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ven add to the burdens which fall upon the Commis-sioners personally. It would, however, seem a simplematter to meet any such difficulty, if and when it.arises, by strengthening the olfice, and we sincerelytrust that considerations of economy will not be allowedto interfere with the full and efficient discharge ofthat supervision of the lunatic population which the Legis-lature has entrusted to the hands of the Commissioners.Of a somewhat different character are the remarks whichare made in the report upon the prejudicial effect whichthe necessity for a judicial order to legalise the detentionof a lunatic will have upon the treatment of the insane.For the view that many persons of disordered minds whowould otherwise be brought early under treatment will,Under this arrangement, be delayed in procuring admissionto asylums there is very much to be said ; but, on theother hand, it should be borne in mind that the law asit stood before 1888 cast such a very serious risk uponthe medical man who certified lunacy that this circum-stance alone had become a source of difficulty very real,and probably not less serious than that upon which theCommissioners remark. In view of this fact, we in-cline to think that the new regulations will not produceany marked effect upon the practice of society in dealingwith its insane members. But it is eminently desirablethat justices and the public should clearly understand thatthe object of detention is not simply the care of hopelesscases, but also, and no legs, the cure of such as are curable.Insanity, like other disorders, is best treated in its earlystages, and to delay recourse to asylum treatment until thehope of recovery is past is a very serious mistake.The statistical returns which accompany the report tell

very much the same tale as they have told for many previousyears. The numbers coming within the jurisdiction of the’Commissioners show a gradual increase, very nearly propor-tioned, so far as can be judged, to the growth of population.A notion has in recent years obtained currency that mental- disease is much more prevalent now than it was at no- distant date. Some increase, and even a considerable in-crease, the figures do show, but there is reason to think thatthe insane population is much more adequately enumeratedin the present reports than was the case thirty or forty yearsago. Making allowance for this circumstance, we find inthese returns no evidence of any actual growth of mentaldisease.

METROPOLITAN ASYLUMS BOARD.

THE following are the rules and regulations under which-the Metropolitan Asylums Board have opened the hospitalsunder their supervision to the medical students of London,in order to afford them facilities for the study of infectiousdiseases:-

GENERAL REGULATIONS.

1. No student shall be admitted to study at the fever hospitals with-out the authority of the Medical School to which he belongs.

2. No student shall be allowed to attend the fever hospitals beforethe end of the third year of his medical education, nor until he hasheld the offices of clinical clerk and dresser.

3. The minimum duration of the course of study shall be two months,the student being at liberty to attend at the hospital at least three daysin each week. In order to obtain a certificate, he shall be required toattend not less than two days in each week during the whole period oftwo months.

4. The fee, which must be paid in advance to the Clerk to the Board,shall be three guineas for the first two months, and one guinea for eachsubsequent month.

5. The student, when so authorised by his school, shall attend at theoffice of the Metropolitan Asylums Board, bringing with him evidenceof the authority required by Regulation No. 1.

6. The Asylums Board shall furnish him with a card, stating thehospital to which he will be attached, and the times at and duringwhich he should attend.

7. A register shall be kept at each fever hospital, in which shall beentered the name and the school of the student and his attendances.

8. When the student shall have satisfactorily completed the course ofstudy he shall receive a certificate to that effect from the AsylumsBoard, after it has been signed by the Medical Superintendent of theHospital at which the student has attended.

9. The student, while within the hospital gates, shall in all respectsbe subject to the control of the Medical Superintendent of the hospitalto which he is attached, and shall strictly obey the regulations madefrom time to time by the Asylums Board with regard to disinfection.

10. In the case of breach of discipline on the part of a student, theMedical Superintendent may suspend him from attendance at thehospital, and shall report the suspension at once to the Clerk to theBoard, who shall report it to the Dean of the School to whichthe student belongs.

RULES AS TO DISINFECTION.

1. Every student will be required to wear, as long as he is within the

hospital, a suit of brown holland overalls, consisting of coat, trousers,and cap, which will be provided by the Asylums Board.

2. As far as the hospital arrangements admit, three rooms shall beset apart for the students. The first, which the student reaches onentering the hospital (room A), shall be a cloak-room, in which he shallhang his outer clothing ; the second room leading out of this (room B)shall be a lavatory ; the third (room C), also in direct communicationwith the second, shall contain the hospital suit, which the studentshall put on, and then pass direct into the hospital.On leaving the hospital, the student shall enter room C and take off

his hospital suit. Then, passing into the lavatory, he shall wash anddisinfect his hands and face ; after which he shall go into room A,resume his outer clothing, and at once quit the hospital.

3. Every student shall keep his hair cut short, and satisfy the MedicalSuperintendent that he is sufficiently protected against small-pox byvaccination or otherwise.N.B -The above Rules and Regulations shall apply, so far as may be

practicable, to any qualified medical man who may be desirous ofattending the course ot study, and who shall obtain the consent of theMedical Superintendent of the hospital at which he may elect to study.

Public Health and Poor Law.LOCAL GOVERNMENT DEPARTMENT.

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

On Diphtheria and Croup in Stalybridge, by Mr. J. SPEAR.-Examination of the vital statistics for this district duringthe past ten years shows a high general mortality, a highinfant mortality, an endemic prevalence of "fever," and alarge increase in diphtheria and in "croup." In 1889 diph-theria is said to have been the cause of seven deaths,"croup" caused seventeen deaths, and four other deathswere registered from such diseases as laryngitis, tonsillitis,

&c. The population is about 28,000. So far as diphtheriais concerned, the non-fatal attacks were but few ; mem-branous croup, on the other hand, is not a notifiabledisease in this district. Multiple deaths in the same house-holds from so-called "croup," as also from that affectionand from tracheitis, all point to a similarity of disease. Theoutbreaks were not commonly traceable to any one cause,but Mr. Spear notes that in a large proportion of cases itwas observed that the infected houses were exposed throughdirect connexions with the sewers to the entrance ofsewer and drain air. This relation of diphtheria to drainand sewer air is one which Mr. Spear adverts to in hisreports very much more frequently than most other investi-gators of similar outbreaks ; but something more than meresewer and drain air must be needed to produce the result.Thus, Stalybridge, for example, had for years past been in aworse state in this respect than in 1889, and yet its mortalityreturns up to the end of 1888 show only two diph-theria deaths for nine years, and even the "croup"deaths were insignificant in number compared with thosewhich occurred last year. And as to direct connexionsbetween the interior of houses and sewers, no less than1000 had been severed in five years preceding the inspectionof the town, and yet it was after this that there came themortality we have referred to. If these sudden onsets ofdiphtheria and allied throat affections be really due to drainemanations, and become prevalent in towns after, ratherthan before, improvements in drains and sewers have beeneffected, it must be owing to some condition which is eitheradded to the drain effiuvia, or to the operation of someother circumstances on the population, who are therebymade susceptible of an infection against which they wereformerly more proof. If this additional condition or con-ditions could be made out, it would go far to clear up theetiology of this obscure disease, and to explain why it isonly within a comparatively recent period that our largetowns, where sewer effiuvia have abounded, have been somuch more free from diphtheria than rural areas wheresewers are only occasionally found to exist.Diphtheria and Fever in the Grays Subdistrict, by

Dr. AIRY.-This subdistrict is included in the Orsett dis-trict, and has within it the Grays Thurrock urban area.During 1889 it had an excess of fever and of diphtheria, therates per 1000 from these two diseases being 0’52 and 0’84respectively, as compared with the corresponding rates 0’18and 0’19 for England and Wales as a whole. The diph-theria caused 13 fatal cases in three quarters, nearly all thedeaths occurring in the latter half of the year, and even

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those recorded do not indicate the total, for the story astold by Dr. Airy is one of the many in which the true- character of the first fatal attack appears to have passedunrecognised, and, the disease subsequently spreading, deathresulted. This is, indeed, the main point of interest

attaching to the history of the outbreak. But in dealingwith the sanitary circumstances with which the diseasewas associated, it is evident that neglect of sanitary dutymust be held to be, in part, responsible for the occurrences.detailed. Thus it is stated, as regards Grays Thurrock,that, although in 1884 Mr. Spear had reported on the wantof sewerage, that need still remains unsupplied, and thedescription given of various portions of the district showshow serious that want is. The outbreaks of fever, thoughnot so fatal or sudden as those of diphtheria, have also inplaces been associated with defective conditions of drainageand otherwise.

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VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

IN twenty-eight of the largest English towns 5468 birthsand 3351 deaths were registered during the week endingJuly 19th. The annual rate of mortality in these towns,which had increased from 16’9 to 17’7 per 1000 in the pre-,ceding three weeks, further rose last week to 18 ’0. Therate was 17’9 in London and 18’0 in the twenty-sevenprovincial towns. During the first three weeks of thecurrent quarter the death-rate in the twenty-eight townsaveraged 17’7 per 1000, and was 2’2 below the mean ratein the corresponding periods of the ten years 1880-89. Thelowest rates in these towns last week were 10’9 in Ports-mouth, 11’9 in Derby, 12’1 in Oldham, and 12’4 in Hull.The rates in the other towns ranged upwards to 21-5 inSheffield, 21’6 in Leeds, 21’8 in Newcastle-upon-Tyne, and26’2 in Manchester. The deaths referred to the principalzymotic diseases, which had risen from 446 to 587 in thepreceding three weeks, declined to 526 last week; they in-cluded 172 from diarrhoea, 159 from measles, 86 from

whooping-cough, 55 from scarlet fever, 31 from diphtheria,23 from "fever" (principally enteric), and not one fromsmall-pox, No deaths from any of these diseases wererecorded in Norwich, Wolverhampton, Blackburn, Preston,or Huddersfield; while they caused the highest death-ratein London, Plymouth, and Leicester. The greatest mor-tality from measles occurred in London, Birkenhead,Bradford, and Plymouth; from scarlet fever in Sheffield andLiverpool; from whooping-cough in Derby; from "fever"in Newcastle-upon-Tyne; and from diarrhoea in Leicester.The 31 deaths from diphtheria included 19 in London,,5 in Liverpool, 4 in Manchester, and 2 in Salford. Nodeath from small-pox was registered in. the twenty-.eight towns; and no small-pox patients were under treat-ment at the end of the week, either in the MetropolitanAsylum Hospitals or in the Highgate Small-pox Hospital.The number of scarlet fever patients in the MetropolitanAsylum Hospitals and in the London Fever Hospital atthe end of last week was 1414, against numbers increasingfrom 1067 to 1348 on the preceding eight Saturdays; thenew cases admitted during the week were 159, against 150and 153 in the previous two weeks. The deaths referredto diseases of the respiratory organs in London, whichhad been 244 and 225 in the preceding two weeks, furtherdeclined to 216 last week, but exceeded the correctedaverage by 34, The causes of 57, or 1’7 per cent., of thedeaths in the twenty-eight towns were not certified eitherby a registered medical practitioner or by a coroner. All thecauses of death were duly certified in Portsmouth, Salford,Oldham, Sunderland, Newcastle-upon-Tyne, and in eightsmaller towns. The largest proportions of uncertilieddeaths were recorded in Leicester, Liverpool, Sheffield, andHalifax.

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HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in the eight Scotch towns,which had declined from 20’6 to 19-7 per 1000 in the threepreceding weeks, further fell to 18-3 in the week endingJuly 19th, but slightly exceeded the rate which prevailedduring the same period in the twenty-eight English towns.The rates in the eight Scotch towns ranged from 10 inLeith and 16’7 in Edinburgh to 21-0 in Dundee and 21-9in Perth. The 474 deaths in the eight towns showed adecline of 35 from the number in the previous week, and

included 31 which were referred to whooping-cough, 27 tomeasles, 11 to diarrhoea,, 5 to scarlet fever, 4 to diphtheria,1 to "fever," and not one to small-pox. In all, 79 deathsresulted from these principal zymotic diseases, against 76 and86 in the preceding two weeks. These deaths were equal to anannual rate of 3’1 per 1000, which exceeded by 0-3 the meanrate last week from the same diseases in the twenty-eightEnglish towns. The highest death-rates from these diseaseswere 4’2 in Aberdeen and 7’8 in Perth. The fatal cases of

whooping-cough, which had been 24 and 38 in the precedingtwo weeks, declined. again to 31 last week, of which 13occurred in Glasgow, 6 in Aberdeen, 4 in Edinburgh, and4 in Perth. The deaths from measles, which had been 28and 24 in the previous two weeks, rose again last week to27, and included 15 in Glasgow and 7 in Dundee. Of the 5fatal cases of scarlet fever, 2 occurred in Leith and 2 inPaisley; and the 4 deaths referred to diphtheria included2 in Edinburgh. The deaths referred to diseases of therespiratory organs, which had been 1C2 and 87 in thepreceding two weeks, further fell last week to 76, butexceeded by 7 the number in the corresponding week oflast year. The causes of 41, or nearly 9 per cent., of thedeaths in the eight towns were not certified.

HEALTH OF DUBLIN.

The death-rate in Dublin, which had been 23’1 and 21’3per 1000 in the preceding two weeks, further declined to20’7 during the week ending July 19th. During thefirst three weeks of the current quarter the death-rate inthe city averaged 21’7 per 1000, the rate for the same periodbeing 17’6 in London and 16’0 in Edinburgh. The 140 deathsin Dublin showed a decline of 4 from the number inthe previous week; they included 5 which were referredto measles, 4 to "fever," 3 to whooping-cough, and notone either to small-pox, scarlet fever, diphtheria, or

diarrhoea. Thus the deaths from the principal zymoticdiseases, which had been 8 and 13 in the preceding twoweeks, were 12 last week; they were equal to an annualrate of 1’8 per 1000, the rate from the same diseasesbeing 3’6 in London and 1’7 in Edinburgh. The 5 fatal casesof measles corresponded with the number in the previousweek. The deaths referred to different forms of "fever,"which had been 3 and 4 in the preceding two weeks, were

again 4 last week; and the 3 fatal cases of wbooping-coughalso corresponded with the number recorded in the pre-vious week. The deaths both of infants and of elderlypersons exceeded those returned in the previous week.Six inquest cases and 5 deaths from violence were regis-tered during the week ; and 46, or nearly a third, of thetotal deaths occurred in public institutions. The causesof 10, or more than 7 per cent., of the deaths were notcertified.

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THE SERVICES.

BENGAL MEDICAL ESTABLISHMENT. -To be BrigadeSurgeons: Surgeon-Major Rajendra Chandra Chandra(dated Feb. 28th, 1890); Surgeon-Major Robert GeorgeMathew (dated March 18th, 1890); Surgeon-Major GeorgeMassy (dated March 29th, 1890; and Surgeon-Major Geo.Cumberland Ross (dated April 30th, 1890).MADRAS MEDICAL ESTABLISHMENT. -To be Brigade

Surgeons : Surgeon-Major Daniel Fredk. Bateman (datedApril 2nd, 1890), and Surgeon-Major Edwd. Forster Drake-Brockman (dated April 21st, 1890).BOMBAY MEDICAL ESTABLISHMENT. — To be Brigade

Surgeon: Surgeon-Major Geo. Archibald Maconachie, M.D.(dated May lst, 1890).INDIAN ARMY.—Brigade Surgeon Samuel Cornwallis

Amesbury, Bengal Medical Establishment, (dated April 30th,1890). The Queen has approved of the retirement from theService of Brigade Surgeon Wm. Dymock, Bombay MedicalEstablishment, being post-dated to May 1st, 1890. TheQueen has also approved of the resignation of SurgeonArthur Rea Edwards, Bengal Medical Establishment(dated April 16th, 1890).ADMIRALTY. - The following appointment has been

made :-Surgeon Richard Miller to the Cockatrice (datedJuly 22nd, 1890).VOLUNTEER CORPS. -Artillery: 1st North Riding of

Yorkshire (Western Division, Royal Artillery): -. Surgeon