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B. A measure for the protection of pregnant and lying-inwomen and newly - born children, by promoting thebetter training of women as midwifery nurses, and theircompulsory registration as such; thereby placing themunder efficient medical control, thus obviating the mis-chievous practices of the present uniontrolled certifiedor diplomated " midwife," and the dangers of unskilledattendance.

C. A system whereby competent nurses could be made avail-able to carry out the instructions of the medical attendant(after the plan of the "district nurses" at present invogue in many places)-thereby bringing the poor whorequire aid during midwifery attendance in line withthose requiring smgical or medical aid.

Your committee believes that such improvements would at once doaway with the asserted necessity for a so-called " midwife," and, withher, a vast amount of crime and suffering.

THE CASE OF MR. LIONEL SMITH.

WE publish a second list of contributions to this most

deserving fund, and beg again to urge the hardship of

Mr. Smith’s case upon the attention of our readers. He has

engaged to leave England in a fortnight’s time to take asmall post under Government in Zululand. He is an abso-

lutely ruined man through no fault of his own, and he hascharges upon him that make it very difficult for him to leaveEngland and begin an official career again until they aresettled. The following contributions additional to those

published in THE LANCET of Jan. 4th have been received byus :-

Public Health and Poor Law.LOCAL GOVERNMENT DEPARTMENT.

REPORTS OF INSPECTORS OF THE MEDICAL DEPARTMENTOF THE LOCAL GOVERNMENT BOARD. ’

Report zpnrt the Sanitary Condition of the 11.d-nainistrcctizeCounty of Bedford for tlae Year 1894, by LEONARD WILDE,M.D., M.R.C.P., D.P.H.-In this report, which is based

upon the annual reports of the local medical officers ofhealth, Dr. Wilde points out that as regards the general i

sanitary condition of the county the most frequent and i

noticeable deficiencies remain pretty much the same as thosedwelt upon in the previous year-viz., unwholesome water- Isupplies, especially in the rural districts, pollution of streamsand roadside ditches, the absence of system in the removal Iof refuse and disposal of excreta, and the lack of infectioushospital accommodation and public disinfection. The popu- Ilation of the various sanitary districts reporting to theCounty Council in 1894 is estimated by the medical officers iof health as follows : urban sanitary districts, 79,750 ; irural sanitary districts, 103,199. The birth-rate in urban I

districts was 27’2 ; in rural districts 26 6 as against 29-6 Jfor England and Wales, the highest birth-rate per 1000living being recorded in the Luton urban and the Welling- rborough rural districts. The death-rate per 1000 of I

population was for the urban districts 14’1, in the rural

14’6, as against 16 6 for England and Wales, the highestdeath-rate, 18 6 per 1000, being reached in the Eaton

Bray rural district, and the lowest, 11-4, in the borough ofBedford. In those districts where it has been possible toinstitute a comparison with the returns of previous yearsthere appears to have been a remarkable decline both in thegeneral and special death-rates. The relative infantile mor-tality per 1000 births was in the urban districts 126 and inthe rural 118. which, although lower than the same rate forEngland and Wales, does not show, as Dr. Wilde notes, anyappreciable diminution upon previous years. The zymoticdeath-rate was in the urban districts 1’4 and in the ruraldistricts 1-3, as against 1’76 for England and Wales. Twocases of small-pox were notified during the year. Bothoccurred at Bedford and illustrated very clearly how thedisease may be spread by tramps. Owing to the delay inpublishing the report of the Royal Commission on Vaccina-tion, Dr. Wilde points out that in certain districts of thecounty vaccination is rapidly becoming voluntary. Indeed,tke half-yearly returns made to the Wellingborough boardof guardians on Aug. 14th, 1895, showed that with 708births in the union only 4 children had been vaccinated 1Taking the whole county of Bedford, only 37’5 percent. of children born are accounted for in the vaccina-tion returns. There has been a decided diminution in the

prevalence of scarlet fever during the year, only 24 caseshaving been reported-8 in the urban and 16 in therural districts. On the other hand, 37 deaths occurred fromdiphtheria, 13 in the urban and 24 in the rural districts, thedisease assuming epidemic proportions in the Biggleswadeanq Woburn rural districts. Eleven deaths occurred fromenteric fever, of which 4 belonged to the urban and 7 to therural districts. Of the latter 4 were in the Wellingboroughunion, now outside the county, a district in which themedical officer of health has strongly condemned the water-supply. Whooping-cough was responsible for 80 deaths andmeasles for 55. The prevalence of the latter during the yearwas a great deal above the average and necessitated theclosure of schools in several districts, owing to extensiveepidemics having broken out. No case of cholera or

choleraic diarrhoea was notified in the county. Thedeath-rate for the county from phthisis was 1-1 per 1000,for the urban districts 1’4 and for the rural districts 0’9.Notwithstanding the advisability of adopting the In-fectious Disease Notification Act, half the urban dis-tricts and two of the rural districts still neglect to doso, although the medical officers of health of thesedistricts are all strongly in favour of the Act. Dr. Wildealso strongly urges the adoption of the Infectious DiseasePrevention Act in the county. Although the importantsubject of the provision of hospital accommodation for theisolation of infectious disease has received a good deal ofattention, he is unable to report any practical out-come as a result, six districts having still no hospitals atall, and one but temporary accommodation for one kind ofdisease. In most of the hospitals in the county a charge ismade for the maintenance of patients, but naturally inthe case of the very poor this charge is waived andthe burden thrown on the ratepayers. Dr. Wilde isof opinion that, except for patients residing outsidethe district and making use of hospitals within the

county, to exact a charge is a very undesirable procedure.The condition of disinfection within the county appears tobe in a still more backward state than isolation, for beyondfumigating and cleansing infected houses disinfection ofclothes by steam is not undertaken by a single local

authority. As regards water-supply, many of the districtsare dependent on wells entirely, which in too many instancesare surrounded by pig-styes, middens, &c., and frequentlyinadequately guarded from surface percolation. In the caseof Leighton Buzzard urban and Wellingborough rural dis-tricts the medical officers point out that the streams arecontaminated by sewage pollution. In most of the townsand villages Dr. Wilde is of opinion that the removal anddisposal of sewage are in a most unsatisfactory condition.Report of the Sanitary Condition of the City of London

for z, by W. SEDGWICK SAUNDERS, M.D., F.S.A.-Insubmitting his annual report for 1894 to the Commissionersof Sewers Dr. Sedgwick Saunders is able to state that thegeneral health of the City is good, no epidemics havingprevailed during the year, while the sanitary condition ofthe houses and streets has been maintained at a high levelof excellence. The estimated night population for the Cityat the end of June, 1894, was 34,831, being a decrease

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of 3489 since 1891 ; and, assuming that the same rate of 3489

diminution will go on till 1901, the population at that datemay be estimated at 28,357. The estimated day populationfor June, 1894, was 315,400, an increase of 14,016 uponthat of 1891, and giving a density of day population ofapproximately 469 per acre as against the thirty-threechief cities and boroughs, which average 34’9 per acre.Calculated upon the night population, the density would beonly 51’8 persons per acre. Of persons belonging to the City600 died during the year, of whom no less than 10’5 per cent.died from injuries and violence, a large proportion of theseincluding persons found drowned in the Thames, whose deaths,their residences being unknown, were registered as occurringin the City. Many newly born infants were found concealedin railway carriages, cloak-rooms in stations, dustbins, andother places. The death-rate for the City in 1894 was 17’2per 1000, as against 17’4 for the whole of the metropolis.The deaths of children under one year of age to 1000 birthswere 157, against 143 for the whole of London. The birth-rate was only 14’9 per 1000, being the lowest in the

metropolis. Of the 520 infants born in the City, 410 were suc-cessfully vaccinated, 2 were insusceptible, 44 died before theage for vaccination, 17 were postponed by medical certificate,42 removed to other districts and were lost sight of, and 5were still pending at the end of the year. During the year anumber of adults were revaccinated. Of deaths from

zymotic diseases, including those which occurred in publicinstitutions within the district, 5 were from scarlet fever, 31from diphtheria, 23 from enteric fever, 4 from erysipelas, 3from measles, and 12 from whooping-cough. There were nodeaths from small-pox. Out of the total number of cases

reported 65’6 per cent. were removed to hospital, while ofscarlet fever and diphtheria cases no less than 86’8 percent. of each were removed. Dr. Sedgwick Saunders bearsstrong testimony to the promptitude and thoroughnesswith which the ambulance service of the MetropolitanAsylums Board is carried out. In a population of1066 inhabiting the artisans’ dwellings in Houndsditch,and composed of 53 per cent. of adults and 46’5 percent. of children, the death-rate was 14’1 per 1000 perannum, of which 60 per cent. was apportioned to childrenunder five years of age. The birth-rate was 44’1 per 1000,and the zymotic death-rate 2’81 per 1000, as against 0’72in the City and 2-6 for the metropolis. The Commis-sioners of Sewers have, after much labour and inquiry onthe part of their sanitary committee, secured a commodiousbuilding at 6, Cotton-street, Aldersgate-street, at a rentalof R275, which has been adapted for the combinedpurpose of an office for the sanitary inspectors and ashelter for persons temporarily dispossessed of their housesduring disinfection after infectious disease. The place wasopened on Jan. 25th, 1894, and since then 77 personshave received temporary accommodation in the house. Dr.

Sedgwick Saunders notes the steady increase in the use ofelectricity in the City, there being now nearly 3000 privateconsumers of electricity, employing 136,000 incandescent

lamps, while 483 electric lamps are placed in the principalstreets, necessitating the removal of 1338 gas lamps. By I

- extended use of the skip system " for the removal of refuse- from houses it has been possible to clear away a largenumber of public dustbins from courts and alleys, and thusto obviate a constant source of complaint and annoyance.The refuse is treated in a destructor apparatus at Letts’sWharf, but the result of its working has not been so

satisfactory as in other cities, due, Dr. Sedgwick Saundersbelieves, to the small quantity of carbonaceous matterleft in London dustbins and the large quantity ofstraw and packing material collected from marketsand warehouses, which check rather than encourage thefree combustion necessary for obtaining the full advan-

tage of cremation. During the year 1401 premises were’inspected, necessitating 9998 visits. At 936 places gravesanitary defects were detected, rendering it imperativein many cases to insist on a completely new system of

drainage being laid down, as, for instance, at Christ’s

Hospital and other important places. To remove foul- emanations from sewers arising from ventilators in roadwaysshafts have been erected, wherever possible, in front of

- adjacent buildings where no objections were raised byowners. In many streets a systematic house-to-house inspec-tion has been carried on, with the result that several houseshave been condemned as permanently unwholesome and unfitfor human habitation, and have been accordingly either closedor demolished. During 1894 about 340,956 tons of meat were

received at the Smithfield markets, including 35,050 tons ofgeneral foreign and meat produce, 71,638 tons American-killedfresh meat, and 49,908 tons Australian and New Zealand.killed fresh meat. Dr. Sedgwick Saunders notes that, whilethe Australian and New Zealand trade has increased only3§ per cent. during the year, the American has increased26 per cent. Of the total amount of meat received -If per cent.was seized, condemned, and destroyed as unfit for humanfood. The treatment adopted for rendering meat unfit forconsumption is first to slash it and then immerse it in a bathof chlorides of sodium and calcium, sulphate of iron, picricacid, and water. During 1894 there were delivered at

Billingsgate-market 128,361 tons of fish, of which the

inspectors of the Fishmongers’ Company seized and destroyed1220 tons as being unfit for human food, the whole of theexpenses of this work being borne by the Company. Inconsequence of some sensational articles in the publicpress depicting the horrors of the only two common lodging-houses in the City, Dr. Sedgwick Saunders personallyinspected both. He found them, with the exception of thekitchens and lavatories, in fairly good order, and by nomeans in such a deplorable condition as described. Hecould not recommend any method of improving the defectiveportions short of demolition and reconstruction. In hiscapacity of Public Analyst, Dr. Sedgwick Saunders analysed161 articles during 1894, exclusively of frequent examinationsof the City water-supply, and of chemicals required for themanufacture of disinfectants. In no case was it deemednecessary to institute a prosecution, although in someinstances the articles came perilously near adulteration,this being especially noticeable in samples of milk. Theexamination of the water from time to time showed’ itsstandard of purity to be satisfactory.

REPORTS OF MEDICAL OFFICERS OF HEALTH.

Stoc7pm.t Urban Sanitary District.-During 1894 thegeneral death-rate of Stockport was but 18’7 per 1000, a ratewhich is 4 below any previously recorded for that district, andas much as 6’7 per 1000 below the corrected average death-rate for the decennium 1884-93 ; the lessened mortality for1894 was, Dr. Charles Porter tells us, mainly due to thediminished mortality from zymotic diseases. In connexionwith the mortality statistics Dr. Porter has drawn up aninstructive table showing the death-rate for each of the years1891-94, inclusive, for each age group of the population,differentiating males from females. The infantile mortalityfor 1894 was no less than 192 per 1000 births, a rate whichcompares most unfavourably with that of other large towns forthe same year. As was the case in Dr. Porter’s last annualreport, a considerable amount of space is devoted to the sub-ject of infantile mortality. He is evidently not inclined toattach very great importance to the question of compulsorilyprolonging the period at present laid down by law duringwhich women shall, after childbirth, absent themselves fromwork as a means of diminishing infantile mortality ; indeed,he thinks that " insanitary conditions of residence, and

especially of excrement disposal, may constitute quite as

potent a factor of infantile mortality as female factorylabour." Dr. Porter is of opinion that some of the proposalsfor checking infantile mortality in factory towns haveapproached the subject from " a too purely medical,theoretical, and utopian point of view" ; and, with theobject of learning something as to the practicability of pos-sible preventive or remedial measures, he visited thirty of thelargest mills in Stockport and talked over matters with themanagers, overlookers, and operatives. As a result of hisinquiries, Dr. Porter is strongly convinced that, to be suc-cessful, any proposal for ensuring the better care of infantsmust be " of a nature to adapt itself to existing conditions"

"

rather than to "suddenly dislocate the deep-rooted customsand prejudices of factory operatives." He suggests that theprovisions of the Infant Life Protection Act, 1872, should beso extended as to include women who now receive childrenfor the day, and that thus these persons should be broughtunder the supervision of the sanitary and other officials. It isalso suggested that the coroner shall be notified withintwenty-four hours of the occurrence of every death amonginfants under one year of age. Although Dr. Porter is ofopinion that action in the direction indicated would do some-thing to improve matters, he evidently considers that thegradual diffusion of knowledge as to the management of infantlife is the direction in which we must in the main lookfor improvement. There were in Stockport during 189437 cases of small-pox, and of these 4 were unvaccinated.

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Of these 4 no less than 3 died, while among the

remaining 33 vaccinated cases there were no deaths.Dr. Porter brings prominently before his sanitary authoritythe necessity for adopting a system of excrement disposalother than that by means of the privy pits now obtaining.There are, it appears, no fewer than 5000 to 6000 of thesepits in the borough ; none of them are properly water-tight,and many are in positions which render the pollution of thesubsoil under habitations a matter of certainty. In eightyinstances the privy contents have to be carried throughliving-rooms. The picture Dr. Porter paints of the dangersand defects of these privy pits should certainly induce thesanitary authority to take steps for their abolition. Entericfever has, he thinks, been frequently spread by means ofthese relics of barbarism" in Stockport. In the matter of

diphtheria, arrangements have been made with Professor

Delepine of Owens College to examine bacteriologicallyspecimens taken from cases suspected of that disease ;and we congratulate the sanitary authority, and also Dr.

Porter, in having established the system. A charge of 3s.to cover expenses is made for each tube, but this charge is

defrayed by the sanitary authority in cases where patientscannot afford to pay it.

VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

IN thirty-three of the largest English towns 6273 birthsand 3861 deaths were registered during the week endingJan. llth. The annual rate of mortality in these towns,which had increased in the four preceding weeks from 17’8to 20’7 per 1000, declined again last week to I8’5. In Londonthe rate was 18’1 per 10CO, while it averaged 18-8 in thethirty-two provincial towns. The lowest rates in these townswere 12’3 in Bradford, 12-5 in Cardiff, 13-0 in Sunderland,16’8 in Swansea, and 15’0 in Plymouth ; the highest rateswere 22’1 in Birmingham, 22’9 in Preston, 23’5 in Liver-pool, 24-0 in Norwich, and 29-7 in Salford. The 3861deaths included 508 which were referred to the principalzymotic diseases, against 544 and 563 in the two pre-ceding weeks; of these, 199 resulted from measles, 105 fromwhooping-cough, 73 from diphtheria, 48 from scarlet fever,40 from fever" (principally enteric), 37 from diarrhoea, and6 from small-pox. No fatal case of any of these diseasesoccurred last week in Swansea; in the other towns theycaused the lowest death-rates in Hull, Sunderland, Brighton,Nottingham, and Bradford, and the highest rates in Burnley,Birmingham, Norwich, Wolverhampton, and Salford. The

greatest mortality from measles occurred in Liverpool,Blackburn, Norwich, Birmingham, Burnley, and Salford;from scarlet fever in Gateshead; from whooping-cough inSheffield, Newcastle-upon-Tyne, Bolton, Leeds, and Derby ;and from fever" in Burnley and Bolton. The 73 deathsfrom diphtheria included 48 in London, 6 in Birmingham,and 3 in West Ham. Three fatal cases of small-pox were regis-tered in London and 3 in West Ham, but not one in any otherof the thirty-three towns. There were 66 cases of small-

pox under treatment in the Metropolitan Asylum Hospitalsand in the Highgate Small-pox Hospital on Saturday last, thellth inst., against 82, 77, and 68 at the end of the threepreceding weeks; 20 new cases were admitted during theweek, against 5, 12, and 9 in the three preceding weeks.The number of scarlet fever patients in the MetropolitanAsylum Hospitals and in the London Fever Hospital at theend of the week was 2839, against 2725, 2798, and 2835on the three preceding Saturdays ; 290 new cases were

admitted during the week, against 210, 184, and 320 in thethree preceding weeks. The deaths referred to diseases ofthe respiratory organs in London, which had been 318 and314 in the two preceding weeks, rose again last week to320, but were less than half the corrected average. Thecauses of 67, or 1-7 per cent., of the deaths in the thirty-three towns were not certified either by a registered medicalpractitioner or by a coroner. All the causes of death were iduly certified in Portsmouth, Bradford, Leeds, Sunderland, iNewcastle-upon-Tyne, and in nine other smaller . townsthe largest proportions of uncertified deaths were regis-tered in West Ham, Birmingham, Leicester, and Sheffield.

HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in the eight Scotch towns,which had increased in the four preceding weeks from I

18’9 to 21’0 per 1000, declined again to 19’6 during the weekending Jan. llth, but was 1’1 per 1000 above the mean rateduring the same period in the thirty-three large Englishtowns. The rates in the eight Scotch towns ranged from12’6 in Leith and 15-4 in Perth to 21-9 in Glasgow and 24-4in Greenock. The 573 deaths in these towns included 23which were referred to whooping-cough, 19 to diarrhoea,14 to measles, 3 to "fever," 2 to diphtheria, 2 to scarletfever, and not one to small-pox. In all, 63 deathsresulted from these principal zymotic diseases, against77 and 82 in the two preceding weeks. These 63 deathswere equal to an annual rate of 2-2 per 1000, whichwas slightly below the mean rate last week from thesame diseases in the thirty-three large English towns.The fatal cases of whooping-cough, which had been35 and 29 in the two preceding weeks, further declinedto 23 last week, of which 17 occurred in Glasgow, 2 inDundee, and 2 in Aberdeen. The deaths from measles,which had been 7 and 10 in the two preceding weeks,further rose to 14 last week, and included 7 in Greenockand 6 in Glasgow. The deaths referred to different forms of"fever," which had declined from 8 to 4 in the three pre-ceding weeks, further fell to 3 last week, of which 2 occurredin Glasgow. The mortality from scarlet fever and fromdiphtheria was considerably below that recorded in anyrecent week. The deaths referred to diseases of the respira-tory organs in these towns, which had been 142 and 135 inthe two preceding weeks, further declined to 131 lastweek, and were 84 below the number in the correspondingweek of last year. The causes of 41, or more than 7 percent., of the deaths in these eight towns last week werenot certified.

___

HEALTH OF DUBLIN.

The death-rate in Dublin, which had been 23’3 and28’8 per 1000 in the two preceding weeks, declined againto 28 during the week ending Jan. llth. During thethirteen weeks of last quarter the death-rate in the cityaveraged 24’0 per 1000, the rate during the same periodbeing 18-0 in London and 17’2 in Edinburgh. The190 deaths registered in Dublin during the week undernotice were within 3 of the number in the precedingweek, and included 7 which were referred to the prin-cipal zymotic diseases, against 3 and 7 in the two pre-ceding weeks; of these, 3 resulted from diarrhoea, 2 from" fever," 1 from measles, 1 from whooping-cough, butnot one either from small - pox, scarlet fever, or diph-theria. These 7 deaths were equal to an annual rate of1-0 per 1000, the zymotic death-rate during the same periodbeing 2-6 in London and 1’9 in Edinburgh. The 3 fatalcases of diarrhcea exceeded the number recorded in anyrecent week. The deaths referred to different forms of"fever," which had been 1 and 3 in the two precedingweeks, declined again to 2 last week. The 190 deathsin Dublin last week included 23 of infants under one yearof age, and 56 of persons aged upwards of sixty years; thedeaths of infants corresponded with the number in the

preceding week, while those of elderly persons exceededthose recorded in any recent week. Eleven inquest cases and9 deaths from violence were registered; and 70, or more

than a third, of the deaths occurred in public institutions.The causes of 9, or nearly 5 per cent., of the deaths inthe city last week were not certified.

THE SERVICES.

MOVEMENTS OF THE MEDICAL STAFF.BRIGADE SURGEON - LIEUTENANT - COLONEL CAREW has

been transferred from Colchester to Edinburgh as PrincipalMedical Officer of the North British District. Surgeon-Majors Magrath and Carter and Surgeon-Lieutenants Smithand Barker have embarked in the Britannia for India. Sur-geon-Major Allport has arrived on leave from Ceylon. Surgeon-Major Carleton has been posted to Cork, and Surgeon-Lieutenant-Colonel Latchford, retired pay, to Galway.

NAVAL MEDICAL SERVICE.The following appointments are notified :—StaS-Surgeons : a

W. Tait to the Impregnable; A. W. May to the Cambridge;E. Ferguson to the Benbow; J. H. Beattie to the Endymion; ;and J. T. W. S. Kellard to the Inflexible. Surgeons: V. Cr.Thorpe, G. Allan, and E. A. Penfold to the E1,dym-ion; H. B.