LAM2 THE VESTRY OF THE PARISH OF LAMBETH. THE ANNUAL REPORT ON Vital and Sanitary Statistics, 1894, by H. WALTER VERDON, M.D., F.R.C.S., Medical Officer of Health, Barrister-at-Law, Member of the Honourable Society of the Middle Temple. TO THE VESTRY OF THE PARISH OF LAMBETH, 1894 THIRTY-SEVENTH ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH, Being a Report for the Year 1894 on the Vital and Sanitary Statistics of the Parish of Lambeth. In pursuance of the provisions of the Metropolis Local Management Act, 25 and 26 Vict., Cap. 102, Sec. 43, I herewith lay before your Vestry a Report for the year 1894, upon the Vital and Sanitary Statistics of the Parish of Lambeth. The population of the Parish of Lambeth, estimated in the month of June, 1894, is represented by 282,246 persons. The calculation is based on the ratio of increase observed in the period of ten years intervening between the last census and the preceding one. The annual increment thus determined is 0.85 per cent. Comparing this estimate with the result of a calculation based on the number of inhabited houses, there is no material difference in the figures. b * 2 4 TYPHOID FEVER. During the year to which this report refers Typhoid fever has continued to occupy the attention of the Officers of the Sanitary Department. The number of cases notified and the fatality among infected persons marks the disease as belonging to a type at once diffusive and virulent. Besides the usual batch of cases which were distributed sparsely but evenly throughout the metropolitan area, and which do not seem to bear any causal connexion with one another, a definite outbreak occurred among the customers of a milk dealer carrying on business in the outer Wards. The earliest case of the connected series was notified at the beginning of the third week of March, and others belonging to the same group were returned in the later days of the same month and during the next. The chief force of the epidemic was felt at Brixton and Stockwell, but the surrounding districts were not exempted. For a few days after the first intimation had been made cases followed one another in close order of succession, and from their number, simultaneous appearance and distribution fears were entertained that the outbreak might assume large proportions. It is a matter of experience that when Typhoid obtains even a limited foothold in a district before the agency of its introduction is discovered, it often shows itself capable of making large inroads upon the public health. The interval of time named the incubative stage, lying between the moment of infection and that of the appearance of the earliest symptom of fever, extends over a period of many days, and consequently the existence of a local infecting agency may not be suspected until after seed has been widely scattered. At Worthing several hundred persons had become the subjects of infection before the water conveying 5 the spores of disease fell under suspicion; and the history generally of epidemic outbreaks affords numerous examples where many people imbibe the latent poison before any single individual actually is observed to suffer from unmistakable signs of the disease. Consequently, when epidemic Typhoid makes its appearance, it seems to descend on the selected area with sudden violence, attacks numbers at the same moment, and induces a sense of insecurity almost akin to panic. So in the epidemic under consideration, at the time when information of the appearance of Typhoid at Stockwell had come to hand through the notification of a single case, fifteen people living in the same district, and inhabiting houses situated widely apart, were actually lying in bed suffering from the incipient symptoms of the disease. In like manner, on the morning of the 2nd of April, when steps were being taken to shut down the sources of infection at the Dairy under suspicion, the notification of twelve cases only had been made, while information which subsequently came to hand proves beyond a question of doubt that at this very time fifty-eight persons living within the pale of the infected area had already imbibed the poison, and were then either passing through the incubative period of the complaint, or undergoing the sufferings contingent on the later and more definitely marked stages. The sudden appearance of many cases in a circumscribed area, after the manner illustrated by the Stockwell epidemic, indicates the existence of a local centre of infection, and distinguishes the outbreak from others where the number of cases is few, their position isolated, and their distribution general throughout the Metropolis. Typhoid characterized by the former mode of incidence is seldom present amongst us, by the latter, always. 6 Looking back over a period of eleven years, I observe the calendar includes about 600 cases occurring annually in the Metropolis from this disease; 400 cases being usually recorded between the months of September and March. These figures relate only to persons who have died, and do not include those who, having taken the disease, had passed through the various stages towards recovery. Estimated on a recognised statistical basis, the latter class swell the total annual number of cases occurring in the Metropolis to 3,600. There is something remarkable about the conduct of Typhoid, "when considered as a perennial disease, which marks it especially as a subject for investigation, It appears year after year in the Metropolis with unfailing regularity, and distributes itself alike in the quarters of the rich and in the quarters of the poor. It observes only a limited partiality for seasons, as no month in the year is exempted from its incidence. Yet it affects the autumn and winter months rather than those of spring and early summer; moreover, the cases do not especially select insanitary houses, where the presence of sewer gas might offer a reasonable explanation for their occurrence, but invade indiscriminately houses sanitary and insanitary alike. Nor is district a determining factor. To-day a case is notified at Kennington, to-morrow at the Lower Marsh; after a few days a third appears at Norwood, and again a fourth at Brixton, and so on. Thus it is to be observed that they are not aggregated together either in point of time or place; nay, if any method may be recognised in their incidence, it is that they do not fall in clusters, but singly and apart. The disjointed order of incidence observed by cases of this class is fundamentally opposed to any hypothesis of local origin. If sewer gas be the vehicle of contagion 7 cases would be found aggregated together in the neighbourhood of some particular sewer, where it may be assumed the bacillus of Typhoid had established a habitat, and in houses where defective drains provide a constant or intermittent supply of contaminated air; again, if milk or water be the medium of contagion, the distribution of cases might be expected to follow the idiosyncrasies of supply. But as I have already remarked, the endemic form of Typhoid under consideration does not exhibit any selective power in regard either to insanitary area or habitation. It does not follow, as far as can be ascertained, the steps of the milkman on his rounds, nor can it be said that it disposes itself in any consequential order within the sphere of distribution of a particular section of the water supply. Typhoid reaches the human system by gaining an entrance at the mouth. Infective particles, mixed either with milk or water, or adherent to the surface of solid and less permeable articles of consumption, are conveyed through this portal to the alimentary tract during the act of eating or drinking. The spores are not inhaled with the air, as general report would have us believe, however largely that medium may have been impregnated by admixture with unwholesome vapours. Nor are they endowed with any exceptional power that enables them to force a passage to the interior through the natural protective coverings of the body. Moreover, Typhoid always comes from Typhoid, and from nothing else besides. Neither water nor milk nor other food can become the soil of Typhoid unless seeds have been planted; nay, sewage itself cannot give birth to Typhoid, or induce its growth, except it have contained within it germs recently cast from the intestines of a person who is the subject of disease. If these sporadic cases of 8 which I have been speaking have a local origin; if they take their birth from a contact locally effected between food stuffs and germ-bearing sewage, they must before now have declared their common parentage by the co-existence of circumstances of time and place, and their relationship by the discovery of those connected facts which link together associated cases of infective disease. Upon no conceivable hypothesis can it be argued that these sporadic cases of Typhoid fever are of local origin. Now, if it be assumed, on the other hand, that the infective particles were imported from without the parish, as food and drink are the only possible media of infection, the bacillus must have been introduced in connection with one or other of these articles. If milk and water be excluded on account of the reasons already stated, and things cooked and boiled likewise removed from the list of food stuffs, which, presumably, may become the carriers of infective particles, the category of articles in connection with which the Typhoid bacillus could and must have come is reduced to small dimensions. Shell-fish and vegetables eaten in their raw state appear to stand alone as fulfilling the essential conditions. Since my Report on this subject reached the Vestry in November, 1894, the opinion which I then expressed, and to which I was driven by the logic of factsnamely, that the sporadic cases of Typhoid occurring in the parish were caused by the consumption of shell-fish and vegetables eaten raw—many facts have come to light which amply confirm these views. In a large number of cases, when the history of the patient can be clearly ascertained, it is to be observed as a notable coincidence that oysters, mussels, or water-cress, in their raw state had been eaten at some time during the twenty-one days antecedent to the date of the onset of symptoms. When this matter in regard 9 to one of these articles of diet—namely, the oyster—was introduced at a later date to public notice in the columns of the press, evidence came to hand from medical men located in all parts of the country, which amply confirmed the opinions I had already expressed upon this subject. In like manner the connection between watercress and Typhoid can now be considered as definitely established. Besides a number of cases coming under my own notice which I have collected, and others which have been detailed to me by medical men in practice, a batch of cases is reported from a distant part of the empire. An outbreak of Typhoid recently occurred on board Her Majesty's ship "Cossack," stationed at Bombay; thirty-three men were attacked, and in the case of seven the disease had a fatal termination. The Commission appointed to investigate the cause of the outbreak declared the disease to be due to the consumption of watercress. The men infected had eaten a quantity of watercress taken from a bed in the vicinity of Parel, a suburb of Bombay. The watercress was found to be growing in a liquid medium of sewage-contaminated water, the bed receiving sewage drained from houses where Typhoid fever at the time was prevalent. That these articles of diet, namely, oysters and watercress, which are largely eaten in London, are, under certain circumstances, sewage bearers, is capable of demonstration. Watercress eaten by people residing in Lambeth, who afterwards became the subjects of Typhoid fever, was grown on the outskirts of a sewage farm and in a medium of liquid sewage and water, and conveyed to the consumer without being previously washed. Oysters eaten by parishioners where a like sequence of events followed, had been fattened especially for London consumption in the channel of a tidal river, the stream of which being shallow 10 was largely contaminated by sewage, and indeed constituted the sewage outlet of a large provincial town, which at the time of investigation was the scene of an extensive outbreak of Typhoid fever. No law at present exists on the statute book which can be made operative to limit or prevent the sale of these sewagebearing articles. No consumer has any assurance that the oyster he buys has not been fattened in sewage water, or the watercress he sees on his breakfast table has not been gathered from a stream no less filthy than an open drain. So long as these sewage-bearing articles are allowed to enter our markets unchallenged, so long will Typhoid and other diseases of a filth origin be prevalent among us and the efforts of the Sanitarian will be, in a corresponding measure ineffective. While sewage-fed oysters and sewagegrown watercress only constitute a very limited section of the supply, the public is not possessed of that power of discrimination that can determine which is pure and which is impure, and consequently both these articles remain under suspicion, their sale falls off, the grower complains of dwindling returns and the public is deprived of the enjoyment of articles of dietary which, when produced under favourable conditions, are exceedingly wholesome. On the other hand, persons who are foolhardy enough to partake of either of these articles without having the means at command of ascertaining definitely the place of their production run no small risk of swallowing infective particles and contracting some dangerous complaint. It is paradoxical that, while the local authorities are straining every nerve to efficiently drain the districts under their control, and remove sewage and organic refuse from the precincts of populated areas, at the same time the central authority, under the designation of a Local 11 ment Board, should obstinately refuse to take any steps to supervise by authorized inspectors, and regulate by byelaw, those trades which supply for consumption at our tables food stuffs open to contamination by sewage. The local authorities are not in a position to help themselves in this matter; they have no means at command by which they can exclude from their markets shell-fish and watercress grown under conditions rendering them dangerous for consumption. Until the Local Government Board sees its way to move in this question, oysters and watercress, except when obtained from reliable sources, should be excluded from the diet list of parishioners. Typhoid Fever in South Brixton and Stockwell. The duration of the outbreak measured from the day when the first case in the series went to bed with symptoms of the disease, to the day when the last was taken ill, extends from the 10th March to the 21st April. As the fever in ordinary course begins insidiously, and its character is not readily recognised in the early stages, the act of notification usually takes place in the second week. Consequently the first case of the series appears on the records of the Office as late as the 16th March, and the last on the 30th April. During the epidemic period 46 persons living in Lambeth and 12 in adjoining parishes suffered from attack, and in ten the attack resulted in a fatal termination. At the time when the earlier cases of the series werf coming under notice, the Administration Area of the County of London was exempt from Typhoid fever in epidemic form, and during the months of March and April, when the 12 disease was locally prevalent, no exceptional incidence in other parts of the Metropolis was observed. Isolated and unconnected cases were appearing in the areas of Local Authorities on both sides of the River, but only with accustomed frequency, and in numbers no larger than those usually recorded at the time of year. Appendix B gives in tabular form the number of cases occurring in the several districts of the Metropolis in March and April. In Lambeth, during the specified period, namely, from March 1st to April 30th, 53 notifications were made at the Office of the Public Health Department. Looking down the list we notice that certificates coming in before the 16th March relate to persons living in the Northern Districts of the Parish: but that certificates received on the 16th and afterwards, with a few exceptions, refer to persons living in the Southern Districts. The epidemic area before the 16th was in the enjoyment of a condition of absolute immunity, and when the outbreak came it selected a district that boasted a clean sheet. The first certificate in the series was received at the Office on the evening of the 16th, and had reference to a person living at Pulross Road. The cause of the attack was unknown. No history of contact with any infected person was made out. No defects connected with drains or water supply were found. No evidence was obtained that had any bearing on the cause. On the 17th, a child living at Bonham Road, Brixton Hill, was taken ill with the same complaint, and two days later persons in Mayall Road and Flaxman Road. From this date to the 31st cases were notified at Loughboro' Park, Holland Street, Geneva Road and Burgoyne Road, and cases in two separate houses in Lambert Road. To recapitulate: The position on the 31st March stood 13 thus:-There were ten houses in South Brixton and Stockwell each giving shelter to a single case of Typhoid fever, no two of them, with the exception of the Lambert Road residences, being situated in the same street. The question of all others that demanded answer was—How and by what means had infection crept into these houses ? The means taken to investigate the cause of an outbreak are largely influenced by a knowledge of the nature and general behaviour of the infecting agent. To sum up in a few words investigations made by competent observers on this subject, I may say: that the infecting agent in Typhoid is an organism belonging to a generic type common among the microbes of disease which has received the name of Bacillus: that the Bacillus of Typhoid is capable of prolonged and independent existence at ordinary temperatures outside the body: that it dies when exposed to an artificial temperature of 180 degrees Fahrenheit: that this organism lives and thrives in sewage and sewage-polluted waters: that, moreover, it does not usually infect through the medium of the air, nor is it often conveyed directly from one person to another, but it invades the human subject with the food he eats and the water and other fluids he drinks, these becoming infected through contamination from contact either direct or indirect with sewage or sewagepolluted water. The result of a consideration of the foregoing biological facts leads us to certain practical conclusions:— I. That any causal connection existing between the cases is not to be looked for in evidence of infection passing from one to another or any personal contact with infected persons. II. That on the other hand, infection is conveyed by food or other articles of consumption. 14 III. That such articles become infective through contamination from contact with sewage or sewagepolluted water. These conclusions furnish us with a definite basis of enquiry. The question of infection by personal contact having been disposed of, the ground is cleared for an examination into the subject of contamination of food and water. The first question suggesting itself is, does contamination take place at a single source, or are the sources multiple? In other words, is the food contaminated at a central place, and afterwards distributed to the houses: or is it contaminated at the houses themselves. Difficulties lie in the way of the acceptance of any theory of multiple contamination. No condition of any of the houses was discovered capable of constituting itself a general infecting agency. Nor was it likely that infection was introduced through the water supply or by the drain. The householders drew water from separate mains and cisterns, and disposed of sewage into separate channels. Indeed, the whole aspect of the outbreak, the sudden appearance in rapid succession of a number of solitary, widely distributed and apparently unconnected cases in a district previously exempt, was opposed to such a theory. If, then, the theory of multiple contamination be dismissed as untenable, the alternative argument holds. We conclude that contaminated food had been supplied to the households involved in the outbreak, from a central place where some infecting agency is at work. We now ask ourselves the question—among the articles of food usually consumed in the ordinary household, which lends itself most readily to the carriage of infection ? And looking down the list, we do not find any other than 15 vegetables and shell-fish eaten raw and meat and milk, that may profitably be taken into consideration. But many of the persons attacked had not eaten raw vegetables or shell-fish. Meat is invaribly cooked before it is eaten, and milk is often boiled. When, however, milk is not boiled or cooked or heated by admixture with tea or coffee, at a temperature above 180 degrees Fahrenheit, it possesses properties singling it out as pre-eminently suited to become the medium of infection. Milk, then, is the only food that answers to the description of the article we are seeking: and consequently milk must be the infecting medium. Our next object is to trace to its source milk that had been consumed at the houses scheduled, and I submit the following list as the preliminary step in that enquiry. Case 1 obtains milk from dairy A. ,, 2 ,, ,, B. ,, 3 ,, ,, B. ,, 4 ,, ,, C ,, 5 ,, ,, B. ,, 6 „ „ B. ,, 7 ,, ,, B. ,, 8 ,, ,, D. ,, 9 ,, ,, B. ,, 10 ,, ,, B. It is apparent that the supply had been obtained from Dairy B. in 70 per cent of the cases notified, and the assumption that the infection came also from Dairy B. follows. Against this assumption, however, are opposed the following facts: I. That three cases had not been supplied with milk from Dairy B. 16 II. That the books of Dairy B. include the names of several thousands of customers, and having reference to the streets where six out of the seven infected persons live, the houses supplied by Dairy B. correspond to 60 per cent. of the whole number; hence the connection between the infected houses and Dairy B. is incidental only. The circumstances connected with case 7, on the other hand, strengthen the assumption against Dairy B. The patient did not live in the usual round of Dairy B. The truck carrying milk was observed to enter the street and leave it without stopping before the door of any other resident. Dairy B. had certainly not many customers here, perhaps only one, and that customer was the only resident who had contracted Typhoid fever. The enquiry on Saturday, March 31st, had only advanced as far as to ear-mark Dairy B. as a place under suspicion; two days later it advanced a stage further. On Monday, April 2nd, cases were notified from Gresham Road and Ridgway Road; of the former there is little to say except that the patient had been in the habit of drinking milk obtained at Dairy B. The circumstances of the latter, however, are out of the ordinary; the subject of notification is a charwoman, and it was stated on enquiry that she bought milk at Dairy E.; on further investigation it was ascertained that her present illness had commenced whilst staying at a flat in Dover Mansions, at which place she was in the habit of drinking milk from Dairy B. These additional cases, coming to my knowledge at a time when Dairy B. was already under suspicion, supplied confirmatory evidence of a character that, in my opinion, warranted interference. What action was then taken is referred to below; but before entering on another matter, permit me 17 to place before your Committee evidence which, coming to my knowledge at a subsequent time, places the question of causation beyond reasonable doubt. Confirmatory Evidence, Case I. A family living at Canterbury Road, obtained regular supply of milk from Dairy F. A special consignment, however, was purchased daily from Dairy B., for the exclusive use of D., a child in delicate health, and served to him in a raw state whilst he was confined to bed. During the time D. was drinking milk from Dairy B., symptoms of Typhoid fever gradually developed themselves. He alone of the family drank from Dairy B., and he alone was attacked with Typhoid fever. Confirmatory Evidence, Case II. Residing at Chale Road, beyond the boundaries of the Parish, R. obtained his household supply at Dairy G., but employed at work in the Parish, he ate his midday meal at a place within the epidemic area. When taking milk with his food, a not unfrequent practice, he obtained it indirectly from Dairy B. His case was notified from St. Thomas's Hospital on April 3rd. Confirmatory Evidence, Case III. A child living at Herbert Road, and in bed suffering from Rheumatic fever, was fed chiefly on milk from Dairy B. served in a raw state. Before complete recovery from Rheumatic fever took place, symptoms of Typhoid developed themselves. The case was notified on April 5th. c * 18 Confirmatory Evidence, Case IV. A child recovering from Scarlet fever was fed on milk from Dairy B. Typhoid supervened. This case was notified on April 6th. Confirmatory Evidence, Case V. A person living at Acre Lane had been notified on March 24th, as suffering from Continued fever. Removed to the hospital, within a few days she died. The household in which she lived was supplied from Dairy B. Although the case was notified as Continued fever, the rapid and fatal termination of the attack points to the probability of Typhoid infection. Confirmatory Evidence, from Cases outside the Boundaries of the Parish. Evidence was now being received of cases attacked by Typhoid in adjoining Parishes, whose households were supplied from Dairy B. Elms Road, Kingswood Road, Leppoc Road, and Christchurch Road, situated in Wandsworth; and Camberwell Grove, Church Street, and Dagmar Road, in the Camberwell District, severally returned cases. From the Midlands a case was notified. The patient had come from Somerleyton Road, Brixton, where she was drinking milk from Dairy B. She was attacked in Birmingham three days after arrival. Confirmatory Evidence from other Cases in Lambeth. On April 3rd a case occurring in Barrington Road, who had been supplied from Dairy B, was notified. On April 4th 19 cases were notified from Gresham Road, Geneva Road, Hayter Road, Loughborough Park, Canterbury Road, and Talma Road, each and all having drunk milk from Dairy B. Coming in later from roads in the epidemic area were cases from Brixton Road, Tunstall Road, Arodene Road, Sudbourne Road, Leander Road, Loughborough Park, Barrington Road, Herbert Road, Approach Road, Raeburn Street, Brixton Rise, Geneva Terrace, Overton Road, Dalberg Road, Acre Lane, Shannon Grove, Landor Road, and Cosbycote Avenue. The last on this further list of 23 cases was taken ill on the 13th April, The milk supply in every case, except the single one of Landor Road, was from Dairy B. From the 16th March, the date of the first notification, to the 21st April, the date when the last case went to bed with symptoms of Typhoid, 49 cases had been reported as occurring in the epidemic area, 45 of which had received milk supply from Dairy B. I have now come to an end of the statement of facts adduced in support of the argument— I. That the outbreak of Typhoid fever occurring in South Brixton and Stockwell, between the 16th March and 13th April, resulted from the consumption of infective milk. II. That such infective milk was supplied by Dairy B. Although I have been unable by enquiry to make out any connection between the four cases not obtaining milk from Dairy B. and the others of the series, yet I venture to think that the evidence before your Committee is sufficiently comprehensive to leave no reasonable doubt on your mind as to the conclusion. But if still further proof be needed, I have only to remind you that within 10 days of interference taking place with the course of business at c * 2 20 Dairy B., a period admissible for cases already infected to declare themselves, the epidemic completely and totally collapsed, leaving only two belated cases to follow 10 days afterwards. Interference having been decided upon, the question arose as to how far, consistently with the furtherance of the purpose in hand, it was possible to narrow the scope of such interference. Evidence pointed to contamination of some milk distributed from the Dairy, but no indication existed as to what milk. The business of Dairy B., as I have already stated, is on a large scale, and the books register the names of several thousands of customers. Management, as in all similar establishments, is divided under three heads— 1. Collection of milk. 2. General work of Depôt. 3. Distribution of milk. Having regard to the collection of milk, the supply is derived from three sources, namely—from (1) Sheds at Brixton, (2) Proprietary Farm, and (3) Dealer at Salisbury. The courses suggested to the proprietor and adopted by him were (a) That the supply from the 2nd and 3rd sources should be discontinued, and milk to make up for the deficiency obtained from other places; (b) That the tank at the Depot, containing water used for cart-washing and miscellaneous purposes, should be emptied and closed; and (c) That thorough cleansing of the premises should be carried out and limewashing of sheds, storehouses, and outhouses. This measure of interference satisfied the requirements of the moment; no milk now was to be distributed except that obtained from the Brixton shed, a place under 21 diate control, and that consigned from farms in respect of which no suspicion could be entertained; moreover, the work of the Depot was open to close supervision, and under these circumstances, having full regard to public safety, it was considered that the business of the Dairy might go on. On the other hand, while the agency of infection remained undiscovered, it was felt that recurrence of the mischief might at any time take place, and there was danger that the milk excluded from the epidemic area might be distributed elsewhere. Besides, the suspension of supply could be nothing more than a temporary expedient, subject any moment to become ineffective through relaxation or disregard. At all events, it was obvious that the enquiry could not be permitted to rest here. Milk for distribution by Dairy B. has been described as coming from three quarters. Certainly the largest in bulk is that derived from the proprietary farm, reaching an average of 20 to 25 churns a day. This source, shut down on April 3rd, was reopened on the 7th, inspection having failed in the discovery of any local condition that could be regarded as the factor of contamination. Next in quantitative importance comes the country supply under consideration. Dairy B. obtained consignments daily from a firm of dealers carrying on business at Salisbury. At many stations on the South Western main line of rails, branch depots ate established by this firm, offering local facilities to farmers for the disposal of their yield of milk, Such stations are Semley, Templecombe, West Pennard. Sittingbourne, Horsley, and Tisbury, besides the more important station of Salisbury itself. From all Dairy B had received consignments during the month of March. As in the case of the proprietary farm this source was closed on April 3rd, and reopened on the 7th. 22 From the third source, namely, that from the Brixton sheds, a yield averaging from three to four churns daily is obtained; insignificant as the quantity is compared with that of the other sections of supply, the milk is prized for its quality. Under the designation of nursery milk it is furnished to customers in sealed cans. The distribution and delivery of milk from Dairy B. is effected through carriage by hand-truck and by cart. South Brixton and Stockwell are served chiefly by truck. But situated at the fringe of this district is an outer or circumferential area served by cart extending into Wandsworth and Camberwell. All carts leave the Depot in the morning before the process of measuring out for the truck round is begun: and leaving at an early hour they have apportioned to them milk deposited at the storehouse on the evening before. But the churns reaching the storehouse in the evening are those brought oniy from the proprietary farm. Hence carts were distributing exclusively milk from the proprietary farm. If milk produced at the proprietary farm is infective we may expect to find in the area specially supplied by milk from this source, a large percentage of Typhoid cases. But no such incidence is apparent. On the contrary, the records furnished to April 7th, the day on which this part of the enquiry was made, and formulated in detail in Appendix D, whilst showing the existence of 21 cases in the inner or truck area, refer only to the presence of three cases in the outer or cart area. It is true several other cases were lying ill then, and evidence of them came in later with notification, but the same argument holds good in reference to both areas. Even taking the later cases into account, the area supplied exclusively with milk from the proprietary farm shows an insignificant incidence as compared with that 23 area served by truck with mixed milk from all sources. But if the milk from the proprietary farm were infective it should have shown a much greater incidence. Hence it is a reasonable deduction that it was not per se infective. The supply obtained from the dealer carrying on business at Salisbury was next taken into consideration. Stations from which this milk was consigned during the month of March are given above, and fuller particulars are contained in the appendix. On enquiry it was ascertained that many Dairies in Lambeth, in whose area of distribution no Typhoid was found, had also obtained consignments from this dealer: some from one station and some from another. In fact, milk from all stations was in daily consumption in Lambeth. Now, as no dairy other than Dairy B. had amongst its customers a succession of Typhoid cases, and as only a very limited number had any at all, it was unreasonable to suppose that 20 cases appearing among Dairy B.'s customers had derived their infection from milk consigned by this dealer, or that milk supplied from this source was per se infective. The third and last source to be brought under consideration is that of the sheds at Brixton. The yield, as before stated, is reserved for a special purpose. After reaching the storehouse it is measured into cans, and these receptacles are sealed and labelled. Thus protected and secured it is delivered on the rounds. Names and addresses of householders receiving nursery milk are entered on a list, but in none of the scheduled houses was a case of Typhoid found. As the whole yield of the home sheds is applied in the manner indicated, no suspicion can be attached to milk collected from this source. During the time to which this report relates, Dairy B. was not in receipt of milk from any other places than those 24 already referred to. But each of these on investigation has been declared non-infective. We may consequently affirm that contamination does not take place before milk collected from all quarters reaches the Depot. Contamination must, therefore, take place either at the Depot or on the round. Difficulties are attached to the acceptance of any theory of contamination during the process of distribution, and after milk leaves the Depot. At this period of the enquiry, on nine truck rounds covering separate areas, and two cart rounds lying widely apart, were cases of Typhoid to be found. When carriers with their trucks and carts leave the Depot, their roads lie in diverging directions. To suppose that the contents of churns are contaminated with Typhoid bacilli, on the separate beats, is to pre-suppose the existence in the epidemic area of eleven separate sources of polluted and typhoid bearing waters. Of course, such a supposition is absurd. Now it has already been shown that milk reaching the Depot is not infective, and that any theory of contamination during distribution is surrounded by insuperable difficulties; the conclusion is manifest, that the milk must be rendered infective at the Depot itself. The Depot comprises buildings and a partially covered yard. The basement of the buildings is a storehouse for milk, the upper part offices and manager's quarters. The offices and manager's quarters are practically distinct from the place in which operations in connection with the storage and handling of milk takes place, and consequently, for the purpose of this enquiry the Depot consists only of storehouse and yard. The storehouse is well ventilated, its flooring is of stone pavement, and its walls of lime-washed bricks. Nothing about it is insanitary. Moreover, much 25 of the milk stored in this place has not proved infective, notably that for nursery purposes. It may consequently be inferred that the atmosphere of the storehouse does not contribute in any appreciable measure to milk pollution. Now, if the facts brought forward by this report, in support of the argument therein contained, are correct—and much trouble has been taken in their verification; and if the conclusions deduced from them are sound—and they appear to me to follow as corollaries, then the scope of the enquiry is now reduced to very narrow limits, and within the boundaries of the Depot Yard, and in a space measuring 80 ft. by 20 ft. superficial area, namely, that section of the yard where the handling of the milk takes place, must the infecting agent be at work. The chief business carried on in this place is the conveyance of churns from vans to the storehouse; the conveyance of churns from the storehouse to carts and trucks, the washing and general cleansing of churns and cans, and the cleansing of carts and trucks. The north side of the yard is bounded by the block of buildings constituting in its upper part the quarters of the manager, and in its lower, offices for business purposes. In the basement is the storehouse for milk. The storehouse door opens upon the yard, which is approached by the ascent of six or seven steps. At the top of these steps is situated a large tank, the walls of which are of concrete. Next to this receptacle, and entering into the formation of one of its side walls, is an iron cauldron used for boiling water in large quantities for washing purposes. Beyond is a range of troughs. To the tank here described and its contents, I wish especially to draw your attention. When first observed the water was clean and sparkling in appearance, nor was 26 there anything superficially suggestive of impurity. Water from this tank was used for miscellaneous purposes, among which the washing of carts and trucks played an important part. Into this water, pails from the stables and cowhouse, encrusted with filth, and brushes used for spoke washing, were dipped and re-dipped. This process could not take place and be continued without the water contained in the tank becoming largely polluted from filth introduced by the articles submerged—and filth gathering on the wheels of carts and trucks in transit would come from many sources. When the tank was emptied on April 3rd, four inches of offensive smelling deposit was found accumulated beneath the water. As the liquid contents of this tank were usually kept warm by heat radiating from the boiler situated in close proximity, they would constitute a very efficient incubator and breeding ground for microscopic organisms. From what we know of the life history of the Typhoid Bacillus, we may be satisfied that this medium would be congenial to its growth and development. That the Typhoid Bacillus might have been introduced is by no means an improbable supposition when we consider the various sources from which this water was known to suffer contamination. Moreover, removed only by the space of a few feet from the base of the tank was the orifice of a yard drain, the trap of which had been broken, and impregnation of the water might even have taken place from rising sewer air. Contained, then, in this tank was practically a sewage-polluted water—a water capable, when mixed with milk, of generating Typhoid in the consumer. The final question might now be asked as to how this polluted water found its way into the churns, but to that question I shall not offer any answer. I only show the 27 presence of water in a condition pre-eminently fitted for the germination of Typhoid at a spot where, if my argument is conclusive, the milk must have been contaminated. To go further than this is to enter the region of conjecture and speculation, and that is beyond the province of this report. 28 APPENDIX A. Cases of Typhoid Fever occurring during March and April in South Brixton and Stockwell, and connected cases outside that area, receiving milk supply from Dairy B. No. Address. Age. Sex. Date of Notification. Date of Going to Bed. Dairy Supply No of Truck or Cart. 1 B. F. Pulross Road 20 F March 16 March 15 A - 2 A. A. Bonham Road 12 F „ 16 „ 10 B 15 T 3 A. C. Flaxman Road 9 M „ 19 ,, 14 C - 4 N. C. Mayall Road 28 M „ 19 „ 15 B 8 T Died 5 G. L. Loughboro' Park 26 F „ 21 „ 15 B 3 T Died 6 L. S. Lambert Road 21 F „ 22 ,, 22 B 21 T 7 B. Acre Lane 21 F „ 24 ,, - B 18 T Died 8 F. E. Lambert Road 51 M ,, 24 ,, 12 B 21 T 9 P.J. Holland Street 9 M ,, 27 „ 13 D - 10 W. G. Geneva Road 5 M „ 29 ,, 22 B 3 T 11 T. M. Burgoyne Road 11 F „ 30 „ 13 B 17 T 12 O. M. Crescent Lane 5 M „ 31 „ 20 B 1 C 13 N. A. Ridgway Road 52 F April 2 „ 24 B 17 T Died 14 A. C. Klea Avenue 12 M ,, 2 „ 26 B 1 C 15 C. P. Gresham Road 17 M ,, 2 ,, 27 B 4 T 16 H. F. Chale Road 16 M 2 „ 28 B 6 T Died 17 J. J. Barrington Road 25 M ,, 3 „ 24 B 14 C Died 18 E. J. Loughboro' Park 9 M ,, 4 „ 20 B 3 T 19 D. E. Gresham Road 25 F ,, 4 „ 26 B 4 T 20 S. L. Canterbury Road 5 M ,, 4 ,, 21 B 17 T 21 F. R. Hayter Road 5 M ,, 4 April 2 B 15 T 22 G. B. Geneva Road 16 F ,, 4 March 31 B 3 T Died 23 B. A. Talma Road 17 F ,, 4 „ 31 B 8 T 24 P. S. Mayfield House 32 M ,, 5 „ 22 B 22 T 25 M. F. Tunstall Road 8 F ,, 5 „ 26 B 6 T Died 26 H. Brixton Road 9 M ,,6 April 1 B 6 T 27 T. E. Loughboro' Park 20 F ,, 7 March 31 B 7 T 28 T. F. Arodene Road 7 M ,, 7 April 1 B 21 T 29 R. G. Leppoc Road 19 F ,,9 March 23 B 1 C 30 J. E. Elms Road 41 M ,, 9 „ 26 B 1 C Died 31 - Christchurch Road - - ,, 9 ,, - B 16 C 32 T. S. Camberwell Grove 1 M ,, 9 ,, 30 B 14 C 33 M. K. Tunstall Road 27 F ,, 9 „ 31 B 6 T 34 B. A. Sudbourne Road 34 F ,, 9 April 4 B 15 T 35 T.W.G. Camberwell Grove 19 M ,, 9 ,, 4 B 14 C 36 P. S. Leander Road 4½ M ,, 9 ,, 5 B 10 T 37 O. P. Brixton Orphanage 16 F „ 10 March 17 B 14 C 38 A. W. Kingswood Road 30 M „ 10 „ 25 B 16 C Died 39 H. W. Church Street 6 M „ 10 ,, 31 B 14 C 40 F. R. Herbert Road 58 F ,, 11 „ 28 B 20 T 41 B. E. Appach Road 9 F „ 11 „ 31 B 10 T 42 A. Dagmar Road 49 F „ 11 April 5 B 14 C 43 M. E. Tunstall Road 2 M ,, 12 „ 10 B 6 T 44 B. F. Tunstall Road 38 F ,, 13 „ 1 B 6 T 29 30 APPENDIX A.—Cases of Typhoid Fever occurring during March and April in South Brixton and Stockwell, and connected cases outside that area, receiving milk supply from Dairy B. No. Address. Age. Sex. Date of Notification. Date of Going to Bed. Dairy Supply No. of Truck or Cart. 45 M. R. Raeburn Street - F April 14 April 1 B 18T 46 S. A. Geneva Terrace 16 F „ 14 ,, 6 B 3 T 47 P. C. E. Cosbycote Avenue 2 M ,, 14 „ 13 B 12 C 48 S. W. H. Brixton Hill 5½ M „ 14 ,, 6 B 10 T 49 W. G. Overton Road 16 M „ 16 ,, 4 B 2 T 50 H. S. Dalberg Road 49 F „ 17 ,, 4 B 8 T 51 H. E. Brixton Road 32 F „ 18 „ 10 B 18 T 52 P. A. Landor Road 10 M „ 20 „ 11 E - 53 G. A. Camberwell Grove 19 F ,, 20 ,, 11 B 14 C 54 P. H. E. Fentiman Road 24 M ,, 21 ,, 11 B 9 C 55 H. A. Acre Lane 21 M „ 23 ,, 8 B 18 T 56 T. G. Shannon Grove 3 F „ 23 „ 12 B 6 T 57 W. F. Somerleyton Road 19 F „ 23 „ 12 B 8 T 58 C. M. Brandon Road 30 F ,, 28 ,, 21 B 6 C 59 W. C. Brixton Hill 20 F „ 30 „ 21 B 10T Case 13—Taken ill at Dover Mansions. Case 16—Worked at 468, Brixton Road. Case 57—Notified at Birmingham. 31 APPENDIX B. Typhoid Cases notified in the whole of London. Parish, Weeks From March 1st to April 22nd, 1894 Average No. of Cases per week. 1 st 2nd 3rd 4th 5th 6th 7th 8th Total Kensington - 1 3 - 1 - - 5 0.62 Fulham - - - 1 1 - - 2 0.25 Hammersmith 1 2 1 1 1 - - 1 7 0.87 Paddington 1 1 - 1 1 3 1 - 8 1 Chelsea 1 3 1 1 2 - 1 1 10 1.25 St. George's, Hn. Sq. - 1 1 - - - 1 1 4 0.5 Westminster - 4 - - - 1 - - 5 0.62 Marylebone - 3 - - 3 3 1 4 14 1.75 Hampstead 1 - 1 - - 2 1 2 7 0.87 St. Pancras - 2 3 4 - 2 1 2 14 1.75 Islington 1 2 5 1 4 2 2 3 20 2.5 Hackney 1 4 4 1 4 3 1 - 18 2.25 Holborn - 2 - - - - - - 2 0.25 Clerkenwell - 2 4 1 - - - 1 8 1 St. Luke's Middlesex - - 1 - - 2 - - 3 0.37 Shoreditch 1 1 1 1 - 1 1 - 6 0.75 Bethnal Green - 2 4 - 1 2 2 3 14 1.75 Whitechapel - - - - - - 1 - 1 0.12 St. George's-in-East - - 1 2 - 2 1 - 6 0.75 Limehouse - 1 1 4 - - - - 6 0.75 Mile End Old Town - 2 1 - 1 1 1 1 7 0.87 Poplar - 6 - 3 - - 2 1 12 1.5 St. George's, South'k - - - - - 2 - 1 3 0.37 Bermondsey - - - 2 1 - 1 - 4 0.5 Newington 1 1 - - 3 - 2 2 9 1.12 Rotherhithe - 1 - 1 1 1 - - 4 0.5 Battersea - 1 2 1 1 1 - 3 9 1.12 Wandsworth - 4 1 1 1 3 4 1 15 1.87 Camberwell - 3 3 3 2 3 4 2 20 2.25 Greenwich 1 6 2 8 - - 2 1 20 2.25 Lewisham - 1 - - 2 - - 2 5 0.62 Woolwich - 1 2 - 1 1 - - 5 0.62 Plumstead - 1 - - - - - 1 2 0.25 Lee - - - - 1 - - - 1 0.12 Lambeth 2 2 4 6 6 14 13 6 53 6.62 Comparison of the No. of cases notified in Lambeth with the remainder notified in the whole of London. 1st 2nd 3rd 4th 5th 6th 7th 8th 22.2 3.4 10.2 15.3 19.3 37.8 43.3 18.1 per cent. per cent per cent. per cent. per cent. per cent per cent. per cent. 32 APPENDIX C. The proprietary farm is situated on an oblong plot of ground, bounded on one side by the main road and a block of cottages, and on another by a brook or creek of running water. The farm buildings consist chiefly of sheds offering accommodation for 200 cattle. These are lofty, well ventilated, sufficiently lighted, and appear to be well adapted for the purpose they serve. Drains are constructed in a position parallel with the front wall of the buildings, but lying outside, and discharge their contents into the main sewer. They are intercepted in their course to the main sewer by the interposition of a syphon approached by means of a manhole walled with brick and closed with a gridded cover. A constant service of water is laid on in direct connection with mains from the Sutton Water Company, and on the premises stored in iron and concrete tanks. At the time when the visit of inspection was made to the farm, some suspicion attaching to the Water Supply, the service pipe was uncovered in a considerable part of its length where it lay in proximity to a drain, and examined. Nothing, however, was found confirming those suspicions. The proprietor was directed to properly trap the drain and ventilate it by shafts rising above the roof of the buildings. It was observed that the cattle were being partially fed on grass cut from the fields of a sewage farm situated in the vicinity, as blades of grass were discovered floating in milk, then in passage through strainers. It was directed that the use of herbage gathered from the sewage farm should be discontinued. 33 The risk also of contamination of milk by admixture of water taken from the brook that forms one of the boundaries of the farm was next considered. That danger should be apprehended from such admixture follows as the result of an investigation into the nature of the stream. It appears that water passing in this channel is the effluent from land under sewage cultivation, and sewage-polluted water lying in the vicinity of a dairy farm must always be regarded as constituting an element of danger. As evidence of the harmless character of the water in question, it was asserted by the proprietor that further down the channel the stream flowed through beds of watercress, and that people eating this greenmeat do not suffer from any unpleasant consequences. The proprietor was directed to cause the complete enclosure of the watercourse in that part of the channel adjacent to the dairy premises with a fence, so that any approach by employees of the farm should be effectually prevented. To ascertain whether milk coming from the proprietary farm was adulterated, samples were taken from churns in transit. When the van carrying them was about to unload at the Depot sixteen samples in all were procured and afterwards submitted to Dr. Muter for analysis. On ooking down the list on the last column of the table it will be noticed that with one exception every sample is declared by the analyst to contain added water. The extent of adulteration ranges from 2.5 per cent. to 16.5 per cent. As the standard employed by the public analyst is that of Somerset House, representing the poorest possible milk, the estimates of the quantity of added water is lower than the facts of the case warrant. Cows kept at the proprietary farm are exceptionally fine and extremely healthy in appearance, and it is unreasonable to suppose that they yield milk as poor d * 34 as that accepted as the standard at Somerset House. Fortunately for the purposes of this argument a single sample was taken from a churn containing genuine milk, and as before stated, was declared as such by the analyst. The manager at the farm had accidentally provided a standard by sending down in the van one churn containing genuine milk with the 15 containing adulterated milk. Taking this sample of genuine milk marked 7a on the table as the standard of comparison, the analyst found in the remaining samples adulteration to an extent ranging from 7.5 to 21.5 per cent. No. Total. Solids. Fa. Solids not Fat. Extraneous Water. Somerset House' Standard 11.50 3.00 8.50 none 4 A 10.76 3.00 7.76 8.7 5 „ 9.72 2.50 7.22 15.0 6,, 10.48 2.90 7.58 12.0 7 „ 12.00 2.90 9.10 none 8,, 10.42 3.10 7.32 14.0 9,, 10.62 3.30 7.32 14.0 10 „ 10.00 2.70 7.30 14.5 11 „ 10.24 2.60 7.64 10.0 12 „ 10.92 3.20 7.72 9.2 13 „ 9.50 2.40 7.10 16.5 14 „ 10.24 2.80 7.44 12.5 15 „ 11.18 2.90 8.28 2.6 16 „ 9.82 2.50 7.32 14.0 17 „ 1114 3.50 7.64 10.0 18 „ 9.30 1.40 7.90 7.0 19 „ 9.02 1.10 7.92 7.0 Average 10.27 2.67 7.60 10.6 35 The introduction of water into milk, coming from the proprietary farm, is accounted for by the condition of the refrigerator in use at that place. Pinholes, or perforations, have been discovered since the adulteration took place in the gridiron or coil, a section of the apparatus through which a stream of cold water constantly runs when the process of cooling is going on. Coils in general favour with dairymen are made of metal, rolled into exceedingly thin plates, in order that the pipe wall should interpose between the warm milk and cold water a medium that interferes in the least possible degree with thermic interchange. The delicate metal, however, is liable to perforation at any time in the ordinary exigencies of usage; and when puncture takes place, milk passing over the coil becomes dduted with water corresponding in amount with the volume of leakage from the enclosed current. Such an accident appears to have happened in connection with the refrigerator in use at the proprietary farm; at least the artificer who was summoned to examine it, declared to the existence of three extraneous apertures. How long watering had been going on, and to what extent dilution had reached through this subtle agency it is impossible to say, but added water in small quantity had been found in milk distributed by Dairy B. a few weeks before, and it is not unlikely that the same leakage was in operation then. The expediency of exercising a close supervision over the produce of dairies where refrigerators are at work is the moral of this discovery. D * 2 36 APPENDIX D. Table of Cases occurring severally in the inner or Truck served area and in the outer or Cart served area before the 7th April, the date when permission was granted to resume Supply from the proprietary farm: Trucks. Name. Address. Data of Notification. No. 3 G. L. Loughboro' Park March 21 W. G. Geneva Road ,, 29 E. J. Loughboro' Park April 4 G.B. Geneva Road ,, ,, „ 6 H. F. Chale Road, and Brixton Road ,, 2 M. F. Tunstall Road ,, 5 H. Brixton Road ,, 6 ,, 4 C. P. Gresham Road ,, 2 D. E. Gresham Road ,, 4 ,, 7 T. E. Loughboro' Park 7 „ 8 N. C. Mayall Road March 19 B. A. Talma Road April 4 ,, 15 A. A. Bonham Road March 16 F.R. Hayter Road April 4 ,, 17 T. M. Burgoyne Road March 30 N. A. Ridgway Rd. & Dover Mans. April 2 S. L. Canterbury Road ,, 4 „ 18 B. B. Acre Lane March 24 L. S. Lambert Road ,, 22 ,, 21 F.E. Lambert Road ,, 24 T. F. Arodene Road April 7 „ 22 P. S. Mayfield House ,, 8 CARTS. No. I O. M. Crescent Lane, Wandsworth March 31 A. C. Klea Avenue „ April 2 ,, 14 J. J. *Barrington Road ,, *Note.—Milk also obtained by this Householder at Dairy premises. 37 ACCIDENT CAUSED THROUGH THE DISCHARGE OF CHEMICALS INTO BROADWALL SEWER. The atmosphere of London sewers, although offensive to the sense of smell, seldom becomes so foul as to expose the lives of sewermen to the dangers of sudden poisoning or suffocation. Ordinary sewage when lying stagnant for considerable periods of time in old-fashioned brick-built and badly ventilated inverts, many of which still remain in connexion with the Metropolitan system, does not evolve gas in sufficient quantity or of such degree of potency as to reduce the atmosphere to a lethal state. Even when the means of ventilation are of the most primitive character, enough pure air is mixed with the impure to neutralize hurtful properties. Besides, people whose business it is to work in vitiated atmospheres are less sensitive than others to their unwholesome influence. By acclimatization they become, in a measure, impervious to the poison. Statistics, as far as they are obtainable, appear to confirm this view. Flushers engaged in the service of Local Authorities are liable as a class to no higher rate of mortality than workmen occupied in other kinds of Municipal employment. They do not suffer more frequently than others from the attacks of Zymotic disease, nor incur a greater risk from the chances of fatal accident. Indeed, deaths from suffocation in the Metropolitan sewers during the last twenty years may be counted on the fingers of one hand. Now, if dangerous fouling result from the presence of gas derived from the decomposition of ordinary sewage: Since many of the sewers of the Metropolis, traversed day after day by sewermen in the regular course of their employment, contain accumulated deposit to the depth of several inches, 38 accidents would be of daily occurrence rather than at intervals measured by years. Although not a matter of actual demonstration, it is a probable inference that in all cases where men are overcome by the lethal atmosphere of sewers, there is another factor at work besides that of ordinary sewer air, and in several instances where a thorough investigation has been made, the accident has been found attributable to the presence in the sewer of dangerous chemical compounds, which have reached its channel through drains from places where chemicals are used in the process of manufacture or refinery. Under existing conditions of the law, the discharge of dangerous chemical compounds into the sewer is a punishable offence. In the consideration of the circumstances attending the deaths of Baker and Garrod, whose lives were lost in the accident in Broadwall sewer, the particulars of which are here detailed, the fact should be kept in mind that this protective provision was made law not before the catastrophe had taken place, but afterwards. The accident of May 4th, resulting in the death of Baker and Garrod, took place in a section of Broadwall Sewer that lies between Commercial Road and Stamford Street. Built of brickwork, this sewer forms a capacious barrel measuring 4 ft. in its vertical and 2½ to 3 ft. in its horizontal diameter. The period of its construction dates back to the early years of the century, when the undivided control of sewers in the Metropolis was vested in the hands of Commissioners. Broadwall Sewer was originally an open ditch which constituted the boundary of the two parishes of Christ Church, Southwark, and St. Mary's, Lambeth, and both before and after it was covered in, it was used in common for the drainage of the houses in both parishes bordering on the Sewer. Some few years ago the Authorities of Christ Church 39 constructed a new Sewer for the use of their own district, and then most of the houses in the parish of Christ Church were disconnected from the old boundary Sewers, but the works of the Oil Refinery were still left to drain into the Boundary Sewer. The entrance of a shaft in Commercial Road, usually closed and hidden beneath the granite paving of the carriage way, marks the place where the channel of Broad wall Sewer attains its highest level, and indicates the point where Broadwall Sewer merges into continuity with that of Commercial Road. Sewage entering the Sewer from inlets on the western side of the shaft is conducted by the trend of the channel in a westerly direction towards Cornwall Road; while sewage entering on the eastern side is conducted in an easterly and southerly direction towards Stamford Street. From this arrangement of gradients it will be observed that no sewage entering the Sewer from inlets on the western side of the shaft finds its way into the Broadwall channel.* As the disused shaft in Commercial Road marks the highest point or summit of the channel, so a side entrance approached from a manhole in Stamford Street marks the lowest point or outlet. This manhole, furnished with a hinged cover and open grating, provides the only ordinary means of access to Broadwall Sewer. Between summit and outlet the channel, like that of all old sewers, follows an irregular course. A few yards from the summit the whole tube of the Sewer is changed in level. This part of the channel is called The Drop, The channel follows a course two feet below its former level. For a distance of 18 feet, where the channel passes beneath the shaft of a closed manhole, this level is maintained without any significant variation. From this point it takes a southerly direction * Vide plan, page 41. 40 and assuming a rising gradient slowly elevates itself in a course of 90 feet to a level some 4 inches above that of the lowest point traversed. The Sewer at this spot is characterized by a displacement sideways, and the jutting wall or buttress which marks the site of the dislocation receives the name of "The Offset." From the means it affords of identifying the place WHERE THE MEN FELL, the conformation of the Sewer at this point is a matter of considerable importance. The gradients from the Offset onwards still continue to rise slightly for a distance of some 60 feet or more, when the channel reaches an elevation of 10 inches above that of its lowest level. Thence the channel imperceptibly falls towards the outlet at Stamford Street. It is to be noticed that the irregularity of the channel favours the formation of a hollow or basin, the brim of which extends from the Drop to a point 60 feet beyond the Offset. At all times, except when emptied by cleansing operations, the basin retains water or sewage. The depression thus formed measures in its deepest part a depth of 10 inches, but growing shallower as the Offset is approached, its depth and volume beyond this point become insignificant. THE INLETS TO THE SEWER. The drains discharging into the Broadwall Sewer in that part of its course lying between summit and offset are four in number. The first in point of position and importance is that which conveys sewage and waste water from the Oil Refinery in Commercial Road. This drain enters at the head of the Sewer a few feet below the summit, and discharges its contents, which are thence conducted without any addition of any kind from any other source over that part of the DIAGRAM OF THE BROAD WALL BOUNDARY SEWER, SHOWING THE DROP IN COMMERCIAL ROAD. 42 channel which has received the name of the Drop. The effluent from the Oil Refinery, in fact, monopolizes this channel, and alone constitutes the stream issuing from the upper end of the Sewer. Three small houses contribute the remaining inlets, throwing their contents into the Sewer many feet beyond the closed manhole. The Broadwall Sewer was thoroughly cleansed in August, 1893. A large quantity of sludge, described by the workmen as chemical-looking stuff, was removed from that part of the Sewer lying in proximity to the inlet from the Oil Refinery. In disturbing the deposit the men complained that the silver in their pockets and silver watch-chains turned black, and even the man engaged in working the windlass on the surface noticed that his silver chain was blackened after a few hours. WORK ON THE DAY OF THE ACCIDENT. On May 4th, at 11.40 a.m., Ryder with his mates Baker and Garrod entered the Broadwall Sewer, descending by the manhole in Stamford Street. Their steps were directed in the first instance along that section of the Sewer lying on the south side of Stamford Street, being a continuation of that already described. The butt end having been reached at a distance of 350 feet from the entrance at Stamford Street, the flushers retraced their steps and approached the section which lies between Stamford Street and Commercial Road. The men were then traversing the Sewer destined later to become the scene of the accident. Ryder led the party, Baker followed and after him Garrod. The stooping attitude assumed by men moving along the channel of a low arched Sewer has the effect of depressing the head to the level of the shoulders or even the body. Since the vertical diameter of Broadwall Sewer measures barely four feet, the distance between the faces of the flushers and the channel of the Sewer 43 could not have exceeded two and a half feet. In this order and attitude the men pressed forward towards the summit of the Sewer passing the Offset with its exposed buttress, sweeping round the curve beneath Commercial Road, walking beneath the shaft of the closed manhole, and finally reaching the Drop, a distance in all from the Stamford Street entrance of 360 feet. The Sewer beneath the shaft of the closed manhole is sufficiently lofty to afford head space and standing room. Hence to this place the men repaired on their return journey from the Drop with the object of recording in their note books the results of their examinations. THE SIGN OF DANGER. Whilst engaged in this occupation Ryder noticed water pouring from that part of the channel monopolized by the issue from the Refinery, and steam in considerable volume rising from the incoming current as passing over the Drop it approached the place where the flushers stood. The men, alarmed, sought safety by immediately setting out towards the open manhole in Stamford Street, Garrod leading, Baker retaining the second place and Ryder following, the first and second men carrying lamps. When they had accomplished about 90 feet on their return journey Ryder experienced a choking sensation, and called on Baker to quicken his steps. Baker replied. Ryder observed Baker's figure moving in front of him and the buttress of the Offset projecting on his left side but noticed nothing more, nor does he remember anything until with returning consciousness he discovers that he is down and groping in the channel of the Sewer. Ryder's recollection of what ensued is naturally somewhat obscure, but he remembers creeping on some little distance and laying his hands on Baker's boots; 44 then scrambling over the body, and further on, coming upon Garrod, and finally he remembers reaching the side entrance to the manhole at Stamford Street, and after some delay being assisted to the surface. Ryder's watch had stopped whilst he was in the Sewer and the hands on the dial pointed to twenty minutes past three. Other circumstances indicate that as about the hour at which the accident took place, and that time was more than three and a half hours after the men had entered the Sewer. THE CAUSE OF DEATH. The bodies of the men, Baker and Garrod, were found lying several feet apart in the channel of the Sewer, near the place described as the Offset, with their faces submerged in sewage. The post-mortem examination revealed the fact that death had resulted from poisoning by sulphuretted hydrogen gas. The cause of death was certified by Dr. Merry of St. Thomas's Hospital, and his opinion was confirmed by Dr. Stevenson, Scientific Analyst to the Home Office, and by the Medical Officer of Health, Dr. Verdon. This opinion was further supported by the results of analysis of Sewage made by the Public Analyst. The Sewage had been taken the morning after the accident from the place where the men fell. The sample, when examined, was certified as containing sulphuretted hydrogen in sufficient quantity to occupy a tenth part of the volume.† Moreover the fluid when agitated by stirring gave off the deadly sulphuretted hydrogen gas with a commotion roughly to be compared with the effervescence of a highly charged mineral water. Even within two hours after the accident when McVeigh and Field of the search party came upon the scene, they experienced and afterwards described an atmosphere charged † Vide Appendix No. 1. 45 to a high degree with offensive vapours, with heat and with steam. THE CORONER'S ENQUIRY. The Jury empanelled to enquire into the circumstances attending the deaths of William Garrod and Richard William Baker held four sittings. The first was held on May 9th and the last on June 12th. The Coroner, in his address to the Jury, summed up the evidence at considerable length, and the jury returned a verdict accompanied by two riders fully in accord with the Coroner's charge. Copied from the Depositions the verdict runs as follows:— Verdict of the Jury.—That the deceased, William Garrod and Richard William Baker, came to their deaths by poisoning by sulphuretted hydrogen, in the Broadwall Boundary Sewer, on 4th May, 1894, and that the said cause was accidental. Riders to the Verdict.—We, the undersigned Jurors, empanelled to inquire into the deaths of William Garrod and Richard William Baker, are further of opinion that the cause of death of these two men is to be attributed to the wretched state of the Sewer, and the bad gases caused thereby, and particularly wish to censure the parish authorities for their careless supervision of this Sewer. We find that Messrs. Younghusband, Barnes & Co., did not tamper with their drains after the accident, and agree with the evidence given on their behalf entirely. THE RIDERS CONFLICT WITH THE VERDICT. The Verdict of the Jury standing alone, namely, that the men Garrod and Baker "came to their deaths from poisoning by sulphuretted hydrogen" (and without reference to the Riders which accompany it), is fully in accord with the opinion of the experts expressed before the Court. The 46 Riders, on the other hand, stand on a different footing. The affirmation that "the cause of death of these two men is to be attributed to the wretched state of the Sewer, and the bad gases caused thereby," is in direct disagreement with the evidence of scientific witnesses given at the enquiry, as it is inconsistent and at variance with the terms of the verdict itself. Sulphuretted hydrogen, in sufficient quantity to cause death, is not a product of Sewage under ordinary circumstances. When found, either the gas itself or the compounds from which it is derived, must have been introduced from an extraneous source. Dr. Letheby, when confronted with this question in 1861, and in reference to a similar accident, after careful analyses of samples taken from a number and variety of Sewers, arrived at the conclusion that sulphuretted hydrogen found in London Sewer air, unless introduced by some agency and from without, never exceeds 0•2 per cent. in volume. The largest contamination of the air of the oldest and most congested of the Parisian Sewers, determined by Gaultier de Claubry in 1829, was 12•5 per cent., and taking the mean of 19 analyses made by him, such contamination did not exceed •81 per cent.† To induce death, or even sudden collapse from poisoning by sulphuretted hydrogen, something more than the trace usually found in the most stagnant sewer air is needed. The celebrated French chemist, Duchatelet, inhaled an atmosphere containing 29 volumes per 1,000 for a considerable time without loss of consciousness. Coming nearer home, the workmen engaged on the construction of the † The Analyses of four samples of residual Sewage taken from Sewers of Lambeth, shows the presence of Sulphuretted Hydrogen respectively, in the following per centages, viz.: 0.07—0.22—2.05—0.38; these per centages represent the volume found in the Sewage itself, and not in the air of the Sewers. Vide Appendix, Nos. 6, 7, 8, 9. 47 Thames Tunnel suffered exposure from time to time to the effects of air contaminated with appreciable volumes of sulphuretted hydrogen without the occurrence of sudden catastrophe. These facts go to show that Sewer gas, even in a congested Sewer, does not contain sulphuretted hydrogen in quantities sufficient to cause death. Consequently the Verdict of the Jury and their Rider—the one affirming that "Baker and Garrod came to their deaths by poisoning by sulphuretted hydrogen," and the other asserting that "the cause of death of these two men is to be attributed to the wretched state of the Sewer, and the bad gases caused thereby"—are propositions incompatible and mutually destructive. DID THE CONDITION OF THE SEWER FACILITATE THE FORMATION OF SULPHURETTED HYDROGEN GAS? It might be urged on behalf of the jury that the words used carried a wider significance and interpretation than has been attributed to them. That the sentence, "The cause of death of these two men is to be attributed to the wretched state of the Sewer," should be taken in a more general and extended sense to mean the state of the Sewer was contributory to the cause of death. But even admitting this wider construction which, however, is at variance with the purport of the second Rider, the modified assumption implied therein is negatived by the evidence of ascertained facts. The only defects commented upon at the inquest, and consequently the only conditions to which the terms of the Rider may be made to apply, are firstly, the presence of residual sewage lying detained in the depression of the 48 Sewer; and secondly, an insufficient number of ventilating shafts. The depression is estimated to contain 620 gallons, and when full measures in its deepest part 10 inches. Nothing is discharged into it except from the inlet of the Oil Refinery, and below the Drop from the drains of three small houses. Six tons of waste water from the Refinery, or, in liquid measure, 2,350 gallons, are poured daily over the Drop, and are precipitated into the head of the depression lying 2 feet below. The flow is intermittent, each discharge lasting about 20 minutes. The volume discharged daily is sufficiently large to displace twice over the residual matters accumulating in the depression. The residual matter is chiefly water, but beneath the surface fluid a deposit collects from one inch to one and a half in thickness. TESTING THE RESIDUAL SEWAGE. On the morning after the accident a sample was taken from this depression for analysis, and the sewage was found to contain a ten per cent. admixture of sulphuretted hydrogen. The analysis also showed the presence, but in smaller quantity, of free sulphuric acid and sulphate of iron.* Much depends on whether this sample fairly represented the ordinary and normal condition of the residual contents of this Sewer, in other words, whether sulphuretted hydrogen in quantity was a product and constant constituent, or whether its presence on this occasion was accidental. If it can be shown that the sludge of the Sewer generates sulphuretted hydrogen gas in quantity and afterwards serving as a magazine holds it in * Vide Appendix No. 1. 49 suspension, then with some show of reason it may be argued that the condition of the Sewer was contributory to the result. If, on the other hand, it can be demonstrated that sulphuretted hydrogen in large volume is not a normal constituent, but as a matter of fact was found on this occasion only, then the fouling of the atmosphere of the Sewer at the time of the accident, and the fouling of the residual sewage, should be regarded as the work of one and the same agency. SUBSEQUENT TESTS OF RESIDUAL SEWAGE. In order to put the question to the test of experiment, sufficient time was allowed to pass after the accident to permit the fouling, which manifestly accompanied that event, to clear away, and the Sewer to resume its normal condition. After the lapse of 12 days, on May 16th, the depression from which the first sample was taken was again requisitioned. On this occasion it was found that the sulphuretted hydrogen which before was so large a constituent had almost entirely disappeared. Analysis proved that this gas was now represented only by a percentage of 1.21.† To provide against any accidental inaccuracy a third sample was taken on May 19th. The result of analysis proved to be even more significant than on the previous occasion. Sulphuretted hydrogen in the interval had entirely disappeared. The sample did not show a trace.‡ The Sewer was kept under observation for many days, and as the characteristic odour of sulphuretted hydrogen was not again noticed, further investigation by analysis was deemed unnecessary. † Vide Appendix No. 2. ‡ Vide Appendix No. 3. E * 50 THE SEWER BECAME SUDDENLY A LETHAL CHAMBER. Direct examination of the residual contents of this Sewer so far point to the conclusion that the presence of sulphuretted hydrogen on the day after the accident was exceptional, and the result of the general fouling which must have taken place on the 4th of May. When it is said that the fouling must have taken place on the 4th May the words are used advisedly. A week before that date the flushers had traversed the Sewer as far as the Offset, passing through the residual sewage near the Drop without experiencing any inconvenience or observing anything unusual. Had the residual sewage harboured sulphuretted hydrogen gas in quantity, then nothing could have prevented its detection. On the very day of the accident the men were engaged in this same Sewer for three-and-a-half hours, one of which was spent in that part of the channel now under notice. Yet until three o'clock they neither felt nor observed anything hurtful or unpleasant. They had traversed the Sewer from end to end, they had waded through the entire length of the residual sewage with their faces about two feet removed from the sludge; yet Ryder, in his sworn depositions declares, " There was no smell in the Sewer." Moreover, Ryder, in his evidence, indicates the advent of the fouling agency when observing an impour from that part of the Sewer lying above the drop. He says "it looked like warm oil and water," it "gave off the same smell as I afterwards smelt and it made me feel faint." Had the residual sewage, through which these men were passing, contained sulphuretted hydrogen in quantity, symptoms of poisoning would have asserted themselves before it had been stirred into ripples by the movement of their feet. 51 Ryder's evidence is conclusive that sulphuretted hydrogen had not effected a lodgment in the sludge of the Sewer before three o'clock on the day of the accident. The condition of the Sewer before the accident and the condition after, both tend towards the conclusion that the fouling of the residual sewage and the fouling of the atmosphere of the Sewer must have been on May 4th, after three o'clock, and that both were effected by the operations of an extraneous agency. DID LACK OF VENTILATION CONTRIBUTE? In a charge to the Jury of considerable length, the Coroner referred to the ventilation of Broadwall Sewer and intimated an opinion that, had a better system been in vogue, gases forming in the Sewer would have been readily dissipated. Since, however, sulphuretted hydrogen gas which, in this instance, was the cause of the mischief, is heavier than air, it is not easy to understand what system the Coroner had in view when he gave utterance to this reflection. Ventilation by shafts and inlets—the method usually employed—except in conjunction with mechanical or other motor force must prove ineffective in the elevation of a heavy medium through a lighter one. The inadequacy of the ordinary means of ventilation in dealing with this dangerous gas is emphasized in the history of a case of poisoning which took place in Germany, and is related by Casper, a celebrated German Pathologist. Casper's Works, translated and published by the Sydenham Society, give the particulars of the case at length. A wooden box had been sunk in the earth to serve the purpose of a tan pit, and an aperture made at the bottom furnished a means of communication with a channel traversing the ground below. Unfortunately, waste products. E * 2 52 prominent among which was a fluid containing 17 per cent. of sulphuretted hydrogen, were conveyed along this channel. A workman, engaged in completing the fittings of this open tank, was observed by his mates, who were standing hard by, to sink down apparently affected by some sudden seizure. An employe immediately descended to render assistance, and after him a second and a third ; but no sooner did they enter the tank than they in like manner fell. The Master of the Works, at a loss to understand what was going on, himself descended and immediately became unconscious. Nor was he the last victim in this strange catastrophe. Others following his example rushed to the rescue. When ultimately the gravity of the situation was fully realized, and effective assistance had been obtained, the men were removed from the tank. Of those who entered four were taken out unconscious, but alive, the remaining six were dead. This remarkable example of poisoning in a tank open to the air demonstrates the futility of relying upon ventilation, even of the most advanced kind, to mitigate the fatal effects of sulphuretted hydrogen when this gas appears in quantity in a covered sewer. HOW CAME THE GAS INTO THE SEWER? The question now remaining for consideration is the source of the sulphuretted hydrogen which fouled the sewer between three and four o'clock on the afternoon of May 4th. Several points connected with the evidence of Ryder, the appearance of the dead men, and the position in which their bodies were found, materially assist in this part of the investigation. When the bodies of Baker and Garrod were examined after death, each of them exhibited large contused wounds on their foreheads. They were such as might have been inflicted by rough contact with the brickwork 53 lining the channel of the Sewer. To cause wounds such as these the contact must have been violent. The flushers must have fallen like men shot, without even extending an arm to save themselves. The lethal effects of the poison must have been instantaneous. When poisoning takes place from sulphuretted hydrogen gas, if the dose be moderate the effects are gradual and the symptoms are characterised by headache, numbness, and nausea. On the other hand, if the dose be large, the effect is instantaneous, and the poison acts as would a narcotic. The wounds on the foreheads of these men may be regarded as an indication that the advent in the Sewer of sulphuretted hydrogen was sudden, and that it approached the men in overwhelming quantities. The position of the bodies marks the order in which they fell, and declares the direction from which the poisonous gas was approaching them. The last thing Ryder noticed before unconsciousness overwhelmed him was the figure of Baker. At this moment the men were advancing in close order. When Ryder returned to consciousness he and Baker were lying several feet apart. Moreover, Garrod's body was found several feet in front of that of Baker. The relative position of the bodies indicates that Ryder went down first, while the other two were still moving on. Then Baker fell, and afterwards Garrod. Had they fallen in the reverse order, Baker must have stumbled over Garrod, and Ryder would have noticed Baker's fall. The bodies of the men would have been found lying together and not separated from each other as they were by many feet. It has already been shown that when the gas reached the men its effect upon them must have been instantaneous. As Ryder was the first to fall and then Baker, and then Garrod, it is sufficiently obvious that the gas must have 54 approached the men from behind, overtaking them on their way to Stamford Street. Moreover, the fact of Ryder's return to consciousness is evidence that the wave of sulphuretted hydrogen, travelling southward along the tunnel of the Sewer, did not occupy any considerable period of time in its passage. Had the duration of that period been prolonged the poison which had shown itself capable of depriving Ryder of consciousness would certainly have finished its work. The further fact that the search party found themselves able to enter the Sewer and remove the bodies is proof that the bulk of the gas had passed away. THE TRUE EXPLANATION. The conclusion deduced from the foregoing facts is that a wave of air, densely impregnated with sulphuretted hydrogen, passed along Broadwall Sewer at the moment of the accident, travelling southward from the direction of Commercial Road, and that such transit was coincident in point of time and approximate in point of duration with a discharge of oily fluid and steam entering the Sewer. The oily fluid and steam entering the Sewer immediately before the accident had been observed by Ryder to be flowing over the Drop, and consequently coming from that section of the channel lying above. Between the summit and the place where Ryder was standing, no drain has an inlet of discharge into the Sewer with the exception of that from the Oil Refinery. The source of the inpour observed by Ryder is not then a matter of doubt. When Ryder says in his depositions, "It looked like warm oil and water, it gave off the same smell as I afterwards smelt, and it made me feel faint," he was speaking of the fluid now traced to the drain of the Oil Refinery. 55 A sample taken from the inlet of this drain on May 16th and submitted to analysis was found to contain small quantities of free sulphuric acid, sulphate of iron, and sulphuretted hydrogen.* In this trio of chemical constituents† the sample corresponds qualitatively with that taken on the day after the accident from the place where the men fell. As it is not the object of this report to incriminate this person or that, but simply to trace the cause of the accident, so it is not necessary to prove that the formation of sulphuretted hydrogen in large volume in this private drain did take place, but amply sufficient for the purpose to show that it could take place. Although fouling the sewer to the extent witnessed on May 4th may never recur, yet it can be shown that chemical compounds are in store in the Oil Refinery, capable when entering the drain lying beneath those premises, of producing sulphuretted hydrogen gas in unlimited quantity, and that the bursting of a butt, the breakage of a carboy, or even the accidental turning of a tap,‡ might at any moment let loose activities that would a second time sweep the sewer with a wave of lethal gas. APPENDIX. The following Certificates were issued by— Dr. MUTER, f.r.s.e.d.: f.i.c.; f.c.s.; Analyst to the Metropolitan Asylums Board: Public Analyst for Lambeth, Southwark, Newington, Rotherhithe, the Wandsworth District, and the County of Lincoln (Lindsey Division). 325, Kennington Road, S.E. London, 8th May, 1894. No. 1. Samples of Residual Sewage taken from Broadwall Sewer on May 5 th, the day after the accident. * Vide Appendix, No. 4. †Vide Appendix, Nos. X & 4. ‡ Vide Appendix, No. 5. 56 Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 5th May, 1894. Sulphuria Acid 0.13 Sulphate of Iron ... 0.60 by weight per cent. Sulphuretted Hydrogen 10.00 by volume per cent. No. 2. Sample of Residual Sewage taken from Broadwall Sewer on May 16 th. 19th May, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 16th May, 1894. Sulphuric Acid 2.84 per cent. by weight. Sulphuretted Hydrogen 1.21 per cent. by volume. No. 3. Sample of Residual Sewage taken from Broadwall Sewer on May 19th. 25th May, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 22nd May, 1894. Sulphuric Acid 1.47 per cent. Sulphuretted Hydrogen None. No. 4. Sample of Effluent taken from the Oil Refinery Drain on May 16 th. 19th May, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, 16th May, 1894. Sulphuric Acid 1.27 Sulphate of Iron 0.60} by weight per cent. Sulphuretted Hydrogen 0.40 by volume per cent. 57 No. 5. Sample of Waste Products taken from a *Tank on the Premises of the Oil Refinery. 25th May, 1894. Certificate of Analysis of Refuse Liquid from a Tank, received from Dr. Verdon, Lambeth, on 22nd May, 1894. Free Sulphuric Acid 54.63 Combined Sulphuric Acid .21 Organic Matter 10.80 Sulphate of Iron .30 Water, &c. 34.06 100.00 No. 6. Sample of Residual Sewage taken from Camberwell New Road Sewer on June 28th. 30th June, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 28th June, 1894 (Camberwell New Road Sewer). This Sewage contains 0.07 per cent. by volume of Sulphuretted Hydrogen. No. 7. Sample of Residual Sewage taken from Webber Street Sewer on June 28th. 30th June, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 28th June, 1894 (Webber Street Sewer). This Sewage contains 0.2 2 per cent. by volume of Sulphuretted Hydrogen. *The tap at the foot of this tank was placed over the mouth of the drain and liquid having the same appearance as that contained in the tank was found in the trap of the drain. 58 No. 8. Sample of Residual Sewage taken from Walnut Tree Walk Sewer on June 28th. 80th June, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 28th June, 1894 (Walnut Tree Walk Sewer). This Sewage contains 2.05 per cent. of Sulphuretted Hydrogen by volume, thus indicating the entrance of some trade refuse or other matter than ordinary Sewage. No. 9. Sample of Residual Sewage taken from Paradise Road Sewer on May 28th. 30th Jnne, 1894. Certificate of Analysis of Sewage received from Chief Inspector Baxter, Lambeth, on 28th June, 1894 (Paradise Road Sewer). This Sewage contains 0.38 per cent. by volume of Sulphuretted Hydrogen. 59 COMBINED DRAINAGE. Under Sec. 68 of the Metropolis Local Management Act, quoted below, it will be observed that all sewers in the Parish of Lambeth, save those vested in the London County Council, are the property of the Vestry, and under Sec. 69 their maintenance and repair is an obligation on the Vestry. In many recent decisions the Courts of Law have ruled that a considerable part of the channel in combined systems of drainage, even when on private property and beneath the sites of houses, are, under certain conditions, sewers, and maintainable by the Parish Authorities. In order that the Committee may fully understand the practical bearings of the many cases which, from time to time, I shall find it my duty to submit to their notice, I have given short definitions of the words "sewer" and "drain," together with a description of when a drain becomes a sewer within the meaning of the Act. I have prefaced these remarks with a copy of the Sections of the Metropolis Local Management Acts relating to combined drainage, and I have concluded with a few recommendations which are put forward for your consideration. Sections of the Metropolis Local Management Act relating to combined drainage. Sec. 250, 18 & 19 Vict., c. 120.—The word "drain" shall mean or include any drain of or used for the drainage of one building only, or premises within the same curtilage, and made merely for the purpose of communicating with a cesspool or other like receptacle for drainage, or with a sewer into which the drainage of two or more buildings or premises occupied by different persons is conveyed, and shall also include any drain for draining any group or block 60 of houses by a combined operation under the order of any Vestry or District Board. Sec. 112, 25 & 26 Vict., c. 102. The word "drain" shall be deemed to apply to and include the subject matter specified in sec. 250, 18 & 19 Vict., c. 120, and also any drain for draining a group or block of houses by a combined operation laid or constructed before the 1st day of January, 1856, pursuant to the order or direction, or with the sanction or approval of the Metropolitan Commissioners of Sewers. Sec. 250, 18 & 19 Vict., c. 120. The word "sewer" shall mean and include sewers and drains of every description except drains to which the word "drain" interpreted as aforesaid applies. Sec. 68, 18 & 19 Vict., c. 120. All sewers made or to be made within any such parish (parishes mentioned under Schedule A of the Act, in which Lambeth is included), except sewers or works vested or to be vested in the Metropolitan Board of Works as hereinafter mentioned, shall be vested in such Vestry. Sec. 69, 18 8c 19 Vict., c. 120. The Vestry . . . shall . . . from time to time repair and maintain the sewers under this Act vested in them. Definition of the word " Drain." A channel that conveys sewage, waste or surface water, discharging from one house only. Definition of the word " Sewer." A channel that conveys sewage, waste or surface water, discharging from two or more houses. When a Sewer becomes a Drain within the meaning of the Act. When it drains a group or block of houses on a combined 61 system, and when constructed after 1st day of June, 1856, under the order of a Vestry or District Board, or when constructed before the 1st day of June, 1856, pursuant to the order and direction, or with the sanction and approval of, the Metropolitan Commissioners of Sewers. Therefore, to prove that a "sewer" is a "drain" within the meaning of the Act, it is necessary that evidence be produced that such sewer was constructed under the order of the Vestry, or under the order or approval of the Commissioners of Sewers. Consequently, when no evidence of such order or approval is forthcoming, a channel that conveys sewage, waste or surface water from two houses or more is a "sewer" within the meaning of the Act, and whether situated on private or public property, its ownership is in the Vestry, and its maintenance and repair are the concerns of the Vestry. Recommendations. That the list specifying cases of drainage constructed under the order of the Vestry, or under the order or direction or with the sanction or approval of the Commissioners of Sewers, be made as complete as the records preserved at the office and elsewhere will permit, and that an index arranged alphabetically be prepared, affording means for the identification of property, the name and description of which has undergone change. That the Vestry be advised to recognise its position and responsibility in cases of defective sewers, when, after search of the records has been made, no evidence of order or sanction is traceable. Since owners of property have, from time to time, illegally conducted operations of combined drainage without the knowledge, order, or sanction of the Vestry, and have, by 62 such illegal action, caused the cost of maintenance and repair of such combined systems, or parts of them, to become a prospective charge on the public rates, the Vestry be advised to take whatever steps may be deemed necessary for securing an amendment of the law relating to combined drainage to the effect that, in the event of disputes arising between the Vestry and owner, having regard to the cost of repair or maintenance of combined systems of drains, or parts of them, that the fact of the existence of a combined system of drainage shall be regarded by the court adjudging the case as sufficient evidence that such system was laid under the order and by the sanction of the Vestry, or in other terms that may appear advisable. 63 THE BIRTH RATE. The number of births registered in Lambeth during the year 1894, reaches a total of 9232 cases, 10 more than the number registered in 1893. The number of male children exceeds by 228 that of female. During the year in the entire Metropolitan area 130,553 births are recorded: 67,685 males and 65,290 females. The table shows the number of births registered in each year for the last ten years: Year. No. of Births. Year. No. of Births. 1894 9232 1889 8906 1893 9222 1888 9074 1892 9226 1887 9143 1891 9099 1886 9074 1890 9017 1885 9143 The birth rate for Lambeth, calculated for the year 1893, is 32.9 per 1000 inhabitants. The Metropolitan rate for the same period is 31.0 per 1000. 64 The number of Births in each District, and a comparison of the number of Births registered in each Quarter. District Population. March. June. September. December. Total. Rate per 1000. Male. Female. Male. Female. Male. Female. Male. Female. Waterloo Road, 1st 14,031 70 74 62 50 63 50 65 64 498 36.6 Waterloo Road, 2nd 14,644 109 I31 116 115 126 132 152 136 1008 {Lying-in {Hospital Lambeth Church, 1st 18,024 66 77 63 79 94 62 96 85 624 33.9 Lambeth Church, 2nd 39,147 225 206 197 176 185 198 210 175 1553 41.9 Kennington, 1st 52,476 232 242 189 228 229 216 230 221 1802 34.4 Kennington, 2nd 44,751 135 115 134 147 136 122 139 116 1053 26.2 Brixton 75,999 305 264 284 239 257 228 258 223 2037 26.2 Norwood 26,779 90 79 79 79 76 84 88 80 657 24.6 285,851 1223 1187 1124 1145 1145 1107 1238 1100 9232 32.9 2410 2237 2287 2338 65 MARRIAGE RATE. The number of marriages celebrated in Lambeth shows a decrease upon last year's figures of 126. Like the birth rate, the marriage rate has fallen year by year. The number of marriages is diminishing, notwithstanding the increase of the population. Number of marriages in the Metropolis, 36,902. Year. No. of Marriages. Year. No. of Marriages. 1894 2224 1889 1997 1893 2233 1888 1985 1892 2107 1887 2066 1891 2140 1886 2184 1890 2060 1885 2275 Calculated for the year, the Marriage rate for Lambeth is 15.4 per 1000. The Metropolitan rate for the same period being 17.0 per 1000. 66 DEATH RATE. Deaths from all causes registered in Lambeth during 1894, and properly belonging thereto, number 4848. In this computation parishioners dying in public Institutions of all characters and denominations situated outside the boundaries of Lambeth are included. But non-parishioners dying in public Institutions situated within the boundaries are excluded. Calculated for the year the death rate of Lambeth is 17.2 per 1000. The Metropolitan rate for the same period being 17.8 per 1000. In the Metropolis the registered deaths numbered 75,262; of these 46,853 were males, and 44,683 were females. The death rate in the five great groups of districts is as follows:— South Districts 19.9 West Districts 18.7 Central Districts 26.6 North Districts 20.0 East Districts 25.1 67 TABLE Showing the mortality rate per 1000, in each Registration Sub-District. Sub-Districts. Estimated Population. Total Mortality. Mortality Rate per 1,000. Inner Group of Sub-Districts. Waterloo Road, 1st 14,031 311 22.2 Waterloo Road, 2nd 14,644 267 18.3 Lambeth Church, 1st 18,024 810 45.0* Lambeth Church, 2nd 39.147 1071 27.4* Outer Group of Sub-Districts. Kennington, 1st 52,476 703 13.4 Kennington, 2nd 44,751 495 11.0 Brixton 75,999 1225 16.1 Norwood 26,779 328 12.3 Lambeth 285,851 5211 * 17.2 * These figures include the deaths of strangers who died in the public Institutions of Lambeth. F * 2 68 The following table shows the mortality, male and female, including strangers, in the different districts, and a comparison of the number of deaths in each quarter. SUB-DISTRICT. March. Male. Female. Total. June. Male. Female. Total. September. Male. Female. Total. December. Male. Female. Total. Total No. of Deaths in each District. Waterloo Road, 1st 35 43 78 35 51 86 36 42 78 36 33 69 311 Waterloo Road, 2nd 34 39 73 32 26 58 30 31 61 32 43 75 267 Lambeth Church, 1st. 126 72 198 114 87 201 129 93 222 90 99 189 810 Lambeth Church, 2nd 187 164 351 135 117 252 128 122 250 120 98 218 1071 Kennington, 1st 108 100 208 85 90 175 72 83 155 84 81 165 703 Kennington, 2nd 74 91 165 59 58 117 47 49 96 61 57 118 495 Brixton 197 200 397 148 161 309 120 134 254 124 141 265 1225 Norwood 43 54 97 46 49 95 40 28 68 32 36 68 328 Totals 804 763 1567 654 639 1293 602 582 1184 579 588 1167 5211 Making a total of deaths in Lambeth—March 1567, June 1293, September 1184, December 1167. 1456 persons died in the public institutions, including 762 strangers. The number of strangers was greater by 111 than in the preceding year. 69 PRINCIPAL ZYMOTIC DISEASES. Deaths from the principal Zymotic diseases registered in Lambeth, and properly belonging thereto, number 707. In this computation parishioners dying in public institutions situated outside the boundaries of Lambeth, being chiefly the hospitals of the Asylums Board, are included, while non-parishioners dying in public institutions situated within the boundaries are excluded. Calculated for the year, the Zymotic death rate of Lambeth is 2 8 per 1,000, the Metropolitan rate for the same period being 32 per 1,000. During the year 1894, under the Notification Clauses of the Public Health Act, 2,549 cases of infectious disease have been reported. Of this number 865 were removed to the Hospitals of the Asylums Board, and 1,684 remained under medical treatment at their own homes. In accordance with the resolution of the Vestry, a Sanitary Inspection was made and the drain test applied in every infected house. The infected houses numbered 2,012, two or more cases occasionally occurring under the same roof. The sanitary defects discovered are grouped under two headings; under the first is found a list of such defects as are referable to the condition of traps, fittings, and appliances. The second has special reference to the drains lying underground and to the soil pipes. 1,089 houses are reported as subject to nuisances arising from defects classed under one or both headings. In 464 houses faults in connection with the drains permitted the escape of sewage or sewage gas; but in 980 defects were observed in the traps, fittings, and appliances. The existence of Scarlet Fever was notified in 965 houses, and sanitary defects were discovered in 530. Diphtheria made its appearance in 463 houses, and sanitary defects were discovered in 261. Typhoid Fever caused an examination to be made in 225 houses, and sanitary defects were discovered in 132. Erysipelas invaded 229 houses, and sanitary defects were discovered in 114. Continued Fever was reported as present in 48 houses, and sanitary defects were discovered in 18. Croup appeared in 26 houses, and sanitary defects were discovered in 7. Small Pox infected 22 houses, and sanitary defects were discovered in 10. Diarrhoea, having been notified under the designation of Cholera, attracted the attention of the Inspectors to 10 houses, 4 of which were the subjects of sanitary defects. Two houses were reported as being infected with Typhus. Sanitary defects discovered in 1. 70 SMALL POX. During the year 26 cases of Small Pox were certified as occuring in the Parish of Lambeth; 18 cases were removed for treatment to the Hospital and 8 cases remained under treatment at home. One death was reported from this disease. In the Metropolis 13 deaths occurred. Sub-Districts. Estimated Population Total No. of Cases Notified Cases Treated at Home. Cases removed to Hospital. No. of Deaths. At Home. In Hospital Inner Group of Sub-Districts— Waterloo, 1st 14,031 4 1 3 ... ... Waterloo, 2nd 14,644 ... ... ... ... ... Lambeth Ch., 1st 18,024 2 ... 2 ... ... Lambeth Ch., 2nd 39,147 3 2 1 ... ... Outer Groups of Sub-Districts— Kennington, 1st 52,476 9 1 8 ... 1 Kennington, 2nd 44,751 4 3 1 ... ... Brixton 75,999 1 1 ... ... ... Norwood 26,779 3 ... 3 ... ... Lambeth 285,851 26 8 18 ... 1 71 SCARLET FEVER. During the year 62 deaths are reported as having occurred from Scarlet Fever. To this cause during the preceding year 69 deaths were attributed. 1198 cases of attack, however, were reported to the Sanitary Department. 517 cases remained under treatment at home, and 681 cases were removed to the Hospitals of the Asylums Board. In the Metropolis 837 deaths were registered. Registrars' Districts. Estimated Population. Total No. of Cases Notified Cases treated at Home. Cases removed to Hospital. No. of Deaths. At Home. In Hospital. Inner Group of Sub-Districts. Waterloo, 1st 14,031 18 12 66 — 3 Waterloo, 2nd 14,644 54 T5 39 — 5 Lambeth Ch , 1st 18,024 99 32 67 1 6 Lambeth Ch., 2nd 39,147 131 44 87 1 7 Outer Group of Sub-Districts. Kennington, 1st 52.476 209 85 124 2 3 Kennington, 2nd 44,751 175 75 100 1 8 Brixton 75,999 323 179 144 9 11 Norwood 26,779 129 75 54 — 2 Lambeth 285,851 1198 517 681 17 45 72 WHOOPING COUGH. Table showing the number of deaths and distribution in the Sub-Districts. In the Metropolis, from this disease, 2,063 deaths were registered. Sub-Districts. Estimated Population. Number of Deaths. Inner Group of Sub-Districts. Waterloo Road, 1st 14,031 3 Waterloo Road, 2nd 14,644 11 Lambeth Church, 1st 18,024 7 Lambeth Church, 2nd 39,147 15 Outer Group of Sub-Districts. Kennington, 1st 52,476 24 Kennington, 2nd 44,751 13 Brixton 75,999 30 Norwood 26,779 6 Lambeth 285,851 109 73 MEASLES. Table showing the number of deaths and distribution in the Sub-Districts. In the Metropolis, from this disease, 3,287 deaths were registered. Sub-Districts. Estimated Population. Number of Deaths. Inner Group of Sub-Districts. Waterloo Road, 1st 14,031 31 Waterloo Road, 2nd 14,644 23 Lambeth Church, 1st 18,024 '9 Lambeth Church, 2nd 39,147 35 Outer Group of Sub-Districts. Kennington, 1st 52,476 17 Kennington, 2nd 44,751 15 Brixton 75,999 27 Norwood 26,779 15 Lambeth 285,851 182 74 DIPHTHERIA. Table showing the number of cases, deaths and distribution in the Sub-Districts. In the Metropolis, from this disease, 2,675 deaths were registered. Sub-Districts. Estimated Population. Number of Cases Notified. N umber of Deaths. Inner Group of Sub-Districts. Waterloo Rd., 1st 14.031 58 10 Waterloo Rd„ 2nd 14,644 32 7 Lambeth Ch., 1st 18,624 48 12 Lambeth Ch., 2nd 39,197 95 26 Outer Group of Sub-Districts. Kennington, 1st 52,476 138 24 Kennington, 2nd 44,751 84 21 Brixton 75,999 131 37 Norwood 26,779 35 4 Lambeth 285,851 521 141 75 TYPHOID FEVER. Table showing the distribution of the disease in the SubDistricts. In the Metropolis, from this disease, 635 deaths were registered. Estimated Population. Number of Cases. Notified. Number of Deaths Inner Group of Sub-Districts. Waterloo Rd., 1st 14.031 8 2 Waterloo Rd., 2nd 14,644 23 5 Lambeth Ch., 1st 18,024 27 5 Lambeth Ch., 2nd 39,147 27 7 Outer Group of Sub-Districts. Kennington, 1st 52,476 33 6 Kennington, 2nd 44,751 40 7 Brixton 75,999 97 11 Norwood 76,779 13 4 Lambeth 285,851 268 47 76 PUERPERAL FEVER. Table showing the number of cases, deaths and distribution in the Sub-Districts. In the Metropolis, from this disease, 210 deaths were registered. Sub-Districts. Estimated Population. Number of Cases Notified. Number of Deaths. Inner Group of Sub-Districts. Waterloo Road, 1st 14,031 1 — Waterloo Road, 2nd 14,644 — — Lambeth Church, 1st 18,024 2 — Lambeth Church, 2nd 39,147 3 I Outer Group of Sub-Districts. Kennington, 1st 52,476 6 2 Kennington, 2nd 44,751 2 — Brixton 75,999 4 — Norwood 26,779 1 — Lambeth 285,851 19 3 77 ERYSIPELAS. Table showing the number of cases, deaths, and distribution of the disease in the Sub-Districts. In the Metropolis, from this disease, 424 deaths were registered. Sub-Districts. Estimated Population. Number of Cases Notified. Number of Deaths. Inner Group of Sub-Districts. Waterloo Rd., 1st 14,031 14 2 Waterloo Rd., 2nd 14,644 8 1 Lambeth Ch., 1st 18,024 16 2 Lambeth Ch., 2nd 39,147 103 3 Outer Group of Sub-Districts. Kennington, 1st 52,476 56 3 Kennington, 2nd 44,751 48 4 Brixton 75,999 51 2 Norwood 26,779 19 — Lambeth 285,851 315 17 78 DIARRHŒA. During the year 1894 there was an increase in the number of deaths from Diarrhoea, the number registered being 144, including three deaths from so-called Cholera, and exclusive of strangers, against 205 in the preceding year. In the Metropolis 1,774 deaths were caused by Diarrhœa. The disease in Lambeth, for the most part, proved fatal in children; 117 of the cases registered are those of children under 5 years of age, and 27 only above that age. July, August, and September were the most fatal months. 97 deaths were registered in those which proved the hottest months of the year. The following table shows the distribution of deaths in the Sub-Districts. Sub-Districts. Estimated Population. Number of Deaths. Inner Group of Sub-Districts. Waterloo Road, 1st 14,031 11 Waterloo Road, 2nd 14,644 14 Lambeth Church, 1st 18,024 4 Lambeth Church, 2nd 39,147 42 Outer Group of Sub-Districts. Kennington, 1st 52,476 22 Kennington, 2nd 44,751 14 Brixton 75,999 23 Norwood 26,779 14 Lambeth 285,851 144 79 Return showing the number of Nuisances removed or abated in the Parish of Lambeth, from the 1st January to 31st December, 1894. Number of Cases 6975 Public Health (London) Act. Notices served 2334 Small Pox 22 Scarlet Fever 965 Typhoid 225 Measles 182 Diphtheria 463 Chicken Pox 1 Diarrhœa 144 Puerperal Fever 17 Erysipelas 229 Membranous Croup 26 Continued Fever 48 English Cholera 10 Asiatic Cholera — Typhus 2 Total 2334 80 Public Health (London) Act, and Metropolis Local Management Act. Notices served 4641 Works Structural:— Drainage Defective 1082 Intercepting Traps with Fresh Air Inlets required 621 Ventilating Pipes required 604 Indoor Sinks connected with the Drain 642 Rain Water Stack Pipes connected with the Drain 764 Bath Waste connected 31 Traps Defective, or of Obsolete Pattern 1558 Closet Pans and Connections Defective 655 Water Supply to Closet Defective 166 Closet Dilapidated 145 Draw Off from Main for Drinking Purposes required 460 Dust Bins Defective 519 Premises Dilapidated 105 Ventilation under the Floors required 411 Roofs Dilapidated 314 Soil Pipes Defective 41 Paving Defective 381 Damp and Unwholesome Houses 63 Dung Receptacles required 110 Works not Structural:— Cisterns Dirty 83 Manure Accumulations 66 Underground Rooms occupied 30 Animals improperly kept 26 Stopped Drains 137 Overcrowding 58 Ballast Burning 6 Foul Urinals 6 Swine improperly kept 1 Refuse Accumulation 46 No Water Supply 79 Dirty Premises 336 Through Ventilation provided 37 9583 Number of Summonses and Orders issued 62 81 SMOKE INSPECTION. During the year 1894 constant supervision has been kept with regard to infringements of the provisions of the Public Health Act as to smoke consumption. 50 Notices have been served chiefly upon manufacturers for reported infringements. It was not found necessary to summons the offenders, the nuisance being abated upon service of the notices. BAKEHOUSES. 230 Bakehouses have been inspected, and 101 notices served to cleanse and whitewash, and for other various Sanitary defects. WORKSHOPS 35 Notices were served to cleanse premises and for other structural and sanitary defects. G * 82 DISINFECTION OF BEDDING, AND BEDDING DESTROYED. Cases in which Bedding has been disinfected At Home 177 At Chamber 2286 Cases in which Bedding has been destroyed 119 Replaced by the Vestry 6 Premises disinfected and disinfectants supplied 5742 Articles of Bedding disinfected:— Feather Beds 606 „ Bolsters 529 „ Pillows 1539 Flock Beds 975 „ Bolsters 514 „ Pillows 1237 Mattresses 413 Palliasses 166 Chair Cushions 430 Clothing 585 Blankets 761 Rugs 133 Counterpanes and Eiderdown Quilts 123 Carpets 11 8022 Articles of infected Bedding destroyed:— Feather Beds 5 „ Bolsters 15 „ Pillows 17 Flock Beds 58 „ Bolsters 9 „ Pillows 26 Mattresses 14 Palliasses 76 Chair Cushions 15 Clothing 46 Sundries 267 544 83 SALE OF FOOD AND DRUGS ACT. Samples procured by Inspector Wiggs, together with the result of Analyses, during the year 1894. Samples. Number procured. Number adulterated. Milk 232 64 Butter 143 32 Mustard 15 ... Pepper 11 ... Coffee 30 9 Tapioca 2 ... Jam 2 ... Rum 3 ... Gin 3 ... Whisky 1 ... Brandy 1 ... Arrowroot 3 ... Lobster 1 ... Cocoa 3 ... Chocolate Powder 2 ... Epsom Salts 1 ... Raspberry Pudding Powder 1 ... Lard 3 ... Meat Preservative 1 ... Bismuth Lozenges 3 ... Gregory Powder 2 ... Liquorice 5 ... Sugar 6 2 Precipitate Ointment 1 ... Ground Rice 1 ... Jalap 2 ... Sal Volatile 1 ... Paregoric 1 ... Sweets 13 ... Sauce 1 ... Pickles 1 ... 495 107 Summonses issued. 81; Convictions, 79; Cautioned, 26. G * 2 85 SUMMONSES UNDER SALE OF FOOD AND DRUGS, MARGARINE, PUBLIC HEALTH, AND LOCAL METROPOLIS MANAGEMENT ACTS. 86 87 Date. Name. Address. Offence. Penalty. Costs. Jan. 12 The Owner 58 & 60 Paradise Street Non-compliance with Notice of Vestry to re-construct the drains, fix intercepting traps and ventilating pipes 4 0 0 0 4 0 Feb. 1 Wm. Smith 104 Oakley Street The premises being without a proper and sufficient supply of water for domestic and other purposes. (Order made to close the premises) ... 0 6 0 „ 23 George Hill 6a Milverton Street The premises being a dwelling house, without a proper and sufficient water supply. (Order made to close premises in 7 days) ... ... Robert Beswick 19 High Street, Lambeth Non-compliance with Notice of Vestry to abate overcrowding. (Order made for premises to be closed in 7 days) ... ... Mar. 9 The Owner 65 Vauxhall Walk Non-compliance with Notice of Vestry to repair defective drains, provide proper closet pan, repair water pipe, pave and drain the yard, and provide a proper dung pit. (Order made for the owner to comply with the requirements of Vestry in 14 days) ... ... „ 15 Henry Stubbs 19 Roupell Street Non-compliance with Notice of Vestry to provide a proper dung hill enclosure, in accordance with the Bye-laws of the L.C.C. (Adjourned for 21 days to enable owner to do the work) ... 0 2 0 , Carried forward 4 0 0 0 12 0 88 89 Date. Name. Address. Offence. Penalty. Costs. Brought forward 4 0 0 0 12 0 Mar. 30 James Abbett 49 Vauxhall Street For removing in London, after 10 o'clock in the forenoon, Fish Offal, contrary to the Bye-laws of the L.C.C. 0 1 0 0 2 0 For removing Fish Offal without a suitable and properly constructed carriage, contrary to the Bye-laws of the L.C.C. ... 0 2 0 John Darling 47 Neville Street For removing in London, after 10 o'clock in the forenoon, Fish Offal, contrary to the Bye-laws of the L.C.C. ... 0 2 0 For removing Fish Offal without a suitable and properly constructed carriage, contrary to the Bye-laws of the L.C.C 1 0 0 0 2 0 April 11 Isaac Hall 10 Surrey Street, Blackfriars Road Exposing for sale Oranges unsound and unfit for the food of man. (Defendant went to prison for 10 days in default of payment) 2 0 0 0 2 0 April 27 Mr. Hart Bedford Music Hall, Camden Town Non-compliance with notice of Vestry to provide a Sanitary Dust Din at 117 Clapham Road 0 5 0 0 2 0 May 4 Mr. Hinks Station Road, Brixton Non-compliance with notice of Vestry to provide a fit and sufficient water supply at 37 Effra Road. (Order made to close premises) ... 0 4 0 „ 10 Owner 129 Waterloo Road Non-compliance with notice of Vestry to reconstruct the drains in accordance with the Regulations of the Vestry. (Order made to do the works in 14 days, costs not allowed) ... ... Carried forward 7 6 0 1 8 0 90 91 Date, Name. Address. Offence. Penalty. Costs. Brought forward 7 6 0 1 8 0 May 16 Mr. Rosenberg 203 Wandsworth Road Non-compliance with order of Vestry to provide a proper water supply for domestic and other purposes (Order made to close premises) ... 0 5 0 July 12 Henry William Haile 211 Wandsworth Road Exposing for sale 62 Eggs which were unsound and unfit for food of man 2 0 0 0 2 0 „ 12 George Bauerlein 100 Lambeth Walk Depositing for the purpose of preparation for sale a piece of Beef which was unsound and unfit for the food of man 5 0 0 0 2 0 „ 12 ,, 100 Lambeth Walk Eight Loaves and Nine Pieces of Bread which were unsound and unfit for food of man 2 0 0 0 2 0 ,, 12 George Hill 7 St. Mark's Road Depositing for the purpose of preparation for sale of 192 pounds of Meat which was unsound, unwholesome, and unfit for the food of man 5 0 0 0 2 0 ,, 12 ,, 7 ,, 84 pounds of Meat which were unsound, unwholesome and unfit for the food of man 10 0 0 0 2 0 „ 12 James Burt 152 Wyndham Road Depositing for the purpose of preparation for sale 2 hundredweight of Meat which was unsound, unwholesome and unfit for the food of man (In default of payment 3 months' imprisonment) 20 0 0 0 2 0 „ 12 ,, 152 ,, Exposing for sale a quantity of pieces of Meat, weighing about 10 pounds, which were unsound and unfit for the food of man. (In default of payment 1 month's imprisonment) 5 0 0 0 2 0 July 31 Fred A. Fountain 203 & 205 Lambeth Walk Depositing for the purpose of preparation for sale certain articles, to wit, pork, beef, and mutton which were unsound, unwholesome and unfit for the food of man 1 0 0 0 4 0 Carried forward 57 6 0 2 11 0 92 93 Date. Name. Address. Offence. Penalty. Costs. Brought forward 57 6 0 2 11 0 Aug. 24 Thomas Johnson 45 Atlantic Road Depositing for the purpose of preparation for sale a quantity of dressed tripe and cow heels, 2 hearts, and 1 cheek which were unsound and unfit for the food of man 2 0 0 0 5 0 Aug. 27 James Rogers & Sons 152 & 154 Westminster Bridge Road Depositing for the purpose of preparation for sale a certain article, to wit, liver, which was unsound, unwholesome and unfit for the food of man 5 0 0 0 4 0 Sept. 14 Mr. King 69, Buckingham Road, Harlesden, N. For non-compliance with Notice of Vestry to repair the roof and fix a new W.C. pan at No. 18 Palace Buildings within seven days (Order made for work to be done forthwith and Owner to pay 5/-costs.) ... 0 5 0 Sept. 26 John Blackarn 92, Westminster Bridge Road Exposing for sale certain articles of food, to wit, one bushel of Pears which were unsound, unwholesome, and unfit for food 1 10 0 0 2 0 Oct. 5 J. Hatchard Smith 41, Moorgate Station Buildings, E.C. Non-compliance with Notice of Vestry to make good all defects to the W.C. drain and provide sound rainwater pipes at No. 9 Topaz Street (Order made to do the work.) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to cleanse the walls and ceilings of front parlour, staircase and scullery, and provide proper rain water pipe at No. 11 Topaz Street. (Order made to do the work in 28 days.) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to cleanse the walls and ceilings of the ground floor rooms and Carried forward 65 16 0 3 17 0 94 95 Date. Name. Address. Offence. Penalty. . Brought forward 65 16 0 3 17 0 Oct. 5 J. Hatchard Smith 41, Moorgate Station Buildings, E.C. staircase, to repair scullery roof, and provide water supply to W.C. at No. 12 Topaz Street (Order made to do the work in 28 days.) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to reconstruct the drainage in accordance with the regulations of the Vestry at No. 16 Saunders Street (Order made to do the work in 28 days.) .. 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to reconstruct drainage of the W.C. and provide a proper water supply for domestic purposes at No. 1 Thrift Place, Topaz Street (Order made to close the premises) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to cleanse the interior walls and ceilings and provide a proper water supply to W.C. and for domestic purposes at No. 2 Thrift Place, Topaz Street (Order made to close the premises) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to reconstruct the W.C. drain and provide a proper water supply for domestic purposes at No. 4 Thrift Place, Topaz Street (Order made to close the premises.) ... 0 5 0 ,, ,, ,, Non-compliance with Notice of Vestry to cleanse and repair the interior walls and ceilings and provide a proper W.C. and water supply for domestic purposes at No. 5 Thrift Place, Topaz Street (Order made to close the premises.) ... 0 5 0 Carried forward 65 16 0 5 7 0 96 97 Date. Name. Address. Offence. Penalty. Costs. Brought forward 65 16 0 5 7 0 Nov. 1 R. Strong The Grange, Finchley Common Non-compliance with Notice of Vestry to remove rubbish from yard, and provide a proper floor and seat to W.C., at No. 61, Cornwall Road, S.E. 0 10 0 1 1 0 „ 2 Maurice Davis 7, Brondesbury Road, Kilburn Non-compliance with Notice of Vestry to cleanse the dirty premises at 22,Dolland Street 0 5 0 0 2 0 ,, 2 ,, ,, ,, ,, Non-compliance with Notice of Vestry to provide a proper receptacle for dung at 23, Dolland Street 0 10 0 0 2 0 ,, 2 ,, ,, ,, ,, Non-compliance with Notice of Vestry to cleanse the dirty premises at 23, Dolland Street 0 5 0 0 2 0 „ 2 ,, ,, ,, ,, Non-compliance with Notice of Vestry to provide a proper W.C., at No. 6, Dolland Street 0 5 0 0 2 0 Nov. 8 John Richard Lill 21, Lant Street, Boro' For non-compliance with Notice of Vestry to put the water closet in proper condition at 4, Short Street, New Cut. (Order made to close the premises forthwith and to pay 5/- costs) - 0 5 0 „ 8 ,, ,, ,, ,, For non-compliance with Notice of Vestry to put the water closet into proper condition, and cleanse and repair the interior, at 5, Short Street, New Cut. (Order made to close the premises forthwith and to pay 5/- costs) - 0 5 0 „ 22 Jules Charles Gaillard 87, Oakley Street Non-compliance with Notice of Vestry to provide a fit and proper water supply at 87, Oakley Street. (Order made to close the premises) - 0 6 0 Carried forward 69 11 0 7 12 0 H 98 99 Date. Name. Address. Offence. Penalty. Costs. Brought forward 69 11 0 7 12 0 Nov. 23 Mr. Bentwick Corporation Chambers, Guildhall Yard Non-compliance with Notice of Vestry to put the drainage into proper order and condition at 76, Milkwood Road (Order made to do work in 14 days) - 0 4 0 „ 23 Thomas Judd 70 Leo Street, Old Kent Road Removing after 10 o'clock in the forenoon fish offal, contrary to the Bye-Laws of the London County Council 1 0 0 0 2 0 „ 23 John Nathan 125 London Road Non-compliance with Notice of Vestry to repair the gutters, water fittings and dustbins at Nos. 2 & 3 Queen's Place 0 2 0 0 10 0 „ 30 Thomas Elliot 60 Old Kent Road Removing fish offal without using a properly constructed carriage, contrary to the ByeLaws of the London County Council 5 0 0 0 2 0 Nov. 30 Thomas Elliott 60 Old Kent Road Removing after 10 o'clock in the forenoon fish offal, contrary to the Bye-Laws of the London County Council 1 0 0 0 2 0 „ 30 The Occupier 1 Bloom Grove, West Norwood Non-compliance with Notice of Vestry to provide a proper and sufficient supply of water for domestic purposes at No. 1 Bloom Grove (Order made to close the premises) - 0 5 0 „ 30 Wm. Thomas Attwood 75 Coleman Street Non-compliance with Notice of Vestry. A dwelling house No. 9 Stockwell Green was in a dirty and dilapidated condition, and bakehouse in an insanitary condition and W.C. defective. (Order made to close premises) - 0 5 0 Jan. 3 (1895) Jules Charles Gaillard 87 Oakley Street Non-compliance with Order of Magistrate prohibiting use of dwelling house at 87 Oakley Street 2 0 0 0 2 0 Carried forward 78 13 0 9 4 0 h * 2 100 101 Date. Name. Address. Offence. Penalty. Costs. Brought forward 78 13 0 9 4 0 Jan. 4 (1895) The Owner 69 Lollard Street Non-compliance with Notice of Vestry to repair the flushbox in the W.C. at 69 Lollard Street 1 0 0 0 2 0 ,, ,, 69 Non-compliance with Notice of Vestry to repair the paving at 69 Lollard Street 1 0 0 0 2 0 ,, 4 ,, 70 „ Non-compliance with Notice of Vestry to provide a proper W.C. pan at 70 Lollard Street 1 0 0 0 2 0 ,, 4 ,, 71 ,, Non-compliance with Notice of Vestry to cleanse the top front room and staircase at 71 Lollard Street 1 0 0 0 2 0 ,, ,, ,, 72 ,, Non-compliance with Notice of Vestry to repair the gutters, water fittings and put the W.C. into proper order and condition at 72 Lollard Street 1 0 0 0 2 0 Jan. 4 The Owner 73 Lollard Street Non-compliance with Notice of Vestry to repair the paving of the yard at 73 Lollard Street 1 0 0 0 2 0 ,, ,, 73 „ Non-compliance with Notice of Vestry to put the W.C. into proper order and condition at 73 Lollard Street 1 0 0 0 2 0 ,, ,, 74 ,, Non-compliance with Notice of Vestry to put the W C. into proper order and condition at 74 Lollard Street 1 0 0 0 2 0 Jan. 4 Thos. Elliott 60 Old Kent Road Removing Fish Offal without using a properly-constructed carriage contrary to the ByeLaws of the L.C.C. 0 5 0 0 2 0 ,, The Owner 68 Lollard Street Non-compliance with Notice of Vestry to put the water closet into proper order and condition at 68 Lollard Street 1 0 0 0 2 0 ,, ,, ,, ,, Non-compliance with Notice of Vestry to repair the paving of the yard at 68 Lollard Street 1 0 0 0 2 0 Carried forward 88 18 0 10 6 0 102 103 Date. Name. Address. Offence. Penalty. Costs. Brought forward 88 18 0 10 6 0 Jan. 11 (1895) A. J. Hill 60 Glasshouse Street Selling Coffee containing 50 per cent. of chicory 0 10 0 0 12 6 ,, G. Skerman 166a Upper Kennington Lane Selling Butter containing 70 per cent. of Margarine 2 0 0 0 12 6 ,, Jane Davies 30 Upper Kennington Lane Selling Butter containing 75 per cent. of Margarine 2 0 0 0 12 6 Feb. 8 W. H. Schofield 4 Lambeth Walk Selling Butter containing 50 per cent. of Margarine 2 0 0 0 12 6 ,, Margaret Jones 138 Tyer Street Selling Butter containing 80 per cent. of Margarine 2 0 0 0 12 6 ,, Wright & Son 304 Camberwell Road Selling Butter containing 80 per cent. of Margarine 5 0 0 0 12 6 ,, William Jones 57 Auckland Street Selling Butter containing 88 per cent. of Margarine 2 0 0 0 12 6 Feb. 22 H. Pickard 204 Upper Kennington Lane Selling Butter containing 90 per cent. of Margarine 0 10 0 0 12 6 ,, H. Hawkes 131 Lambeth Walk Selling Butter containing 80 per cent. of Margarine 1 0 0 0 12 6 .. A. M. Grove 291 Camberwell Road Selling Butter containing 80 per cent. of Margarine 3 0 0 0 12 6 ,, G. Stevens 347 Kennington Road Selling Butter containing 80 per cent. of Margarine 2 0 0 0 12 6 ,, W. Tipping 266 Brixton Road Selling Butter containing 85 per cent. of Margarine 2 0 0 0 12 6 ,, D. B. Evans 80 Atlantic Road Selling Butter containing 56 per cent. of Margarine 3 0 0 0 12 6 Mar. 8 J. Jones 85 Webber Street Selling Milk containing 20 per cent. of added water 5 0 0 0 12 6 ,, F. Fielding 17 Coin Street Selling Butter containing 72 per cent. of Margarine 2 0 0 0 12 6 ,, Mary Williams 48 Cornwall Road Selling Butter containing 84 per cent. of Margarine 0 10 0 0 12 6 ,, Harry Crook 98 York Road Selling Coffee containing 65 per cent. of Chicory 2 0 0 0 12 6 ,, Thomas Jones 75 Oakley Street Selling Butter containing 80 per cent. of Margarine 2 0 0 0 12 6 ,, M. Whyley 27 Oakley Street Selling Milk containing 20 per cent. of added water 0 10 0 0 12 6 Mar. 9 John Williams 180 Warham Street Selling Milk containing 15 per cent. of added water 3 0 0 0 12 6 ,, W. Glover 55 Camberwell New Road Selling Butter containing 50 per cent. of Margarine 3 0 0 0 12 6 ,, Harry Falder 7 Bolton Street Selling Milk containing 20 per cent. of added water 2 0 0 0 12 6 ,, John Wright 5 Bolton Street Selling Butter containing 72 per cent. of Margarine 2 0 0 0 12 6 carried forward 137 18 0 24 13 6 104 105 Date. Name. Address. Offence. Penalty. Costs. Brought forward 137 18 0 24 13 6 Mar 9 John Wright 5 Bolton Street Selling Milk containing12 per cent. of added water 1 0 0 0 12 6 ,, J. Lyon 44 Warham Street Selling Coffee containing 60 per cent. of Chicory 2 0 0 0 12 6 ,, ,, ,, Selling Butter containing 76 per cent. of Margarine 2 0 0 0 12 6 April 5 Edward Hughes 37 Lower Kennington Lane Selling Milk containing 25 per cent. of added water 2 0 0 0 12 6 ,, ,, ,, Selling Butter containing 90 per cent of Margarine 1 0 0 0 12 6 ,, A.Mills 4 Lower Kennington Lane Selling Butter containing 85 per cent. of Margarine 2 0 0 0 12 6 ,, A. Herwig 16 Hurley Road Selling Butter containing 85 per cent. of Margarine 2 0 0 0 12 6 ,, ,, ,, Selling Coffee containing 35 per cent. of Chicory 1 0 0 0 12 6 Apr. 20 W. Marsh 11 The Grove, South Lambeth Selling Butter containing 55 per cent. added Margarine 1 0 0 0 12 6 „ 20 ,, ,, Selling Coffee containing 50 per cent. added Chicory 2 0 0 0 12 6 „ 20 A. Higgons 154 Old South Lambeth Road Selling Butter containing 80 per cent. added Margarine 2 0 0 0 12 6 ,, 20 F. Broome 15 Bonnington Square Selling Butter containing 70 per cent. added Margarine 3 0 0 0 12 6 ,, T. E. Archard 124, Vauxhall Street Selling Butter containing 35 per cent. added Margarine 2 0 0 0 12 6 ,, 20 ,, ,, ,, Selling Coffee containing 30 per cent. added Chicory 2 0 0 0 12 6 May 3 Messrs. Dibbins & Sons 329 Coldharbour Lane Selling Milk containing 10 per cent. added water 1 0 0 0 12 6 „ 3 John Cramp 77 Acre Lane Selling Milk containing 18 per cent. added water 2 0 0 0 12 6 „ 3 John Bloomfiéld 486 Brixton Road Selling Milk containing 20 per cent. added water 0 5 0 0 12 6 ,, 3 Daniel Davies 447 Coldharbour Lane Selling Milk containing 12 per cent. added water 3 0 0 0 12 6 ,, 21 J. Lickfold Rogate, Sussex Selling Milk containing 7 per cent. added water 3 0 0 0 15 0 June 1 J. Wright 17 Santley Street Selling Butter containing 55 per cent. added Margarine 0 10 0 0 12 6 ,, S. A. Bennett 91 Acre Lane Selling Coffee containing 40 per cent. added Chicory 2 0 0 0 12 6 ,, Richard Wilson 146 Acre Lane Selling Coffee containing 50 per cent. added Chicory. 2 0 0 0 12 6 June 15 Morgan Jones 5 Milkwood Road Selling Butter containing 88 per cent. added Margarine 2 0 0 0 12 6 Carried forward 178 13 0 39 3 6 106 107 Date. Name. Address. Offence. Penalty. Costs. Brought forward 178 13 0 39 3 6 June 15 E. J. Adams 57 Loughboro Road Selling Butter containing 75 per cent. added Margarine 1 0 0 0 12 6 ,, 15 W. G. Clark 32 Robsart Street Selling Milk containing 7 per cent. added water 0 10 0 0 12 6 „ 29 H. Attrill 207 Westminster Bridge Road Selling Milk with 40 per cent. of cream abstracted 3 0 0 0 12 6 „ 29 John Edge 71 Hartington Road Selling Milk with 47 per cent. of cream abstracted 3 0 0 0 12 6 „ 29 George Smith Manor Farm, Stockbridge, Hants Selling Milk containing 40 per cent, added water 9 0 0 1 12 6 „ 29 J. Palfrey 237 Westminster Bridge Road Selling Milk containing 16 per cent, added water 2 0 0 0 12 6 „ 29 A. Burnett ... 155 South Lambeth Road Selling Milk containing 10 per cent, added water 2 0 0 0 12 6 July 13 „ 13 Edward Ray- ment John Jones 65 Abbey Street, Ber- mondsey 9 Dawlish Street Selling Milk containing 17 per cent, added water ... Selling Milk containing 18 per cent, added water... 5 0 0 2 0 0 0 12 6 0 12 6 „ 18 George Savage 60 York Road ... Selling Milk containing 12 per cent, added water... 0 10 0 0 12 6 Sept. 21 Cornelius IB in stead 29 High Street, West Norwood Selling Milk containing 14 per i cent, added water 0 10 0 0 12 6 „ 21 C. Turner ... 71 Ethelred Street Selling Milk containing 16 per cent, added water . .. 2 0 0 0 12 6 „ 21 J. E. Rowling 20 St. Albans Street ... Selling Milk containing 7 per cent, added water... — „ 0 12 6 „ 21 G. F. Barnes... 55 Knight's Hill Selling Milk containing 9 per cent, added water... 10 0 0 12 6 „ 21 T. J. Allen ... 32 High Street, West Norwood Selling Butter containing 70 per cent, added Margarine 3 0 0 0 12 6 Oct. 5 J. Sheppard & 238 Brixton Hill Selling Butter containing 60 per cent, added Margarine 2 0 0 0 12 6 „ 5 LO. J. Luetchford 35 New Park Road Selling Butter containing 70 per cent, added Margarine 2 0 0 0 12 6 „ 5 Jones Bros. ... 5 Milkwood Road Selling Butter containing 90 percent, added Margarine 2 0 0 0 12 6 „ 11 J. R. Brushett 59 New Cut Selling Butter containing 70 per cent, added Margarine 5 0 0 0 12 6 „ 19 James Cook... 1 St. Oswald's Place ... Refusing to sell an article to Inspector for the purpose of Analysis by the Public Analyst 2 0 0 0 2 0 Carried forward ... 226 3 0 51 3 0 108 109 Date. Name. Address. Offence. Penalty. Costs. ■ Brought forward 226 3 0 51 3 0 Oct. 19 W. Rattenbury Secretary London, Glo'ster and North Hants Dairy Co. Selling Milk containing added water to the extent of 14 per cent. 10 0 0 12 6 \ov. 9 Thomas Felse Stevens. The South Eastern Dairy, 40 Swan Place, Old Kent Road Selling Milk deficient in cream to the extent of 75 per cent. 5 0 0 0 12 6 „ J6 Theophilus J. James 17 Denny Street Selling Milk containing 1 2 per cent, added water 2 0 0 0 12 6 „ 16 James Bros 118 Lower Kennington Lane... Selling Butter containing 50 per cent, added Margarine 5 0 0 0 12 6 „ 16 it It t) Selling Milk containing 12 per cent, added water 5 0 0 0 12 6 „ 16 H. Lane 80 Lower Kennington Lane... Selling Butter containing 7<» per cent, added margarine 3 0 0 0 12 6 „ 2 Benjamin Jones 149 Prince's Road Selling Milk containing 7 per cent, added water 0 5 0 0 12 6 Dec. 11 Thomas Jones 75 Oakley Street Selling Milk containing 9 per cent, added water 10 0 0 0 12 6 „ 19 Victoria Tea Co., Ltd. 120 Lower Marsh Selling Coffee containing 85 per cent. Chicory 10 0 0 1 13 6 „ 21 Freeman, Horsley 8c Co. 2 & 4 Denmark Hill Selling Coffee containing 30 per cent. Chicory ... 0 10 0 0 12 6 Jan. 10 1895 E. Gillingham 42 North Lode Street, Glastonbury Selling Milk containing 30 per cent, added water... 10 0 0 0 16 0 „ 10 1895 1) i) ii Selling Milk containing 16 per cent, added water... 5 0 0 0 16 0 „ 10 1895 )) 1 1' Selling Milk containing 18 per cent, added water ... 5 0 0 0 16 0 £ 287 18 0 55 17 0 110 LAMBETH MORTUARY RETURNS FOR THE YEAR 1894. Bodies Deposited — By Private Undertakers 187 By Parish 55 By Police 67 309 219 Postmortems were made, and 243 Inquests held. 111 COW HOUSES AND SLAUGHTER HOUSES. The following Licenses were granted: — SLAUGHTER HOUSES. Old Licenses renewed 53 Old License refused 1 Total number of Licensed Slaughter Houses 53 COW HOUSES. Old Licenses renewed 35 Old License refused 1 Total number of Cow Houses in Lambeth 35 H. Walter Verdon, M.D., F.R.C.S.