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Medical Officer of Health reports, 1891 - Ross-shire

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HH62/2/ROSS/1 23 a ROSS AND CROMARTY COUNTY COUNCIL. ANNUAL REPORT FOR 1891 BY WILLIAM BRUCE, M.A., M.D., LL.D., MEDICAL OFFICER OF HEALTH. DINGWALL: LEWIS MUNRO, PRINTER AND PUBLISHER. 1892.
HH62/2/ROSS/3 DINGWALL, 29th March, 1892. To the County Council of Ross and Cromarty. GENTLEMEN, In conformity with the Regulations of the Board of Supervision, dated May 1st, 1890, issued in virtue of the Authority conferred by Section 53 (1) of the Local Government (Scotland) Act, 1889, I herewith beg to present to you my Report for 1891, drawn up on the lines laid down in Section 1. of those Regulations. I have the honour to be, GENTLEMEN, Your obedient Servant, WILLIAM BRUCE, Medical Officer of Health. ROSS AND CROMARTY COUNTY COUNCIL. Annual Report for 1891 BY WILLIAM BRUCE, M.A., M.D., LL.D., Medical Officer of Health. THE County of Ross and Cromarty covers an area of more than two million acres, of which about one-third may be described as cultivated, while the remainder is either untilled or uncultivable Its length may be set down at sixty-seven miles, and its breadth at fifty-eight. The chief division is into Insular, West Coast, and East Coast - the two former being usually grouped together owing to similarity of climate and likeness in the occupation of the inhabitants, the bulk of whom devote their attention partly to fishing and partly to farming. On the East Coast the two avocations are kept distinct, and the larger portion of the population is strictly connected with the land. The aggregate number living in the County all over, according to the census of '91, was 79,667 The climate, on the whole, may be described as genial, and, as a rule, it is neither very hot nor very cold. It is said that tem- pests are comparatively rare, and so are fogs and thunderstorms. The rainfall varies very greatly, being high in the West, becom- ing less and less as we proceed eastwards; until at Tarbatness it amounts to scarcely twenty inches per annum. The Geological features are thus described by Mr Horne:-
HH62/2/ROSS/5 [Page] 4 "The inland portion of Ross-shire (the Lews) is composed of crystalline gneiss and schist, with the exception of some small patches of Torridon sandstone to the east of Stornoway. Boul- der clay and other glacial deposits are spread over much of the low-lying ground, and extensive areas are covered with peat. "In like manner, the greater part of the united counties on the mainland is composed of various types of crystalline gneiss and schist. "But to the west of a line drawn from Ullapool, by the head of Loch Maree to Loch Kishorn, there is a great development of Torridon sandstone, giving rise to the lofty mountains of Coigach and Applecross. Overlying these sandstones we find other ancient sediment snow forming quartzites and limestone. Here and there along the western seaboard there are patches of crystalline gneiss exposed, where the Torridon sandstone has been worn away. "Again, along the eastern margin of the County, between Dornoch and Beauly Firths, there is a belt of Old Red Sand- stone, forming the most fertile portion of the whole area. "In all the valleys draining the eastern side of the main watershed on the mainland there are extensive deposits of boulder clay, moraines, and alluvial gravels. Similar deposits are met with in the Old Red Sandstone areas, together with the deposits belonging to the raised beaches." Having made these general remarks we propose now to consider more particularly the sanitary condition of the County and its inhabitants under the following heads:- (1) The want of knowledge of the laws of health, and the best remedies for the same. (2) The condition from a sanitary point of view of the county generally, and the best means for improv- ing the present state of things, more especially of the villages and schools. (3) The present supplies of drinking water, and how to improve these both in quality and quantity. (4) The state of the dwelling-houses of the poorer part [Page] 5 of the population, especially those of the labour- ing classes, and the most likely means of improve- ment. (5) The question of recommendations or bye-laws in con- nection with labourers' houses, more especially as applicable to new houses. (6) Segregation of the sick (a) in their own houses, (b) in hospitals. (7) Sanitary inspection and disinfection. Although the death rate in the County is comparatively low, amounting, as we shall see when we come to look more closely into the question, to about 16.5 per 1000, taking the mean of three selected years; yet it does not follow that its sanitary condition may not be greatly improved, or that the resident population practise the laws of health. In fact there are good reasons for believing the opposite, and we shall try to show, without inquiring too minutely into the present state of knowledge, at least at this stage, how best this deficiency can be met. It may be well as a preliminary to point out why this very important subject has not attracted more attention amongst us, and how it is that on the whole the state of health with us is good. The first and chief reason for the average good health of our community is undoubtedly the healthiness of the employments of the great majority of the population, viz., farming and fish- ing, and the absence of the many occupations deleterious to health practiced in other places. The second may be set down to the comparatively small amount of overcrowding. The third is the fact that there is not the same grinding poverty as a rule as is to be found in the large towns; and fourth, no doubt much is due to the high standard of morality so creditable to the Highlander. So much for the bright side of the picture; the dark side is the want of personal cleanliness, the bad housing, the carelessness as to purity of water supply, the ignorance as to ventilation, proper clothing, avoidance of nuisances, and the need for proper nursing, segregation, and disinfection of the sick. On all these heads we shall have to enlarge as we pro
HH62/2/ROSS/7 [Page] 6 ceed in our report. Meantime, assuming that this is the true state of matters, how are we to set about reform? It is plain that it cannot go very far and take a good hold unless the people themselves are more or less in sympathy with it. Mere coercion will not do. Having considered this matter very carefully we are con- vinced that efforts must be consistently made to explain the principles of Hygiene. Acting on this conviction, at the invi- tation of the Association for Advanced Education in the County, I agreed to deliver a course of lectures on Hygiene weekly, both at Dingwall and Tain, and a similar course is being given in Stornoway by Dr Macdonald, whose name I took leave to men- tion to the Association. I am glad to say that these lectures are well attended, and that several teachers are taking advant- age of them in order to qualify themselves to, in turn, teach Hygiene to their pupils. I would press on the County Council the view that a knowledge of the laws of health must begin in the Public Schools of the County. It is not to be expected that the older people will change their ways of living or will even see anything wrong therein. But it is different with the young. Their minds are open and plastic, and almost anything can be made of them by their schoolmasters. Of the close connec- tion between morals and manners need not insist. And surely I do not require to point out what civilisers such as agencies may become. Correct ideas as to personal cleanliness and decency every boy and girl must feel break down barriers be- tween himself or herself and the outer world, and allow them to go forth to the world on equal terms with other competitors. But I would wish to insist still further on this point because the schoolmaster can here teach both by precept and example. Every sanitary arrangement connected with a public school ought to be perfect, because the health of the children so much depends on it. The cubic space allowed is as a rule much too small, hence all the more need for free ventilation. Then it is almost certain that most outbreaks of epidemics can be traced to school gatherings - another powerful argument in favour of strict attention to every sanitary detail. And supposing all these perfect, it is further essential that the schoolmaster should himself be thoroughly acquainted with the laws of health, should [Page] 7 indeed know a great deal about physiology; the working of the different organs especially of the brain; the care of the senses such as the eyesight; but above all be an enthusiast in the cause of sanitation. There are many teachers who both under- stand and practice the laws of health, but, I am sorry to say, there are others who are careless or indifferent. I consider it the bounden duty of every schoolmaster to make a daily in- spection of the offices connected with the school, to note and correct any nuisance, to see that the scavenging is properly done, to make sure that the water supply is abundant and pure, and to personally supervise the ventilation by freely opening all the windows during the intervals of work, and specially at night. Further, he should make sure that the floors are pro- perly swept, periodically washed, and at longer intervals the walls cleaned down and whitewashed or painted. But the teachers cannot be expected to look after all these matters unless the School Boards do their duty in the first place. I have taken special pains to visit most of the Schools in the County, and I am very sorry to have to say that the great majority are sanitarily disgraceful. I shall give details in another portion of this report, but I may be allowed to point out in this place, the chief faults. First, a great many Schools have no proper supply of abundant and pure drinking water on or about the premises. A healthy active boy in the summer season will drink at least a quart of water daily. There are schools with 200 children in attendance with no water within a quarter of a mile. How can such children be healthy? Second, there are very few Schools provided with lavatories, or where there are such in existence they are out of order. Third, where water-closets have been provided they have in most cases be- come broken down. Fourth, there is hardly such a thing any- where as a proper urinal with some simple flush and drain. They may be all said to smell vilely. Privies as a rule are badly planned and ill-kept, and there it a great want of method in cleansing them out sufficiently often. I have no hesitation in insisting that every School should have an ample supply of water for drinking and for cleansing. The first may be most conveniently obtained, as indeed, in most cases it is obtained by sinking a well. It is simply marvellous to find that
HH62/2/ROSS/9 [Page] 8 scarcely a School site has been selected on account of the proximity of a good well - a common point of advantage in choosing the position of an ordinary dwelling-house. "The Department," is greatly to blame in not Iaying down a rule in this respect. Water, for purposes of bodily cleanliness is best furnished from rain water tanks. They need not be very large to meet the demands all the year round in our climate. The water having been provided, then there ought to be lavatories in every School, with soap and a towel provided by the School Board. I was much interested to find this privilege taken free advantage of by the fisher boys and girls in the Cromarty School. A word from the master on dirty hands or faces would keep everything right. I have already spoken of the urinals. They too could be readily flushed automatically and periodically by the rain water collected from their roofs. I am opposed to W.C's. as a rule. They require much water, constant attention, and when out of order need the expensive and troublesome services of a plumber. An arrange- ment of dry prviies, such as are so well planned and managed at Tarbat and Culbokie is simple and sufficient. Indeed, l am inclined to believe that, after all, the pail system would be at once the simplest and best. Mr Ross, at Ferrintosh, worsk it well. In either case, a piece of land should be attached to the School where the contents could be applied as manure. Mr Meldrum finds it useful on his small farm, used in this way. Many Schools want better means of ventilation and heating. No inlet for cold air should open too near the children, and a supply of warmed, fresh air, as in the Manchester grate, which I found working very well in several cases, is to be recom- mended. The outlets should be always protected by flaps. In most cases they frequently act, especially in stormy weather as inlets. It may be thought that I am entering into too much detail as regards Schools, and perhaps I should have directed my attention to Churches and Halls. But not only are the greatest dangers arising constantly from neglect of the laws of health in connection with children crowded together, fasting, it may be, and susceptible to all the deadly ailments of childhood, but I wish the Council to be persuaded that in the interests of Hygiene here they have an opportunity never [Page] 9 perhaps to recur, of presenting object lessons of the necessity of attention to sanitary rules daily, nay hourly, to the young and open mind. If health be the valuable thing we all believe it to be, surely we cannot afford to lose the best possible chance of setting forth its importance and enforcing its safeguards. My friend, Dr Ross, Barvas, who has sent me a most careful and thoughtful document on the public health of his parish, has suggested the printing and publishing of a leaflet in Gaelic summarising the leading points of Hygiene and especially ex- pounding the rules for dealing with outbreaks of infectious disease. I hope that he and I may be able to arrange for this, which I feel sure would be of great service to many, and I trust the County Council may give its sanction to such a publication. The next division is a very wide one, viz., the Sanitary Con- dition generally of the County, but is really narrowed by the other sections which follow. The first subject to consider is the primary one of means of communication. It is only dawn- ing on our legislators that there are parts of Scotland and Ireland where there are no roads. It is simply disgraceful that such a state of things should exist within the bounds of a rich and prosperous country like our own. The providing of means of transit is the very first step in sanitary progress, and without such we officers of public health are powerless. I trust then, Parliament in its wisdom will see the urgency of the petition for help, and mercifully grant its prayer. As Dr Ross in his report well shows, good roads and drainage go together. In connection with very many townships in the West and even in the villages of the East Coast, means for loading off the surface water quickly are urgently needed. Otherwise stagnant, putrifying pools are left to breed all sorts of noxious, organic substances, fit hot-bed for the germs of disease, and it may be of death. The next most important point is the disposal of slop waters which may be carried off by the channels spoken of, or in the absence of sewers, carried into ordinary tile drains which, where there is sufficient fall, might be used to irrigate, at a proper depth from the surface, some convenient piece of ground. The solid refuse, including the excreta, should be
HH62/2/ROSS/11 [Page] 10 collected in a proper midden, well cemented and kept dry until it could be carted off and applied to the arable ground. If possible, where there is no W.C. every house should possess a privy - in connection with the midden as a rule, so situated as not to be dangerous to the health of the owner or his neighbours. Where new houses are to be built, the site should be dry, well exposed to the sun and air, and yet, if possible, rather sheltered from north and west winds. Where there are say over fifty houses together constituting a hamlet or village, some organised means of dealing with refuse requires to be arranged for - in other words, there should be a public scavenger. Unfortunately in the meantime there is no power given even to Water and Drainage Districts to employ such a useful man. The Medical Officers of Health Association lately sent a deputation to the Lord-Advocate on this subject and it is to be hoped legislation will be passed enabling such sub-Districts to carry out so highly necessary a means of protecting the public health. I consider good scavenging in many escas would save costly schemes of underground drains and sewers - schemes not only expensive but entailing large and free supplies of what is not always easy to be got, water. On one matter I consider it wisest to be quite explicit. I do not approve of public privies in villages such as Ullapool. They only meet the wants of one third of the population, and make no account of the slops and other refuse from the house. I consider a small water-tight midden with its privy, if well situated at a little distance from the house and properly and periodically cleared out to the fields, not at all objectionable on the score of public health. Our third Division is the present condition of the Water Supply and how to amend it. That water is a common vehicle for carrying poisonous matter into the human system all sanitarians allow and deplore. The connection between Cholera, Typhoid Fever, and fouled drinking water has been proved over and over again. Not that it follows that this is the only means of access into the body of these terrible plagues. We shall [Page] 11 probably have to show that the last mentioned must be hunted for in other quarters than wells, if we wish to stamp it out altogether and in every instance. Yet water, it almost goes without saying, like air, must be pure for health. Long acquaintance and much study of this question has con- vinced me that a great deal of the water drunk in the County is impure, or at least liable to be contaminated at any moment, and specially on the breaking up of frost or drought followed by much fall of rain. Most of the common wells are recep- tacles for merely surface water, liable to have all sorts of dirt and decaying substances washed into them, and very often situated on the brink of a burn, ready to be overflowed by the first spate. Where spring or loch, or river water, cannot be procured, there is no difficulty in protecting such wells by a cover and ring of cement, the latter two feet at least in depth, so as to secure that extent of filtering medium outside, and with a pump fixed above for drawing the water and preventing its being dirtied by pails left carelessly about. Villages and hamlets should, if possible, and the expense be not too great, set agoing a Water District, with the sanction of the District Committees, and provide themselves with water from pipes. In considering the increase to their rates, they should allow for the saving of trouble in having water brought into their houses or near them, instead of having to be carried for some distance. I am not an advocate for the Districts taking burdens upon their constituents at large for such purposes. The work should be done locally; and the superiors whose feus such amenities improve, ought to help freely - as so many proprietors have already so generously done. We, as guardians of the Public Health, will not rest content until every house- holder has a fair supply of unchallengeable water brought as near his door as possible - only every one interested must lend a helping hand in providing what is, next to food and air, so necessary an element of health. Our fourth head is the state of the Houses of the Poorer Class, and especially of those of the labouring portion of the population. This may be described, after roads and bridges, as the question of the hour. A comfortable healthy living house will tempt many a labouring man to stick to the country
HH62/2/ROSS/13 [Page] 12 in spite of the attractions of the town. Looking at the ques- tion, as we have the right only to look at it, as sanitarians, the addition of a sufficient piece of ground to mainly keep himself and his family will be likely to add to his health and comfort, and in this light I would advocate such holdings strongly. Do the houses referred to us as a rule, come up to the require- ments of health? We are bound to answer they do not. The most clamant failures are, we need scarcely say, on the West Coast and in the Lews. There the primitive huts, so well if rather truculently described by Dr Macaulay in his last year's report, are very far removed from what might be called the minimum of sanitary necessity. The wall of separation must be, as soon as possible, built up between man and beast. It is to be hoped that the Lewis District Com- mittee will put its foot down in this respect, and give notice that such partitions of stone and clay (without any direct passage between house and byre), must be erected within say the next five years in every cottage in the island. This is the first step; the next will be providing proper chimneys; and windows to open, and then carrying the roof to the extreme outside of the house wall. The present practice of supporting the roof on the inner wall directs all the water off the former into the soil between the two skins, as it were, and keeps the whole tenement in a constant state of damp. The large fires and the peat smoke are the two counteracting agents; otherwise the evils resulting from the present state of things would be much worse than they are. Here, too, the erection of proper middens and other conveniences must, by and by, be enforced. The problem on this side of the country is mainly one of how best to set about improving the cottages of the plough- men. Their houses undoubtedly require such looking after. Luckily, or unluckily, in many cases the only cure is entire reconstruction. The roof is leaky and bad; the walls are merely stone and clay; the floor is a sodden mass of irregu- larly moulded filth; the windows are too small and do not open; the cubic space is ridiculously small for a family, and the necessary adjuncts are conspicuous by their absence. The model to be aimed at would be something like the following:- They should have a slated roof, stone and lime walls covered [Page] 13 inside with lath and plaster, hollow bricks, a cement floor - partly of wood - well-sized windows, hinged or hung with weights; the living rooms sufficient in number and cubic space; with middens, &c., put down in the proper place, and at a fair distance from their doors and windows. Where the present dwellings are fairly good, improvements ought to be gradually made, in order to bring them up to a proper standard. It may be necessary in order to secure all these reforms that provision be made by statute to enable proprietors to borrow money at an easy rate of interest and repayment for this improvement, one so intimately connected not only with the health of our working class, but also with the due supply of labour to our fields and farms. I have placed in a separate section the question of whether District Committees, with the sanction of the County Council should, or should not, draw up a list of recommendations, showing what they deemed to be the minimum requirements in ploughmen's houses that may hereafter be built as looked at from the point of view of Public Health. Dr Bell of Scatwell, in his well-known interest, not only in Public Health generally, but particularly in that of the labouring classes, has put his shoulder to the wheel in this good work, and is assisting me to draft these "bye-laws," as they might be called. Such a code would give us a standard with which to measure any case complained of, and might very well be applied to all new houses - the numbers of which, in any one year, cannot be great. Of course care must be taken not to make excessive demands; and the rules must possess a certain amount of elasticity, otherwise the effect would be to discourage all new erections - a very untoward result of well- intentioned regulations. In no department of sanitary work is more attention required than in this. Overcrowding - while the most insidious of all "nuisances" - is undoubtedly the most deadly. Attention will be drawn further on in this report to the excessive death rate from consumption and its allies. It may be very safely asserted that bad air, it may be, breathed over and over again, is of all causes the most likely to engender lung disease; and lung disease costs the country
HH62/2/ROSS/15 [Page] 14 more than possibly all other diseases taken together take out of the pockets of the nation at large. We pass on now to consider the highly important question of the provision made for segregating the infectious sick. In the Lews and many parts of the West Coast if there were an organisation so well constituted as to meet this difficulty, very little infectious disease should prevail. A great deal has been said lately, and no doubt with truth, as to the dangers of Militiamen and others introducing disease from the East Coast to the Lews. But to be forwarned is forarmed. With a proper staff of sanitary officials, guided by what Dr Ross allows has done good service already, the notification of disease, no difficulty should be experienced in at once stamping out most fevers and allied diseases. I grant that with measles and other complaints which incubate for long periods there would be more risk of spreading. But even with them a very strict system of quarantine would prove, I doubt not, effectual in stopping the infection from extending. A great deal would depend upon the zeal of the local doctor. It is evident that a medical man on the spot has the best chance of extinguishing incipient flames, so to speak, and hence the folly of not enlist- ing every local doctor in the great army of public sanitarians, instead of restricting the duties to a select few. No more pernicious or defamatory doctrine could be preached than that of defining the functions of the private medical attendant as those of encouraging disease, his trade, forsooth, whereas every such individual worthy of the name of physician, every day in his life, and often it may be in the space of twenty-four hours, does his best to stamp out and destroy all the seeds of disease! Much might be said on the subject of domestic pre- ventive medicine. But we hope, as we have already said, to put the public on its guard by distributing ample printed directions or leaflets on Scarlet Fever, Typhoid Fever, Measles, &c. The second means of checking the spread of disease is by hospitals built for that purpose. At present we have only two - one at Dingwall, and another at Storno- way, With regard to the latter, doubtless it has done good service in its day, as hardly any retreat of the kind could be set apart for its purpose without proving of much service. [Page] 15 And yet, it is indeed a poor affair, and utterly unworthy such a thriving, pushing, populous place and international shipping town as Stornoway is fast becoming. The dangers of imported disease into the town must be very great, especially at the busy herring harvest season, and a means of segregating at once a case of serious infection is a great desideratum. The present infirmary is ill situated for a proper water supply, has no thorough and safe system of drainage, is cold and ill ar- ranged, and, above all, does not possess, I understand, any staff - even the neucleus - of skilled nurses. The building should be at once remodelled and extended, the walls doubled in thickness, a proper system of heating adopted, and a trained nurse with an assistant provided. Perhaps, in the circum- stances, it would be most economical to add on a Surgical and Medical ward, or wards, and thus to economise the nursing staff when epidemics were absent, in ordinary nursing work. This we find to answer in Dingwall with a little care and extra trouble, and is to be tried, I am glad to say, at Cro- marty. As yet no other hospital is spoken of, except it may be, proposition to turn Fortrose Poorhouse into such an in- stitution. This would be a mistake. It is not built as an hospital should be from the foundation, for its own peculiar purpose. It is by far too big, and would only serve a corner of the Black Isle itself. Patients will only go so far when ill from fever with safety to themselves, and without causing danger to the public at large. What is wanted is a small hospital in every corner of the County which is of sufficient size to steadily support a resident medical man of good stand- ing and experience. Properly speaking we want in this County about 10 such Infirmaries. How are they to be built, maintained, and staffed? The Public Health Acts enjoin on every Local Authority to provide such retreats, and it is legal to lay on rates for such purposes. Surely in these days of equivalent grants there will be no difficulty, after Mr Dar- roch has got his roads, in erecting and providing the expense of what a moment's thought must convince anyone of the need for such "pest-houses." The worse the dwellings the more the necessity for the removal of the sick when labouring under infectious disease of a severe kind, for the sake of the
HH62/2/ROSS/17 [Page] 16 patients and their friends. Surely that is an indisputable pro- position. Just consider (1st) the chances of recovery in such atmosphere as we know to prevail in, say, the Lews Huts; and (2nd) the tremendous risk of the spread of the disorder, to say nothing of the next to impossibility of clearing out from such premises the inveterate seeds of such disorders as Typhoid and Diphtheria. We do not think it necessary to argue all this out. We confidently assume it to be proved to the hilt. But there is one point (the 3rd), to consider, and it undoubtedly is a great difficulty and expense in the set- ting up of local hospitals, viz., providing a suitable staff, effi- cient and yet not too expensive. Even if money were as plentiful for ever, as it seems to be just now for any and every experiment, yet the organisation would rust and fall to pieces of itself, if complete to start with, and only intermit- tently made use of. Our proposal is this, establish a Central Nursing Home, with a matron and a staff of probationer nurses in training, in one of the poorhouses, preferably Tain, which might be set apart for such a purpose. Of course there would require to be a certain number of beds occupied by the sick for teach- ing the pupils practical work. These beds might be occupied with chronic cases unsuited for ordinary infirmaries, or bed- ridden fatuous cases presently in Asylums. At any rate it need not compete with existing hospitals. Wherever infec- tious disease broke out a nurse or nurses might be sent from the centre, who would open the local hospital, keep it open as long as necessary and then return to the Home. As a rule, contagious disease does not break out all along the line, and thus a few nurses would serve all within an extensive circuit. The nurses, too, could be much better in hand, besides the saving of expense, and would have much more interest in their work. They would be available for district nursing, so called, outside the hospitals, and also for surgical emergen- cies and accidents. On the 7th and last head I might say a great deal, but my friend, Mr Mackenzie, will doubtless have much to urge on this subject which more properly belongs to him. I shall, [Page] 17 therefore, reserve my remarks until I have discussed Infection as relating to particular diseases in a subsequent portion of this report. All I shall mention now is my firm conviction that the sanitary inspector of parishes has, perhaps through no fault of his own, done his work very perfunctorily, and that he is destined to play a very important part, if well directed and seconded by his Local Authority, in the future. In considering the causes, origin, and distribution of dis- eases in the County, there are two aspects in which this question can be looked at. It may be considered in con- nection with sickness, and also in relation to deaths. If it were possible to get accurate returns of the former, this would, of course, give us more information than the latter Many well intended attempts have been made to secure this result, but they have broken down. The notification of infectious diseases, if carried out - as we hope it may soon be - all over the County, will be extremely useful in collecting statistics of sickness as distinguished from deaths. As to these the most important disorders from the point of view of Public Health, I have made a list, of which more will be said later on, of what I have called preventible diseases, in which, 23 in number, I have taken leave to include, besides the diseases usually known as infectious, likewise cancer and tubercular disease. The latter is now known to be a parasitic disease, i.e., germs are always found to accompany it, and may be said to cause it. The former in Sir James Paget's opinion will, by and by, be placed in the same category when the germ is found. I fear Dr Russell's discovery is not likely to be verified just yet. Using this list, and applying it, not to show the absolute but the relative presence of 23 common diseases, I find, on ex- amining the records of sickness in my private practice for the three years, '70-71, and '72, and again for three years, '83-84, and '85, the most common cause of sickness was con- sumption, and its allied diseases, of which I had over 30 cases; whooping-cough in the second period also shows over 30; pneumonia, which was undoubtedly epidemic, as it was also in the practice of my neighbours, Drs Adam and Sutherland, at the same time, viz., in '85-86, exceeds 30 also in the se: cond triennium; while typhoid comes close up, being 27 in
HH62/2/ROSS/19 [Page] 18 the former and 20 in the latter. Diphtheria, including croup, accounts for 14; rheumatic fever for 5 in '70-71 and '72, and 8 in the second period. Cancer, which was only 4 in the first period; in '84-85 and '86, amounted to 10; erysipelas, 2 and 4; scarlatina 12 in the latter, and did not occur at all in the earlier period. These figures are merely fragmentary; but so it must be allowed are those which we have to deal with in comparing the deaths in a selected triennium also. They are so because there are so many deaths, as we shall see further on, uncertified. This is a great stumbling block to the statis- tician; and has also to be lamented in some respects for the sake of the sick and dying. Opinions may differ as to the real value of medical services in the way of prolonging life. But it must be allowed that such help in serious sickness should be within the reach of everyone. It is to be feared that in outlying districts many die, who could not, if they would, obtain such assistance. One or two such districts are known to me, and, in default of a living being found for a local doctor, I think the attention of those who send medical missionaries abroad should be turned to dark places at home. It humbly seems to me that a man who proposes to devote his life to the spiritual care of such people as those referred to, might very well spend his probationership in studying for and securing a diploma of medicine which would serve him and his parishioners in good stead in the too common cases where the nearest doctor is half-a-day's journey away. But taking the death tables as they stand over the whole County, during the three year period again, '85-86 and '87, we find 395 deaths set down as due to consumption and its allies = to an annual death rate of 1.68 per 1000. Next to it comes croup - probably, really diphtheria, which we include in the 131 cases a large and terrible record = annually to .543 per 1000 living; measles accounts for 73 deaths = to .300per 1000 per annum; cancer to 67 = .284 per 1000 annually; diarrhoea 61 = a rate of .258; whooping cough 46 = .195; influenza 21 (there will be a bigger record we fear, for '91-92) = .089; typhoid fever 19 = .080; scarlatina 14 = .059; puerperal fever 13 = .055; tetanus 11 = .047; typhus fever 6 - .025; and blood poisoning - a vague term - 7 = .029, all per 1000 per annum. [Page] 19 The total per centage of deaths per annum, taking the whole County together on an average of three years, comes to about 16 1/2, a creditable enough figure. (C) DISTRIBUTION of DISEASE as SHOWN by REGISTERED DEATHS. I have mentioned that I have selected twenty-three dis- eases as either preventible or which we hope in course of time may become so. I shall shortly run over the different regis- tration districts, noting peculiarities in the survey. The period embraced is from 1885 to 1889 inclusive, or a quinquennium. Beginning with In Applecross (population, 917.2) there were 6 deaths from tuberculosis, 2 from influenza, and 1 each from pneumonia and diarrhoea. Total deaths 70, of which 57 were uncertified. Avoch (population, 1817), in the Black Isle, wher fisher- men bulk largely, and where the water supply is scanty, and the village of Avoch is somewhat overcrowded, and drainage rather inefficient, we find from 1885 to 1889 inclusive that there occurred 9 cases of pneumonia, 1 of diarrhoea, 1 of measles, 1 of typhoid fever, and 19 of consumption and allied disorders, but none from cancer. Total mortality, 138. In Alness (population, 1036.6), there died - 2 from pneu- monia, 4 from diphtheria, and 2 from croup, 1 from puerperal fever, 5 from whooping cough, and 10 from tuberculous diseases. Total mortality, 87. The record in Barvas (population, 4612.6), is 2 of blood poisoning, 8 of cancer, 13 of pneumonia, 7 of diarrhoea, 1 of erysipelas, 6 of measles, 2 of puerperal fever, 5 of typhoid, 6 of typhus (the first time we have come across this virulently infectious disease), 3 of whooping cough, 4 of diphtheria, and 41 of croup, so called, while tuberculous diseases account for 27 Total mortality, 351. In Carloway (population, 2965), there were 4 from diarrhoea, 2 from pneumonia, 3 from cancer, 1 from erysip- elas, I each from puerperal and rheumatic fever, 7 from whopping cough, 40 from tuberculous diseases, 40 from croup,
HH62/2/ROSS/21 [Page] 20 and none from diphtheria. (We shall have to notice this terrible death-rate from what must have been really diph- theria in connection with other districts in the Lews.) Total mortality, 246. Carnoch (population, 267.8), has 2 deaths from diph- theria, 1 from whooping cough, and 1 from consumption. There were only 6 deaths in 5 years. Coigach (population, 1111.2) has 1 death from whooping cough, 5 from consumption, &c.; but there are 61 deaths uncertified out of 74 in the 5 years. Contin (population, 638.4), has 2 deaths from pneumonia, 1 from measles, 1 from croup (none from diphtheria), 1 from whooping cough, and 5 from consumption, &c. Total imor- tality, 37. Cromarty (population, 2007.8), has 2 deaths from cancer, 8 from pneumonia (7 in '86), 6 (as we would expect from bad and careless feeding of infants) from diarrhoea, 1 from erysip- elas, 1 from puerperal fever, 1 from typhoid, 1 from croup, and 13 from consumption, &c. (The proportion of uncertified deaths is one-third.) Total mortality, 169. Dingwall (population, 2453.2), shows 1 from blood poison- ing, 9 from cancer, 9 from pneumonia (4 in April, '89), 3 from diarrhoea, 2 from diphtheria, 1 from croup, 1 from erysipelas, 5 from measles, 1 from tetanus, 2 from typhoid, 42 from con- sumption, &c. (The proportion of uncertified deaths is low, as we would expect here = 1 only in 17.) Total, 245. Edderton (population, 700.8), has one death each from cancer, pneumonia, and puerperal fever, 2 from whooping cough, and 4 from consumption, &c. Out of a total of 43. In Fearn (population, 1994), the record is 1 death from blood poisoning, 4 from cancer, 1 from diarrhoea, 1 from diph- theria, 2 from measles, 1 from puerperal fever, the same number from rheumatic fever and scarlatina, 1 from lock-jaw, 6 from typhoid (all in the summer of '85), and 17 from con- sumption, &c. In a total death-rate for 1 to 5 years of 151. Fodderty (population, 1871.6), shows 2 deaths from [Page] 21 pneumonia, 3 from diarrhoea, 1 from diphtheria, 1 from measles, 1 from puerperal fever, and 19 from consumption, &c., out of a total of 160. Glenshiel (population, 406), shows 1 death from blood poisoning, 1 from cancer, and 1 from consumption, &c., out of a total of 27 (of which 15 are uncertified). Gairloch (N. and S., population, 4257.6), has - cancer, 6; pneumonia, 6; diarrhoea, 1; diphtheria, 3; erysipelas, 1; mumps, 1; rheumatic fever, 1; scarlatina, 1; typhoid, 1; con- sumption, &c., 42. Total deaths, 304, out of which 200 are uncertified. In Knockbain (population, 1765.2) there was 1 death from pneumonia, 3 from diphtheria, 1 from croup, and 4 from consumption, &c., out of a total of 111. Kintail (out of a population of 628) has one death each from blood poisoning, pneumonia, and cancer, 3 from whoop- ing-cough, while there are 7 from consumption, &c., out of a total of 59, of which 34 are uncertified. In Kinlochluichart (population, 630.8) there were in all 37 deaths, of which 2 are set down to whooping-cough, 3 to consumption, &c. 14 are uncertified. Killearnan (population 975.6) shows 2 deaths from pneumonia, 1 from whooping-cough, and 7 from consumption, &c., out of a total of 82, more than half being uncertified. In Kilmuir (population, 1072.8) their died in the three years 83, of these 1 died of cancer, 4 of pneumonia, 3 from diarrhoea, 1 each from rheumatic and scarlet fever, 1 from orcup, [croup] 5 from typhoid (in 1886 between February and May) 13 from consumption, &c. Kiltearn (population, 1253.4) shows 2 deaths from pneu- monia, 3 from scarlatina, and 9 from consumption, &c., out of a total of 83 (30 of which are uncertified). Kincardine (population, 1106) has 4 deaths from cancer, 5 from diarrhoea, 2 from measles, 1 from scarflatina, [scarlatina] 1 from typhoid, and 11 from consumption, &c., out of 85 in all, 40 being uncertified.
HH62/2/ROSS/23 [Page] 22 Logie, in a population of 852.8, had 80 deaths, out of which there were 4 from cancer, 2 from pneumonia, 2 from rheumatic fever, 1 from scarlatina, 2 from typhoid, and 4 from consumption, &c., out of 80 altogether. Lochbroom (population, 2911.2) shows a total of 236 deaths, 1 being ascribed to blood poisoning, 7 to cancer, 5 to pneumonia, 2 to diphtheria, 2 to croup, 2 to diarrhoea, 2 to erysipelas, 1 to measles, 1 to tetanus, and 27 to consumption, &c., out of a grand total of 236 (113 being uncertified). Lochs (population, 7612.4) shows deaths as follows - 1 from blood poisoning, 4 from cancer, 9 from pneumonia, 3 from diarrhoea, 2 from diphtheria. 13 from croup, 20 from influenza, 21 from measles, 3 from rheumatic fever, 1 from typhoid, 1 from typhus, 56 from consumption, &c., and 6 from whooping-cough, out of a total of 347 (154 of which are un- certified). Lochcarron (population, 1416.4) has a death aggregate of 120, of which 3 are put down to cancer, 3 to pneumonia, 2 to rheumatic fever, 2 to typhoid, 1 to typhus, 3 to whoop- ing-cough, and 7 to consumption, &c. More than half are un- certified Lochalsh (population, 1940.8) shows the large return of 13 deaths from cancer, 2 from pneumonia, 4 from diarrhoea, 1 erysipelas, 1 from typhoid, while there are 15 from consumption, &c., out of a total of 134 (54 being un- certified). Nigg, with a population of 956, has 1 death from cancer, 4 from pneumonia, 2 from erysipelas, 2 from whooping- cough, 1 each from typhoid and croup, out of a total of 79 (29 being uncertified). Rosskeen has a population of 3597.4, and there were in all 280 deaths. Of these 1 was ascribed to blood poison- ing, and 1 only to cancer. From pneumonia there were 10, from diarrhoea 3, from diptheria 2, from croup 1, measles 4, rheumatic fever 1, and scarlatina 2, while, strange to say, there is not one put down to typhoid. 6 died from [Page] 23 whooping-cough, and the deaths from consumption, &c., were 33. Only about one-seventh were uncertified. In Resolis (population, 1373) there died in the quin quennium altogether 116. 2 were put down to cancer, 6 to pneumonia, not one to typhod, [typhoid] 1 to croup, 19 to consumption, &c. The proportion uncertified was about one-third. The population of Rosemarkie is 1348.9, and the deaths in 5 years 134, which gives an annual death-rate of [blank] per 1000. Of these there died 1 from blood poisoning, 10 from pneumonia (of which 7 died in 1888), 1 each from diptheria and erysipelas, 4 from whooping-cough, and 13 from con- sumption, &c. One-sixth uncertified. In Applecross (Shieldaig) the population is 1300.6, and the total deaths in 5 years 109, of which 87 are uncerti- fied. The returns show 1 death from each of the following diseases in our list: - Cancer, erysipelas, influenza, rheumatic fever, typhus, whooping-cough and croup, while 2 are ascribed to consumption, &c. This is, on the whole, the most barren return we have yet come across, and is really of little use in any inquiries as to the statistics of disease. Strathoykel (with a limited population of 330) shows 1 death from pneumonia, 1 from whooping-cough, and 1 from consumption and allied diseases. The totals are 17, of which 11 are uncertified. Stornoway (population, 11,235) parish and burgh is the largest of all the registration districts, and, consequently, the number of deaths is greatest, viz., 885. The chief diseases in our list are, as we would expect, consumption, &c., showing an aggregate of 98, next comes diphtheria with 2 and croup with 54, together 56, then pneumonia with 41, measles with 40, whooping-cough 33, diarrhoea 18, puerperal fever 13 (an alarming number), cancer 11, erysipelas 6, blood poisoning 4, typhoid fever 4, scarlatina 3 (very small), and tetanus 1. There were 250 uncertified, or in the proportion of rather over one-fourth of the whole number. Tain, landward and burgh, has a population of 2894.4, and the total deaths amounted in 5 years to 266. Of these 9
HH62/2/ROSS/25 [Page] 24 are set down to cancer, and an equal number to pneumonia, while diarrhoea is credited with 21 (far too high, and implies bad infant feeding, and probably a dearth of milk), of measles there are 5, of typhoid fever 4, of diptheria none, but of croup 2, there were also 2 from whooping-cough, and 25 are set down to consumption, &c. The uncertified amount to 46. In Tarbat the population amounts to 1773, while the deaths were 147 in the five years referred to. Of these 7 (a very high proportion) are set down to cancer, 1 to pneumonia, 2 to diphtheria, 3 to scarlatina, 2 to typhoid, and 3 to whooping-cough, while 11 are said to be connected with con- sumption and its allies. About one-third are not certified. Urray (population, 2367.4). The deaths for 5 years sum up to 145. 1 is put down to cancer, and the same number to blood poisoning, puerperal fever, scarlatina, and croup, and 2 to diphtheria. There were 2 also from pneu- monia, while there were 6 from typhoid, and only 3 are put down to consumption, &c. There is the very large number of 83 uncertified, which is hard to understand with four or five doctors practising within the parish. Certainly there is no resident doctor, and many are far away from medical aid. Uig (population, 2352) had 137 deaths in the period of 5 years. Here there must have been a great deal of influenza, as the record shows 16 deaths. There was also the startling number of 12 deaths from tetanus. 1 is ascribed to cancer, 2 to pneumonia, 3 to erysipelas, 2 to measles, 1 to puerperal fever, none to typhus, none to diphtheria, but 6 to croup, 1 to whooping-cough, and 18 to consumption, &c. The propor- tion of uncertified is a little over one-fourth. Urquhart, or Ferintosh (population, 2406.8) concludes our lists of districts. The deaths amounted to 201. Cancer counts for 3, pneumonia, typhoid fever, and whooping-cough for 1, diphtheria and croup for 2 each, scarlatina for 3, while consumption, &c., are set down for 16. The uncertified are at a rate of nearly 1 in 3. Note. - The population is the estimated mean number living, for the period of 5 years - '85, '86, 87, '88, and '89 - under consideration. [Page] 25 Looking at these results as a whole the most striking fact, where the deaths are fairly well certified is, the large propor- tion of them, which are due to tuberculous diseases, i.e., to con- sumption and its allies. These, in many cases, amount to 12 per cent. If we consider that a certain number is put down to pneumonia, a larger still to bronchitis and pleurisy - that tuberculous disease attacking the abdomen, is frequently certi- fied as due to dioerrhea, and probably a considerable propor- tion of the uncertified cases of which in every district there is a large number, is composed of cases of tuberculous disease; I believe we shall not be far wrong in alleging that tuber- culous diseases probably account for 20 per cent. or one-fifth of the whole mortality. It is pleasing to think that cancer is not credited generally with many deaths, though here too it need not be doubted that amongst uncertified cases a large number is really due to cancer, it being a disease in the majority of cases of degenerating old age. I think it will be surprising to many as it was to me to find so many deaths ascribed to pneumonia. It will be very interesting to discover later what part of this rate is due to "infectious" pneumonia. It is gratifying to be assured that there are not many deaths con. nected with lying in or the puerperal period. It is also a pleasure to !earn that smallpox was not the cause of a single death in the period examined, and that scarlatina and typhoid were not fatal to many. On the other hand whooping-cough, measles, typhus and diphtheria must have prevailed largely; and they undoubtedly caused many a fatal issue. But a study of the facts as recorded prove that these were very unequally distributed and as portions of most districts escaped so should, with proper precautions, all. Whooping-cough and measles visit in turn almost all localities, but they are not equally fatal everywhere. Something must be set down to the age of those attacked. Where there are many very young children in proportion to the older people it follows that the mortality will be heavier - and this is the condition of things where the population is increasing most rapidly, and where too the dangers of overcrowding are worst, say in towns and in fisher townships. The remedy here is plain, to prevent overcrowd- ing and discourage too early marriages to be secured coin-
HH62/2/ROSS/27 [Page] 26 cidentally by stringent regulation as to cubic space in every dwelling. But reverting to the point at which we started viz. - The Distribution of Disease, it will be convenient to con- sider the remaining diseases, viz. : typhus and diphtheria, in- cluding croup, puerperal fever and tetanus as they occur; first on the West Coast and second on the East Coast. As regards tetanus or lockjaw it is almost unknown on this side and pro- bably that which occurs in the Lews, and scarcely anywhere else is the lockjaw of very young infants - newly-born babes. It is I understand dying out, but the matter requires and will secure attention by and by. Investigations in St Kilda point to filth and some absurd notions of dealing with the umbilical cord as the real cause. It is interesting to know that in Germany the germs found in persons suffering from tetanus have been also discovered in garden soil. If this come to be proved, there need be no difficulty in stamping out the lockjaw of infants. With regard to puerperal fever, investigations on the spot are urgently required. If it be true, as I have been informed that puerperal fever is even more frequent than the returns would imply - the great majority of the cases being of a mild type, it seems from what I hear of the nursing of women in childbed pretty plain, that here too filth is the great agent in propagating the disease. I have spoken already of the miser- able condition of the houses of the crofter fishermen on the West Coast. Much is due to that state of things, but more is really owing to habits of sloth and dirt which education ought to correct - aided it might be by providing well-trained nurses to play the part of midwives amongst the West Coast and Island populations. But the most striking contrast between the East and West Coasts is the prevalence of typhus and diphtheria to a much greater extent on the latter side of the County. Let us try to account for this fact. The question of the origin of in- fectious disease is in most cases a very difficult one. Typhoid fever too common, alas, on this side of the county, breaks out again and again and in spite of our efforts to discover its vagaries we get lost in our search after its track. But modern [Page] 27 science by making it plain that these diseases are due to germs has completely upset all the de novo notions of the source of in- fections and distinctly settled that every single case is due to a previously existing one of the same kind. The practical de- duction is that in every outbreak all the germs should be killed; and then of course the breed would be stamped out. A grand result, truly, if possible! alas not practicable but surely an ideal point to aim at. Disinfection if it be worth the name at all, must be thorough and complete. Here let me stop for one moment to say that a great deal of so-called dis- infection is not only of no avail but does harm. The great disinfectors are fresh air, clean water, soap and elbow grease. Without these all the vaunted disinfectants which are usually only deodorants are utterly useless. Careful experiments have conclusively proved that dry heat, steam, carbolic acid, chlorine, corrosive sublimate, and these almost exhaust the list of real disinfecting agents, will only kill germs and the seeds of germs when used at a strength which would quickly kill all other animal life exposed to their action. What then is to be done, more especially on the West Coast and islands to really destroy contagion? I fear it must be said that we must destroy the nest as well as the eggs. The body and bed clothes ought to be boiled - woollen garments thoroughly baked, steamed, or exposed for long periods outside to sun, wind and rain, and everything comparatively valueless burnt; the roof sent to the fields for manure; the wood work burnt in great measure or steeped in chloride of lime solution; the floors removed and replaced with concrete; and the walls knocked down and built up afresh. Plainly, this cannot be done at the expense of the tenant. It ought to be carried through at the sight and charge of the Local Authorities, and if well and completely done it would pay them to do it. Consider not only the waste of human life but the expense involved in a serious outbreak of typhus or diphtheria! Surely if we can afford to slaughter valueable herds of cattle for the sake of the remaining stock we can pay for the stamping out of human disease. It seems to me the difficulty lies in convincing Local Authorities that such diseases can be prevented. Both philosophy and practice point decidedly to this result, if only the instruments and means are
HH62/2/ROSS/29 [Page] 28 perfectly suited to the end in view. Here lies the difficulty, a difficulty not to be overcome without an earnest desire on the part of officials and masters to do their duty irrespective of trouble and with an eye to a sure and certain result rather than to a saving of expense. A point may here be noted. I have been told that fevers, and particularly puerperal fever is more common at the season when the dung-pits are emptied. I have compared the figure very carefully and made a note of them for April and May. I find the mortality is rather under than over the average monthly bill in these months. Mere bad smells per se do not cause disease. The next division of this Report is that which contains an account of my inquiries and proceedings during the past year. I shall take these two heads in turn, and begin with the inquiries I have conducted. My first duty was to try to find out the incidence of disease in the different localities within the County, and for this purpose I obtained leave from the Registrar-General for Scotland to consult the local registers in his office. As these Death Returns were likely to be of permanent value, and, once begun, could be easily kept up for future reference, I ven- tured to employ a clerk to make copies of them, beginning at 1885 and coming down to the close of 1890. When written out they were bound into volumes, each parish separately. They have proved of great interest and importance, as afford- ing solid ground for further investigations, and as time passes they will become more and more useful. I have brought the books down to the Committee for their inspection, and when an office has been provided they will always be at the disposal of any one who is curious in vital statistics. I have made free use of the tables in the 2nd division of my Report. My next desire was to make a general survey of the County, and in going my rounds I had chiefly in view the sanitary inspection of villages and schools. As to the former, the County Sanitary Inspector, who accompanied me in several [Page] 29 of my tours, is, I know, prepared to report very fully. It is not therefore necessary for me to trouble the Council with details. I shall content myself with saying that, as far as I am aware, and I have visited all the more important com- munities in the County, his notes and criticisms are well founded. Much, as I have already said, waits to be done in the ways of a better water supply, thorough drainage, and organised scavenging, before their condition becomes, from a public health point of view, even respectable. In the sanitary condition of schools, for reasons already stated, I have taken great interest, and I shall now give short notes on those I have visited, making remarks, chiefly under the three heads of cubic space and ventilation, water supply, and provision for dealing with excreta. Culbokie School. - Fair cubic space; ventilation only by the windows, which causes cold draughts when the tem- perature is low; water supply suspicious (I pointed this out to the Managers at the time the well was dug), being within a few feet of the site of the privies. The supply fails in summer. Steps should be taken to protect the well, or remove it altogether, and to procure a constant supply. The arrangements connected with the privies are excellent. Mr Fowler deserves great credit for his interest in securing good sanitation. There is no lavatory in the school. Mulbuie School. - Cubic space sufficient, according to code rules; but the ventilation is deficient in so far as there is no special means for admitting fresh air other than by the windows, and no cross current established above so as to ensure the withdrawal of foul air quickly. There is good water from a pump in the playground; but no lavatory. The privies are clean, and in daily use. The urinal would be better to have a flushing tank provided. A scavenger attends regularly. Kinkell School. - Ventilation deficient in small class room. Here and in Conon School there is a system of closed pipes devised to carry the foul air into a flue, but it is out of order in both cases, and should be discarded. There are com- plaints of cold draughts during winter. The privies are clean
HH62/2/ROSS/31 [Page] 30 and well-kept; but the boys scarcely make use of their's at all. Here is a point worth attention. In some cases the boys are actually told not to use them. Now, in the interests of decency, if not of public health, I have to say that this is quite wrong. The boys should be told that they must use the privies provided, and that it is unseemly and wicked to squat down at the first quiet corner they come across. This may seem a trivial matter; but surely the moral, civilis- ing training of school life is a mighty engine in advancing the progress of the nation, and every means must be used to improve the condition of poorer classes in the Highlands and Islands. There were at Kinkell defects in the drains requir- ing attention. These have been remedied since my visit. The ash-pit should be removed further off, cemented, and covered. Mr Ross uses the pail system partly, with great advantage. There is good water from a pump-well; but no lavatory in the school. Conon School. - The remarks made about Kinkell School apply here as well as regards ventilation. The boys' privies smelt a good deal. The arrangement for the school- master's family is bad. It could be improved by making a door into the yard used by the girls. There is a good supply of water and lavatories are in use. The urinal should possess a flushing tank. Strathconon School. - There is little to criticise here. The privies might be more visited, and their ventilation im- proved. Scatwell School. - This school is very dirty. The openings for ventilation are pasted up. The privies are not in use, and there is no urinal here or at Strathconon. There is no water supply at either school, and, of course, no lava- tories. The drains about the house look to be choked, and there is no provision for the disposal of slops here or at any of the schools visited. Ullapool School. - A model school when it comes to be enlarged. Children evidently filthy in their habits; but the more need for steady supervision. Some of W.C. seats [Page] 31 should be lowered and urinals provided. Water should be accessible to all the class-rooms, and lavatories provided with soap and towels. The scavenger should make his rounds more frequently and be well paid for his work. Strathcannaird School. - The only remarks needed here are that there is no drinking water or lavatories, and that the privies are too far off, and not used. Here, as in most other cases, the roof water is not stored as it might well be for the use of the teacher, if not of the pupils. Plockton School was shut when I was in the village inquiring as to its water supply. The school is not supplied as it could easily be, if water be obtained, as I was told it could, from the pipe supplying Duncraig House. I believe also that the school on the east side of Lochcarron has no water supply. Dr Mackay reports that this has been at- tended to since. Alness School requires more ventilation, especially in the lobbies. These lobbies are, as a rule, ill ventilated, and, being used for hanging up overcoats, &c., often smell most vilely. If possible, they should be both warmed and venti- lated. A little planning at the beginning might, in many cases, easily secure this. No doubt many infectious diseases are propagated by dirty clothes, and damp garments must be very bad for the children who wear them. No water supply. Privies very close to class-room. Applecross School. - Warming and ventilation here good. This is an instance of a school provided with W.C.'s They are all more or less out of order, and the boys' one, which is very badly situated, not in use at all. The school- master should not have a W.C. in his house, but get the use of one of those outside (of which there are three), exclusively for himself and family. Edderton School. - Ventilation good. Buildings clean. Privies fairly clean, but a drain is wanted to carry off urine and slops. No water in the building (it could be easily got from a burn quite near) and no lavatories. Ardross School. - Ventilation good. Buildings clean
HH62/2/ROSS/33 [Page] 32 and well kept. Manchester grate does not seem to be of much use, probably air inlets too small. There are W.C.'s here. The boys' is well looked after, but the girls' is not so tidy. The drain and cesspool connected with them has no ventila- tion. The back yard is damp and wants gravel, and requires a drain put in to take off surface water with a proper gully. Tullich School. - Heated by a Manchester grate, and well ventilated. Boys' and girls' privies fairly clean. Diffi- culty about scavenging. Pump-well machinery not quite in order. Rain water should be stored, as the well water is very hard. No lavatories. Scotsburn School. - School here too small for the number. No thorough ventilation. Heating seems sufficient. Privies clean, but require remodelling. No flushing for the urinal. No water in the building, and no lavatories. Rain water should be caught and stored in a suitable tank. Scant provision for children's hats and cloaks. Newmore School. - Ventilation good. Heating suffi- cient by Manchester grate. Privies not in very good order; cleaned out only once a year. Pump water hard, no provi- sion for taking advantage of rain water. No lavatories. Achmore School (the Lews). - Too small for number of children (if they attend), being only 60 cubic feet for each child. Ventilation fairly good. Privies fairly clean, but no division for the sexes. The water supply is deficient in quality and quantity, the arrangement being a tank from a burn, which is nearly dry. Any other supply is 200 yards off. There are no lavatories. Barvas School. - Rooms good. Fairly warm and well ventilated; but there should be more roof openings for the exit of foul air, and protected with flaps in case of down draughts. Infant department overcrowded, but space could be got off some of the other class-rooms. Privies very little used, and no proper provision for storing dry earth as a deo- doriser. The water is chiefly from a pump-well, and, as usual, is very hard. The rain water tank should be enlarged. There are no lavatories. [Page] 33 Laxton School. - Complaint is made of the rooms being cold, and a better grate should be put in. No ventilation except by the windows. There is no division between the boys' and girls' privies, and they are unventilated. The system is of the worst kind, the closets being supplied occasionally by bucketfuls of water drawn from the well, and a plug then removed to allow the excreta to escape into a drain! There is a sunk well with very hard water, but there is no attempt made to exclude surface pollution; and in fact it is so polluted. The rain water tank should be en-larged. Here, as in many other places, there is evidently no systematic rule of opening the school windows when the children leave school for the day. Portnaguran School. - Well ventilated and well kept. Schoolmaster's house very smoky. Privies unclean. Urinals out of order; neither used at all. Water supply from pump quite red and evidently very strongly inpregnated with iron. There should be a second cask supplied for rain water. No lavatories. Bayble School. - Locked up when I called. Privies nt [not] in use. No apparent supply of potable water, and no lavatories. Gairloch School. - Ventilation sufficient. Privies little used. Water supply might be got near by. Poolewe School answers its purpose fairly well. Seems rather cold. No water supply, and no lavatories. Torridon School. - (The same remarks apply also to Kinlochewe School.) In both cases there were burst pipes. The overflow from the cesspool in the latter case is likely to soak into and contaminate the well water. There are no lavatories. In both schools more attention should be given to promoting ventilation by regularly opening doors and windows. Achnasheen School. - Ventilation good, but com- plaints of cold. Grate is too small, and probably the allowance of coals, 1 1/2 tons yearly, too scanty. Girls' privies disused, and out of order; boys' pipe burst. No water in school, and no lavatory.
HH62/2/ROSS/35 [Page] 34 Cullicudden School warmed by Manchester grate, which is out of order. Ventilation by ceiling openings, pro- tected by flaps. (Pulleys out of order). Smells heavy at 11 A.M. Windows all shut, though the day is fine. Ventilators in class-room not working. Boys' privies cleared out once a year; fairly clean. Girls' scarcely used at all. No entrance to these, except through school. Sunk well water much im- pregnated with iron, and hard. Cover of well not watertight, and surface water gains admittance. Should be cemented up. Lavatories dependent on a pail. No rain water stored. Newhall School. - Want of floor space and over- crowding. Warming sufficient. Privies cleared out once a year. Boys' little used. Girls' clean. No flushing for urinal. The same remarks apply to the well and water as at Culli- cudden. Playground untidy with pools about. Gate posts rotten. Both here, and at Cullicudden, the School Board neglecting its property, and showing no interest in well-being of children or masters. Cromarty School very complete with late additions. Wide lobbies. Large storage for rain water. Lavatory with 3 basins, with soap and towel. Much used and appreciated by children. Special lavatories for teachers, an excellent hygienic feature. The privies are kept sweet by fresh ashes being thrown in every day; emptied by scavenger for 2s 6d as required. The whole cost for cleaning, lighting fires, and keeping lavatories, is £9 per annum for 320 children on roll. Mr Copland takes much interest in every domestic detail. Kiltearn School. - Fairly clean and well ventilated. Privies locked up. The Schoolmaster complains that the smell is unbearable in summer, being too close to his house. No water supply or lavatories. Glenglass School. - Rather cold, but airy. Privies not very tidy. No water supply or lavatories. Bridgend School, Rosskeen. - A model building, and everything well kept by the teacher. The ventilation and warming are very good, but a plan and directions should be hung up in every school where a Manchester grate is in use. [Page] 35 In this case the inlets for fresh air are blocked up to a great extent. There are lavatories, but they are outside and unpro- tected. One pipe was frozen at my visit. They should have a shed put over them at once. There are trough W.C.'s in good order, but they require daily discharging into the sewer - perhaps a recommendation rather than a drawback. Invergordon School. - There is a blow down from the ventilators here, which should be remedied by providing them with flaps. Boys' and girls' closets very clean, but dependent for water by pumping - cistern dry when I saw it. There is no lavatory inside the school, or W.C. in the teacher's house. The sewer is said to pass under the school, and there seems to be a cesspool somewhere (?). A good supply of drinking water from a tap in the ground. Saltburn School. - Abundant supply of good water. The building looked deserted and ill kept. The privies were dirty. Kilmuir-Easter School. - Well kept in every respect. The ventilators are permanently open, and must cause down- draughts of cold air in winter. The privies are clean, and superintended by Mr Meldrum himself daily, who makes good use of the excreta as manure to his land, of which he is lucky enough to hold as much as makes a schoolmaster's croft. Good water from a pump at a little distance, but no lavatory. Logie-Easter School. - Ventilators permanently open as at Kilmuir. No proper place for hanging the clothes of the children. The same remarks apply to water and lavatory as at Kilmuir. The boys' and girls' privies are quite clean. There is no flushing for the urinals. The kitchen sink pipe was choked, but a promise was given by a member of the School Board that it would be put right. Inver School. - Ventilation and cleanliness defective. No proper means for the admission of fresh air. The privies are exceedingly filthy, and there is no proper method of scavenging in practice. The pump is out of order, and the children drink out of a dirty ditch near the school. Portmahomack School.—Ventilation good, privies
HH62/2/ROSS/37 [Page] 36 rather dirty, urinals smell strongly. No water supply, and no lavatories for more than 200 children, the nearest well being 1/4 of a mile off. Some remedy should be quickly found for this state of matters. West Tarbat School. - Ventilation fairly good, but some means for admission of fresh air should be tried other than windows, which, besides, are not working properly. Water from pump, no lavatories. Privies well kept. Balmuchy School. - Ventilation good. Privies in good order. No water supply, a pump well being disused on account of its proximity to liquid manure pool on the neigh- bouring farm. No lavatories, and, of course, no flushing of the urinals. Hilton School. - Ventilation imperfect, and school- rooms not very clean. Privies dirty. No drinking water on the premises, and a surface well liable to contamination is in use. Pitcalnie School. - Ventilation and general cleanli- ness very satisfactory. Privies well kept. No water on the premises. Nigg School. - ln good sanitary condition. Privies tidy, urinals flushed. Pump-well in the playground out of order at visit - to be attended to. Ardgay School. - Mr Macleod takes a strong personal interest in sanitary arrangements, which are all in good working order. Knockbain School. - Ventilation indifferent, sufficient openings if properly used. Privies in a wretched condition, quite neglected, and have not been cleaned out for some time; wet, which could be kept out, as is done at Culbokie. Water supply, a spring 100 yards off. Water seems good, but no protection from surface pollution. Munlochy School. - Ventilation all right. Privies too near the main building. Lavatories, but no water. Here I would recommend W.C.'s, as the supply of water in the village is ample, and the excreta would be carried off the pre- [Page] 37 mises at once. The girls' privies, as usual, are clean, but the boys' very dirty. Tarradale School. - Cubic space rather scanty. Ven- tilation arrangements good and well attended to. The privies are unclean, untidy, and scavenging very ill done. The last refuse had been lying for a week or more, close to the school, unremoved. The drainage of the schoolhouse entirely out of order. Complaint was made by letter to the School Board, and this was remedied. Avoch School. - Undergoing extensive repairs when visited. Redcastle School. - Shut up when I passed. Water in the playground ample, but none in the school, and no lava- tories. Privies in fairly good order. Tore School. - Supply of water urgently required. Only source a drain some distance off. Schoolroom cold in winter. Boys' privies very dirty. Fodderty School. - Ventilation good on the whole, but sometimes a down-draught. Openings are perhaps rather small when the weather is warm. Lobbies where children's clothes are hung ill aired. Boys' privies very little used, being in too exposed a place. No regular scavenger. There is an ample supply of good water, and there should be no difficulty with lavatories. A good feature here is a large shed where the children get their meals. Contin School. - Ventilation good, and well looked after. There should be moveable flaps over the openings in the roof. A plentiful supply of good water. The girls' W.C. is out of order; the boys', from being badly placed, is not used at all. The Manchester grate does not seem to have an inlet for air, and is not working. The school is dirty, being used for other purposes than for the pupils alone, and would require more frequent washing out. Maryburgh School. - Everything here well looked after. I am rather doubtful about the moveable box arrange- ment, which is the plan for dealing with excreta here. There
HH62/2/ROSS/39 [Page] 38 is a good well close to the school, but some plan of pumping the water into the building itself should be adopted, and lavatories supplied for the use of the pupils. Additions are being made to the accommodation. I have thus visited and carefully inspected, from the public health point of view, almost all the schools on the mainland, with the exception of a few in Gairloch, and one or two in Lochbroom. In the Lews the majority have not been so visited. The County Sanitary Inspector has kindly given me an opportunity of consulting the notes of his inspections. Generally, I find the ventilation is defective, and where there are W.C.'s, and there seem to be many in the Lews, a large number of them are out of order. They are usually supplied with water from a force pump, and, if this fails, of course the closets are not flushed, and become a source of danger to the health of the children, and a nuisance generally. So much for inquiries ex proprio motu. I shall next take up the other branch of my proceedings, matter, in which I have given advice or rendered assistance other than those connected directly with infectious disease, which will be dealt with under a division of their own. The largest portion of my time and attention has been devoted to arranging the organisation of public health service in the County. Ross and Cromarty, besides having one-third of its population situated at a distance by sea of nearly eight hours' steaming from Strome Ferry; has the other two-thirds very much scattered, and the configuration of the land and water is such that it is necessary in travelling, if saving of time is the main object, to return to the centre and start afresh. It is simply impossible for one M O. H. to be at once the County and District servant unless he is expected to be half the year from home. Even with the Lews cut off, a very large portion of his time would be wasted on the road and great expense incurred. It became therefore necessary to devise a scheme of a central authority with efficient local assistance, and after many meetings and much deliberation, the County Council, through its Public Health Committee, fixed upon the plan of giving the services of the County Medical Officer and Sanitary Inspector gratis, as Head District Officers, provided the Districts themselves afforded the necessary help on the spot. The Mid Ross, Western, South Western, and Black Isle Districts have agreed to this proposal, but have not as yet quite settled on the District Staff. No difficulty is apprehended [Page] 39 on this score. The Lewis and Easter Ross Districts have not up to this time come to a decision on the subject. I believe this scheme, if adopted, will satisfy the Board of Supervision, and I am sure is the one most likely to work without friction and to the greatest advantage of the Public Health. It will enlist almost every medical man in the County in the army of sanitarians, and if disease is to be quickly, safely, and pleasantly stamped out, this is the most promising way of doing it. The other matters in which I was engaged, were visiting and reporting on a ruinous tenement in Lochcarron, visiting and corresponding with the Highland Railway Company in re- gard to insanitary surfacemen's houses at Coulin, which they promised to renew; inspecting Tarradale village on several occasions, where the water was deficient and the drainage bad; attending a public meeting at Alness in connection with pro- posed introduction of water, and giving advice and assistance to the Easter Ross District Committee in regard to nuisances alleged to exist at Culisse. It may be useful to enlarge upon this latter, as it may form a precedent in regard to the manner of dealing with such cases. The District Sanitary Inspector had found some sanitary defects in the farm house and had reported his opinion to the Local Authority, going the length of condemning the house as a nuisance. His zeal outran his discretion in so far as he should have first courteously asked the proprietors to have the nuisance abated. If he had done so it is said the mischief would at once have been put right. This has invariably been the practice of the County M. O. H. and S. I., and in every case our recommendations have, as soon as possible, been complied with. The County S. I. and myself advised this course to be taken in the Culisse case, and I have lately seen a letter from the District Sanitary Inspector stating that everything has been carried out to his satisfaction. While the Public Health Officers of the County are ready to hear all complaints and most anxious to discover and remedy all nuisances, they are very loth to take the high hand; or be guilty of anything like oppression of the rich or poor. It is past the wit of man for instance to devise a W.C. which will exclude every atom of sewer gas. The best must be made of the existing arrangements, and let me add much, very much, depends on the personal, close, steady supervision of the tenant over traps, ventilation open- ings and discharges. It is to the next Division (d) of our syllabus that we must look chiefly for fruit from our proceedings. With the general adop- tion of the Notification of Infectious Diseases Act - an adoption
HH62/2/ROSS/41 [Page] 40 which has already borne good fruit in the Lews — the starting- point of most of our sanitary investigations and improvements, will be the inquiry into individual cases of fevers and septic illnesses generally. No one can legally or even reasonably refuse the utmost facilities to the Sanitary Officers to investigate the cause and origin of such devastating diseases, nay, they will rather wel- come their presence and second their efforts. But to make a close scrutiny (and unless it be thorough it is not likely to lead to any good result) of premises where no trouble has de- clared itself would only lead to opposition and bad feeling. I say this much because it may be alleged that we Officers of Health should at once ferret out and extinguish every nuisance existing within the County. This idea is both impracticable and impossible. The only serious epidemics that prevailed within the County - if we leave that of influenza alone, as the greatest number of cases will fall within the next year, and will then be better discussed - were those of measles in the camp of the Inver- ness-shire Militia at Muir of Ord, typhus in the Lews, and whooping-cough also mostly confined to that district of the County (at least in fatality), and typhoid at Achilty. With regard to the outbreak of measles I went every day to the camp for a week and can testify that all possible precautions against the spread of the disease were taken by Dr Macfadyen, the surgeon in charge, and by the P.M.O. for Scotland, Brigade- Surgeon Dr Allan. It can scarcely be said that the War Office authorities were sufficiently prepared for such an extensive series of cases. Neither the hospital tents, the nursing nor the medi- cal care was on a sufficiently generous scale. On the whole the results were good considering the gravity of the type of the disease, a gravity which at the time it was wisest not to emphasise. The origin of the epidemic was distinctly traced to Harris; and to the West it unfortunately was carried afresh. There was no law, legal or martial, to keep them apparently well - who had been in contact with the sick - from travelling home and carrying in their bodies, the unde- veloped seeds of the disease. Every possible precaution was taken, but unless these men could have been forcibly detained, the untoward result was sure to flow and infection to spread in the poor fellows' homes. If some power of quarantine were given to Local Authorities such difficulties might be met and overcome. Whooping-cough was extremely fatal in Barvas; no doubt a great reason being the bad atmosphere within and the un- [Page] 41 fortunate dread of fresh air from without, which equally pre- vail in the Lews. The hope of this result not again occurring lies in the better housing of the people and the coincident spread of wholesome hygienic knowledge. For these latter improve- ments we look with confidence to the schools and schoolmasters. It would be easy to prove almost to a demonstration the con- nection between deaths from whooping-cough and bad air, or the want of air; but I need not, I think, trouble the Council with what they are well assured of. I pass on to consider the epidemic of typhus, which prevailed in the Lews in the summer and autumn of '91, and I fear I must enter at some length into the subject, as it affords lessons for the future management and the possible stamping out of such outbreaks. On the 13th October I had a letter from the County Clerk, enclosing a complaint from the Lews, and alleging that fever was present in the Village of Limerva and elsewhere. I immediately telegraphed to Dr Macaulay. the M.O.H. for that parish, and received the following reply:- "Some children and a young man in Limerva, had apparently mild typhus fever - all now convalescent." In answer to a letter, asking for further information, Dr Macaulay wrote to me as follows - (l omit portions of the letter of no general interest):- "I could find no evidence of its being introduced from without. . . There had been 11 cases of typhus at Limerva - all recovered. The Lews Sanitary Inspector had been to Limerva to disinfect all the fever infected houses. The Public School at Limerva has been closed by medical certificate." In reply, I again wrote to Dr Macaulay, asking him to re- port any fresh outbreak, and to try by further enquiries to ascertain the origin of the epidemic, and directing his attention to the fact that typhus fever had been prevailing recently, as I myself knew, at Stornoway. Having no further information, and having discussed the subject with the Chairman of the Lews Committee, I considered the disease had ceased to prevail. But on the 26th October I had a fresh complaint that typhus fever had broken out at Eishken Lodge, and that efficient means of disinfection had not been carried out by the district S. I. I now considered it my duty to visit the locality and make en- quiries on the spot in connection with the whole matter. I went to Stornoway on the 1st November, and on the 3rd pro- ceeded to Eishken Lodge, and went on also to the village of Limerva, where Dr Macaulay was good enough to meet me. I took very careful notes of what I saw and heard, but I
HH62/2/ROSS/43 [Page] 42 shall only trouble the Council with a short summary of these and a few observations. Everything was right at the Lodge, and the bothy had been thoroughly disinfected. From careful inquiry I am satisfied that the disinfection carried out by the district S. I. was of the most perfunctory character, while that done subsequently by a woman employed by Mr Platt, from Stornoway, was, as I have said, most effectual and complete. At Limerva there were still several cases of fever. I cannot say positively whether they were typhus or typhoid, but that they were cases of fever - and of a highly infectious character - there could be no doubt. Cases had been present, at any rate from midsummer, without any proper attempt having been made to check the progress of the epidemic. Disinfection was a mere farce - the Sanitary Officer simply leaving a bottle of something with only verbal directions. and not entering the houses in which the disease had occurred. I could not ascer- tain whether Dr Macaulay had reported the cases to anybody but himself. Certainly he had not done so to me, although in my letter of the 10th, I had specially asked him to report any fresh cases. Here was an undoubted outbreak of epidemic disease of a most serious kind without any effectual means having been taken to check it, and though the notification of Infectious Disease Act is in force in the island, yet nothing was done to draw the attention of the County S. I. or M.O.H., or the Board of Supervision, as laid down in their regulations, to the occurrence. It humbly seems to me that the only proper remedy for this state of matters is to appoint the County S.I. and M.O.H. respectively Chief District Officers. and so secure that such cases of infectious disease are not merely notified to the notifier him- self, or even to one district Medical Officer for the Lewis, but periodically reported (say once a week) to the head officials - whose duty it will be to see that thorough means of, as far as possible, checking the spread of such deadly diseases as typhus fever, are efficiently carried out. For this end it will be necessary not only to have a Princi- pal Sanitary Officer for the Lews. who will devote himself with skill and energy to the work, but also a sufficient Local Staff as mentioned in our scheme of sanitary organisation submitted to the Public Health Committee, and which will probably be laid before you at your May meeting. Disinfection, we say it again, is a task which requires time and great attention. The duties of Sanitary Inspectors must be performed in a very different spirit from that in which they have hitherto been carried on in County Districts. The aim must be to follow the example of such towns as Glasgow and Aberdeen, where [Page] 43 the inspection and disinfection are most effectively done. All this will imply attention on the part of District Committees, and it must be confessed considerable outlay of money. To get such disagreeable work done it must be well paid for. But I am confident the return in the improved health of the district will amply recoup the expenditure. The fourth epidemic I shall notice is that of an anamalous outbreak of typhoid which occurred at Achilty. By the kind- ness of Dr Tregelles Fox I was supplied with full notes of all the cases. Their great general peculiarity was the mild charac- ter of the majority of them. Few were ill more than seven days. But two, at least, were grave; one recovering after be- ing a very long time in the Hospital at Dingwall, and the other dying. The outbreak could be traced back to a point where it seemed highly probable that the milk was the means of dis- seminating the disease all over the place, but I failed to carry out the story of the beginning of the epidemic much further. The drains of the farmhouse were found to be somewhat de- fective. The proprietor at once had them put in order, and they are now, I hear from the County Sanitary Inspector, work- ing satisfactorily. I do not believe the faults found in these sanitary arrangements go any way to explain the real origin of the disease, though they may be held to account in some measure for its spread. While there is great mass of evidence to the effect that the germs of typhoid live and thrive in water, and consequently in sewers, where they may possibly escape into living rooms along with sewer air, yet, on the other hand, facts are accumulating showing probability of direct bodily trans- ference, and also that the infective germs find a nidus in clothes, &c. I made some statistical investigations a quarter of a cen- tury ago, which I showed to the late Dr Murchison, the great authority at that time on fevers. They convinced me, at least, that typhoid fever does frequently spread by direct infection, exactly as do typhus and the other exanthematous disorders. If this view be correct we have, as I have already said, one strong argument more in behalf of thorough disinfection of the right kind. and the greatest inducement to detect the disease early, to isolate it if possible, and to, in short, stamp the disease out entirely. One aspect of the natural history of typhoid must also be kept in view, that it seems to cling with affection to some particular places or localities. It is to be hoped that the re- searches of bacteriologists will show us both the favouring and unfavouring conditions of the life of the microbe, and thus put us in a position to cope with its growth and reproduction. An account of the hospitals for infectious disease must, as yet, be short. We have only two in the County - first, the
HH62/2/ROSS/45 [Page] 44 Ross Memorial Hospital at Dingwall; and second, the Hospi- tal at Stornoway. The latter I have already spoken of in my general survey of the County. I have also indicated the pres- sing need for more Local Hospitals, and the means I would suggest of organising a Nursing Staff for their due and efficient working. We can fortunately point to our Infirmary in Ding- wall as an encouragement to other districts. Beginning in a modest way, it has expanded to its present position where it supplies the needs for an infectious hospital to a large part of the County - not, of course, to the larger portion, which is, as yet, unsupplied. Having had the experience of starting and carrying on perhaps the first County Hospital for infectious and other diseases opened in Scotland, I persuaded the mana- gers to add infectious wards to the original scheme. I can confidently affirm that these wards have done an incalculable amount of good in this community, both in staying the spread of infectious disease and in providing the best of nursing to those unfortunately affected. On several occasions Strathpeffer has had to thank Dingwall for, it may be, preventing a panic in that fashionable watering-place and a stampede of its visitors! The Dingwall Hospital can claim to possess the first ambulance on wheels existing in Scotland I may be allowed to add that I think the medical attendants of fever cases in the hospitals should be paid fair fees for their services. Most of the patients can afford a fee and would have had to give it if they had re- mained and been attended at their own homes; and such being the case it is scarcely reasonable or just that the doctor should suffer by recommending, as he invariably does, his clients to take advantage of the care, nursing, and increased medical at- tention they get in that valuable institution. We should properly at this point, consider the different dis- trict reports, more especially as bearing on the condition of Slaughter-Houses, Dairies, Bake-Houses and Common Lodging- Houses. As regards the latter they may be said to be non- existent in the County proper, and are few even in the Burghs. But there is, it must be feared, much overcrowding. Only a house to house visitation can cope with this mischief, and so the question must be postponed until a proper working staff is organised. We hope shortly to have these matters arranged and then to be able to set to work, not only with this source of disease, but also with the condition of the other subjects already mentioned. We may note in passing, that we have found the Bake-Houses almost all in good order with the exception of one in Ullapool. The Slaughter-Houses, as far as inspected, are much in want of regulation and supervision, and so also are Dairies. As regards these latter, there are not many accord- ing to the technical distinctions in the County. The condition [Page] 45 of Graveyards too will have to be carefully noted, and where the ground is too limited as it is in many cases, additional Cemetery accommodation will have to be recommended and it may be enforced. In conclusion, I have to express the hope that the Public Health organisation in the County may soon be fixed on a satis- factory and permanent basis. The views of the Sanitary In- spector and myself are before the Public Health Committee, and would, we believe if carried out, secure the wished-for re- sult of all sanitary efforts, viz., the steady improvement of the health of the County, and the restriction of preventible disease within the narrowest possible limits.
HH62/2/ROSS/47 TABLE 1. [Table inserted] TABLE 11. - BIRTHS AND DEATHS OCCURRING IN THE COUNTY DURING THE YEAR 1891. [Table inserted]
HH62/2/ROSS/49 TABLE III. - BIRTH RATE, INFANTILE, AND OTHER DEATH RATES. [Table inserted] NOTES TO TABLE III. (a) The population rates for '91 are not corrected to the middle of the year, as there was no time to do so, owing to the fact that many of the local returns only came in at the last moment. (b) The Dingwall rates are corrected by deducting the deaths in the Ross Memorial Hospital for the corresponding periods. From Tain returns, for Easter Ross Poorhouse, there ought to be deducted from 1885 to 1889 inclusive, 10.6; from '90, 12; and from '91, 15. From Rosemarkie, for the Black Isle Poorhouse, the deductions are 5, 5, and 6 for the same periods. (c) Croup has, as far as possible, been kept to a category by itself. In the Lews the term is frequently applied to capillary bronchitis, &c. (d) I have included phthisis in the respiratory diseases. It would be more symetrical to exclude it. (e) I have not differentiated the deaths under 5 and over 5. Those under 5 are almost entirely uncertified, and the information would only be misleading. (f) With regard to uncertified deaths I do not think they affect the numbers set down under zymotic diseases to any appreciable extent. But, doubtless, the figures under cancer and consumption, &c., would be much larger if all the causes of death were known. (g) Carnoch has no deaths during '91. I would have liked to have analysed the Returns and compared the different results; but, for the reasons above given, this must stand over till a future opportunity. Meantime the facts will be accumulating, and the inferences to be drawn will be more reliable. II No Returns for '91.