health of the London County Council. PROCEEDINGS DURING 1905. PREMISES. NUMBER OF PLACES. Number of inspections, 1905. Number of notices, 1906. Number of prosecutions, 1905. On register at end of 1904. Added in 1905. Removed in 1905. On register at end of 1905. Milk premises 291 15 2 304 925 55 — Cowsheds 1 — — 1 26 — — Slaughter-houses 12 — — 12 92 — — Other offensive trade premises 1 — — 1 41 — — Ice cream premises 167 — 3 164 334 45 — Registered houses let in lodgings 2070 37 — 2107 7757 (a)* 50 (b)†1105 (a) — (b)†1 Total number of intimation notices served for all purposes, 2134. Overcrowding—1905. Number of dwelling rooms overcrowded 95 Number remedied 95 Number of prosecutions — Underground rooms— Illegal occupation dealt with during year 22 Number of rooms closed 22 Insanitary houses— Number closed under the Public Health (London) Act, 1891 — Number closed under the Housing of the Working Classes Act — Number of premises cleansed under Sec. 20 of L.C.C. (General Powers) Act, 1904 109 Shelters provided under sec. 60 (4) of the Public Health (London) Act, 1891— Number of persons accommodated during the year No shelter Revenue Acts— Number of houses for which applications for certificates were received during year 6 Number of tenements comprised therein 17 Number of tenements for which certificates were (a) granted 17 Continued on page 92. • (a) For overcrowding. † (b) For other conditions. 92 Continued. Number of prosecutions under By-laws under Public Health Act, 1891. (a) For prevention of nuisance arising from snow, ice, salt, filth, etc., — (b) For prevention of nuisance arising from offensive matter running out of any manufactory, etc. — (c) For the prevention of keeping of animals in such a manner as to be injurious to health — (d) As to paving of yards, etc., of dwelling houses ... — (e) In connection with the removal of offensive matter, etc. 1 (/) As to cesspools and privies, removal and disposal of refuse, etc. — (g) For securing the cleanliness of tanks, cisterns, etc. — (h) With respect to water closets, earth closets, etc. — (i) With respect to sufficiency of water supply to water closets... — (j) With respect to drainage, etc., (Metropolis Management Act, section 202) — (k) With respect to deposit of plans as to drainage, etc. (Metropolis Management Acts Amendment (By-laws) Act, 1899)... — Mortuaries— Total number of bodies removed 394 Total number of infectious bodies removed 11 OFFENSIVE BUSINESSES. The only business coming within the statutory description "offensive," other than that of a slaughterer of cattle, carried on in the Borough, is that of a Fat extractor, at Tobin Street, in the Potteries Notting-dale. In connexion with this factory, a formal complaint of nuisance was received from a gentleman who owns many of the houses in the vicinity. With the Chief Sanitary Inspector, I visited the premises on July 10th. The interior was in an unsatisfactory condition, the atmosphere almost intolerably hot and stinking. I reported the facts, and the Public Health Committee resolved to view, and did so in July, when the premises were found in a clean, dry, and generally unobjectionable condition, but for the sickening malodours clinging to everything about them. In September following a certificate signed by 65 inhabitants of the neighbourhood was received, making formal complaint of the nuisance. The Public Health (London) Act, 1891, was not named ; but obviously the certificate was based on the provisions of Section 21 of that enactment. It was not the first time, by several, that the inhabitants had in like manner invoked the aid of the Sanitary Authority in regard to this matter, to which references have been made in my annual reports extending over many years. The Sanitary Committee of the late Vestry, moreover, in more than one report, animadverted on the nuisance; and, particularly, in a report dated 25th October, 1898, they observed that— " It could not be questioned that, at times, smells of the most obnoxious character emanate from the premises to the serious inconvenience, if not danger, of the inhabitants of the houses in the immediate vicinity.* The Committee expressed the opinion that the matter should be dealt with either by complaint to the Petty Sessional Court, or by proceedings in the High Court. Proceedings were ordered to be instituted in the Petty Sessional Court; but the action of the Vestry was forestalled by the London County Council, whose proceedings proved abortive, under the circumstances set out in my annual report for 1898 (page 94). Three of the Sanitary Inspectors were deputed to keep observation on the premises, and did so for some weeks in the autumn; but their reports did not appear to justify the institution of proceedings; some of the inhabitants, moreover, expressed satisfaction with the improved state of affairs brought about by the intervention of the Public Health Committee, and which seemed to justify the impression that the nuisance was in a considerable measure caused by want of care in the conduct of the business—as by allowing effluvia to escape, by opening of doors, and in other ways, instead of compelling the discharge of them through the furnace by proper use of the apparatus provided for the purpose. Such neglect may from one point of view be regarded as pardonable, for the conditions under which the employes work, when the doors are closed, must be almost intolerable. In the result no proceedings were instituted. The premises are still kept under observation, and it will be interesting to observe whether, in the ensuing summer, exercise of the same care as in the autumn of last year will suffice to protect the inhabitants from a recurrence of the nuisance. 93 Summary of the Work of the Sanitary Inspectors during the Year 1905. (See page 90.) Sanitary Districts. No. of Complaints made by Inhabitants, &c. No. of Houses, Premises, &c., inspected. No. of Re-inspections of Houses, Premises, &c. Results of Inspection. House Drains. Water Closets. Dust Receptacles. Water Supply. Miscellaneous. Written Intimations of Nuisance served.* Notices served by order of the Public Health Committee. Notices served under the Lodging-House By-laws Final Notices (signed by Medical Officer) served. i Houses, Premises, &c., Cleansed, Repaired, Whitewashed, &c. Houses disinfected after illness : Infectious disease, † Reconstructed, Repaired, Cleansed, &c. Ventilated, Trapped, &c. Repaired. Supplied with Water. Soil-pipes ventilated. New provided. Repaired, Covered, &c. Cisterns erected. Cisterns Cleansed, Repaired, Covered, &c. Waste-pipes connected with Drains, &c., abolished. No. of Lodging Houses newly Registered under 94th Section of the Public Health (London) Act, 1891} Yards and Areas paved and drained. Animals removed, being improperly kept. Regularly Inspected. Legal proceedings, i.e.. Summonses. Bakehouses. Dairies, Milkshops, &c. Licensed Cow-house. Licensed Slaughter-houses. No. I. District 123 1,042 2,141 331 61 47 13 208 95 60 6 237 7 — 49 79 4 99 — — 77 13 7 42 — — 1 No. II. „ 76 1,057 2,235 193 87 237 54 289 88 209 9 61 119 5 33 16 5 71 1 — 121 4 9 35 — 2 8 No. III. „ 62 750 2,930 186 31 272 28 264 65 45 18 50 14 1 37 8 17 — 13 40 3 6 43 1 1 — No. IV. „ 105 912 1,896 305 59 54 13 160 70 24 10 59 87 5 52 13 2 13 1 20 19 6 16 42 — 1 2 No. V. „ 52 867 1,759 290 48 12 10 113 99 30 1 68 30 6 12 1 — 5 — — 5 1 13 29 — — — No. VI. „ 85 811 1,885 172 47 64 27 74 30 59 20 55 2 3 21 5 5 6 — 4 30 5 11 23 — 2 2 No. VII. „ 104 1,059 1,595 160 21 236 29 154 67 58 32 142 75 20 9 68 4 72 1 — 87 1 7 27 — 4 1 No. VIII. „ 92 983 1,650 124 26 63 15 165 52 47 4 10 26 11 23 10 3 7 — — 22 2 8 17 — 1 1 No. IX. „ 92 887 1,694 240 39 132 10 118 100 89 14 104 66 5 24 29 12 39 2 — 79 1 13 27 — — — No. X. „ 69 823 1,704 133 52 38 16 78 45 50 9 57 3 6 16 7 — 8 — — 27 — 7 19 — 1 5 860 9,191 19,489 2,134 471 1,155 215 1,623 711 671 123 843 379 62 276 236 36 337 5 37 507 36 97 304 1 12 15 * Under the provisions of sec. 3 Public Health (London) Act, 1891. † Done under the supervision of a Special Officer. ‡The total number of houses on the Register in December, 1905, in round figures, was 2,100. 94 LICENSED SLAUGHTER-HOUSES. Twelve slaughter-houses were licensed by the County Council in October—six in North Kensington and six in South Kensington. The several premises were regularly visited by the sanitary inspectors, and inspected, in September, by the Public Health Committee. The business of a slaughterer of cattle has not been established anew in the Borough since the passing of the (now repealed) Slaughter-houses (Metropolis) Act, 1874, in which year there were 56 licensed premises. The names of the licensees, and the localities of the premises, are as follows:— North Kensington. Lonsdale Mews Mr. Grove. 13, Archer Mews Mr. Bawoombe. 10, Edenham Mews Mr Goddard. 195, Clarendon Road Mrs. Simmons 235, Walmer Road Mrs. Van. 273, Kensal Road Mr. Miles. South Kensington. 35, Earl's Court Road Mr. Matson. 21, Peel Place, Silver Street Mr. Osborne. 25, Silver Street Messrs. Stevenson and Cox. 133, High Street, Notting Hill Miss Candy. 113, Holland Park Avenue Mr. Holloway. 128, Marlborough Road Mr. Little. The number of slaughter-houses in the administrative county has undergone a considerable diminution; viz., from 1,500 in 1874 to 317 in 1905. In the annual report for 1898 (pages 98-102), I dealt with the subject of "Abattoirs versus Private Slaughter-houses," in connection with an abortive attempt by the Public Health Committee of the County Council to bring about the substitution of public for private slaughter-houses. The report of the Committee (21st July, 1898), containing the recommendation, was shelved—on a motion to proceed to the next business—much to my regret, as an advocate for 30 years of public abattoirs. No further action in the matter has since been taken by the County Council. The Conference of Delegates of the Borough Councils (referred to at page 89) adopted unanimously a resolution on the subject of slaughter-houses as follows:— "That the time has arrived when private slaughter-houses should cease to exist in London." LICENSED COW HOUSE One cow house, in North Kensington, was licensed by the County Council, in October, for the keeping of three cows. The licensee is Mr. Arnsby, and the premises are located at 187, Walmer Road. In bygone days, within my experience, there were 28 licensed premises, containing 500 cows. There has been a considerable reduction in the number of cow houses in the administrative county: viz., from 1,044 in 1880, to 252 in 1905. The County Council intimated to cowkeepers, some years since, that their Public Health Committee were of opinion that, in the case of premises newly licensed, the recommendation of the Royal Commission on Tuberculosis, that no cow house should be erected within 100 feet of a dwelling-house, should be observed. The Council can, of course, enforce the condition if they think fit. Dairies Order.—The Council, as Local Authority in regard to milkshops, etc., received last year 15 applications for registration. At the close of the year 304 premises were on the register. The several premises are regularly inspected. At many small general provision shops, milk is sold in small quantity, usually from a glazed earthenware vessel standing on the counter, and mainly for the convenience of customers; but also in self-defence, lest customers should be induced to transfer their general dealings to other shops where this necessary article of diet can be obtained. The containing vessels at these little shops are kept clean; but the air of the premises is far from "pure"; the commonly prevailing odour being that of mineral oil, or of some one or other of the miscellaneous articles of food, cooked or uncooked, groceries, etc., vended thereat. I should be glad to see a better state of things; but the Local Authority appear to have no power to refuse registration to would-be vendors of milk. 95 fried Fish Shop Business.—In connection with proposed amendments to the Public Health (London) Act, 1891, elsewhere referred to (page 89), the Sanitary Committee of the late Vestry expressed the opinion that the business of a fried fish seller should be added to the list of those specified in Section 19, in order to the regulation of the conduct of the business, and so as to prevent it from being an annoyance to adjoining occupiers. This business gives rise to nuisance when carried on negligently; i.e., without necessary precautions to prevent the escape of effluvia, and it is a not infrequent subject of complaint: decided cases, moreover, class it as an " offensive business." The several premises are kept under observation. The Conference of Delegates of the Borough Councils held in July, 1904 (vide page 89), adopted a resolution (No. 36) to the effect, " That the business of a fried fish shopkeeper should be added to the list of offensive businesses specified in Section 19 of the Public Health (London) Act, 1891." Marine Stores.—The business of a marine store dealer is not scheduled in the Public Health (London) Act, 1891, as an " offensive business," though it gives rise to offensive smells, and has been held by the Court of Appeal to be ejusdem generis with the businesses originally scheduled as "offensive" in the (now repealed) Slaughter-houses (Metropolis) Act, 1874. Acting upon my advice, the late Vestry made application to the late Metropolitan Board of Works, in 1883, to schedule the business under that Act, but withoutsuccess; and in 1896, upon receipt of complaints of nuisance arising in the conduct of the business, a similar application was made to the County Council under the provisions of Section 19 of the Public Health (London) Act, 1891. This application, likewise, was unsuccessful. The subject was dealt with fully in the annual report for 1896—pages 119-123. The premises where the business is carried on, to the number of 17, are kept under observation. The Conference of Delegates of the Borough Councils held in July, 1904 (vide page 89), adopted a resolution (No. 35) to the effect " That the business of a marine store dealer should be added to the list of offensive businesses specified in Section 19 of the Public Health (London) Act, 1891." The County Council were requested to make orders to carry out the resolutions, 35 and 36, but have not done so. REFUSE. House Refuse.—The work of collection of ashes and miscellaneous rubbish from the 23,000 inhabited houses, has been systematised by division of the borough into districts, and provision has been made for inspection of ash-pits, and oversight of the dusting gangs, the arrangements being under the supervision of the Borough Engineer, subject to the control of the Works Committee. A call is made at every house once a week, and further improvement is scarcely practicable until the objectionable practice of refuse-harbourage shall have given place to the more rational system of daily collection from movable receptacles. The arrangements for domestic storage at " flats " are usually unsatisfactory, the receptacles being placed in unsuitable positions : complaints are common. In some instances the Works Committee have made arrangements for clearing the receptacles more often than once a week. Nuisance from house refuse does not arise from ashes, the proper contents of the receptacle, but from the addition thereto of matters of organic origin, which should be burned. In the annual report for 1903, reference was made to the views on this subject of a Conference of delegates of the Metropolitan Borough Councils, held in 1900, by which a resolution was adopted that " house refuse should be removed daily when practicable." The Public Health Committee of the County Council subsequently stated the reasons which, in their judgment, made removal at frequent intervals necessary. They did not think it practicable to make a by-law requiring a universal daily collection, but thought a bi-weekly removal should be made compulsory. A by-law to this effect was drafted and submitted to the several Borough Councils for their observations, pursuant to Section 114 of the Public Health (London) Act, 1891; but the proposal did not meet with a favourable reception, and no further action was taken in the matter. The subject was dealt with again at the Conference of Delegates of the Borough Councils held at the County Hall in July, 1904—to which reference has already been made (vide page 89), the following resolutions being adopted, viz.:—(a) That the daily removal of house refuse in suitable districts is advisable. (b) That 96 dust collection should be carried out by responsible officers of the sanitary authority without the intervention of a contractor. (c) That improved dust carts should be adopted, so covered as to minimise annoyance caused to passers-by during collection of house-refuse, especially in crowded thoroughfares; and (d) That the method of destruction of house-refuse by fire should be universally adopted in London. Nuisance in the Removal of House Refuse.—Several urgent complaints were made last year with regard to nuisance from the contents of the dust-carts being blown about the streets owing to the lack of suitable coverings. These complaints, only too well-founded, were brought to the attention of the Public Health Committee, who referred them to the Works Committee, without comment. Removal of Offensive Trade and Other Refuse.—At the Conference above adverted to, the delegates of the Borough Councils adopted a resolution to the effect— "That the collection of fish offal and other offensive trade refuse should be undertaken by the Sanitary Authorities at the expense of the producers. "In June, 1904, the County Council had, upon the recommendation of the Public Health Committee, decided to apply to Parliament, in the Session of 1905, for powers" enabling sanitary authorities to undertake, if they think fit, the collection and removal of offensive trade refuse; and empowering them to require payment of a reasonable sum by the owner or occupier of any premises from which such refuse is removed"; but the matter was not dealt with in the Council's General Powers Bill. In the annual report for 1903, the history of this question of removal of refuse matters was given at length; it had been dealt with in many previous reports, more especially in and since the year 188T, when the late Metropolitan Board of Works first took it into consideration. Nuisance from Stable Refuse.—The subject of nuisance from offensive collections, or delay in removal, of stable refuse, has found a place in these reports for thirty years. Until within a comparatively recent date, the principal cause of nuisance was the sunken dung-pits, now generally displaced by the iron cage-receptacles* recommended by me in 1875. More than a quarter of a century ago the late Vestry made regulations with a view to secure the removal of the refuse three times in each week, on alternate days; and on the whole, the work of clearance has been effected of late years in a fairly satisfactory manner. Nuisance now arises most frequently in connection with the removal of peat moss litter. The County Council, appreciating the gravity of the complaints on this score, made a new by-law in 1901, requiring removal of this description of refuse under the conditions applicable to the removal of offensive matter generally. But nuisance will not cease so long as peat refuse, on removal from stables, is deposited in a fixed receptacle, from which it must needs be transferred to the carriage provided for its conveyance through the streets. Intolerable stink arises in the turning over of the refuse, and the only remedy for the nuisance, long practised in the borough, is by the immediate deposit of it in the vehicle in which removal is to be effected. But nuisance in connection with peat refuse will never be wholly prevented until sanitary authorities shall have obtained power, and be required, to remove stable refuse at the cost of the owner. In the (now repealed) Sanitary Act of 1866, power to do this, at their own cost, was given to the sanitary authority, but only with the consent of the owner; and in many of these reports the late Vestry were advised to undertake the duty. As the law now stands, the occupier of any premises may "require" the sanitary authority to remove any trade refuse on payment (Public Health Act, 1891, Section 33); but the sanitary authority need only, "if they think fit," collect and remove" manure and other refuse matter from any stables the occupiers of which signify their consent in writing to such removal" —a consent which may be withdrawn or revoked after one month's previous notice (Section 36). The owner of such refuse cannot "require" the sanitary authority to remove it, nor is he under any obligation to pay for the removal; although, doubtless, many occupiers of stables would willingly do so, and be quit of a troublesome responsibility, and of liability to fine for non-compliance with the regulations. The law obviously requires amendment. FLOODING OF BASEMENTS OF HOUSES. In June, flooding of basements of houses, due to the insufficiency of the County Council's Counter's Creek main line sewer to carry off the combined sewage and storm water, was the subject of many complaints from inhabitants of numerous streets both in North Kensington and South Kensington. The same thing happened, but to a much less extent, in October. * About 1,600 stables in the Borough have been provided with these iron cage receptacles; whilst upwards of 700 brick receptacles above ground, and nearly 600 sunken pits, have been abolished in the mews, which are not far short of 200 in number. 97 In the eighth monthly report, 1904, I informed the Council that the Main Drainage Committee of the London County Council had reported that "a new storm water sewer ought to be constructed from the Middle Level Sewer to the Counter's Creek Sewer," with the object of "preventing the flooding of basements of houses at Notting Hill and between Holland Park Avenue and Kensington Road." They pointed out that " there is now a storm overflow between the Middle Level and Counter's Creek sewers; but the storm water, instead of being carried by a special sewer, reaches Counter's Creek sewer by passing through a number of local sewers. Floodings occur on each side of these local sewers, which become surcharged very quickly." In the eleventh report I stated that the County Council had accepted a tender " for the construction of a relief sewer from Cornwall Road, Notting Hill, to Upper Addison Gardens, at a total estimated cost of £32,000." The construction of that sewer is now far advanced. The contract time for the completion of the work is July next; but the chief engineer of the County Council informed me some months since that, "judging from the rate of progress," he "hardly anticipated that the work would be finished within that period." He was, however," urging upon the contractor the necessity for completing it by the time the contract specifies." It is to be hoped that the sewer will suffice for the intended purpose. SEWER SMELLS. Many complaints of offensive smells from sewer ventilators at road level, and untrapped street gullies, were received. In several instances the complaints were consequent upon the occurrence of outbreaks of infectious disease in the locality of the offensive openings. Acting on the instructions of the Public Health Committee, I forwarded reports on this subject direct to the Works Committee, who in numerous instances took measures for abating the nuisance by syphontrapping of street-gullies, and by pipe (in substitution of road level) ventilation of sewers. Reference may be made to one particular complaint, which led to the abolition of 38 brick pit gullies in Edenham Street, Appleford Road, Bosworth Road, Golborne Gardens, and Adair Road; all in North Kensington. Renewed complaint was made by an inhabitant of Neville Terrace, South Kensington, of a very offensive smell from a road level ventilator to the County Council's main line sewer. In July, 1904, the Works Committee requested the County Council to substitute a lamp, or pipe shaft, in place of the offending aperture. A few weeks later the County Council's chief engineer offered to recommend the Main Drainage Committee to erect a ventilating column 42 feet high, and 12 inches in diameter, at the junction of Neville Terrace and Selwood place. The Works Committee, having viewed the proposed site, expressed the opinion that the column, if erected, would "provoke greater complaints than the existing surface grating," and the County Council's engineer was so informed. The subject of this nuisance generally was dealt with fully in the annual report for 1904 (pages 83-84). I can only repeat that it would be well to deal with it effectually (a) by ventilating sewers, wherever practicable, by lofty iron colums, (b) by abolishing dead ends of sewers, and establishing aerial connection between adjacent sewers; or, where this is not practicable, by ventilating dead ends efficiently; and (c) by syphon-trapping street gullies, and wholly abolishing existing brick-pit gullies, which exceed six thousand in number. THE VENTILATION OF SEWERS. Acting upon the recommendations of the Public Health Committee and the Works Committee, the Council, in December, 1904, requested the County Council to convene a Conference of the Borough Councils to "consider as to the best means of ventilating the sewers throughout the whole Metropolis."* This subject has engaged the attention of the Kensington Sanitary Authority, at sundry times—for 35 years to my knowledge—having been brought to their attention by me in 1871, in consequence of numerous complaints by inhabitants of offensive smells from sewer ventilating gratings, at street level, and untrapped street gullies. A special committee, appointed to "consider * The proposed conference was not held. 98 the matter, and if possible devise a remedy," conferred with Mr. (afterwards Sir J. W.) Bazalgette, the engineer of the late Metropolitan Board of Works, who entered fully into the question, and explained to them the steps that had been taken to abate the annoyance in connexion with the main sewers under the control of the Board. The Committee were forced to the conclusion that no effectual means of sewer ventilation, for the prevention of sewer smells, had been discovered, and thereupon brought their well-intended but ineffectual labours to a conclusion. Among the remedies for the evil suggested by myself, in 1871, one was that, "whenever a new sewer is constructed, it should be ventilated at the highest (or dead) end, by a shaft carried up above the level of the adjoining buildings," a remedy which, as was then pointed out, could be applied in the case of existing sewers in mews at no great expense." In 1874 a specific instance of nuisance, injurious to health, from sewer smells, was reported on in connexion with complaints from Notting Hill (now Campden Hill) Square, where numerous cases of " fever " had occurred. The nuisance was abated, and all cause for future complaint removed, by connecting the dead end of a sewer to an adjacent sewer, and ventilating the system at the point of junction. No year ever passed without complaints from various localities; and in 1897, an unusual number having been received, my report on the subject (No. 9, page 108) was referred to the Sanitary Committee, who dealt fully with the matter, after obtaining a report from the Law and Parliamentary Committee on the law of the subject. The Surveyor also submitted a report "On Sewer Ventilation and Sewer Smells"; and, at the request of the Sanitary Committee, I made a further report on the subject. Both reports were forwarded to the County Council, who were requested to instruct their chief engineer to " convene a Conference of the Surveyors and Medical Officers of Health to discuss the question with him, with a view to his reporting upon the general question of metropolitan sewer ventilation." The Conference, to which the Medical Officers of Health were not invited, took place early in 1898. The chief engineer drew up a report of the proceedings which was communicated to the sanitary authorities, together with the resolutions adopted—all of which were substantially in accord with the views of the Vestry's surveyor, viz.:— 1. That the closing of sewer ventilators in response to complaints increases the general evil, the diminution of which is to be attained by the multiplication of the ventilators at regular intervals. 2. That in connection with any interceptor hereafter fixed on a main house drain, it is advisable to carry a ventilating pipe from the sewer side of the interceptor, up the front, side, or back of the house, to the satisfaction of the local sanitary authority, and that the outlet drain from the interceptor shall not be flap-trapped in sewer, unless required by the local sanitary authority. 3. That pipe ventilators, up buildings, or otherwise, when possible, should always be adopted, in addition to surface ventilators. The County Council's engineer summed up the matter by stating that "the remedy for sewer emanations is to be looked for from the maintenance of more ventilating openings, both at the street level, and by means of pipes carried up houses and other buildings." With reference to the third resolution of the Conference, the Sanitary Committee recommended "that the surveyor be requested to report as to any practicable action which might be taken by the Vestry" for the prevention of nuisance, by improving sewer ventilation. Since that date many pipe ventilators have been erected, many offensive ventilating openings at street level closed, and many offensive street gullies trapped, with the result of permanently removing local cause for complaint. It may be mentioned here that attempts have been made at sundry times to provide a chemical remedy for the nuisance. One such—successful as a laboratory experiment—was tried in * The question of sewer ventilation in mews was fully dealt with in the Annual Report for 1896, page 128. 99 Kensington some 30 years ago. Others have formed the subjects of patents; not one of which has come into general use, a fairly sure indication of their practical inutility. The late Metropolitan Board of Works and the County Council, alike, expended vast sums on disinfectants with the same object, to little purpose. My own view has always been that abatement of nuisance from this cause should be sought by means for admitting to the sewers copious streams of atmospheric air. In 1887, Sir Henry Roscoe, F.R.S., who had been retained by the Metropolitan Board of Works as chemical expert adviser, expressed the view, in a report on "the deodorisation of sewer emanations," that the free admission of air is the only efficacious means of preventing foul emanations: first, by the oxidation of putrescent sewage; and second, by the dilution of any offensive gases evolved. "The policy of closing the air openings to the sewers, instead of allowing as much fresh air to enter as is possible," was, he said, "based upon a wrong scientific principle; the only feasible plan of rendering the sewers sweet, being to carry out thoroughly, and on a proper scale, the system of pipe ventilation recommended (in 1886) in the excellent report of the Board's Special Purposes and Sanitary Committee." In my annual report for 1887, reference was made to a system,* having for its object, the free admission of air to sewers, in regard to which it was stated that Sir Henry Roscoe's assistant in the investigations undertaken for the Board, and also the flushing inspector of the Metropolitan Board's sewers in the Poplar district, had spoken favourably. The principle involved in this system found favour at the Conference (in 1898), of the engineers and surveyors, whose recommendations, in effect, aimed at securing the multiplication of surface ventilators and upcast shafts, so as to flood the free space in sewers with fresh air. This, moreover, would appear to be the object aimed at in the latest patented ("Shone") system of sewer ventilation; power, however, being used for the extraction of foul air, by means of fans operated by electricity—a plan admittedly costly in installation and in working. Here it may be mentioned that the question of sewer ventilation engaged the attention of the late Metropolitan Board of Works during many years, and formed the subject of several reports by their engineer, which, so far as they relate to the years 1856-1866, comprise a record of ineffective or impracticable suggestions. The reports in my possession are:— (1) Report by the Engineer, Mr. (afterwards Sir J. W.) Bazalgette on "the Ventilation of Sewers" (6th January, 1866), embodying the results of "experiments . . . for testing the value of charcoal or other deodorising ventilators"; and (2) Report by the Engineer (31st May, 1866) on a reference requiring him to report "what experim ents had been made during the preceding twelve months by himself and the assistant etmineers, with respect to the ventilation of the sewers of the Metropolis, and the result of such experiments." The methods to which the engineer's attention had been directed during the period in question, were (a) by the use of charcoal ventilating grates; (b) by ventilation through chimney shafts and furnaces; (c) by ventilation through pipes carried to the tops of buildings, &c., and (d) by diluting the sewage with water.] (3) Report by the Engineer and Dr. W. A. Miller, F.R.S. (19th December, 1866), on experiments with respect to the ventilation of sewers through charcoal ventilators. (4) Further report by the Engineer (31st March, 1869) on a reference requiring him to "report . . . the result of all his most recent experiments in connexion with the ventilation of sewers, and also any suggestions which he may be able to make in reference to this question." (5) Report on the ventilation of sewers made in conformity with a resolution of the "Ventilation of Sewers Committee" that "the various opinions with regard to the ventilation of sewers which have been arrived at by Committees of the Board employed to inquire into the subject, and the orders of the Board thereon, be collated and classified in the Clerk's and Engineer's departments and submitted . . This last report (18th July, 1876), prepared by Mr. J. E. Wakefield, clerk of the Board, and approved by the engineer, dealt with the subject in two parts:— (1) Chronological sketch (1856-1874). (2) Classification of Results, under the headings, (a) General Conclusions, (b) Methods of Ventilation that have been tried in different localities with a variable amount of success, (e) Various schemes that have, from time to time, been submitted to the Board with reference to the ventilation of sewers. * "A new system of ventilating and puritying sewers," invented and patented in (or about) the year 1877, by the late Mr Robert Parker, formerly surveyor to the Board of Works for the Poplar district. 100 The Special Purposes and Sanitary Committee of the Board made a report on the subject (12th January, 1886), of which I have no copy, but certain recommendations contained therein, already referred to as having been approved by Sir Henry Roscoe, are set out in a "Report upon the Question of Sewer Ventilation," by the late Vestry's surveyor (24th September, 1889). Among the opinions expressed, and the remedies suggested, in the summary report (5), adverted to, the following may be cited. (a) "The only effective mode of preventing the escape of foul gases from sewers is the rapid removal and deodorisation of the sewage by copious dilutions with water."—(Engineer, Metropolitan Board of Worts, 1856.) (b) "By ventilating shafts in the trunk sewers for the purpose of drawing the foul gases away from the branch sewers"; and "By erecting shafts with large fireplaces so constructed as to consume the deleterious gases before they pass up the chimney."—(Br. Lantester, Medical Officer of Health, St. James's, Westminster, 1857.) (c) Before a Committee of the House of Commons appointed (in 1858) to enquire into the state of the Thames, ventilation of sewers by means of furnaces and shafts was suggested. This system, "possibly efficacious for a particular and limited area," could not be "utilised to the wide range of the Metropolis.'' Mr. Haywood, engineer to the City Commission of Sewers, spoke of the "exceeding difficulty in doing it at all," but if it could be done, it would only be "at an enormous expense." Ventilation by furnaces was described by him as being "impracticable"; for the air would be drawn only from the inlets nearest to the furnaces, (d) On a proposal to " ventilate by means of a water fan "(suggested by Mr. White, M.R.C.S., 1860), the engineer reported that this plan had been "sufficiently considered to enable him to state that an attempt to carry it out would prove a failure," and, in any case, any good effect would not be perceptible beyond the first inlet to the sewer through which air could enter the shaft, (e) Large lamps to serve as ventilating shafts were recommended in 1860. (f) Charcoal trays were extensively employed in 1866 to mitigate stenches; and proved effectual for the purpose by occluding the ventilating gratings, (g) The efficacy of water. for diluting the sewage, was again emphasised in 1866; but the remedy was said to be too costly— the water companies, moreover, not being willing (or able) to supply the requisite quantity— and also the efficacy of pipes carried to the tops of buildings : but it was stated that householders objected to the practice for fear of injury to health—an objection which carries less weight now. (h) In 1869 the engineer referred to ventilation by means of air flues connected with the furnaces and shafts of factories and other buildings; "the current of air through the pipes appears to be constant, having the same appreciable effect in the sewer as an ordinary ventilating shaft." (i) A committee of the Metropolitan Board in 1872, after four years of investigation, reported that " no one plan of ventilation, however well adapted to succeed locally, would be applicable to the whole of the Metropolis." Reference is made in certain of the reports to the utility of intercepting valves (described indifferently as flaps, screens, shutters) in branch sewers connected with main sewers, to prevent the noxious gases passing from the main sewer into the branch sewers: this treatment is said to be more efficacious where combined with the erection of ventilators at the upper (dead) ends of pipe sewers. Reference has already been made to the views of Sir Henry Roscoe, who prepared a number of reports—all of which were summarised in my annual reports for 1887-1889—dealing with "The Deodorisation of Sewage in the Metropolitan Sewers," and "The Deodorisation of Sewage at the Outfalls"; the latter being a subject of pressing importance at the time, owing to the state of the River Thames. With regard to the use of chemicals for disinfecting the emanations from the Board's sewers, it appeared that a mixture of manganate of soda and sulphuric acid had been employed, at a cost, in 1866, of £40,000, with but little advantage. Sir Henry Roscoe did not favour a large expenditure for this purpose, but expressed the opinion that if it were determined to disinfect the sewers at all, bleaching powder and sulphurous acid would be cheaper, and as efficacious. But he was of opinion that "the most effective method of accomplishing the deodorisation of the offensive emanations was, whenever practicable, to dilute them with fresh air by means of suitable ventilation." The history would not be complete without a reference to the reports on the subject, presented to the Kensington Sanitary Authority by their late surveyor—3rd March, 1885, 24th September, 1889, and 18th October, 1897. Mr. Weaver favoured the use of pipes carried up houses, if sufficiently numerous, in addition to a sufficiency of gratings at street level, and exhaust ventilating pipes from the dead ends of sewers. Flushing, however, was the remedy he most affected; were not the cost of water prohibitive, and supposing the requisite quantity forthcoming. He would also flush "dead ends" by means of automatic flushing tanks, with inner cisterns constantly discharging disinfectants into the flush-water. The latest expression of this gentleman's views is contained in a report to the Works Committee (July, 1904), in which it is stated that, "with an intimate acquaintance with all the known methods of sewer ventilation, natural, mechanical, and chemical," he had "nothing to add or alter" in the report of 1897." "As an outcome of that report, 167 pipe-shafts had been fixed in different places by order of the Council up to 130 TABLE B. Annual Number of Deaths in Kensington from the Principal Diseases of the Zymotic Class (1856-1905); and Death-rate from these Diseases, in Kensington, and in London. The Year. Population. Deaths from the Seven Principal Diseases of the Zymotic Class. Zymotic Death-rate. Small-pox. Measles. Scarlet Fever. Diphtheria. Whooping-Cough. Fever. Diarrhoœa. Total. Per 1,000 persons living. Deaths per 1,000 Deaths from all Causes, Kensington. Typhus. Enteric. Pyrexia. Kensington. London. 1856 57,078 13 35 Not separ- 15 ately classified. 27 Not separately classified. 26 Not separately classified. 62 178 3.1 4.3 144 1857 59,683 1 20 28 50 32 79 210 3.5 4.3 176 1858 62,288 2 26 61 63 38 30 220 3.5 5.1 171 1859 64,893 10 42 76 10 23 71 232 3.6 5.1 173 1860 67,498 18 30 89 7 56 23 36 259 3.8 3.8 175 1861 70,108 2 57 51 14 37 32 65 258 3.7 4.5 178 1862 76,350 ... 30 110 28 54 51 24 297 3.9 5.1 185 1863 81,350 49 83 89 22 22 54 54 373 4.6 5.9 229 1864 86,350 5 100 90 16 56 60 63 390 4.5 5.6 211 1865 91,350 20 55 31 18 37 78 103 342 3.7 4.9 197 1866 96,350 11 49 21 13 58 44 106 302 3.1 6.7 154 1867 101,350 25 22 26 9 76 53 89 300 3.0 3.9 155 1868 106,350 4 84 169 33 34 52 113 489 4.6 4.8 219 1869 111,350 7 33 104 11 79 51 112 397 3.6 5.6 177 1870 116,350 8 70 198 14 55 5 24 17 154 545 4.7 5.2 220 1871 120,234 120 64 95 11 72 6 26 16 129 539 4.5 6.0 223 1872 127,606 68 43 29 14 77 4 28 10 110 383 3.0 3.8 169 1878 132,826 1 38 10 11 44 6 27 8 145 290 2.2 3.3 119 1874 138,616 ... 121 32 26 45 9 28 15 112 388 2.8 3.3 144 1875 144,488 ... 23 83 23 107 2 21 6 107 372 2.6 3.9 133 1876 148,338 8 128 59 17 124 3 27 6 126 498 3.3 3.6 172 1877 151,360 84 54 31 10 34 2 14 5 99 333 2.2 3.5 127 1878 154,305 24 53 77 20 185 3 26 4 181 573 3.7 4.1 184 1879 158,316 24 60 51 26 93 1 14 8 71 348 2.2 3.3 116 1880 161,462 11 75 105 22 95 4 24 5 128 469 2.9 3.7 163 1881 163,151 55 67 38 8 85 2 22 5 101 383 2.3 3.6 140 1882 163,540 ... 77 62 25 119 1 25 6 61 376 2.3 3.5 139 1883 163,860 1 39 28 24 44 2 30 3 80 251 1.5 2.7 96 1884 164,180 26 32 18 17 81 ... 26 4 110 314 1.9 3.5 119 1885 164,500 25 111 7 22 98 ... 12 ... 86 361 2.2 3.0 130 1886 164,820 ... 56 11 34 82 ... 11 ... 90 284 1.7 2.8 102 1887 165,140 ... 108 44 40 86 ... 11 2 124 416 2.5 3.1 145 1888 165,450 ... 124 26 89 100 ... 21 2 58 420 2.5 2.7 148 1889 165,760 ... 14 28 111 26 ... 19 ... 71 269 1.6 2.3 111 1890 166,080 ... 140 26 35 93 ... 15 ... 78 387 2.3 2.8 131 1891 166,308 ... 29 16 28 84 ... 24 1 91 273 1.6 2.3 89 1892 167,200 ... 109 36 31 63 ... 15 2 77 333 2.0 2.8 115 1893 167,900 9 18 51 83 65 ... 17 ... 98 341 2.0 3.1 117 1894 168,600 ... 108 22 75 61 ... 21 3 56 346 2.1 2.7 132 1895 169,300 ... 33 27 89 39 ... 15 1 118 322 1.9 2.6 117 1896 170,465 ... 173 39 72 99 ... 15 1 61 460 2.7 3.1 159 1897 170,700 ... 33 29 82 19 ... 21 1 125 310 1.8 2.6 116 1898 172,000 ... 120 23 26 52 2 12 ... 112 347 2.0 2.8 124 1899 172,400 ... 24 10 42 59 ... 23 ... 101 259 1.5 2.5 86 1900 173,000 ... 98 4 27 33 ... 16 ... 105 283 1.6 2.2 105 1901 176,628 1 77 15 38 62 1 11 ... 115 820 1.8 2.3 121 1902 177,500 11 93 21 20 21 ... 19 ... 78 263 1.5 2.2 96 1903 178,000 ... 34 14 24 90 ... 9 97 268 1.5 1.8 109 1904 178,500 1 67 5 17 19 ...| 6 1 128 244 1.4 2.2 96 1905 179,000 ... 54 21 9 60 ... 13 ... 90 247 1.4 1.7 99 Note.—The Medical Officer of Health is indebted to Dr. Tatham, Superintendent of Statistics in the Department of the Registrar-General, for many of the figures above the horizontal line between 1870 and 1871; and to Mr. Stephens, Clerk to the Kensington Board of Guardians, for the Annual Number of marriages set out in Table A between 1856 and 1870 inclusive. 131 TABLE C. Births, and Birth-rate; Deaths, and Death-rate; Deaths from the Seven Principal Diseases of the Zymotic Class; and Zymotic Death-rate, in Kensington, 1856-1905: Arranged in Quinquennial Periods. Quinquennial Period. Births. Birthrate. Deaths. Deathrate. Deaths from Zymotic Diseases. Zymotic Deathrate. per 1,000 persons living. Small-pox Measles. Scarlet Fever. Diphtheria WhoopingCough. Typhus Fever. Enteric Fever. Pyrexia. Diarrhœa. Total. 1856-1860 9,557 30.7 6,540 21.0 44 158 276 — 206 Not separately classified. 142 Not se parately classifitd. 278 1,099 3.53 1861-1865 11,562 28.5 8,261 20.4 76 325 371 98 206 275 309 1,660 4.09 1866-1870 17,090 32.1 10,853 20.4 55 258 518 80 302 224 574 2,011 3.78 1871-1875 20,861 31.4 12,595 18.9 189 289 249 85 345 27 130 55 603 1,972 2.97 1876-1880 23,149 29.9 14,517 18.8 151 370 323 95 531 13 105 28 605 2,221 2.87 1881-1885 21,383 26.1 13,438 16.4 107 326 153 96 427 5 115 18 438 1,685 2.05 1886-1890 19,428 23.5 13,816 16.7 1 442 135 305 387 ... 77 4 421 1,772 2.14 1891-1895 18,512 22.1 14,235 16.9 9* 297 152 306 312 ... 92 7 440 1,615 1.92 1896-1900 18,209 21.2 14,075 16.4 ... 448 105 249 262 2 87 2 504 1,659 1.93 1901-1905 17,561 19.7 12,898 14.4 13 325 76 108 252 1 58 1 508 1,342 1.51 •All in 1893. TABLE D. Death-rate in Kensington, per 1,000 persons living, from each of the Seven Principal Diseases of the Zymotic Class; Arranged also, in two groups; viz. (1) The four notifiable infectious diseases—Smallpox, Scarlet Fever, Diphtheria, and "Fever"; and (2) The three non-notifiable diseases—Measles, Whooping-Cough, and Diarrhœa. Quinquennial Period. 1 2 3 4 5 6 7 Death-rate per 1,000 from— Smallpox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. "Fever." Diarrhœa. The Seven Diseases. The Four Notifiable Infectious Diseases. (Columns 1, 3, 4, and 6.) The three Non-notifiable Infectious Diseases. (Columns 2, 5, and 7.) 1856-1860 0.14 0.49 0.89 — 0.66 0.46 0.89 3.53 1.48 2.05 1861-1865 0.19 0.80 0.91 0.24 0.51 0.68 0.76 4.09 2.02 2.07 1866-1870 0.10 0.49 0.97 0.15 0.57 0.42 1.08 3.78 1.65 2.13 1871-1875 0.28 0.44 0.37 0.13 0.52 0.32 0.91 2.97 1.11 1.86 1876-1880 0.19 0.48 0.42 0.12 0.69 0.19 0.78 2.87 0.92 1.95 1881-1885 0.13 0.39 0.19 0.12 0.52 0.17 0.53 2.05 0.60 1.45 1886-1890 0.00 0.53 0.16 0.37 0.47 0.10 0.51 2.14 0.63 1.51 1891-1895 0.02 0.35 0.18 0.36 0.37 0.12 0.52 1.92 0.67 1.25 1896-1900 0.00 0.52 0.12 0.29 0.31 0.11 0.59 1.93 0.52 1.41 1901-1905 0.01 0.37 0.09 0.12 0.28 0.07 0.57 1.51 0.29 1.22 [Index. INDEX. Page. Age and Sex Distribution of the Population at the Census of 1901 3 Agriculture; Circular on Milk Standards, of the Board of 69 Alcoholism; Deaths from 29 Ambulance Service; Arrangements for removal of patients by the Asylums Board's 73 „ „ Asylums Board willing to provide for non-infectious patients, an 76 „ „ Corporation of London and County Council's schemes for providing a Street 74 „ „ Council resolve to petition Parliament with view to provision of Metropolitan 78 „ „ History of the Asylums Board's 76 „ „ Stations of the Asylums Board's 79 Appendix I. Statistical Tables, Nos. VI.—XII. 110 „ II. Statistical Tables, A, B, C, and D: Marriages, Births, Deaths, Infantile and Zymotic Mortality, &c., 1856—1905 129 Area of the Borough 5 Asylums Board; Work in 1904 of The Metropolitan 70 Bakehouses 89 Baths and Washhouses; Number of Bathers and Washers, in the year 1905-6, at the 103 Births and Birth-rate; in the Borough, the Sub-Districts, &c. (Table, page 8) 6 Births; Number of, and Birth-rate, in 10 years, 1895-1904, and in 1905 8 Births; Illegitimate in 1905, Number of 6 Births; Annual Number of, and Birth-rate, 1856-1905 (Tables A and C, Appendix II.) 129-131 Births; Particulars now obtainable by Public Health Authorities with respect to 60 Borough; Development since 1856, and since 1871, of the 4 By-Laws for Houses let in Lodgings 81 Cancer, Malignant Disease; Deaths from 29 Census of 1901; Population of the Borough at the 3 Cerebro-spinal ("Spotted") Fever 40 Chapel of Rest for the Dead; Use of the 106 Child-mortality and School attendance 64 Circulatory System, Deaths from Diseases of the 29 Cleansing of Persons Act 102 Common Lodging-houses; List of 82 Consumption; Asylums Board's action with regard to Prayer of Memorial of Metropolitan Medical Officers of Health inviting them to become Sanatorium Authority for 49 „ Council's action with regard to the Prevention of 40 „ Disinfection after 41 „ Hospital Provision at Poor Law Infirmaries for 48 „ Lady Inspectors' report on Voluntary Notification of 50 „ Local Authorities invite Asylums Board to become Sanatorium Authority for 47 „ Notification (Compulsory) desiderated for 42 „ Sanatoria, Need of for 42 Coroner's Court; Inquests held at the 33 Counter's Creek Sewer; Flooding of Houses due to Insufficiency of 96 Cow-house, Licensed 94 Creches (Municipal); Report of the Public Control Committee of L.C.C. on 63 Dairies Order; Registration of Milk Shops under the 94 Death; (Tables, page 18, and page 112) Assigned Causes of 16 „ Summary of Causes of 19 Death-rate; Annual, 1856—1905 (Table A, Appendix II.) 129 „ from Zymotic Diseases; Arranged in Quinquennial Periods, 1856-1905 (Table D) 131 „ in 1905, in the Borough, the Sub-Districts, &c. 13 „ in 1905; The Corrected or True 10 „ of England and Wales; and of Inner, Outer, and Greater London 16 „ of Foreign, Colonial, and Indian Cities 16 Deaths and Death-rate; In Borough, Sub-Districts, Parliamentary Divisions and Wards (Table Page 13) Deaths at Public Institutions within the Borough 30 „ of Parishioners at Public Institutions, &c., without the Borough 32 ii. Page. Deaths of Illegitimate Children, under Five Years of Age 12 Diagnosis; Cases admitted to hospital on mistaken 72 Diarrhoea; Deaths in Kensington and in London from 27 „ Deaths in Kensington, 1856—1905, from (Tables B, C and D, Appendix II.) 130-131 Digestive System; Deaths from Diseases of the 30 Diphtheria; Deaths in Kensington, and in London, in 1905, from 24 „ Deaths in Kensington, 1856—1905, from (Tables B, C and D, Appendix II.) 130-131 Diseases; Deaths from General 19 Disinfection, The Cost of, in 1905 and in 1891 104 Disinfecting Station in course of erection 104 District Rates of Mortality (Table, page 9) 12 Drainage; Supervision of Reconstruction and Repair of defective House 90 England and Wales; Death-rate, in 1905, of 10 Enteric Fever; Deaths in Kensington and in London, in 1905, from 26-27 „ Deaths in Kensington, 1856—1905 from (Tables B, C and D, Appendix II.) 130 131 Factory and Workshop Act, 1901; Proceedings under the (Tables, 84-88) 82 ,, ,, „ Chief Sanitary Inspector's Report on Men's Workshops 86 ,, „ „ Lady Inspectors' Report on Women's Workshops 83 Females Enumerated at the Census, 1901; Number of 3 Fever; Deaths in Kensington and in London, in 1905, from 26 „ Deaths in Kensington, 1856—1905, from (Tables B, C and D, Appendix II.) 130-131 Fever Hospital Accommodation 73 Flooding of Basements of Houses; New Sewer constructed for preventing 96 Fried Fish Shop; An Un-scheduled "Offensive Fusiness" 95 Gas-Works; Effluvium Nuisance at the 103 General Diseases; Deaths from, Zymotic 19 „ „ Deaths from other than Zymotic 28 Health; Board of Education issue syllabus of teaching of the Laws of 65 Health Visitor Appointed 58 „ ,, Report on Infantile Mortality by the 58 Hospital Accommodation for Infectious Disease (Table, page 74) 73 Hospitals; Deaths at Outlying 32 „ Use made of 71 House Refuse 95 Houses (Inhabited); Number of, in 1905, and Increase of, since 1856, and since 1871 4 „ Let in Lodgings; Number of Registered 81 Housing of the Working Classes; Action of the Borough Council with respect to the 80 Hygienic (Asphalte) Paving of Streets 103 Illegitimate Children under Five Years of Age; Deaths of 12 Ill-Nourished School Children 65 Infantile Mortality in Kensington, in London, and in England and Wales 11 Infantile Mortality; Local Government Board's new table of stated causes of death 56 „ „ 1871—1905 (Table A, Appendix II.) 129 „ „ Health Visitor's Report on 58 Infants; The Care of 58 Infectious Diseases in London, in 1905; Ages at Notification of 34 ,, „ Cases of, Notified in London, 1890—1905 (Annual Number) 34 „ „ Notifications of in London, and in Kensington, and the Metropolitan Cities and Boroughs (Table) 34-38 „ „ Sickness and Death-rate from (Table) 39 Infirmarv; Deaths at the Borough 31 Influenza; Deaths in Kensington, and in London, from 27 Inquests 33 Lady Inspectors of Workshops, &c.; Annual Report of the (Tables, pp. 84 and 85) 83 „ „ First Appointments, in 1893, of 82 „ „ Report on Notification of Consumption by the 50 „ „ „ Measles and Whooping Cough by the 21 & 26 Legal Proceedings 90 Local Diseases; Deaths from 29 iii. Page. Males Enumerated at the Census, 1901; Number of 3 Marine Stores; Business of, recommended for Scheduling under the Public Health Act 95 Marriages, and Marriage-rate, 1905, and preceding ten years; Number of 6 „ „ „ 1856—1905; Annual Number of (Table A, Appendix II.) 129 Measles in Kensington and in London; Deaths from 21 Metropolitan Ambulance Service; a Desideratum 74 Metropolitan Asylums Board; The Work of the 70 Midwives' Act 66 Mortality; District Rates of 12 „ Infantile 11, 55 & 129 „ Senile 12 „ Zymotic 19 Mortuary; Use of the Public 1895—1905 (Table) 105 Municipal Creches 63 Municipal Milk Depots; Bill introduced to facilitate provision of 65 Nervous System; Deaths from Diseases of the 29 Notification of Infectious Disease; in Kensington and in London {Tables, pp. 34-38) 33 ,, of Phthisis, in Kensington, Voluntary 50 Notting-Dale Special Area; Statistics of the 12 Offensive Businesses 92 „ „ Fried Fish Shops and Marine Stores; Unscheduled 95 Offensive Smells in Streets 97 Outlying Public Institutions, &c.; Deaths at 82 Outworkers 84 Parliamentary Divisions of the Borough 5 Paving of Streets, Hygienic 103 Phthisis; Deaths and Death-rate, in Kensington and in London, from Pulmonary 28 „ Voluntary Notification of 50 Population of the Borough at the Census of 1901; Age and Sex Distribution of 3 „ „ „ Decennial Censuses, 1801—1901 4 „ „ „ 1856—1905; Estimated Annual (Table A, Appendix II.) 129 „ „ „ in 1905; Estimated 5 Public Baths and Washhouses; Number of Bathers and Washers in the year 1905—6 at the 103 Public Health (London) Act, 1891; Conference on the Administration of the 89 „ „ ,, ,, Proposed Amendment of the 89 Public Institutions; Deaths at (Table, page 31) 30 Public (and Public-house) Sanitary Conveniences; Number of 101 Puerperal Mortality in 1905 28 Rateable Value, 1823—1905; Increase of 4 Refuse; House 95 „ Stable 96 Registered Houses; New By-Laws for 81 Registration District and Sub-Districts 5 Respiratory System; Deaths from Diseases of the 30 Sanatorium Question 42 „ Life in a 50 Sanitary Conveniences, Public 101 Sanitary Inspectors; The Work of the (Statistical Tables, pages 91 and 93) 90 Scarlet Fever in Kensington and in London, in 1905; Deaths from (Tables, pages 22-24) 21 ,, in Kensington, 1856—1905; Deaths from (Tables B, C and D, Appendix II.) 130-131 School Attendance and Child Mortality 64 Senile Mortality 12 Sewers; Ventilation of (Historical Resume) 97 Sewer Smells in Streets: Untrapped Street Gullies and Surface Ventilators, the Causes of 97 Sex and Age Distribution of Population, in 1901 3 iv. Page. Shelter for Persons during Disinfection of Rooms; The Need of a 104 Slaughter-houses; Licensed 94 Small-pox 1856—1906; Annual Number of Deaths from (Tables B, C and D, Appendix II.) 130-131 „ Views of the Royal Commission on the Amount of Hospital Accommodation required for 73 Special Area (Notting Dale); Statistics of the 12 Statistical Tables; The Local Government Board's prescribed Forms for 17, 18, 37, 56, 87 & 88 „ „ Nos. vi.—xii. (Appendix I.) 110 „ „ Births, Deaths, &c., 1856—1905 (Table A, Appendix II.) 129 Statutory Notices issued in 1905; Number of 90 Street Ambulance Services; City Corporation and County Council propose to establish 76 Streets, &c., in which Cases of Infectious Disease were notified, in 1905; List of 124 „ in which Deaths from Infectious Diseases occurred, in 1905; List of 121 Syphilis; Deaths from 28 Tables prescribed by the Local Government Board to be used:— (i.) Population, Births, Deaths under One Year, and at all Ages, and in Public Institutions, &c.; in 1905 and the preceding ten years; whole District 17 (ii.) Population, Births, Deaths at All Ages, and under One Year; in the Borough, and the Sub-Districts; in 1905 and the preceding ten years 18 (iii.) Infectious Disease; Cases of, Notified at different Ages, in the Borough, and in the Sub-Districts; and Cases removed to Hospital 37 (iv.) Death, Causes of, and Ages at, in 1905 18 (v.) Infantile Mortality; Deaths from stated causes 56 (vi.) Factories, Workshops, Laundries, Workplaces and Homework 87-88 Tables (Other), in the Report:— Population of Kensington; Age and Sex Distribution, in 1901, of the 3 „ „ at Censuses 1801—1901, inclusive 4 Birth-rate in the Metropolis, and in the Borough (Sub-Districts, &c.), in 1905 8 Death-rate in the Metropolis, the Borough, the Sub-Districts, the Parliamentary Divisions, and the Wards; in 1905 13 Death; Summary of Causes of 19 Zymotic Diseases; Deaths in the Borough and the Sub-Districts, &c., at Home and at Hospitals, from (Table) 19 Scarlet Fever; Notifications, Removals, Deaths, &c.; in four-weekly Periods; in 1905, and in the preceding ten years, from 22-24 Diphtheria; Notifications, Removals, Deaths, &c., in four-weekly Periods; in 1905 and preceding ten years from 25-26 Infectious Disease Notification, Kensington; 1895—1905 38 „ „ „ London; 1890—1905 34 „ „ Sickness and Death-rate; in 1905 and preceding ten years (Table VI.) 39 Vaccination Officer's Return for 1904; and Statistics of "Lost" Cases in London, and England and Wales; 1883—1902 67 & 68 Workshops, &c.; Lady Inspectors' Report on 83 Sanitary Inspectors; Summary of the Work of the (Tables) 91 & 93 Tables in Appendix I.:— (vi.) Population (Estimated), Inhabited Houses, Marriages, Births, Deaths, &c.; in 1905, and preceding ten years 110 (vii.) Birth-rate and Death-rate; Death-rate of Children; and Deaths in Public Institutions; in 1905, and preceding ten years 111 (viii.) Deaths, from all Causes, in 1905 (Summary of Table viii., page 19) (ix.) Deaths from the Principal Diseases of the Zymotic Class; Pulmonary and Tuber- 112 cular Diseases; Wasting and Convulsive Diseases of Infants; Gross and Proportional Mortality; 111 (x.) Deaths from the Principal Diseases of the Zymotic Class; in Kensington, and in London, and in England and Wales, in 1905, and preceding ten years 120 (xi). Streets, &c., in which Deaths from Infectious Diseases occurred in 1905 121 (xii). Streets, &c., in which Cases of Infectious Diseases were notified in 1905 124 v. Page. Tables in Appendix II.:— (a) Population; Marriages and Marriage-rate; Births and Birth-rate and Deaths and Death-rate (1856-1905), and Infantile Mortality rate (1871—1905) 129 (b) Zymotic Diseases; Annual Number of Deaths, in Kensington; and Death-rate from, in Kensington and in London (1856—1905), from the Principal 130 (c) Births and Birth-rate; Deaths and Death-rate; Deaths from the principal Zymotic Diseases, and the Zymotic Death-rate : Arranged in Quinquennial Periods— 1856—1905 131 (d) Zymotic Diseases; Death-rate from each of the Principal; in Quinquennial Periods (1856—1905); Grouped to show the Rate from the Four Notifiable, and the Three Non-Notifiable Diseases, respectively 131 Tenement Houses; Water Supply of 106 Tenements of less than five Rooms in 1901; Number and Population of 3 Tuberculosis; Deaths and Death-rate, in Kensington and in London, from 28 Uncertified Deaths; in London, and in England and Wales 32 Underground Rooms 103 Untrapped Street Gullies; Effluvium Nuisance from 97 Urinary System; Deaths from Diseases of the 30 Ventilation of Sewers 97 Vaccination Officer's Report for 1904 (Statistical Table, page 68) 66 „ Statistics; "Lost" Cases in London, and in England and Wales, 1883—1902 67 Violence; Deaths, and proportion of to 1,000 of the Population, in 1905, from 30 & 33 Vital and Mortal Statistics (1905); Summary of (Table, page 15) 14 Wards; Number and Names of the 5 Water Supply 106 „ of Tenement Houses 106 Whooping-cough; Deaths in Kensington, and in London, from 26 Working Classes; Housing of the 80 Workshops, Laundries, &c.; Annual Report of the Lady Inspectors of 82 Workshops, Men's; Anuual Report of Chief Sanitary Inspector 86 Written Intimations of Nuisances 90 Yards; Paving of 103 Zymotic Diseases; Deaths and Death-rate, in the Sub-Districts, the Parliamentary Divisions, and the Wards, from 20 „ „ Death-rate, in Kensington, in London, and in England and Wales, from 19-20 Zymotic Mortality; in Kensington, 1856—1905 (Tables B, C, and D. Appendix II.) 130-131