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Report on the notification of infectious diseases and the provision of isolation hospitals within the county of Surrey in 1892
174
INFCTIOUS
DISEASES
AND
REPORT ON THE NOTIFICATION OF INFECTIOUS DISEASES AND THE PROVISION OF ISOLATION HOSPITALS WITHIN THE COUNTY OF SURREY IN 1892. "~ ]By EDWARD SEATON, M.D., F.R.C.P., County Medical Of~cer.
Wn'H the single exception of the Godstone Rural Sanitary District, which extends from Caterham on the north-west to Lingfield on the south-east, and which comprises an area of 44,000 acres, with a population of over ~5,ooo, the whole of the authorities in the County of Surrey are now, through adoption of notification, in a position to estimate the extent of their responsibilities in dealing with diseases which tend to become epidemic. One of the chief responsibilities which is immediately cast upon sanitary authorities is that of providing hospitals for the reception of cases the isolation of ~hich is correspondingly important when home isolation is impossible. Such hospitals, as I have already observed in a p,evious report, to be really useful must be ready beforehand--must be also safe, comfortable, well managed, free of charge, and easy of access. Without such hospital provision, many cases, notwithstanding notification, must remain at home, at the risk of constituting centres of infection. The uses of the Notification Act are not confined to the prevention of disease by the isolation of the infectious sick. In the summer of last year you had a practical illustration, in a report I submitted to you, of the advantage of notification in helping detection of the cause of an obscure outbreak of enteric (typhoid) fever. Without systematic notification I should have been unable to explain at all satisfactorily the occtnrence of this outbreak, and, but for notification, it would have been impossible to indicate with any approach to certainty the means by which its recurrence could be effectually prevented; so that, apart altogether from questions connected with the isolation of the infectious sick, there is much advantage arising from notification, especially in the case of town populations, where the ramifications of infected food or contaminated water supplies would for some time be hidden or unsuspected, but for the effect they immediately produce on that delicate public health indicator, " T h e Notification Register." It may therefore be claimed for notification that even without hospitals it may, under certain circumstances, be extremely useful in giving opportunity for checking the spread of epidemic disease. .At the same time there is no disputing that an authority which provides for notification without providing also standing and efficient means of hos* From a report of Dr. Seaton to the Sanitary Committee of the Surrey County Council, February, I893.
I S O L A T I O N HOSPITALS. pital isolation leaves a very important part of its duty unperformed. Of the Surrey United (Dr. Jacob's) Districts, Dorkit~g stands alone as being entirely without any hospital provision. Taking the facts from Dr. Jacob's last published reports it will be seen that the prevalence of scarlet fever in the Dorking district has been very much greater than in the adjoining districts of Guitdford and ReigatePthe proportions being 8 per ~,ooo in the Dorking district, 2 per i,ooo in the Reigate district, and i per r,ooo in the Guildford district. It will be again noted that in x89~ , as in *89 o, the proportion ot persons attacked to households invaded was greatest in the Dorking district, i.e., in the district entirely without hospital accommodation. Reiterated experience has shown that scarlet fever is one of the diseases amenable to prevention, and that, by removal of cases to hospital, along with co-related administrative measures, the spread of the disease may be controlled even when it occurs in the crowded ~lwellings of the very poor. It is a most significant fact, therefore, that the greatest proportion of persons attacked to houses invaded (i.e., the more frequent extension of scarlet fever within invaded households) occurred in the only rural district in this part of the county which is without any provision for hospital isolation. Commenting upon the urban areas within Dr. Jacob's United District, I observed in my previous report that they are all of them without hospitals, unless, indeed, the accommodation provided by the Sutton Local Board can be regarded as a hospital. Since the publication of that repo,~ negotiations have been taking place between the several authorities comprised in the Epsom Union, viz., Epsom (urban and rural), Sutton, and Carshalton, with a view to the establishment of some joint hospital provision. I have myself been engaged, with Dr. Jacob, in conferring with members of the Epsom Local Board and others with a view to promoting such combination ; but I deeply regret to say that we have signally failed to persuade the Epsom Urban Authority that it is to the interest of their town to join with the neighbouring authorities. As matters at present stand, the Local Board is proceeding to erect a hospital for its own purposes, leaving the other three authorities to carry out a joint scheme, which cannot be so satisfactory as it would have been had the town of Epsom been embraced in the combination. With regard to this policy of Epsom Town in matters where cgmmon interests are so much concerned, I shall submit points for your consideration later on; in the meanwhile, I continue the history of the development of this branch of preventive work in the county . . . . . As matters now stand, the following urban and rural districts may be said to be already sufficiently provided for in the matter of hospital accommodation.
INFECTIOUS
DISEASES
AND
( I ) U'rban.--Guildford, Godalming, Surbiton. (2) Rural.--Guildford, Kingston, Reigate, Richmond. Chertsey (rural) is making first-rate provisiofi, while Epsom (rural), Sutton and Wimbledon (urban) have a certain amount (though by no means sufficient or adequate) of provision. Taking the whole population of the county now provided for in this way, it will be found that the proportion of the population provided for at present amounts to more than a third of the total population of the county ; whereas, when I last reported on the whole subject, the amount was less than one-fourth. This shows a considerable amount of advance during 18 months, although I believe it is far short of what might be expected if the main difficulties connected with hospital provision were dealt with by the county instead of by the Local Authorities. These difficulties arise from two causes, (a) the limited opportunity which authorities, acting separately, must have for selecting sites ; (b)the absence of any power on the part of the Local Government Board, or the County Council, to declare what areas shall be combined together. I have thus briefly recorded the present state of affairs in the matter of hospital provision. It may be expected that I should further state my views on those aspects of the question which affect t h e public health of the whole county, and which must, therefore, be a matter of concern to you. Since the publication of my Report in ~89 I, I have had many opportunities of acquiring information re. specting local circumstances lhrough having been frequently consulted by Sanitary Authorities in the case of initial outbreaks of disease. T o my previously acquired experience I am thus able to attach an amount of local knowledge which will, I trust, be helpful to you in your deliberations. First, let me draw attention to the most serious aspect of the whole question, viz., the almost wholly defenceless state of those parts of the county nearest to London. When the cholera alarm occurred last year, I could not but reflect anxiously upon the condition in which some of the most populous districts outside the metropolitan area would be placed in the event of importation and spread of this disease. At Mitcham, for example--a poor and populous district--there was no place at all, not even a workhouse, in which a case could be received, or the inmates of the invaded house sheltered. The district is not now quite in the same condition ; nevertheless, with regard to Mitcham, and all that part of the administrative county from Croydon to Richmond, with inclusion of Kingston-on.Thames, the same remark applies, viz., that as regards provision for the infectious sick they are, as compared with the metropolis, in a very defenceless state, should the authorities be called on to deal with epidemic cholera or small-pox. Secondly, with regard to the selection of hospital
ISOLATION
HOSPITALS.
r75
sites. The question of " site selection" governs the question of " declaring which are the most suitable areas for combination." In other words, upon the choice of a certain spot for the establishment of a hospital must depend the declaration of what towns or districts shall be included in the combination. As regards Wimbledon and Richmond (urban) there were at one time hopes that these authorities might possibly be willing to join, and of their own accord to seek my advice upon the question of a site. In the suburban parts of Surrey, the question of the selection of sites must always be an exceedingly difficult one, and it is very desirable that the County Council should have some defined statutory powers in the matter. In speaking of site selection, I should also mention that some authorities (such as, for example, that of Epsom urban), in choosing a site for their hospital, have no doubt thought of land which they could most easily acquire or devote to this object. Such land may be part of a sewage farm, or in other respects unfavourably situated for such a purpose as the treatment of the sick. * It should be impressed upon authorities that in the selection of sites for hospitals of this kind they must look to the future. For although such accommodation as they are proposing to erect may at the present time be considered sufficiently good, since it affords at any rate better accommodation for the sick than that which they obtain in their own homes, still, it must also be taken into account that hospitals of this kind, when they are once established, become used mainly for the prevention of the spread of disease, and that some of the persons whom the authorities may be called upon to isolate may reasonably expect that the site of the hospital should be amongst unexceptionable surroundings. Thirdly, as regards combination of authorities. We have received a most conspicuous illustration of the slowness with which this is effected, as in the case of the Guildford District ; and of the manner in which one authority may, like that of Epsom (urban), go far to spoil the action of other neighbouring authorities by adopting a policy of "holding aloof." Fourthly, with regard to the construction of the hospital buildings, and the character of the accommodation provided. I cannot too strongly comment upon the undesirability of establishing, even as temporary accommodation, hospital provision likely to bring discredit upon the system of notification and isolation of infectious diseases. I refer now to the fact that there already exists so-called hospitals within the county, notably that at Wimbledon, which are not proper places for the treatment of the sick, and which may, at times (as I am able to testify from my own observation), become overcrowded and unhealthy. Authorities need to be reminded that the first care they should have in offering any means for the isolation of persons
176
HOSPITAL ACCOMMODATION FOR SMALL-POX FOR LANCASHIRE.
suffering from one disease, say scarlet fever, is that persons isolated should not be thereby exposed to the risk of catching another disease, say small-pox, or vice versa, by reason of cases of the two different diseases being placed under the same roof, or otherwise, without efficient separation. In conclusion, I would observe that, although the advance which has been made in the county in respect of this branch of prevent!ve work is by no means insignifican t , it is hardly such as to form a subject of much congratulation. Small-poxis at the present time spreading throughout England. During the last few years the neglect of vaccination has been growing apace. Medical officers of health, therefore, throughout England view with grave anxiety the threat of general epidemic prevalence of this disease, the main safeguard against which (viz., vaccination) is in many places less accepted than heretofore. No doubt much of the indifference to vaccination has been encouraged by a vague idea that there is a system of preventing small-pox by means of notification and isolation. It cannot be too strongly insisted upon at the present time, that to depend upon notification and isolation as the main safeguard against small-pox is most dargerous. These measures are valuable, and under some circumstances indispensable, aids for the prevention of epidemic small-pox, the main safeguard against which is vaccination. The hospital isolation of small-pox is attended with exceptional difficulty, owing to the spread of the disease in populous districts round hospitals. T h e wonderful success which has resulted from the establishment of the hospital ships at Longreach may be pointed to in opposition to the views of those who seem to be opposed to the establishment of any small.pox hospital at all. Nevertheless, it cannot be denied that the danger arising from small-pox hospitals in populous districts has enormously increased the amount of opposition which is raised to their establishment. The same objection does not hold good in the case of scarlet fever, and I must, finally, again repeat that in districts of Surrey, where there is no provision for scarlet fever (against which there is no such protection as that afforded against smallpox by vaccination), the inhabitants suffer trom a greater prevalence of the disease. THE METROPOLITANPUBLIC GARDENSASSOCIA'r~ON has for many years been doing an unassuming but most important work in London in providing breathing and resting places for the old, and playgrounds for the young in the midst of densely populated localities. In the tenth annual report the Chairman of the Association (the Earl of Meath~ aives a summary of the work accomplished by it during the last decade, which must commend it to all interested in the public health.
ON
HOSPITAL ACCOMMODATION FOR SMALL-POX FOR LANCASHIRE. :By EDWARD SERGEANT, L.R.C.P., etc., County Medical Officer ~.f Health. ~
Ir~ the quarterly return of deaths, which I have the honour to lay before you, it will be observed that small-pox is unfortunately making rapid progress in the administrative portion of this county, and there is reason to believe that many of the Lancashire county boroughs also are equally, if not more seriously affected. The cases of smallpox notified during the quarter amounted to 444, and resulted in 58 deaths, while in the first quarter of the year two cases and one death were notified, in the second quarter 18 cases and two deaths, and during the third quarter there were t r 9 cases and six deaths. The greatest spread of the disease has taken place in Warrington, which was accountable for 34~ cases and 5 o deaths ; and of these, 1 i2 cases and I 5 deaths occurred in October, I56 cases and 3o deaths in November, and 73 cases and r 5 deaths in December. The diminution in the number of cases notified continues, and there are other evidences to show that the epidemic is satisfactorily declining. From the first occurrence of disease in July and August, the greatest care was exercised in isolating the infected and with respect to revaccination and disinfection. But it was soon tound that the available accommodation at the Borough Infectious Hospital was not sufficient, and many of the earlier cases had to be treated at home until additional accommodation could be provided. As a consequence the patients were imperfectly isolated and the spread of the disease was mcilitated. It must also be admitted that the proximity of the small-pox pavilion to a crowded portion of tho district may have assisted materially in the distribution of infection. The dangers mentioned are fully recognised by the Warrington Corporation, and on the i3th inst. I had, by request, a conference with a subcommittee on the subject, and it was suggested that as smallpox could not be safely treated in ordinary infectious hospitals, the County Council should obtain powers for providing special hcspitals sufficiently isolated and in every way suitable for the treatmentmwithout danger to the public--of this highly intectious disease. I therefore recommend you to favourably consider the proposal made ; and as there is daily evidence of the rapid spread of small-pox from one district to another, unavoidable in the case of smail areas separately governed, it becomes apparent that in order efficiently to curtail the spread of this disease, a large supervising body like the County Council must be deputed to undertake the work for the good of the whole administrative area. • A report to the Public Health Committee of the Lancashire County Council, January, 1893.
INFCTIOUS
DISEASES
AND
REPORT ON THE NOTIFICATION OF INFECTIOUS DISEASES AND THE PROVISION OF ISOLATION HOSPITALS WITHIN THE COUNTY OF SURREY IN 1892. "~ ]By EDWARD SEATON, M.D., F.R.C.P., County Medical Of~cer.
Wn'H the single exception of the Godstone Rural Sanitary District, which extends from Caterham on the north-west to Lingfield on the south-east, and which comprises an area of 44,000 acres, with a population of over ~5,ooo, the whole of the authorities in the County of Surrey are now, through adoption of notification, in a position to estimate the extent of their responsibilities in dealing with diseases which tend to become epidemic. One of the chief responsibilities which is immediately cast upon sanitary authorities is that of providing hospitals for the reception of cases the isolation of ~hich is correspondingly important when home isolation is impossible. Such hospitals, as I have already observed in a p,evious report, to be really useful must be ready beforehand--must be also safe, comfortable, well managed, free of charge, and easy of access. Without such hospital provision, many cases, notwithstanding notification, must remain at home, at the risk of constituting centres of infection. The uses of the Notification Act are not confined to the prevention of disease by the isolation of the infectious sick. In the summer of last year you had a practical illustration, in a report I submitted to you, of the advantage of notification in helping detection of the cause of an obscure outbreak of enteric (typhoid) fever. Without systematic notification I should have been unable to explain at all satisfactorily the occtnrence of this outbreak, and, but for notification, it would have been impossible to indicate with any approach to certainty the means by which its recurrence could be effectually prevented; so that, apart altogether from questions connected with the isolation of the infectious sick, there is much advantage arising from notification, especially in the case of town populations, where the ramifications of infected food or contaminated water supplies would for some time be hidden or unsuspected, but for the effect they immediately produce on that delicate public health indicator, " T h e Notification Register." It may therefore be claimed for notification that even without hospitals it may, under certain circumstances, be extremely useful in giving opportunity for checking the spread of epidemic disease. .At the same time there is no disputing that an authority which provides for notification without providing also standing and efficient means of hos* From a report of Dr. Seaton to the Sanitary Committee of the Surrey County Council, February, I893.
I S O L A T I O N HOSPITALS. pital isolation leaves a very important part of its duty unperformed. Of the Surrey United (Dr. Jacob's) Districts, Dorkit~g stands alone as being entirely without any hospital provision. Taking the facts from Dr. Jacob's last published reports it will be seen that the prevalence of scarlet fever in the Dorking district has been very much greater than in the adjoining districts of Guitdford and ReigatePthe proportions being 8 per ~,ooo in the Dorking district, 2 per i,ooo in the Reigate district, and i per r,ooo in the Guildford district. It will be again noted that in x89~ , as in *89 o, the proportion ot persons attacked to households invaded was greatest in the Dorking district, i.e., in the district entirely without hospital accommodation. Reiterated experience has shown that scarlet fever is one of the diseases amenable to prevention, and that, by removal of cases to hospital, along with co-related administrative measures, the spread of the disease may be controlled even when it occurs in the crowded ~lwellings of the very poor. It is a most significant fact, therefore, that the greatest proportion of persons attacked to houses invaded (i.e., the more frequent extension of scarlet fever within invaded households) occurred in the only rural district in this part of the county which is without any provision for hospital isolation. Commenting upon the urban areas within Dr. Jacob's United District, I observed in my previous report that they are all of them without hospitals, unless, indeed, the accommodation provided by the Sutton Local Board can be regarded as a hospital. Since the publication of that repo,~ negotiations have been taking place between the several authorities comprised in the Epsom Union, viz., Epsom (urban and rural), Sutton, and Carshalton, with a view to the establishment of some joint hospital provision. I have myself been engaged, with Dr. Jacob, in conferring with members of the Epsom Local Board and others with a view to promoting such combination ; but I deeply regret to say that we have signally failed to persuade the Epsom Urban Authority that it is to the interest of their town to join with the neighbouring authorities. As matters at present stand, the Local Board is proceeding to erect a hospital for its own purposes, leaving the other three authorities to carry out a joint scheme, which cannot be so satisfactory as it would have been had the town of Epsom been embraced in the combination. With regard to this policy of Epsom Town in matters where cgmmon interests are so much concerned, I shall submit points for your consideration later on; in the meanwhile, I continue the history of the development of this branch of preventive work in the county . . . . . As matters now stand, the following urban and rural districts may be said to be already sufficiently provided for in the matter of hospital accommodation.
INFECTIOUS
DISEASES
AND
( I ) U'rban.--Guildford, Godalming, Surbiton. (2) Rural.--Guildford, Kingston, Reigate, Richmond. Chertsey (rural) is making first-rate provisiofi, while Epsom (rural), Sutton and Wimbledon (urban) have a certain amount (though by no means sufficient or adequate) of provision. Taking the whole population of the county now provided for in this way, it will be found that the proportion of the population provided for at present amounts to more than a third of the total population of the county ; whereas, when I last reported on the whole subject, the amount was less than one-fourth. This shows a considerable amount of advance during 18 months, although I believe it is far short of what might be expected if the main difficulties connected with hospital provision were dealt with by the county instead of by the Local Authorities. These difficulties arise from two causes, (a) the limited opportunity which authorities, acting separately, must have for selecting sites ; (b)the absence of any power on the part of the Local Government Board, or the County Council, to declare what areas shall be combined together. I have thus briefly recorded the present state of affairs in the matter of hospital provision. It may be expected that I should further state my views on those aspects of the question which affect t h e public health of the whole county, and which must, therefore, be a matter of concern to you. Since the publication of my Report in ~89 I, I have had many opportunities of acquiring information re. specting local circumstances lhrough having been frequently consulted by Sanitary Authorities in the case of initial outbreaks of disease. T o my previously acquired experience I am thus able to attach an amount of local knowledge which will, I trust, be helpful to you in your deliberations. First, let me draw attention to the most serious aspect of the whole question, viz., the almost wholly defenceless state of those parts of the county nearest to London. When the cholera alarm occurred last year, I could not but reflect anxiously upon the condition in which some of the most populous districts outside the metropolitan area would be placed in the event of importation and spread of this disease. At Mitcham, for example--a poor and populous district--there was no place at all, not even a workhouse, in which a case could be received, or the inmates of the invaded house sheltered. The district is not now quite in the same condition ; nevertheless, with regard to Mitcham, and all that part of the administrative county from Croydon to Richmond, with inclusion of Kingston-on.Thames, the same remark applies, viz., that as regards provision for the infectious sick they are, as compared with the metropolis, in a very defenceless state, should the authorities be called on to deal with epidemic cholera or small-pox. Secondly, with regard to the selection of hospital
ISOLATION
HOSPITALS.
r75
sites. The question of " site selection" governs the question of " declaring which are the most suitable areas for combination." In other words, upon the choice of a certain spot for the establishment of a hospital must depend the declaration of what towns or districts shall be included in the combination. As regards Wimbledon and Richmond (urban) there were at one time hopes that these authorities might possibly be willing to join, and of their own accord to seek my advice upon the question of a site. In the suburban parts of Surrey, the question of the selection of sites must always be an exceedingly difficult one, and it is very desirable that the County Council should have some defined statutory powers in the matter. In speaking of site selection, I should also mention that some authorities (such as, for example, that of Epsom urban), in choosing a site for their hospital, have no doubt thought of land which they could most easily acquire or devote to this object. Such land may be part of a sewage farm, or in other respects unfavourably situated for such a purpose as the treatment of the sick. * It should be impressed upon authorities that in the selection of sites for hospitals of this kind they must look to the future. For although such accommodation as they are proposing to erect may at the present time be considered sufficiently good, since it affords at any rate better accommodation for the sick than that which they obtain in their own homes, still, it must also be taken into account that hospitals of this kind, when they are once established, become used mainly for the prevention of the spread of disease, and that some of the persons whom the authorities may be called upon to isolate may reasonably expect that the site of the hospital should be amongst unexceptionable surroundings. Thirdly, as regards combination of authorities. We have received a most conspicuous illustration of the slowness with which this is effected, as in the case of the Guildford District ; and of the manner in which one authority may, like that of Epsom (urban), go far to spoil the action of other neighbouring authorities by adopting a policy of "holding aloof." Fourthly, with regard to the construction of the hospital buildings, and the character of the accommodation provided. I cannot too strongly comment upon the undesirability of establishing, even as temporary accommodation, hospital provision likely to bring discredit upon the system of notification and isolation of infectious diseases. I refer now to the fact that there already exists so-called hospitals within the county, notably that at Wimbledon, which are not proper places for the treatment of the sick, and which may, at times (as I am able to testify from my own observation), become overcrowded and unhealthy. Authorities need to be reminded that the first care they should have in offering any means for the isolation of persons
176
HOSPITAL ACCOMMODATION FOR SMALL-POX FOR LANCASHIRE.
suffering from one disease, say scarlet fever, is that persons isolated should not be thereby exposed to the risk of catching another disease, say small-pox, or vice versa, by reason of cases of the two different diseases being placed under the same roof, or otherwise, without efficient separation. In conclusion, I would observe that, although the advance which has been made in the county in respect of this branch of prevent!ve work is by no means insignifican t , it is hardly such as to form a subject of much congratulation. Small-poxis at the present time spreading throughout England. During the last few years the neglect of vaccination has been growing apace. Medical officers of health, therefore, throughout England view with grave anxiety the threat of general epidemic prevalence of this disease, the main safeguard against which (viz., vaccination) is in many places less accepted than heretofore. No doubt much of the indifference to vaccination has been encouraged by a vague idea that there is a system of preventing small-pox by means of notification and isolation. It cannot be too strongly insisted upon at the present time, that to depend upon notification and isolation as the main safeguard against small-pox is most dargerous. These measures are valuable, and under some circumstances indispensable, aids for the prevention of epidemic small-pox, the main safeguard against which is vaccination. The hospital isolation of small-pox is attended with exceptional difficulty, owing to the spread of the disease in populous districts round hospitals. T h e wonderful success which has resulted from the establishment of the hospital ships at Longreach may be pointed to in opposition to the views of those who seem to be opposed to the establishment of any small.pox hospital at all. Nevertheless, it cannot be denied that the danger arising from small-pox hospitals in populous districts has enormously increased the amount of opposition which is raised to their establishment. The same objection does not hold good in the case of scarlet fever, and I must, finally, again repeat that in districts of Surrey, where there is no provision for scarlet fever (against which there is no such protection as that afforded against smallpox by vaccination), the inhabitants suffer trom a greater prevalence of the disease. THE METROPOLITANPUBLIC GARDENSASSOCIA'r~ON has for many years been doing an unassuming but most important work in London in providing breathing and resting places for the old, and playgrounds for the young in the midst of densely populated localities. In the tenth annual report the Chairman of the Association (the Earl of Meath~ aives a summary of the work accomplished by it during the last decade, which must commend it to all interested in the public health.
ON
HOSPITAL ACCOMMODATION FOR SMALL-POX FOR LANCASHIRE. :By EDWARD SERGEANT, L.R.C.P., etc., County Medical Officer ~.f Health. ~
Ir~ the quarterly return of deaths, which I have the honour to lay before you, it will be observed that small-pox is unfortunately making rapid progress in the administrative portion of this county, and there is reason to believe that many of the Lancashire county boroughs also are equally, if not more seriously affected. The cases of smallpox notified during the quarter amounted to 444, and resulted in 58 deaths, while in the first quarter of the year two cases and one death were notified, in the second quarter 18 cases and two deaths, and during the third quarter there were t r 9 cases and six deaths. The greatest spread of the disease has taken place in Warrington, which was accountable for 34~ cases and 5 o deaths ; and of these, 1 i2 cases and I 5 deaths occurred in October, I56 cases and 3o deaths in November, and 73 cases and r 5 deaths in December. The diminution in the number of cases notified continues, and there are other evidences to show that the epidemic is satisfactorily declining. From the first occurrence of disease in July and August, the greatest care was exercised in isolating the infected and with respect to revaccination and disinfection. But it was soon tound that the available accommodation at the Borough Infectious Hospital was not sufficient, and many of the earlier cases had to be treated at home until additional accommodation could be provided. As a consequence the patients were imperfectly isolated and the spread of the disease was mcilitated. It must also be admitted that the proximity of the small-pox pavilion to a crowded portion of tho district may have assisted materially in the distribution of infection. The dangers mentioned are fully recognised by the Warrington Corporation, and on the i3th inst. I had, by request, a conference with a subcommittee on the subject, and it was suggested that as smallpox could not be safely treated in ordinary infectious hospitals, the County Council should obtain powers for providing special hcspitals sufficiently isolated and in every way suitable for the treatmentmwithout danger to the public--of this highly intectious disease. I therefore recommend you to favourably consider the proposal made ; and as there is daily evidence of the rapid spread of small-pox from one district to another, unavoidable in the case of smail areas separately governed, it becomes apparent that in order efficiently to curtail the spread of this disease, a large supervising body like the County Council must be deputed to undertake the work for the good of the whole administrative area. • A report to the Public Health Committee of the Lancashire County Council, January, 1893.