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one’s patients to a stranger implies, may be glad of some fewhints on the subject. If the services of a personal friend canbe obtained, so much the better; if not, resort must be had toadvertisements, medical agents, or perhaps to some friend onthe staff of the practitioner’s old hospital. Answering advertise-ments implies some little delay, for of course references are ]necessary. Too much reliance must never be placed on these, forthough testimonials may be given in perfect good faith they,are generally written immediately the engagement is con-cluded and before any but the most serious causes ofdissatisfaction have come to a principal’s knowledge. Someagents request all principals to whom they have sent a locum’tenens to fill up forms concerning him at the end of the.year, and in this way they manage to purge their lists ,of unsatisfactory men, who, it is only fair to say, formbut a small minority. The lowest terms generally offered- to a locum tenens are three guineas a week, with, ofcourse, board, lodging, and travelling expenses to andfro. The agent charges a small fee, generally 10s. 6d., to-each party. ’

Supposing all arrangements made and the day fixed forgoing away, care should always be taken to secure a sufficiently’long interview with the locum tenens to show him all the:surgery and other arrangements, and to have a good talk with,him over the cases under treatment or likely to be so. Ofall these he should jot down notes unless the principal has.already done so. Many memoranda are required which wouldnot be found in the notes of a hospital clinical clerk-e.g.,whether visits should be paid daily or otherwise and whether:any particular period of the day is unsuitable. Care.should be taken that every bottle in the surgery and,.store cupboard is properly and sufficiently labelled, and,- if private formulas are employed, that they should be easily.accessible. If private abbreviations are used in the day-book, the locum tenens should be told what they mean;’vaccination arrangements also must be explained to him. He- should be shown where all the dressings, splints and instru-ments are, and told what neighbouring practitioners he shouldapply to for assistance, and what to do if drugs or dressingsrun short. The stable arrangements should be shown him, and’it should be clearly settled whether he or the groom is to drive.The night bell, speaking-tube and slate for messages must beshown him, and, if possible, a map of the district left withIhim.

The confinement list will be worthy of a few minutes’ conver-.sation, and he must know how many after-visits are expected’.in a normal case. The scale of fees must be told him and he- must understand whether he has authority to give receipts. It- its often better to let the locum tenens send an acknowledgment- of money received, with a promise that a formal receipt will be. sent by the principal on his return. In case payments have tobe made to the groom or surgery boy or for postage, some’money should be left with the locum tenens. Whereappoint-ments are held the duties should be clearly explained, and’he should be told how to distinguish between club and

private patients who may call at the surgery, otherwise the- day-book may be filled by the names of those who donot pay, while those of private patients are omitted.If possible, a definite date should be given for the prin-cipal’s return, so that the locum tenens may take another- .engagement.

As to household arrangements, a locum tenens should betreated with consideration and his tastes should be as far as

possible consulted. In conclusion, it may be said that thoughdifficulties and unpleasantness do at times occur during the:absence of a principal, the probability of anything takingplace at all seriously damaging to a practice is exceedingly,small if ordinary care be exercised in making the arrangements, and especially if the holiday be limited to three or four"weeks.

DERBYSHIRE ROYAL NURSING INSTITUTION.-The annual meeting of the Derbyshire Roval Nursing andSanitary Institution was held on the 5th inst. at theSt. James’s Hall, Derby. The Mayor (Mr. T. H. Harrison)presided. The twenty-seventh report gave a satisfactoryaccount of the working of the institution with regard to bothits financial condition and the benefit conferred on the poorby means of the Society. Since 1865 (when the Associationwas established) 219 nurses had been supplied to the public.The services of Dr. Ogle as honorary secretary for twenty-seven years were duly acknowledged.

Public Health and Poor Law.LOCAL GOVERNMENT DEPARTMENT.

REPORTS OF MEDICAL OFFICERS OF HEALTH.

St. Luke’s, Middlesex. —In this metropolitan district thedeath-rate for 1891 reached as high as 30’1 per 1000. Thecorresponding rate for 1886-89 was only some 21 per 1000,and the great increase is found by Dr. Yarrow to be mainlydue to bronchitis and pneumonia brought about by the influ-enza epidemic. The ordinary zymotic diseases were by nomeans exceptionally prevalent and it seems that specialattention is given as regards those which are notified.It has been suggested in St. Luke’s that erysipelas might beeliminated from the list of such diseases, and that measlesshould take its place. To the latter proposal Dr. Yarrowtakes exception. He holds that it is practically of no usehaving notification without means of hospital isolation. Weimagine that anything like hospital isolation of erysipelasdoes not exist; whilst, on the other hand, a number ofmedical officers of health have found that considerableadvantage has accrued as the result of their being able todeal with the spread of measles through the agency of

elementary schools, as they obtain thus early knowledge ofits existence in individual households.

Bollington Urban District. - According to Mr. JamesAllen the death-rate of this district during 1891 was 15’6per1000 living. The unsatisfactory condition of the privies andmidden-privies is maintained, but it is stated that a differentmethod of scavenging has been inaugurated. Another defectlies in the reception of sewage into the bed of a stream whichbecomes dry, the result being an obvious nuisance.

VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

IN thirty-three of the largest English towns 5782 births and3395 deaths were registered during the week ending Aug. 6th.The annual rate of mortality in these towns, which had de-clined in the preceding three weeks from 17’9 to 17’3 per1000, was last week 17’4. In London the rate was 17’2per 1000, while it averaged 17 ’5 in the thirty-two provincialtowns. The lowest rates in these towns were 94 in

Wolverhampton, 10’0 in Gateshead, 10’8in Croydon and 10’9in Burnley; the highest rates were 21’0 in Salford, 21.1 inBirkenhead, 21-4 Cardiff, 23-9 in Sunderland and25’2inLiverpool. The 3395 deaths included 623 which were

referred to the principal zymotic diseases, against 625and 585 in the preceding two weeks; of these, 300 re-

sulted from diarrhoea, 126 from measles, 61 from scarletfever, 57 from diphtheria, 54 from whooping-cough, 25from fever" (principally enteric) and not one from small-pox. These diseases caused the lowest death-rates inHalifax, Brighton, Croydon and Newcastle-upon-Tyne, andthe highest rates in Liverpool, Sheffield, Sunderland, Birken-head and West Ham. The greatest mortality from measlesoccurred in Bristol, Salford, West Ham, Oldham andSunderland ; from scarlet fever in Swansea and Plymouth;from whooping-cough in Preston, Burnley and Birkenhead;from "fever "in Sunderland and from diarrhoea, in Derby,Bolton, Sheffield, Portsmouth, Leicester, West Ham, Liver-pool and Cardiff. The 57 deaths from diphtheria included42 in London, 3 in Birmingham and 2 each in WestHam, Preston and Sheffield. No death from small-pox was registered either in London or in any of thethirty-two provincial towns; 7 cases of this diseasewere under treatment in the Metropolitan Asylum Hos-pitals and 4 in the Highgate Small-pox Hospital onSaturday last. The number of scarlet fever patientsin the Metropolitan Asylum Hospitals and in theLondon Fever Hospital at the end of the week was

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2995, against numbers increasing from 1226 to 2864 onthe preceding nineteen Saturdays ; 346 new cases were

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admitted during the week, against 382 in each of theprevious two weeks. The deaths referred to diseases of therespiratory organs in London, which had declined from 185

- to 155 in the preceding five weeks, further fell to 143 lastweek and were 47 below the corrected average. The causes