Vestryof St. George the Martyr, SOUTH WARK. Annual Report MEDICAL OFFICER OF HEALTH, F.J WALDO, DIPLOMATE IN PUBLIC HEALTH OF THE ROYAL COLLEGES OF PHYSICIANS AND SURGEONS (ENGLANS) member of theroyal college m surgeons (england) fellow and member of council of the soiety of medical officers of helth medical officer of health of tme honourable societies of the inner and middle temples. PRINTED BY ORDER OF THE VESTRY. VESTRY HALL, BORUGH ROAD, SOUTHWARK. 1894. T. Cornell, Printer to the Vestry, 66, St. George's Road, Southwark, S.E. * Sou21 Cesfry of St. Georcje the Martyr, SOUTH WARK, Annual Report FOR 1893, of the MEDICAL OFFICER OF HEALTH, F. J. WALDO, M.A., M.D. (Cantab.) diplomate in public health of the royal colleges of physicians and surgeons (england); member of the royal college of surgeons (england) j fellow and member of council of the society of medical officers of health ; medical officer of health of the honourable societies of the inner and middle temples. PRINTED BY ORDER OF THE VESTRY. VESTRY HALL, BOROUGH ROAD, SOUTHWARK 1894. t. Cornell, Printer to the Vestry, 66, St. George's Road, Southwark, S.E. ANNUAL REPORT on THE SANITARY CONDITION of the Parish of St. iBeorge the Martyr, Southuiarh, FOR THE YEAR 1893, by the MEDICAL OFFICER OF HEALTH. To the vestry of the parish of St. george the MARTYR. SECTION I—STATISTICAL. Gentlemen, My Second Annual Report, which I now have the honour to submit to you, treats of the sanitary condition and environment, for the year 1893, of one of the poorest and most densely populated districts in the whole of London. The following summary of facts will be found useful in approaching the various matters contained in this report. Area.—St. George's, Southwark, covers 284-375 acres. The roads and streets, as returned to the end of 1893, measure 19 miles, 5 furlongs, 14 poles. Boundaries.—The parish, in shape somewhat like a hatchet, is surrounded by no less than six other Sanitary Districts. It is bounded on the north by St. Saviour and St. Olave, on the west by Lambeth, on the South by Newington and Camberwell, and on the east by Bermondsey. (See Chart.) k*cc Geological Formation.—The sub-soil of Southwark consists of porous made earth, sand, and gravel, of a depth of fifteen to twenty-five feet, overlying the London Clay. Saline Springs rise at times to the surface, and in certain excavated parts of the parish—e.g., Theatre and Music Hall, necessitate the constant use of pumps, worked by gas engines. Elevation.—The district is low-lying and flat, and is situate at an average of half a foot below the Trinity high water mark of the Thames, as against a mean elevation for London of 47'5 feet above the same mark. 4 Parish of St. George the Martyr, Southwark. Houses.*—At the Census of 1891, there were 6,946 inhabited houses, 732 uninhabited, and 44 building, containing an average of 8-5 persons to a house. According to the 1881 Census, the inhabited houses numbered 6,761—i.e., 185 less than in 1891. Table I. Sub-District. Area in Acres. HOUSES. Inhabited, Uninhabited, Building, 1881. Inhabited, Uninhabited, Building, 1891. Borough Road 64 1,880 108 4 1,986 294 12 London Road 117 2,243 118 1 1,963 128 18 Kent Road 103 2,638 120 11 2,997 310 14 Whole Parish 284 6,761 346 16 6,946 732 44 Table II. Total tenements and tenements with less than five rooms, distinguishing those occupied by various numbers of persons, according to the Census of 1891. Total No. of Tenements in Saint George's. Number of Tenements with— Number of Occupants of Tenements. 1 2 3 4 5 6 7 8 9 10 11 12or more 13,855 One Room, 4,170 1,076 1,589 783 452 191 58 18 1 2 - - - Two Rooms, 4,086 173 832 875 799 600 413 233 105 44 12 — - Three Rooms, 2,317 38 272 386 393 389 318 250 154 76 29 6 6 Four Rooms, 1.462 11 83 142 223 245 228 199 138 98 56 27 12 Tenements.—In the Census instructions a tenement is defined as " any house or part of a house, separately occupied either by the owner or by a tenant." On comparing Tables I. and II. it will be seen that the number of tenements is almost exactly double that of the inhabited houses. Of the tenement occupiers, one-third live in two rooms, and another third in a single room. In other words, about 1 in 14 of your population is born, grows up, drinks, eats, sleeps, and often dies within the four walls of a one-roomed tenement. Density.—The population estimated to the middle of the respective years, 1892 and 1893, gives the following number of persons to each acre:— Table III. Persons to an acre. 1892 1893 Sc. George, Southwark 210.6 211 London 57.1 57.7 * A house, according to the Census Instructions of England and Wales, is defined as a separate building which comprises all the space within its external walls, and separated from the next adjoining building by an unbroken party wall. A tenemented "flat" is not the same thing as a house. A man living in a house dwells under his own roof, not under another man's " flat." Annual Report of the Medical Officer of Health,—1893. 5 The population density of St. George's is, roughly, four times that of London, and four hundred times that of the United Kingdom. Population.—Table IV. gives the number of inhabitants of the whole parish and of each sub-district, according to the Census of 1891, and also the figures estimated to the middle of the years 1892 and 1893:— Table IV. Sub-districts. Population. 1891 1892 1893 Borough Road 16,624 16,691 16,758 London Road 21,221 21,212 21,203 Kent Road 21,867 21,915 21,963 Whole Parish 59,712 59,818 59,924 London 4,222,157 4,264,076 4,306,411 Table V., Showing the population of each of the sub-districts of the whole parish, and of jondon, at the Census of 1881 and 1891:— Sub-districts. Population. 1881 1891 Borough Road 15,953 16,624 London Road 21,318 21,221 Kent Road 21,381 21,867 Whole Parish 58,652 59,712 London 3,815,544 4,211,743 The Returns of the Registrar-General show an increase of population between 1881 and 1891 of 671 for the Borough Road sub-district, and of 486 for the Kent Road sub-district; whereas, in the London Road Sub-district, on the other hand, they indicate a decrease of 97. Taking the average annual increase, for the whole of London for the same period at 39,619, the ratio for these three sub-districts should be 172, 226,. and 210 respectively; or, in the whole parish, the increase should be 608, whereas the returns show 106. It will be seen, therefore, that the actual figures from your sub-districts show a considerable relative deficiency. The explanation of this lessened ratio of increase of population may, in my opinion, be sought for in one or more of the three following causes:—(1.) A certain number of persons become non-resident owing to want of house room and other reasons. (2.) The births in the district are diminished. (3.) Deaths are increased. 6 Parish of St. George the Martyr, Southrwark. With regard to these points it may be at once stated that the accommodation afforded by new houses is not enough for anything like a large additional number of persons. It is obvious that any increase among those who work in the district, but who reside at a distance, will tend to swell the birth rates of other parishes. The two remaining points (2 and 3) will be fully discussed further on, under the heading of Birth-rates and Mortality. Meanwhile it will be sufficient for the present purpose to state that the rate of births in your parish is fractionally lowered, while at the same time the deaths have increased. Proportionate Increase or Decrease Between 1881—91. Borough Eoad should increase 172. Actual increase 67 London Eoad 210. Actual decrease 9 Kent Eoad 226. Actual increase 48 Whole Parish 608 Actual increase 106 It is well known that a death-rate in a district mounts up in direct proportion to the density of population, a fact which was first laid down as a general law by the late Dr. Farr. Now, the death-rate of 27'6 per 1000 in St. George's is excessive, as will be seen from a consideration of the following figures:— Table VI. Years. St. George, Southwark. London. Death-rate per 1,000. Death-rate per 1,000. 1841—50 inclusive 30 25 1851—60 27 24 1861—70 ,, 27 24 1871—80 25.2 22.4 1881—90 25.0 20.5 1892 25.2 20.3 1893 27.6 21.3 From the foregoing facts, therefore, I think it is not unreasonable to attribute this diminished ratio of increase of population in your parish mainly to the higher death-rate, and this again to a more ultimate origin in overcrowding. Births and Birth-Rate. Table VII. gives the births and birth-rate per 1000 per annum for the years 1892 and 1893 in each sub-district in the whole parish, in London, and in the 33 large English towns. Annual Report of the Medical Officer of Health,—1893. 7 Table VII. Number of Births. Birth-rate per 1,000. 1892. 1893. 1892. 1893. Borough Road 638 604 38.1 36.1 London Road 700 689 33.0 32.4 Kent Road 813 828 37.0 37.6 Whole Parish 2,151 2,121 35.9 35.3 London 131,535 132,965 30.9 30.9 33 large English Towns 324,190 328,342 31.9 31.9 It will be seen that although the birth-rate is a fraction lower than that of the preceding year, it is nevertheless considerably above that for the whole of London. The diminished rate of increase of population in the three sub-districts of the Parish of St. George's is, therefore, not attributable to a falling off in the number of persons born into the parish. As already hinted, it is in the main to be looked for in a relatively high death-rate. A reference to the section on the mortality of infants and children will reveal the startling fact that nearly one half of the total deaths in St. George's, Southwark, takes place under five years of age. The fact is notable that the birth-rate in St. George's is higher than in London and in the thirty-three large English towns, and again, in the relatively poorer subdistricts of the Borough Road and Kent Road than in the London Road. In both cases it may, I think, be explained by the fact that the limitation of families is carried into effect by the better to do classes rather than by the poor. This important problem will have to be faced some day. Deaths and Death-Rate for 1893. 1395 deaths were registered in the parish during the fifty-two weeks ending December 31st, 1893, giving an average of 27 per week. Of this total 130 were deaths of non-parishioners in hospitals and asylums within the district; 392 of parishioners who died in outside public institutions and extra-metropolitan asylums. There were, therefore, 1675 deaths among your parishioners, equivalent to an average mortality of 27-6 per 1,000. The death-rate for all London in the same year was 21-3 per 1,000, which is in itself, according to many authorities four more per 1,000 than should occur from " the mortality incident to human nature." In St. George's, then, the "death-toll," as it has been aptly called, claims 6-3 persons out of every 1,000 in excess of an already excessive rate. On the latter estimate there have been no less than 378 unnecessary deaths in St. George's, Southwark, during the year 1893. In the 41 Metropolitan sanitary districts the lowest death-rates were 12.9 in Hampstead, 14.6 in Lewisham (excluding Penge), 15.2 in Wandsworth, 16.1 in St. George, Hanover square, 16 4 in Plumstead, and 17.6 in Kensington. The highest rates, on the other hand, were 27 6 in St. George, Southwark, 28.2 in Limehouse, 30.0 in Strand, 30.8 in St. Luke's, and a similar figure in St. George in the East. The facts of your death-rate are briefly as follows:— 8 Parish of St. George the Martyr, SouthivarJc. Table VIII. Sub-District. No. of Deaths. Death-rate per 1,000. Deaths under 1 year to 1,000 Births. 1892. 1893. 1892. 1893. 1892. 1893. Borough Road 548 573 32.3 34.1 220 226 London Road 435 521 20.4 24.4 172 208 Kent Road 526 563 24.0 25.6 177 205 Whole Parish 1,509 1,657 25.5 27.6 188 213 London 86,355 91,536 20.3 21.3 155 157 33 Large Towns 209,985 222,178 20.7 21.6 164 181 From the foregoing tables it is clear that the death-rate of St. George's, Southwark, is abnormally high. One is naturally led to enquire whether a further analysis of facts and figures will throw any fresh light upon this unenviable state of affairs. In looking over the returns of these three sub-districts one is at once struck by the fact that the general death-rate per 1000 in the Borough Road exceeds that of the Kent Road by 8-5 per 1000, and that of the London Road by 10 per 1000. This disproportion may, in my opinion, bo attributed to four causes, (1) Deaths in public institutions, which are unequally distributed among the various subdistricts ; (2) Density of population, especially in the Borough Road Sub-district; (3) Poverty, which is conspicuous in each of the sub-districts, but most of all in the Borough Road; (4) Absence of open air spaces, of which there are none in the Borough Road. We will next proceed to discuss these points in detail. (1) Deaths in public institutions. The deaths which require notice under this heading are those of parishioners of one sub-district who die in the hospitals of another sub-district. In the Evelina Hospital for Children, situate in the Borough Road sub-district, I find that 3 deaths were those of parishioners from the London road, and 14 from the Kent Road sub-districts. Correcting for these 17 deaths, the death-rate for the Borough Road sub-district is reduced from 34-1 to 33.1 per 1,000, a number which is still excessive. The late Dr. Farr held that " a sustained rate of mortality above 17 in 1,000 always implies unfavourable sanitary conditions," and, further, that, " any rate above 30 implies sanitary conditions highly destructive to human life." In another place, he says that, " When any city experiences a higher rate than the average, it should become a matter of serious inquiry and concern to its citizens." Also, " The causes of the differences of the rates of mortality are various, and in every case demand careful investigation on the spot by the town authorities." And, " Wherever the mortality exceeds 17 in 1,000 there is much sanitary work to be done." If we accept these general statements of Dr. Farr, one of the highest authorities on public health, it is clear that a great deal of sanitary reform is needed in the Parish of St. George's, Southwark. (2) Density of population, which is in no small extent accounted for by the existence of the large institutions already spoken of, and which contain on an average 1,621 inmates. These institutions are scattered in a fairly even manner throughout the sub-districts. They may be divided into hospitals, asylums, schools, and workhouses—(a) Hospitals—Two hospitals, the Evelina and the Royal South London Ophthalmic Hospitals, situated in the Borough Road and London Road sub-districts Annual lieport of the Medical Officer of Health,—1893. 9 respectively. (b) Asylums—One lunatic, Bethlehem Hospital for Lunatics, the Blind Asylum, and Miss Sharman's Home, in the London Road sub-district; Deaf and Dumb Asylum in the Kent Road sub-district, (c) King Edward Schools and the Yorkshire Schools, both in the London Road sub-district, (d) St. George's Workhouse, in the Borough Road sub-district. The density of population is materially augmented by a number of large and densely-crowded buildings which exist in all the sub-districts. These are the so-called "model" dwellings, which accommodate about 12,800 inmates. There are,moreover, 39 common lodging-houses, scattered all over the parish, and registered for the accommodation of 1853 men and women. The majority of these houses and "model" dwellings are situated in the Borough Road sub-district. Lastly, there is the Salvation Army Shelter on the border of the Borough Road sub-district, which receives from 800 to 900 persons nightly. Another factor of importance in the question of density is found in the large amount of slum property met with all over the district, which consists mainly of small houses each containing several families. This class of property is specially found in the Borough Road sub-district. (3) Poverty. Mr. Charles Booth in his valuable work, entitled, " Life and Labour of the People in London," lays down the general law that density of population coincides with the degree of poverty. He gives the following statistics for the relative amount of wealth and poverty in the Metropolis:— Living in comfort 69-3 per cent. Living in poverty 30'7 per cent. For the central part of South London, which includes the parish of St. George's, Southwark, he finds Living in comfort 53 per cent. Living in poverty 47 per cent. In Southwark, comprising the Borough Road Sub-District, and St. Saviour's Parish, Southwark, the figures are Living in comfort 32.1 per cent. Living in poverty 67.9 per cent. According to Mr. Booth, the district covered by a circle with a radius of half-a-mile from St. George's Church, gives a higher percentage of poverty than any other in London; next on the list come the School Board blocks of Greenwich, Goswell Road, and Bethnal Green. A further classification of the 67.9 percentage of population of the district of Southwark (as above defined) living in poverty, gives the following results:— A. The lowest class—occasional labourers, loafers, and semi-criminals—the elements of disorder . 6.3 per cent. B. The very poor—casual labour, hand to mouth existence, chronic want 20.3 per cent. C and D. The poor—including alike those whose earnings are small, because of irregularity of employment, and those whose Work, though regular, is ill-paid—18s. to 20s. a week for a moderate family 41.3 per cent. 67.9 per cent. 10 Parish of St. George the Martyr, Southwark. Of the total above poverty, 32.1 per cent, in the area surrounding the Parish Church of St. George-the-Martyr, we find E and F. The regularly employed and fairly-paid working-class of all grades 28.8 per cent. G & H. Lower and upper-middle-class, and all above this level 3.3 per cent. 32.1 per cent. From these figures it appears that the south of London is the poorest part of the metropolis; further, that the central portion is worse off than other parts of that district; lastly, that the particular sub-division which includes the Borough Eoad sub-district is the most poverty-stricken in the whole of London. On examining the above facts we obtain the following striking general results:— The Borough Eoad, which has the highest death-rate of the three sub-districts, is conspicuous for its poverty, its density of population, and its absence of air spaces. On the other hand, the London-Road sub-district, which has the lowest deathrate of the three sub-districts, is inhabited by a less-crowded and better-to-do class, and is fairly supplied with open-air spaces. I think, gentlemen, that a candid consideration of the returns of these subdistricts must lead us to the inevitable conclusion that poverty, bad housing, and overcrowding have a direct influence on the death-rate. In other words, preventable conditions are responsible for a large margin of wasted human lives, not to mention the stunted and helpless individuals, the burden of whose support is cast upon the ratepayers. (4) Open air spaces, which may be grouped under three headings s— (1) Public institutions occupying a large area. (2) Broad streets. (3) Areas, such as disused burial grounds, formally set apart as places of recreation. It should be noted of the three sub-districts—(a) The Borough Road sub-district, which is the worst from a sanitary point of view, has the Evelina Hospital and the Workhouse, both buildings without grounds; there are only two wide streets, and no proper recreation grounds ; (b) The London Road sub-district contains the Blind Asylum, with about 1J acres of open space, the Royal Bethlehem Asylum for Lunatics, with 9 acres of open space, King Edward Schools with 1£ acres of open space, and the Royal South London Opthalmic Hospital without grounds: there are several wide roads, but no formal air spaces; (c) Kent Road sub-district—the only public institution is the Deaf and Dumb Asylum (a small building), one broad street (the Old Kent-Road), there are two recreation grounds of about half-an-acre apiece laid out on the site of disused burial grounds. The death-rate of the 33 great towns of England and Wales, with a population of 34-4 persons to an acre, was 21-6 per 1,000 the lowest being :— TABLE IX. Croydon 16.3 per 1000. Huddersfield 17.2 „ Halifax 17.4 „ Derby 18.2 „ Portsmouth 18.2 „ Annual Report of the Medical Officer of Health,—1893. 11 The highest were:— Bolton 24.1 per 1,000 Manchester 24.1 „ Preston 26.4 „ Liverpool 27.3 „ The death rate of Edinburgh was 19.8, that of Glasgow 23.4, and that of Dublin 270. The lowest rates in foreign and colonial cities were:— Sydney 157per 1000. Brisbane 16.3 ,, Christiania 17.5 „ San Francisco 17.9 „ Amsterdam 18.6 ,, Cincinatti 187 „ While the highest were:— Breslau 29.1 ,, Madras 30.9 „ Alexandria 36.3 ,, Moscow 35.9 „ St. Petersburgh 39.6 „ Zymotic or Preventable Death Rate. It may be noted that the term "zymotic" applies to the following seven diseases : —Small-pox, measles, scarlet fever, diphtheria, whooping cough, "fever" (i.e., typhus, simple continued, and typhoid), and diarrhoea. I have called the above zymotic diseases "preventable," because I regard all communicable disease, broadly speaking, as coming under that heading. Diarrhoea is a symptom rather than a disease, and, although not usually communicated from one person to another, it may be regarded as the almost invariable result of bad environment. At the same time, it must be clearly understood that a vast amount of preventable disease, such as that due to alcoholism, is not zymotic in the ordinary sense of the term—that is to say, disease communicable from the sick to the healthy. The corrected death-rate in St. George, Southwark, from the seven principal zymotic diseases was 4-0 per 1,000 in 1893, as against 3'0 per 1,000 in the whole of London for the same period, and 3-18 in the 33 great towns of England and Wales. As in the calculation of the general death-rate, so with the zymotic death-rate, the deaths of non-parishioners occurring within the district have been excluded, whilst on the other hand the deaths of parishioners in public institutions outside the parish have been included. Unless a proper distribution of these deaths be made, especially of those from zymotic diseases, no really trustworthy data can be secured upon which to calculate the rates of mortality. Among the,41 Metropolitan Sanitary Districts the zymotic death-rates ranged from 1-3 per 1,000 in Hampstead, and in the City of London; 1*5 in St. Martin-inthe-Fields; 16 in St. George, Hanover Square; 17 in Lewisham ; and 18 in St. James, Westminster, to 4-0 in St. George, Southwark; 41 in Bethnal Green; 4 6 in Shoreditch; 4-7 in Limehouse; 4 9 in Clerkenwell and in St. George-in-the-East; and 5 6 in St. Luke. From these figures, therefore, it is evident that St. George's, Southwark, has an excessive death-rate from zymotic diseases. 12 Parish of St. George the Martyr, Southwark. Table X.—For the Year 1892. Birth.rate per 1,000. Death.rate per 1,000. Zymotic death.rate. Influenza death.rate. Phthisis death.rate. Other Tubercular Diseases death.rate. Respiratory Diseases death.rate. Deaths under 1 year, to 1,000 births. Percentage of deaths under 5 to total deaths. St. George's, Southwark 35.9 25.2 3.6 0.2 1.8 1.8 5.5 188 44.3 London 30.9 20.3 2.8 0.5 1.8 0.8 4.5 155 39.9 As compared with the year 1893. St. George's, Southwark 35.3 27.6 40 0.1 2.2 1.6 6.7 213 45.8 London 30.9 21.3 3.0 0.3 1.8 1.9 4 5 157 38.4 Table XI. Mortality in St. George, Southwark, in 1893, from the seven principal Zymotic Diseases. Actual number of Deaths in St. George, Southwark. St. George's, Southwark, proportion to total London deaths, according to its population. Diarrhœa 63 47 Whooping Cough 59 32 Scarlet Fever 41 22 Diphtheria 41 45 Measles 22 23 Fever (chiefly Typhoid) 12 8 Small.pox 7 3 The mortality is thus seen from the foregoing table to be excessive from diarrhoea, whooping cough, scarlet fever, fever, and small.pox in St. George's as compared with all London. Diarrhoea.—This disease was the cause of 63 deaths as against 53 for 1892. The increased fatality of diarrhoea was probably due to the exceptional summer heat and drought, acting chiefly in the close courts, alleys, and adjacent badly.kept streets, especially in the Borough Road and Kent Road sub.districts. In 1892 the usual summer outbreak, which had begun in the month of June, was arrested by the comparatively cold weather of July. Forty.three of the deaths were of infants under one year of age, sixty.two in those under five, and one in a person over that age. The fact is significant that the pail system of dust removal is followed in the London Road sub.district alone, the one in which there have been the fewest deaths recorded from diarrhoea during the past two years. In a report presented by me to your Vestry in 1892 I advocated the extension of the pail system of dust removal throughout the parish. Annual Report of the Medical Officer of Health,—1893. 13 Such a reform would, I believe, materially assist in reducing the excessive deathrate from diarrhoea. Prompt removal of all decomposing matter in or about houses, a pure and plentiful supply of water, good food, and, in the absence of mother's milk, the feeding of infants on boiled cow's milk, are among the chief safeguards against this disease. Table XI. discloses the fact that the actual number of deaths in St. George's from diarrhoea is 16 in excess of its proportion of total London deaths according to population. Whooping Cough.—This fatal complaint is not included in the list of " dangerous infectious diseases " that are notifiable. In 1893 it killed 59 infants and children as against 46 in 1892. Of the 59 deaths 20 were those of infants under one year of age. The annual mortality from whooping cough in St. George's is 27 in excess of the average for London. The disease is commonly looked upon as a trifling and necessary evil, and the sufferer often succumbs to secondary lung troubles induced by neglect. Scarlet Fever or Scarlatina.—The epidemic prevalence of this disease in London during 1893 has exceeded that of any year on record. The total number of scarlet fever cases admitted to the Metropolitan Asylum's hospitals was 14,548, of which total 901 died. In 1892, 13,093 admissions gave 839 deaths. The annual mortality in the Board's hospitals, per 1,000 of estimated population, was 0.37 as against 0.27 in 1892. Out of a total of 581 cases of scarlet fever—notified in St. George's—there were 41 deaths, of which number 32 were under and nine above the age of five years. This agrees with the known behaviour of the disease, which, as a rule, is most fatal to children under five years of age, and notably so to infants in the first and second years of life. A remarkable feature shown by Table XI. is the large excess of 19 deaths in St. George's from scarlet fever over and above its proportioo/to the total London deaths. The curves relating to scarlet fever on chacj^indicate the seasonal prevalence of the disease. The managers of the Asylurtr Board's hospitals warned the various local authorities on May 13, 1893, that all their available beds would shortly be filled up and that sanitary authorities would be called upon to provide for their own infectious sick. These anticipations were more than realised, and from the middle of June to nearly the end of the year the removal of large numbers of infectious patients was deferred, so that many patients remained at home until the end of their illness. By means of frequent personal application at the chief office of the Board I succeeded in gaining the early removal of several cases from one and two-roomed tenements in crowded flats and from self-contained houses with small shops attached. I have no hesitation in asserting that a saving of much suffering, broken health and loss of life would have been effected had the following advice contained in my Annual Report for 1892 been acted upon:— " Should the Parish be again visited by a similar outbreak of scarlet fever or other communicable disease—not at all an unlikely occurrence—the putting into practice the principles advocated by me in a Special Report ' on a Proposed Reception House' and approved by the Vestry, might be the means of averting similar catastrophies." The Report advises, amongst other matters, " the isolation of the healthy members of an infected family in a temporary shelter, which might also be utilised, should the accommodation in the Asylum Board's hospitals fail at any time (in which case the Vestry would become responsible), as a temporary substitute for hospital isolation." 14 Parish of St. George the Martyr, Southivark. In a report signed by your late Chairman of the-Public Health Committee and presented to your Vestry, recommendation III. is as follows:— "As regards hospital accommodation the house in Market-street, in addition to its ordinary use, might, having 20 rooms, be utilized in case of emergency as a hospital, and, without overcrowding, about 30 patients could be accommodated." Diphtheria.—Diphtheria, shows the largest number of cases and deaths ever recorded, both in St. George's and throughout London. Considering the advances made in general sanitation of late years some more direct cause than mere filth must be looked for to explain the increased mortality from diphtheria. Amongst the chief exciting causes are:—(a) Density of population; (b) close aggregation in schools with insufficient ventilation and floor space; (c) aggregation in block buildings and on their staircases and court yards ; (d) dampness and cold. 2,848 cases of diptheria were admitted to the Board's hospitals from all London in 1893, out of which number 865 died There were 186 cases notified in St. George's, from which number 41 died—33 under and eight over five years of age. Diphtheria, like scarlet fever, is always most fatal in infants. The maximum mortality occurs in the first year of life, when it reaches the high percentage of 69 9, subsequently falling with every additional year of life to the minimum of 3-6 per cent, amongst persons between 30 and 35 years of age. Amongst adults those who are in attendance upon the sick are most liable to suffer, particularly mothers, nurses, and medical men. " Sore throats " in young children should always be regarded with suspicion, and the fact remembered that diphtheritic infection may be conveyed from the mouth of a patient as long as one month after convalescence. Reference to the Chart will show the seasonal prevalence of the complaint. Measles.—Twenty-two deaths, all under five years of age, took place in St. George's in 1893, as against 66 in 1892. The aggregate number of deaths during the two years is exceeded among the zymotic class of diseases by diarrhoea only. Measles caused 1,661 deaths in London in 1893, which was less than one-half the number registered in 1892. There is no compulsory notification of measles in London, and the disease is generally looked upon by parents and guardians as a necessary and trifling event to which all must submit. In many cases it is not until serious complications, in the shape of lung mischief, have set in that it occurs to the parent to seek medical aid. In healthy houses, well nourished and well-cared-for children almost invariably make a good recovery. Amongst the poor and badly nurtured children of Southwark, brought up in cold, damp and overcrowded tenements', the proportion of deaths to attacks is as much as 20 or 30 per cent. Measles is most prevalent and most fatal in the winter months of November, December and January, and less so in the late spring months of May and June. Enteric or Typhoid Fever.—41 cases of this filth disease were notified as against 28 in 1892. Of this nnmber seven died in 1893 and seven in 1892. The Chart shows the usual increased prevalence of typhoid fever in the late autumn. Like diarrhoea, typhoid is most virulent when developed by a hot and dry summer, such as was the case in 1893. This fever is transmitted from the infected to the healthy, chiefly by means of water and air polluted by specific bowel discharges. Animal Report of the Medical Officer of Health,—1894. 15 Water or food becomes polluted from contact with infected sewage or infected sewer air. Tne poison may be taken into the system either through the medium of the stomach or by the lungs. The number of deaths in St. George's from typhoid fever in 1893 was four in excess of its proportion of total London deaths according to its population (vide table XI.) Small-pox.—This disease was prevalent in the northern and midland towns of England during 1892, and became epidemic in London in the winter of 1892-3. A single case was notified to me in December, 1892. The patient—a tramp— contracted the disease in Pentonville Prison and the rash was detected on him in the bathroom of St. George's Workhouse. The fears expressed by me at the end of 1892 that small-pox would probably become prevalent in London during 1893 have unfortunately been justified. During the period mentioned there were 206 deaths notified in London, and 2,378 cases entered the Asylum hospitals. This is the largest number of deaths since 18H4 and 1885, when there were as many as 1,251 and 1,403 deaths respectively from small-pox. The epidemic was most prevalent in the early spring, and reached its maximum in May. There are certain points in its behaviour worthy of notice, such as (a) its origin and spread during November and December, 1892, and the first four months of 1893, by the agency of male vagrants ; (b) its subsequent distribution amongst the residential population, particularly in the poorer parts; (c) the | important part played in the spread of the disease by the unregulated Salvation Army and other shelters. Dr. Long's Report on the history of the small-pox epidemic of 1893, to the Committee of the River Ambulance Service of the Metropolitan Asylums Board, bears on the last point. Under the heading of vagrants he shows, In the following table, how many patients traced their infection to various shelters:— Dec., 1892. Jan., 1893. February. March. April. May. June. July. Totals. Salvation Armv Shelters:— (a) Blackfriars—St. George's, Southwark ... ... 3 3 6 16 3 ... 31 (b) Lisson Grove, Edgware Road, Marylebone 3 2 3 8 11 5 ... ... 32 (a) Horseferry Road, Westminster ... ... 1 7 5 1 ... ... 14 (a) Others 1 2 5 6 8 ... 1 ... 23 Free Shelters generally ... 1 4 2 3 ... ... ... 10 Totals 4 5 16 26 33 22 4 ... 110 It should be noted that cases are here referred to the places of original infection, and not to those from which they were actually removed. Class (d) Under Salvation Army Shelters, includes cases referred to shelters at which a few people only were infected, such as Stanhope-street, Clare Market, Quaker-street, Spitalfields, Royal Mint-street, St. John's-Square, Clerkenwell, West India Dock-Road. 16 Parish of St. George the Martyr, Southwark. In the same report, Dr. Long, in discussing the cause of the epidemic north of the Thames, says :—" That between 50 and 60 cases were attacked in April, May and June, in an area f mile by £ mile, extending along the Edgware-road, with its centre very near the Salvation Army Shelter in Lisson-street, Marylebone; this fact is suggestive, though there is no direct evidence of the outbreak being secondary to the shelter." So far as St. George's and the South of London are concerned, I have a firm impression that small-pox in 1893 was largely spread through the medium of the Blackfriars Salvation Shelter, and to a much greater extent than the figures in Dr. Long's table would appear to warrant. My experience tells me that many of the workhouses, infirmaries, and general hospitals, together with the licensed common lodging houses, and particularly the casual ward, played the part of filters in removing vagrant infection. In my Annnal Report for 1892, a warning note was sounded in the following words:—" I fear the Salvation Army Shelter, situated in the Blackfriars-road, which is capable of accommodating nightly 400 men and youths, practically in one large dormitory, at a charge of Id. and 2d., according to the nature of the accommodation —i.e., Bunk, bench, or bare floor—will, in the future, prove a serious means of spreading small-pox, and other communicable diseases." " I understand the shelter is to be enlarged, and I believe that prompt measures should be taken, in the public interest, to place this and other similiar shelters— benevolent or purely money-making in their aims—under the salutary provisions of the Common Lodging House Acts." Since writing the above the shelter has been enlarged, and will now accommodate 500 persons in the Id. shelter, 288 in the 2d. bunk dormitories, and 40 in the 3d. cubicle dormitory; in times of pressure, by utilising a covered passage, the whole place can be made to contain a total of 900. These figures were furnished by the Officer in charge of the Shelter. In the case of Edwai'ds v. the Superintendent of the Blackfriars Shelter, I was asked by the counsel for the defence whether I could suggest—as a practical sanitarian—any addition to the regulations which were alleged to be in force. I answered that a reduction of numbers and the fixing of a maximum for the several dormitories of the shelter might be made with advantage. That suggestion, however, has not been acted upon. Measurements of the shelter, for instance, which harbours on an average 350, and occasionally as many as 500 persons, give on the former estimate a floor space of 8 square feet and a cubic space of 130 cubic feet per head. On the higher estimate of 500 occupants the dormitory gives only 6 superficial and 90 cubic feet of space to each inmate. In common lodging-houses in London, which are under police supervision, the existing regulations insist on 31 superficial and 341 cubic feet of space to each adult over 12 years. In workhouses 300 cubic feet are allowed for each adult in a dormitory ; in military barracks about 600 cubic feet; in prison cells, under the separate confinement system, about 800 cubic feet with artificial ventilation; and in the best general hospitals about 1,200 cubic feet of space for each bed, and 100 superficial square feet of floor space. From a comparison of these facts and figures it will be seen that I do not exaggerate when I say that overcrowding to a dangerous extent exists in the Blackfriars Shelter, especially when we consider the exhalations given off from the dirty bodies and clothes of the vagrants by whom it is frequented. Annual Report of the Medical Officer of Health,—1893. 17 TABLE XII. A comparison of the minimum cubic and superficial space allotted to each Adult n the Dormitories of various institutions. Cubic Space. Floor or Superficial Space. Cubic feet. Square feet. Blackfriars Penny Shelter 90 6 Common lodging houses in London 341 31 Workhouses 300 Military Barracks 600 Prison Cells 800 General Hospitals 1,200 100 This list emphasises the utterly inadequate space allowance in the shelters, amounting to less than one-third of the minimum cubic space elsewhere, and little over one-thirteenth of the amount considered necessary in a good general hospital. The placing of Salvation Army and other shelters under the protective provisions of the Common Lodging House Acts has been repeatedly advocated by me in Special Reports during the past two years. It has also been urged by your Vestry, both by letter and in the form of resolution addressed to the Local Government Board. Questions on the same subject have been asked in the House of Commons, to which unsatisfactory replies have been given. Copies of resolutions—similar to those previously arrived at by your Vestry—have been forwarded by the Metropolitan branch of the Society of Medical Officers of Health to the Local Government Board and to the Home Office. The only result so far has been the official appointment of Dr. Airey, Medical Inspector to the Local Government Board, to inquire into the Sanitary condition of the Night Shelters of the Salvation Army in the metropolis. I have written to the Local Government Board requesting the favour of a copy of Dr. Airey's Report. The reply received from the Assistant Secretary stated that "the Report in question was not intended for publication; and that the Board could not undertake to supply me with a copy." By the courtesy of Mr. J. Duncombe Mann, the Secretary of the Metropoltan Asylums Board, and the kind assistance of Dr. Walter F. Frith, the acting Medical Superintendent of the Hospital Ships at Long Reach, I am able to present a complete list of small-pox admissions. H-l CD £ 3 Co 2? c*> 2 is & I3 S- a -* TABLE XIII. Gases admitted to the Metropolitan Asylums Board's Hospital Ships, from St. George's, Southwark, during 1893. No. Name. Sex. Age. Address. Date of Admission. Statement as to prirnar; Vaccination Number of Scars. Collective Area. Re-vaocinated. Result. 1 J. M. M 21 St. George's Workhouse Jan. 4 Infancy 2 .66 sq. in. Not Recovered 2 H. J. M 54 „ „ „ „ 26 „ 1 .15 „ Aged 20 „ 3 J. G. M 39 „ „ „ Feb. 11 „ 2 .19 „ 10 years ago „ 4 C. F. M 43 Pocock Street „ 14 „ 1, doubtful Unrecorded Not „ 5 T. P. M 30 High Street, Borough „ 23 „ Several Obscured „ „ 6 G. W. M 21 1, Redeross Court, Borough March 2 Not None — „ „ 7 G. N. M 31 Salvation Army Shelter, Blackfriars Road „ 3 Infancy 2 .37 sq. in. Not „ 8 J. 0. M 35 St. George's Workhouse „ 28 „ 2 1.50 „ 21-3-93 sue. „ 9 C. R. M 30 Salvation Army Shelter, Blackfriars Road April 1 „ 2 .22 „ Not „ 10 A. G. M 34 „ „ „ „ 6 „ 1 .50 „ „ „ 11 T. F. M 27 Tower-Street, Westminster Bridge Road „ 10 Not None — „ „ 12 J. C. M 35 Bean Street, Friar Street „ 13 Infancy 4 .65 „ Not „ 13 w. s. M 27 St. George's Workhouse „ 13 „ 4 .40 „ „ „ 14 J. G. M 39 Newington Causeway „ 15 „ 1 .28 „ „ „ 15 E. G. M 20 Salvation Army Shelter, Blackfriars Road „ 21 Not None - - „ 16 T. A. M 33 „ „ „ „ 23 Infancy 2 .18 „ Not „ 17 J. B. M 8 Redeross Street, Borough May 3 Not 1, doubtful Unrecorded „ „ 18 E. H. M 28 Salvation Army Shelter, Blackfriars Road „ 9 Infancy 2 .56 „ „ „ 19 H. L. M 21 Charles Street, Westminster Bridge Road „ 9 „ 5 2.97 „ „ „ 20 F. H. F 14 Quinn Square, Waterloo Road „ 11 Not 1, doubtful — „ „ 21 F. M. M 45 Salvation Army Shelter, Blackfriars „ 12 „ None - - Died 22 T. L. M 48 Friar Street, Blackfriars Road ' ,, 12 Infancy 3 .23 „ Unrecorded Recovered 23 A. A. F 23 Borough Road „ 13 „ 3 .44 „ Not „ 24 J. H. B. M 35 High Street, Borough „ 13 „ None — Unrecorded „ 25 J. W. M 27 „ „ „ „16 Do not know 2, doubtful - Not „ 26 R. F. M 54 St. George's Workhouse „ 17 Infancy Unrecorded Uurecorded - „ 27 J. R. M 63 „ „ „ „ 18 „ None — Not Died 28 W. S. M 60 „ „ „ „ 20 „ 3 .11 sq.in. 14 yr ago 20-5-93 Not small-pox 29 C. L. F 32 Friar Street, Blackfriars Road „ 25 „ 3 abt.30 „ Not Died 30 E. H. M 21 Salvation Army Shelter, Blackfriars Road „ 25 „ 3 .36 „ Recovered 31 E. J. S. M 43 Waterloo Road „ 25 „ 2 .30 „ „ „ 32 G. M. M 18 Bean Street, Blackfriars Road „ 26 „ None — „ „ 33 H. D. M 21 Marshalsea Road, Borough „ 27 „ 4 .60 „ „ „ 34 F. H. F 35 Quinn Square, Waterloo Road 27 „ 2 .38 „ „ „ Annual Report of the Medical Officer of Health,—1893. 19 TABLE XIII (Continued.) 35 D. R. M 28 Morley's Lodging House, Southwark Bridge HoBid May 29 Infancy 3 1.30 sq. in. Not Recovered 36 A. V. M 30 Disney Street, Redeross Street, Borough „ 29 „ 3 Indefinite „ „ 37 J„ P. M 27 Salvation Army Shelter, Blackfriars Road „ 29 „ 3 .50 sq. in. „ „ 38 G. G. M 24 High Street, Borough (from St. Olive'sChambers „ 31 „ 2 .89 „ „ „ 39 J. C. M 52 Salvation Army Shelter, Blackfriars Road June 1 „ 3 .35 „ „ „ 40 E. L. F 30 Lodging House, Lombard Street, Borough „ 4 „ 3 Indefinite „ „ 41 J. H. P. M 31 Southwark Bridge Road „ 5 „ 1 12 sq. in. „ Not small-pox 42 E. P. M 3 Chatham Street, Old Kent Road .. 5 Not None — — Recovered 43 C. P. F 11 „ „ „ 5 Infancy 5 245 „ Not „ 44 A. F. F 44 Lombard Street, Southwark Bridge Road „ 10 „ 1, doubtful Indefinite „ „ 45 H. 0. D. M 30 St. George's Circus „ 12 „ 4 1.62 sq. in. 1872 „ 46 C. R. G. M 5 Swan Place, Old Kent Road „ 12 Not None — — „ 47 E. B. F 38 Chatham Street, Old Kent Road „ 12 Infancy 2 Indistinct Not „ 48 F. D. M 32 Salvation Army Shelter, Blackfriars Road „ 13 1) None — „ „ 49 W. M. M 19 St. George's Buildings, Borough „ 16 5 years old 4 abt .50 sq. in. „ „ 50 D. G. F 5 William Street, Darwin Street, Old Kent Road „ 19 Not None — „ „ 51 J. H. F 26 Great Suffolk Street, Borough „ 20 Infancy 2 38 „ Not „ 52 M. A. G. F ly.lm Swan Place, Old Kent Road .. 27 June 22, '93 4 vesicles — „ Died 53 C. H. G. F 7 „ „ „ „ 27 June 11, '93 4 scabs — „ Recovered 54 H. M. M 31 Southwark Bridge Road „ 29 Infancy 4 .82 „ „ 55 L. E. F 31 Mason Street, Old Kent Road „ 30 „ 4 abt-40 ,, agd.14, 5-7-93 Notsmall-poi 56 W. C. M 28 Salvation Army Shelter, Blackfriars Road July 9 „ Unrecorded Unrecorded 1891 Recovered 57 A. C. F 23 Disney Street, Borough „ 17 „ 3 81 sq.in. Not „ 58 M. A. W. F 55 Marshalsea Road, Borough „ 17 „ 3 Indefinite „ Died 59 M. A. C. F 37 King's Court, Great Suffolk Street, Borough „ 19 „ 3 „ 11 years ago Recovered 60 M. M. F 40 Levy's Lodging House, Marshalsea Road, Borough „ 21 „ 1 .03 sq. in. Not „ 61 E. M. F 36 High Street, Borough Aug. 5 „ 3 .39 „ „ „ 62 A. M. M 8 Marshall's Buildings, Webber Street, Blackfriars Road „ 16 Not None — - „ 63 S. A. H. F 23 Grey Street, Blackfriars Road „ 26 Infancy 3 abt .30 ,, Not „ 64 M. W. F 12 Quinn's Buildings, Waterloo Road Sept. 13 Do not know None — „ „ 65 M. M. L. F 4 „ „ 15 Not „ — - „ 66 W. W. M 42 „ „ „ 25 Infancy „ - Not „ 67 G. W. M 6 „ „ „ 25 Not „ - — „ 68 F. W. F 4 „ „ „ 25 „ „ - - „ 69 E. W. F 38 „ „ „ 27 Infancy 4 abt 2.07 „ Not „ 70 J. L. M 5 „ „ „ 26 Not None — - „ 71 R. L. M 1 „ „ „ 28 „ „ - - „ 72 W. G. M 24 Newington Causeway Nov. 13 Infancy 1 47 „ At school „ 20 Parish of St. George the Martyr, Southwark. Altogether 80 cases of small-pox were notified during 1893. Seventy-two cases only appear on the list, the remaining eight patients having been treated at their own homes. Prom the list it appears that 49 of the patients were males and 23 females. Also, that the addresses given were 12 times Salvation Army Shelter, Blackfriars road, 8 times St. George's Workhouse, and 7 times various common lodging houses. These attacks occurred in men, with the exceptiou of three women who were removed from a couple of common lodging houses. During the early part of the outbreak the disease was more marked among the floating population than in the latter months, when it was mostly confined to the poorer settled classes. In May and June the epidemic reached its height. (Sec Chart.) It is remarkable that of the 72 cases, 61 cases came from Ward I. Borough Road, 8 from Ward III. (Kent Road), and 3 only from Ward II. (London Road.) It is a significant fact that the Salvation Shelter, Workhouse, and majority of common lodging houses are situated in Ward I. Among the sufferers in St. George's were your Assistant Disinfector and the officer in charge of the Blackfriars Salvation Shelter, both of whom declined my offer of re-vaccination several weeks before they were attacked. Of the 72 cases mentioned in the list, 50 had been vaccinated, 2 had been vaccinated during the period of incubation of small-pox, and in 5 instances the evidence afforded by scars was inconclusive. 63 cases had not been re-vaccinated, 2 were re-vaccinated while the Small-pox was upon them, and 7 cases—2 of which proved ultimately to be diseases other than small-pox—had been re-vaccinated. Of the 5 deaths, in no single case had re-vaccination been practised, 2 aged 55 and 32 years respectively, had been vaccinated in infancy, and 3 had never been vaccinated. The principal lessons to be gathered from the small-pox experiences of the past year are :—(1) The supreme importance of vaccination and re-vaccination. (2) The prevention of the spread of small-pox among the community generally, by the early detection of the disease among the vagrant class. Your Sanitary Authority received no official returns relating to vaccination. After an unsuccessful appeal to the Clerk and Guardians of St. Saviour's Union, I obtained otherwise the following Local Government Board returns for 1892 and 1893. TABLE XIV. RETURN made to the Local Government Board, by Messrs. Cloake & Frith, Vaccination Officers of the St. George the Martyr District, of the St. Saviours, Southwark Union, respecting the Vaccination of Children whose Births were registered in their Districts from 1st January to 31st December, 1892, inclusive. Registration Sub-Districts comprised in the Vaccination Officer's District. • Number of Births returned in the "Birth List Sheets" as registered from 1st Jan. to 31st Dec. 1892. Number of these Births duly entered by 31st January, 1893, in columns 10, 11, and 13 of the " Vaccination Register " (Birth List Sheets,) viz : Number of these Births which on 31st January, 1893, remained unentered in the "Vaccination Register" on account (as shown by Report Book) of Number of these Births remaining on 31st January, 1893, neither duly entered in the "Vaccination Register" (colums 3, 4, 5, and 6 of this Return) nor temporarily accounted for in the "Report Book" (columns 7, 8, and 9 of this Return.) Col. 10 "Successfully Vaccinated " Col. 11 Col. 13 "Dead, unvaccinated " Postponement by Medical Certificate Removal to Districts the Vaccination Officer of which has been duly apprized. Removal to Places unknown, or which cannot be reached; and Cases not having been found. "Insusceptible of Vaccination " "Had Small Pox" 1 2 3 4 5 6 7 8 9 10 1.—Borough Road 643 490 — — 83 3 1 60 6 2.—London Road 703 529 1 — 85 6 9 69 4 3.—Kent Road 810 569 — — 95 8 7 124 7 TOTAL 2156 1588 1 — 263 17 17 253 17 Annual Report of the Medical Officer of Health—1893. 21 22 Parish of St. George the Martyr, Southwark. TABLE XV. RETURN made to the Local Government Board, by Messrs. Cloake & Frith, Vaccination Officers of the St. George the Martyr District, of the St. Saviours, Southwark Union, respecting the Vaccination of Children whose Births were registered in their Districts from 1st January to 31st December, 1893, inclusive. Registration Sub-Districts comprised in the Vaccination Officer's District. Number of Births returned in the "Birth List Sheets" as registered from 1st Jan. to 31st Dec. 1893. Number of these Births duly entered by 31st July, 1894, in columns 10, 11, and 13 of the " Vaccination Register " (Birth List Sheets,) viz : Number of these Births which on 31st July, 1894, remained unentered in the " Vaccination Register" on account (as shown by Report Book) of Number of these Births remaining on 31st January, 1894, neither duly entered in the "Vaccination Register" (colums 3, 4, 5, and 6 of this Return) nor temporarily accounted for in the "Report Book" (colums 7, 8, and 9, of this Return.) Col. 10 "Successfully Vaccinated " Col. 11 Col. 13 "Dead, unvaccinated" Postponement by Medical Certificate Removal to Districts the Vaccination Officer of which has been duly apprized. Removal to Places unknown, or which cannot be reached; and Cases not having been found. "Insusceptible of Vaccination" "Had Small Pox" 1 2 3 4 5 6 7 8 9 10 1.—Borough Road 641 456 3 — 88 12 6 72 4 2.—London Road 697 496 3 — 74 29 13 73 9 3.—Kent Road 828 576 4 — 110 30 5 95 8 TOTAL 2166 1528 10 - 272 71 24 240 21 Annual Report of the Medical Officer of Health,—1893. 23 The returns for 1892 and 1893, compiled by Messrs. Cloake & Frith, the vaccination officers, show on the total number of births, a margin of 13'3 and 15"3 per cent, of infants not officially registered as vacciuated; that is to say, in 1892 less than 87 per cent, of the total number born in your Parish remain unaccounted for by the Guardians. In 1893, again, less than 85 per cent, were returned as vaccinated. The following table is extracted from the' latest available reports of the Medical Officer of the Local Government Board. TABLE XVI. Metropolitan Union 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 St. Saviours, Southwark. 7.0 8.0 5.7 6.7. 6.0 8.7 9.1 13.1 18.9 17.1 12.4 This table shows the number of children per cent, of total births remaining "unaccounted for," including cases postponed. It will be thus seen that of late years less vigilance has been shown by the Guardians in the discharge of their responsible duties under the Vaccination Acts. It appears that in no single instance have the Guardians given instructions to their Vaccination Officers during 1852 and J 1893 to prosecute persons for failing to have their children vaccinated. The law, as it at present stands, says, " Every parent or person having the custody of an j unvaccinated child, who, after certain proceedings, disobeys the order of a Justice, directing the child to be vaccinated within a certain time, is liable to a penalty not exceeding twenty-shillings, and upon proof of continued disobedience, after such order is made, the said parent or person may be fined again and again, and even sent to prison in default of payment of the penalty." The members of the Royal Commission appointed to inquire into the question of compulsory vaccination, who have been sitting for some years past, reported in 1892, that, in their opinion, " the imposition of repeated penalties in respect of the non-vaccination of the same child should no longer be possible, and should cease to be inflicted altogether." They also stated that they had arrived at this conclusion "quite independently of the question whether vaccination should continue to be compulsorily enforced." This interim recommendation of the Commission may or may not be carried out, but it in no way absolves Boards of Guardians from discharging the duties devolving on them with respect to the Vaccination Acts. With the experiences of the small-pox epidemic of 1893, gentlemen, fresh in your memories, the grave nature of the responsibility incurred by the failure of the Guardians to extend to this poor and densely crowded parish the protection afforded by the great discovery of Jenner need not be further insisted upon. A copy of the placard issued under the title "Small-pox and its Prevention," distributed generally throughout your parish, and particularly to the occupiers of infected houses, the keepers of the common lodging-houses, the Salvation Shelter, and the Guardians of the Casuals and Relief Stations, will be found under Appendix A. It will be noticed that I emphasise the urgent need of (1) Revaccination ; (2) The immediate removal of every case of small-pox to an isolation hospital. On July 20th, 1893, I prosecuted on behalf of the Vestry, W. M., under Section €8, Sub-section I. (a) of the Public Health (London) Act, 1891, for having wilfully exposed himself in a public thoroughfare while suffering from small-pox. Mr. Fenwick, the magistrate, doubted at first my ability to prosecute, and I told him I did so very reluctantly, having advised the Sanitary Authority of St. Georgethe-Martyr more than once to engage a lawyer in all such cases. 24 Parish of St. George the Martyr, Southwark. Dr. Fisher, late House Physician to Guy's Hospital, proved having notified the patient as suffering from small-pox, and of having told the defendant such was the case, and that he must remain in the isolation room pending the arrival of the ambulance. Inspector Anscombe and the caretaker of St. George's Industrial Buildings gave evidence as to defendant being found on the balcony of his "flat" after having made his escape either through the window or door of the isolation room. I mentioned that the case was the first of a series of 19 small-pox patients, who had walked through the public streets to four general hospitals and to the Union l'elief station, with proof forthcoming of wilful exposure ; also that the Vestry asked for a conviction with nominal punishment only. The magistrate remarked that the case, in his opinion, was a very serious one indeed, and that the defendant would have to pay a fine of 40s. and 2s. costs or suffer 21 days' imprisonment. The defendant went to gaol. It should be added that the patient on returning to his own home from Guy's Hospital was found in a bedroom which contained a number of articles of millinery in process of manufacture by the women of the household. Cholera. On September 3rd, 1892, I presented a Special Report to your Vestry, on "The precautionary measures to be taken against the introduction and spread of Asiatic Cholera within the Parish." This report emphasised, among other matters, the need of:—(1) The frequent and periodical inspection of drinking-water cisterns. (2) The closing of shallow wells, the water from which was liable to pollution, and to subsequent use for drinking and domestic purposes. (3) Increased vigilance on the part of the inspectors in the siezure of all tainted food, such as meat, fish, and poultry, as well as of unripe and unsound fruit and vegetables. (4) A frequent flushing of the sewers, together with a thorough cleansing of all roads, streets, courts, alleys, gullies, and urinals. (5) The extension of the pail-system of dust removal throughout the parish. (6) The furnishing of a I ouse or houses to be used for the reception and disinfection of the persons and clothes of the families of those suffering from cholera (or from other infectious disease) pending the treatment of the patient at home, and the disinfection of the infected houses, bedding, and clothes. To these recommendations the following were added :—(1) The increase and re-construction of your Sanitary Staff. (2) The carrying out of a house-to-house inspection throughout the parish, (3) The enforcement of a new set of bye-laws for registration and inspection, promotion of cleanliness, and prevention of over-crowding, in lodgings let or occupied by members of more than one family. (4) The disuse of Fraser's apparatus for disinfecting with dry heat, and the introduction of one of Lyon's steam-under-pressure disinfectors, together with the erection of an incinerator. The following letter was received by me from the Asylums Board :— The Metropolitan Asylums Board, Norfolk House, Norfolk Street, W.C. 25th August, 1893. Dear Sir. Cholera, I enclose a list of the Boards Cholera Ambulance Stations, and of the Hospitals and Infirmaries which have promised to provide accommodation for) patients 26 Ambalaaces will not be placed at the said stations, unless cholera actually appears in an epidemic form in London. Any isolated cases that occur, and are notified to the Board, will be removed by the ordinary Ambulance Service. If it should become necessary to bring the Special Cholera Service into use, a staff of bearers will be provided by the Board; but in case of emergency, the cholera ambulances will be at the disposal of Medical Officers of Health, or any medical men, for the removal of patients to avoid delay. Yours faithfuily, T. DUNCOMBE MANN, Clerk to the Board. To P. J. WALDO, Esq., M.D. Medical Officer of Health for St. George the Martyr. Transport of the Sick—The only Ambulance Station provided in St. George's for the housing of special cholera litters was at the Workhouse in Mint Street. Hospital Accommodation—The following is a list of institutions which promised to provide accommodation for patients in the South of London:— N ame of Sanitary District in which the accommodation is situated. No. of beds In what Building. Notice required and other remarks. Plumstead 60 Woolwich Infirmary, Plumstead. Greenwich ? Seamen's Hospital. No answer Greenwich 60 Greenwich Infirmary. Rotherhithe 92 St. Olave's Infirmary, Lower road. 3 day's notice St. Olave's 50 Guy's Hospital. St. Saviours 100 Workhouse, Marlboro Street, Blackfriars Road. N ewington ? Workhouse, Westmorelandroad, Walworth. No answer Lambeth ? St. Thomas' Hospital Westminster Bridge Road. No answer Lambeth 100 Workhouse, Princes Road. 7 day's notice 462 Our first experience of cholera in England during 1893 occurred in June, when an infected vessel arrived in the Tyne, from Nantes, with a patient, who died the same day. In July and August other vessels brought cases up the Thames, the Humber, :uld the Mersey, and isolated attacks were verified at Hull and Grimsby. The latter fishing-town probably became infected through importation from Antwerp. During September and August the disease spread from Grimsby to various places in England. Pour undoubted and fatal cases of Asiatic cholera occurred in London during September. They were as follows:— Date of Death. Address. (1) Female, aet. 50 September 6th Marsham-Street, A cleaner in the House Westminster, of Commons. 26 Parish of St. George the Martyr, Southwark. (2) Female, aet. 54. September 11th. Fulham Workhouse. A laundry worker in Fulham Workhouse. (3) Male, aet. 61, September 12th. Kennington-Road, A master sculptor. Lambeth. (4) Male, aet. 60. September 26th. Quinn's-Buildings, A glass cutter. St. George's, Southwark. Case 4 was notified to me as one of cholera on Tuesday, September 26th, 1893, by Dr. Cooper, a gentleman who has had considerable experience of the complaint in India. At the request of Dr. Cooper I visited the patient on the afternoon of September 26th, and found him lying in a bed on one of three small rooms opening directly into each other. The unfortunate, sufferer was then in a dying condition ; his pulse was imperceptible, his face pinched, he could not speak ; in short, he was in an extreme state of collapse, and died at 10 o'clock the same night. In addition to the collapse I noticed that the motions were bloodstained, and I was informed that there was a complete suppression of urine. The patient appeared to have passed into this stage after that of urgent vomiting, purging, and cramps, from which, I was told, he had suffered some few hours previously. From information primarily gained from the patient's master, his wife, and the superintendent of the cholera-infected " model," the following particulars were gleaned:—The patient, a glass-cutter, worked for a glass insurance company, his workshop consisting of three small rooms opening into one another, practically forming one room, on the ground-floor of " Model " buildings in St. Saviours, Southwark. The patient took up his abode in Quinn's-Buildings, Waterloo Bridge-Road (in Ward 1) with his wife and two young children which she took in to farm about four weeks before his illness began. No strangers were subsequently entered as tenants in the block save one family that came in after the commencement of patient's illness. Patient's work took him to various districts, both in the inner and outer metropolitan circles, within the few days immediately preceding his illness. He had, however, not slept away from home. Patient had, on two occasions, visited a tavern on business, near a railway station, at Canning Town, one and two weeks prior to his death. During the same period, he was reported also as having worked in the neighbourhood of the Victoria Docks. On Thursday, September 21st, patient took a van to a wholesale house in Christchurch Parish, where he purchased glass. On Friday, September 22nd, he cut two panes of glass for the keeper of a common lodging house near King's Cross, and later, on the same day, he measured a new shop front close to Maryland Point Railway Station. I visited patient's workshop in St. Saviour's, which proved to be in an insanitary condition. This fact, together with the need of disinfection, was duly reported by me to the Medical Officer of Health. I also made certain personal investigations and enquiries at the wholesale glass warehouse before alluded to, and visited the common lodging house at King's Cross accompanied by the police inspector and sergeant in charge of the house. Of the two w.c.'s placed in the back yard of the lodging house, and very possibly used by the patient, the water apparatus of one was out of order and gave no flush, and both were in a dirty condition. The lodgers were congregated in an underground basement common kitchen, artificially lighted in the absence of day-light. These facts I communicated to the Medical Officer of Health of the district within which the lodging house was situated. I wrote also to the Medical Officer of East Ham. With regard to the patient, he generally enjoyed good health, and was an abstemious, hard-working, and careful-living man. He had not been feeling well Annual Report of the Medical Officer of Health,—1893. 27 during the ten days preceding his death. On Friday, September 22nd, he ate some liver and bacon. On Saturday, September 23rd, diarrhoea commenced. The next day, feeling better, he partook of some beef-steak pudding, and the diarrhoea returned during the evening. On Monday, September 25th, he commenced work, but at 10 a.m. complained of diarrhoea to his master, who told me "he looked pale." The diarrhoea was allowed to remained unchecked and untreated up to this period, when it became more severe and was accompanied by vomiting. The same evening he was attended by Dr. Cooper, to whom I am indebted for the following clinical account of the case:— "The patient's face and finger nails were bluish, the hands were clenched and sodden, and the voice husky. His breath was felt to be cold. The pulse was frequent, small, and feeble, and the general condition was one of collapse. Pain in the stomach was complained of, as well as cramp affecting the calves of the legs. There was copious vomiting and purging of thin fluid, for the most part of a whitish colour, like water in which rice has been boiled, and unmixed with bile. The intellect was clear, and the patient was able to answer questions in a sensible manner." In a word, all the clinical symptoms of Asiatic cholera were present. At the post mortem examination, at which I was present, the intestines were found injected throughout their whole length, and there was a little fluid in the peritoneal cavity. Submucous hemorrhages were disclosed in the lower ileum and the large intestine. This extravasation was extensive in the head of the caecum. A portion of the lower ileum, with its contents, was taken to Dr. Klein. Report by Dr. Klein :—" The mucous membrane was deeply congested, the Peyer's patches and solitary follicles prominent and deeply congested; the contents of the ileum a brownish fluid. On microscopical examination numerous epithelial flakes could be distinguished. Crowds of different bacteria present, among them a fair number of comma and S shaped forms. Peptone salt cultures yielded crops of commas, giving markedly the cholera-red reaction. The peculiar character of these commas was this, that, while in gelatine plate cultivations, the colonies were of the general character of the choleraic commas, except that the liquefaction proceeded very slowly, in gelatine stab cultures they did not produce liquefaction. In agar and other media they did not differ from the typical cholera commas." My own report completely corroborates that of Dr. Klein. Some of the contents of the ileum, cultivated in broth, containing 1 per cent, of peptone and J per cent, salt, gave positive evidence under the microscope of Koch's comma bacilli, which I consider to be the specific cause of Asiatic cholera. This same peptone-salt culture distinctly gave, on the addition of a single drop of pure sulphuric acid, the characteristic rose-coloured tint called the cholera-red reaction—thus confirming the former test. On my first visit to the patient's workshop, which he occupied alone, I noted a crate partially filled with sheet glass, lying open, on end, with its packing of straw disturbed. This straw, I was told, the patient had handled the week preceding his death. At the wholesale house from whence the crate came, I was told that 80 per cent, of the crates similar to the one I described came from Antwerp. On returning to the workshop I found on examination the crate was marked with the Antwerp stamp. From this observation, coupled with the fact that Antwerp had been for some time a cholera-infected port, it appears probable that the straw with which the glass was packed had Koch's comma bacilli in it. The straw, handled by the patient, might then easily have conveyed organisms, which later on reached his stomach, and so gave rise to the fatal attack of cholera. It should be added that every possible precaution was taken to prevent the spread of the disease. The family was removed, all infected bedding and clothing destroyed, the water-closet used by the deceased closed, and rooms disinfected. 28 Parish of St. George the Martyr, Southivark. A possible source of cholera infection through the handling of straw from an infected port has therefore been established, The evidence consists of (a) The history of the attack ; (b) The testimony of Dr. Cooper, the medical man in attendance ; (c) The independent bacteriological examination carried out by Dr. Klein and by me. We may conclude, then, that the case in Quinn's Buildings was one of true Asiatic cholera. Influenza.—Seven deaths were registered in the parish from this disease, which number was 17 less than St. George's proportion of total deaths from influenza in London. Twelve deaths were registered from this cause in 1891, and 14 in 1892. The deaths in the whole of London attributed directly to iufluenza were 1,526 in 1893, 2,264 in 1892, 2,336 in 1891, and 652 in 1890. Puerperal Fever—There were five deaths from this virulent and highly-contagious disease in 1893, as against three in 1892. Bach of the five patients was attended by a different medical practitioner and midwife. The latter were advised by me regarding the disinfection of their persons, and cautioned to discontinue their practice for at least six weeks after the death of a patient. This advice, so far as I could learn, was followed in each instance. The infected clothes of the midwives were burnt, and their money value paid to the owners. Each case of puerperal fever was reported by me to your Health Committee, with a view of compensation for loss of employment, and of thus encouraging the midwives to aid in preventing the spread of the disease. In one instance—that of a poor midwife—compensation for loss of time and practice was given by the Committee. The death rate from puerperal fever might be materially lessened, if not completely wiped out, by the more general use of antiseptics in the case of lying-in women. Erysipelas.—One hundred and forty-two cases were notified (against 108 in 1892) and six deaths recorded from this disease. Of these cases, 64 occurred in the Borough Road, 42 in the London Road, and 36 in the Kent Road sub-districts. As stated in my Annual Report for 1892, my experience tells me that the special micro-organism producing erysipelas thrives best in those situations where dampness, want of light, and stagnation of air are combined. The infection is commonly spread in underground basements, which, but for the saving word "separately" in the Act, might be closed on the charge of illegal occupation. The occupiers too often, however, rent the whole house, let off the upper portion of it, and dwell in the basement, which is sometimes little better than a cellar, and liable to sewage reflux in times of heavy rainfall. Tubercular Complaints.—These, including phthisis, or consumption of the lungs, come under the class of constitutional diseases. In St. George's they caused 3 8 deaths per 1,000, as against 3'7 for London. Respiratory Diseases. The death-rate from diseases of the respiratory organs (not including consumption of the lungs) was 6.7 in St. George's, as against 4.5 per 1,000 in London. In other words 2.2 more persons die per 1,000 in your parish from this cause than is the case in London as a whole. Of the total number of deaths, 226 were from bronchitis and 138 from pneumonia. The following Table (corrected) gives the number of deaths from bronchitis, pneumonia, or inflammation of the lungs, and phthisis, or consumption, in the three sub-districts of St. George's during 1892 and 1893:— Annual Report of the Medical Officer of Health,—1894. 29 Table XVII. Sub-District. No. of Deaths- 1892. Total No. of Deaths—1893. Total Bronchitis Pneumonia Phthisis Bronchitis Pneumonia Phthisis Borough Road 51 42 39 132 48 41 25 114 London Road 68 28 71 167 83 41 29 153 Kent Road 78 79 83 240 95 56 1 152 Total 197 149 193 539 226 138 55 419 The foregoing table discloses the fact that the greatest number of deaths from diseases of the lungs has taken place in the London Road and Kent Road subdistricts, and fewest in the Borough Road sub-districts during the past two years. The reason for the unequal distribution of the mortality is at present speculative, and the subject remains open for future enquiry. As in the preceding three years, the deaths from pneumonia were again largely in excess of the average, and it is probable that to this cause have been assigned many deaths which were really due to influenza. This observation, it may be noted, applies not only to St. George's but also to the whole of London. Alcoholic Excess. In my Report for 1892, I remarked that the deaths attributed directly to chronic alcoholism and to delirium tremens did little to indicate the actual loss of life due to the abuse of alcohol. I further pointed out that the natural wish to spare the feelings of surviving relatives prevented the returns from mentioning the real cause of death. Hence the offensive term " alcoholism" was often replaced by one of its secondary results, such as disease of the liver, brain, kidneys, or stomach. With this fact in view the following suggestion was made:— " That a nearer approach to truth as regards alcoholism and certain other diseases could, I think, be arrived at were it made obligatory, in future, for medical practitioners to forward all death certificates, in confidence, direct to the Registrars, instead of handing them to relatives, which is at present the usual procedure." Since the above was written the Select Committee appointed by the House of Commons to report on death certification, has recommended ■' that medical practitioners should be required to send certificates of death to the Registrar, instead of handing them to the representatives of the deceased. Mortality of Infants and Children. The number of infants dying within the first year of life was 462. These figures give the high rate of 213 deaths to every 1,000 births in St. George's, as compared with 164 deaths per 1,000 births for London. The highest rate in the metropolis was 219 in the Strand, and the lowest in Hampstead, where it was 102—less than one half of that in St. George's. Of a total of 1,657 deaths at all ages in St. George's, 776 occurred in those under five years, which gives the large percentage of 46 8 to the total number of deaths, as compared with the percentage of 38'4 for London. 30 Parish of St. George the Martyr, Southwark. TABLE XVIII. The following are the most prominent Diseases causing the Infant Mortality under One Year of Age :— Deaths, 1892. Deaths, 1893. Diarrhoea 23 43 Tabes Mesenterica (bowel phthisis) 221 58 161 37 Tubercular Meningitis, Hydrocephalus 20 10 Other Tubercular and Scrofulous Diseases 16 11 Premature Birth 24 36 Convulsions 35 41 Bronchitis 45 50 Pneumonia 32 24 Dentition 21 14 Whooping Cough 11 20 Suffocation in bed 11 12 Debility, Atrophy, and Inanition 42 84 Other cases not specified or ill-defined 34 6 Total 336 367 From the foregoing list it is seen that "Debility, Atrophy, and Inanition" is the chief cause of infantile death in St. George's. This ill-defined group refers mainly to chronic wasting disease, produced by malnutrition, which is again a consequence of improper feeding. Infants fed naturally on mother's milk generally escape these fatal consequeuces, which chiefly affect children brought up by hand. Infants during the first six months of life are as little fitted to digest bread, arrowroot, cornflour, biscuits, tops and bottoms, or any of the so-called infant foods, as they would be to live on sawdust, shavings, or other foreign matter. Another noteworthy feature in the list, is the excess of deaths from diarrhoea during 1893 over that of 1892. This may he explained by the hot and dry summer of the former, as compared with the comparatively cold and wet weather of the latter year. Death from summer diarrhoea during the first few months of lifemay be in large part prevented by the sterilisation of tainted food, or better still, by the use of breast milk only. The deaths from tubercular diseases, which include tabes mesenterica, popularly known as " consumption of the bowels," tubercular meningitis, hydrocephalus, (water on the brain) and scrofula, are probably due largely to the use of unboiled milk, derived from cows suffering with tubercle iu the glands of the udder. This fact points to the need of an increased supervision of dairies. Lastly, deaths from convulsions and premature births are noticeable. The former term is a symptom of a disease rather than a disease itself. Death owing to premature births is often a sequel to improvident and early marriages. The many causes leading to loss of infant life in St. George's may be thus summarised:— (1) Bad environment, such as insanitary conditions, overcrowding and absence of parks and open spaces. (2) Improper and insufficient food. (3) Mismanagement by mothers through ignorance. (4) Early marriages. (5) Debility of mothers. (6) Maternal neglect, due to mothers being more or less employed away from home in factories and workshops. (7) Use of opiates : usually in the form of patent medicines. The mortality of children between the ages of two and five years is recorded as due chiefly to bronchitis and pneumonia, and to such preventable diseases, as measles, whooping cough, diarrhoea, diphtheria, and scarlet fever. Annual Report of the Medical Officer of Health,—1893. 31 It is difficult to exaggerate the vast importance to the parish, that you, gentlemen, should take immediate steps to check the existing excessive and needless mortality among young and helpless children. Brought up in the poisoned air of crowded courts and tenements, these gutter children are terribly handicapped in the race of life. As the late Dr. Farr remarked— "the weaklier lives are, under this state of things, cut off; but it must also be borne in mind that many of the strongest children are wounded and are left weakly for life." Apart from general moral and sanitary measures, I have no special remedies to suggest for these evils, other than those urged in my Annual Report for 1892. They are the provision of:— (1) Open breathing spaces. (2) Creches or day nurseries for the better protection of infants during the hours they are deprived of maternal care. It would be idle for me again to expatiate on the advantages resulting from open spaces—since my advice on this matter has been so often proffered, hitherto, I regret to say, without any practical result. A large proportion of the mothers of St. George's follow occupations such as fur pulling (peculiar so far as I know to the Borough), collar dressing, laundry work, sweetmeat packing to wholesale confectioners, working in pickle, jam, and other factories, box making, book folding, and mantle making. The only creche known to me in this parish is one connected with the church of St. Alphege, and situate at No. 23, Warwick-Street. It is open, at a charge of 3d. per day, from 8 a.m. to 8 p.m. daily, with the exception of Sundays, when it is closed altogether, and on Saturdays, when the closing hour is 3 p.m. The creche, supplied with seven cots, accommodates as many as 20 boys and girls between the ages of three weeks and four years. Two nurses, specially skilled in the rearing and feeding of children, are in constant attendance. An increase in the number of partially self-supporting creches within the parish would, I believe, materially lessen the high death rate and higher sick rate among the children of those mothers who work during the day in factories and workshops. 32 Parish of St. George the Martyr, Southwark. Table XIX. TABLE OP DEATHS during the Year 1893, in the Metropolitan Sanitary District of St. George, Southwark; Classified According to Diseases, Ages, and Localities. (Prepared in accordance with the instructions of the Local Government Board.) Names of Localities adopted for the purpose of these Statistics; Public Institutions being shown as separate localities. MORTALITY FROM ALL CAUSES AT SUBJOINED AGES. MORTALITY FROM SUBJOINED CAUSES, DISTINGUISHING DEATHS OF CHILDREN UNDER FIVE YEARS OF AGE. At all ages. Under 1 year, 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65 65 and upwards Small-pox. Scarlatina. Diphtheria. Membranous Croup. Fevers. Asiatic Cholera. Erysipelas. Measles. Whooping Cough. Diarrhoea and Dysentery. Rheumatic Fever. Ague. Phthisis. Bronchitis, Pneumonia, and Pleurisy. Heart Disease. Injuries. All other Diseases. Total. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal. Boro' Road 331 136 56 17 6 90 26 Under ... ... 9 ... ... ... ... ... ... ... ... 5 22 11 ... ... 2 37 2 9 95 192 5 upwards ... 3 1 ... ... 1 ... ... 1 ... ... ... 2 ... 2 ... 23 42 17 9 38 139 London Road 425 135 65 14 11 139 61 Under 5 ... 9 3 ... ... ... ... ... ... 2 3 22 7 ... ... ... 45 ... 3 105 200 5 upwards ... 3 3 ... ... 4 ... ... 2 1 2 ... 2 ... 2 ... 28 59 29 8 Kent Road 430 153 101 19 10 107 40 Under 5 ... 7 2 ... ... ... ... ... ... ... 14 ... 37 ... ... 1 65 ... 6 122 254 5upwds ... ... 2 ... ... 2 ... ... 2 ... 1 ... ... 2 ... ... 52 30 3 82 176 Evelina Hospital 158 46 83 29 ... ... ... Under ... ... 11 ... ... ... ... ... ... ... 1 ... 24 11 ... ... 4 26 2 ... 50 129 5 upwds ... ... 6 ... ... ... ... ... ... ... ... ... 2 ... ... ... 2 1 4 ... 14 29 St. George's Workhouse 25 4 ... ... ... 20 1 Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 3 4 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 12 ... 1 8 21 Royal Bethlem Hospital and) 25 ... ... ... ... 21 4 Under 5 ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. .... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 3 1 ... 20 25 Royal Eye Hospital 1 ... ... ... ... ... 1 Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Totals 1395 474 305 79 27 377 133 Under 5 ... 16 25 ... ... ... ... ... ... ... 3 22 68 66 ... ... 7 173 4 19 375 779 5 upwds. ... 6 12 ... ... 7 ... ... 5 1 4 ... 6 ... 6 ... 54 170 81 21 244 616 The subjoined numbers have also to be taken into account in judging of the above Records of Mortality. Deaths occurring outside the district among persons be- 392 24 49 13 16 247 43 Under 5 1 16 18 ... ... ... ... ... ... ... 1 ... ... 2 ... ... 1 8 1 4 21 73 5 upwds 6 3 2 ... ... 1 5 ... ... ... ... 3 ... ... 2 1 ... 74 64 25 20 114 319 Deaths occurring within the district among persons not belonging there to 130 36 38 22 12 1 1 Under 5 ... ... 10 ... ... ... ... ... ... ... 1 ... 13 7 ... ... 2 21 2 2 36 94 5 upwds ... ... 6 ... ... ... ... ... ... ... 1 ... 2 ... ... ... 2 6 5 1 13 36 Annual Report of the Medical Officer of Health,—1893. 33 Table XX. TABLE OF POPULATION, BIRTHS, AND OF NEW CASES OF INFECTIOUS SICKNESS, coming to the knowledge of the Medical Officer of Health, during the year, 1893, in the Metropolitan Sanitary District of St. George, Southwark; classified according to Diseases, Ages, and Localities. (Prepared in accordance with the instructions of the Local Government Board.) Names op Localities adopted for the purpose of these Statistics; Public Institutions beingshown as separate localities. Population at all ages. Registered Births. Aged under 5 or over 5. New Cases of Sickness in each Locality coming to the knowledge of the medical officer of health. Numrer of such Cases Removed from their homes in the several localities for treatment in Isolation Hospital. Small-pox. Scarlatina. Diphtheria. Membranous. Croup. Typhus. Fevers. Cholera. Erysipelas. Small-pox. Scarlatina. | Diphtheria. Membranous Croup. Fevers. Choleraic Erysipelas. Census 1891. Estimatedtp middle of 1893. Enteric or Typhoid. Continued. Relapsing. Puerperal. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal Boro' Road 16,624 16,758 604 Under 5 ... 6? 21 2 ... ... ... ... ... ... 5 ... ... ... 32 9 ... ... ... ... ... ... ... ... ... ... 5upwds. 41 110 51 1 ... 14 ... ... 1 ... 59 ... ... 39 51 12 ... ... 2 ... ... ... ... 5 ... ... London Road 21,221 21,203 689 Under 5 3 68 10 1 ... ... ... ... ... ... 4 ... ... 3 23 3 ... ... ... ... ... ... ... ... ... ... 5upwds. 28 160 53 3 ... 16 1 ... 2 1 38 ... ... 28 91 15 ... ... 6 ... ... 1 ... ... ... 1 Kent Road 21,867 21,963 828 Under 5 1 55 14 3 ... 1 ... ... ... ... ... ... ... 1 21 6 ... ... ... ... ... ... ... ... ... ... 5upwds. 7 126 27 ... ... 10 ... ... ... ... 36 ... ... 7 54 9 ... ... 2 ... ... ... ... ... ... ... Evelina Hospital ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... St. George's Workhouse ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Royal Bethlem Hospital and King Edward School ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Royal Eye Hospital ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 59,712 59,924 2121 Under 5 5 upwds. 4 185 396 45 131 6 ... 1 ... ... ... ... ... ... ... 4 76 18 ... ... ... ... ... ... ... ... ... ... 76 4 ... 40 1 ... 3 1 133 ... ... 74 196 36 ... ... 10 ... ... 1 ... 8 ... ... 34 Parish of St. George the Martyr, Southivark. SECTION II— GENERAL. The Water Supply. Professor Frankland states in his Annual Report to the Registrar General on the results of monthly chemical analysis, with physical and bacterioscopic examinations of drinking water during 1893, that the weather generally has been favourable to the operations of the companies, save in February and October. The water in use in St. George's is supplied by (a) the Lambeth Company ; (6) the Southwark and Vauxhall Company. Both these companies draw their supplies from the Thames, below Teddington Lock, the former at West Molesley, the latter at Hampton. The river above these points receives various contributions of organic matter of animal origin, such as the drainage from manured land, the effluent from sewage works, and even raw sewage itself. Indeed it has been computed that there is a population of upwards of a million persons inhabiting the Thames Valley above the intakes of the water companies, to say nothing of 1,600,000 animals living on the same area. These numbers are moreover steadily increasing. The water is " hard." It is, therefore, expensive for washing, and unsuitable for use in steam and kitchen boilers and hot-water pipes, in which it produces incrustations and deposits. The hardness of the water is almost entirely due to the presence of bi-carbonate of lime in solution. This is easily reducible by treatment with lime before delivery, a practice already successfully carried out by the Colne Valley Company. This mode of softening is by far the most economical, for it entails only about one-eightieth of the expense which devolves upon the private consumer, in the shape of additional soap required for washing. The water, unlike that drawn from deep wells, varies largely in temperature, being unpleasantly warm aud vapid in summer, and rea lily liable to become frozen in the service-pipes in winter. Professor Frankland asserts that disease-giving germs are prevented, by efficient sand filtration, from gaining an entrance from the river into the companies' drinking water. Although the Metropol s Water Act provides that "every company shall effectually filter all water supplied by them within the metropolis for domestic use," there is no statutory definition extant of what is really meant by the term "effectually filter." Professor Koch, the greatest living bacteriologist, says of .the following rules:— The observance of Nos. (2) and (3) would suffice to remove the danger of infection from filtered water, so far as is possible to do so, by means of filtration through sand. It should be observed that Professor Koch does not agree with Dr. Frankland as regards the complete efficacy of sand filtration as a purifier of water. Annual Report of the Medical Officer of Health,—1893. 35 Briefly, Koch's rules are:—(1) The maximum rate of filtration should not exceed 1.1 or 2.1 gallons per hour, per square foot of filter surface; (2) A separate bacterioscopic examination of the water issuing from each filtering basin should be made daily; (3) Filtered water containing more than 100 living micro-organisms in a cubic centimetre should not be allowed to reach the pure water reservoir. In other words, such water is unfitted for domestic use. Professor Frankland states that his bacterioscopic examinations were made monthly. Professor Koch, advises a daily examination, and holds that a weekly examination is in all circumstances to be looked upon as insufficient. Dr. Frankland's tables show the Southwark and Vauxhall Companies' water to be less pure, bacterially, than that of any of the eight metropolitan water companies. Its maximum number of microbes, per c.c., numbered as many as 1,220, 134, 566, and 180, in the months of January May, October, and December respectively. The Lambeth Companies water yielded a maximum of 366 and 202 microbes per c.c. in January and December respectively. Its average rate of filtration, per square foot, per hour, was 2.4 gallons. This figure, which represents the "mean," be it observed, exceeds Professor Koch's " maximum" of 2.1 gallons. According to the report of Major-general Scott for 1892, the maximum monthly rate of filtration per square foot, per hour, of the Southwark and Vauxhall Company, was 3'50 gallons. The Eoyal Commission, appointed to inquire into the water supply of the metropolis, have lately reported, among other matters, that they find the water, as at present supplied, to be of a high standard of excellence and purity. They also consider that it can be used without danger, provided there is adequate storage and efficient filtration. Notwithstanding this finding of the Commission, the principle involved in first accepting the sewage-polluted water, and then asking commercial companies to filter it efficiently, without fixing any standard, does not commend itself to my mind. Sir George Buchanan, in his evidence before the Commission, hit the mark when he said he was of opinion that " contaminated waters do, under certain unknown conditions, produce disease, the cause of which cannot be detected either by chemical, microscopical, or bacteriological examination. The only really reasonable course to adopt, therefore, when a water is known to be polluted, as the Thames is, was to avoid its use." Should it be eventually proved that the decision of the Commissioners was arrived at in consequence of incomplete or defective evidence, it will be necessary to substitute water drawn from a pure deep well or lake, in place of the existing polluted supply. 36 Parish of St. Geori/e the Martyr, Southwark. Abstract of Report on the Parish Water Supply for Domestic Use. With the aid of your inspectors, I have examined the water cisterns of the 41 "model" dwellings scattered throughout the Parish. These cisterns were, for the most part, on the roofs, often imperfectly covered in, and in most cases within a few feet of the openings of the soil pipe ventilators. The latter condition renders the water liable to contamination by sewer poisons, and in this way might sow broadcast the germs of diarrhoea, typhoid fever and cholera. The water in the cisterns was frequently filthy, its surface covered with smut3 from the chimneys, and in a few instances with a layer of decayed vegetable matter two inches deep, while the sides of the cisterns were coated with slime one-third of an inch in thickness. Many foreign bodies were found in the tanks. It has been reported to me that a boy was seen to wash his face and hands with soap in a cistern supplying a block. In all necessary cases I have served owners with notices calling upon them to remedy defects. Constant supervision, however, will be necessary to compel owners to cleanse periodically and to keep in repair the cisterns. In private dwellings I find an equally bad state of affairs. The cisterns are often badly placed, as, for instance, directly over water-closets or in areas near the dust-bins. In a few of the "model" dwellings I have induced the owners to supply water direct from the rising main. The cisterns, periodically cleansed, supply the waterwaste preventers in the water-closets, and in times of need only, a screw cock attached to the head of a pipe coming from the cistern and joining the rising main, affords a temporary and secondary supply. This system, particularly with a constant supply, is found to work admirablv in practice. This plan, however, cannot be applied in the case of lofty " model " dwellings supplied by the Southwark and Vauxhall Water Company The reason for this is that the Company fails to carry out the obligations to provide water at the pressure clearly laid down in the "special" or private Act, which would more than reach the highest flat in Southwark. The surface wells in your district have been shown by analysis to furnish water that is polluted and highly dangerous to health. These wells have all been closed, with the following exceptions :— (1.) A private pump in a gut manufactory. This has been padlocked, and is now used by the foreman for trade purposes only, while Company's water has been supplied for drinking purposes. The saline water from the well bleaches the gut more effectually than can be done by ordinary tap water. (2) A pump in a private yard is now padlocked, and each occupier of adjacent stabling has been furnished with a key under strict orders to use the water for the washing of carts and horses only. A notice board fixed above the pump states that the water from the well is unfit for drinking and domestic purposes. (3.) A pump connected with a trough has been padlocked and strict orders given to the attendant to keep the trough empty, and to supply horses in special buckets. Other troughs in the district, supplied with tap water, are liable to spread glanders. This is a matter for the Board of Agriculture to deal with. (4.) This pump the magistrate at Lambeth Police Court ordered to be closed for one month, and in the meantime to be put in such a state that it should not continue to yield impure water. From the surroundings of the well it is impossible to fulfil this condition. The water has been proved to be highly contaminated with sewage matter. (5.) Analysis showed the water of this well to be contaminated, but on the case being brought into court it was decided against the Vestry by the magistrate—Mr. Byron—with costs. This dangerous well is still open. Annual Report of the Medical Officer of Health,—1894. 37 Abstract of Four Special Reports dealing- with the Southwark Salvation Shelter and the Spread of Small-Pox. During the first portion of 1893, Southwark. in common with the rest of London, was visited by an epidemic of small-pox, greater in extent and severity than any that has visited the metroplis since the year 1885. Many of the cases (already fully reported) were traced by me to the agency of tramps in the Salvation Army Shelter situated in the Blackfiiars-Road. Several of these wanderers, with small-pox spots upon them, walked from the shelter through the public streets to the crowded out-patient departments of general hospitals and of Union relief stations. So soon as the nature of this virulent and highly contagious disease was detected, the patients were isolated in rooms provided for that purpose, pending the arrival of the ambulance, which subsequently conveyed them to the small-pox hospital ships. How many more escaped observation and detection, to spread the loathsome disease among those unprotected by vaccination and re-vaccination, it is impossible to estimate. In January and February, 1893, in accordance with the instructions of your Health Committee, I wrote to the Local Government Board two letters, in which I pointed out the serious danger threatening the public health, due to the spread of small-pox and other catching complaints, through the medium of night shelters. I also called the Board's attention to the Resolution of your Committee, urging the necessity of placing Salvation and other similar shelters under the regulations of the Common Lodging House Acts. It will be within the memory of your Vestry, that in June, 1893, proceedings were taken by the Sanitary Authority against the superintendent of the Blackfriars shelter, for knowingly letting for hire the part called the "penny shelter" directly connected with, and practically forming part of the "too late " 2d. bunk dormitory, in which it was alleged that a man had been suffering from a dangerous, infectious disease, without having it properly disinfected to the satisfaction of a qualified medical practitioner, as attested by his certificate. After three adjournments the magistrate found :— (1.) That there was exposure of a small-pox patient in the shelter. (2.) That many persons were admitted to the shelter on the same and following nights. (3.) That the disinfection alleged to have been carried out in the shelter was inefficient in the face of a dangerous infectious disease. (4.) The magistrate decided that there was a letting for hire of part of a house, and that the medical certificates produced were not in accordance with the Public Health Act. He fined defendants £20. The defendants appealed to the High Courts of Justice against this finding, the magistrate having first stated a case, at the request of the learned counsel for the defence. In the Court of Appeal, Messrs. Justices Wills and Wright have recently decided there was not a " letting " of the " Penny Shelter," and have accordingly reversed the magistrate's decision on that point. The judges remarked that the superintendent merely harboured or sheltered licensees or guests, which is a very different thing, legally, from "letting" to lodgers. The question of the legality of the certificates granted by a doctor on hearsay evidence, and dated back three days, was not discussed. 38 Parish of St. George the Martyr, Soutlnvark. The Public Health Act, so far, at least, as disinfection is concerned, does not therefore apply, as in the case of private houses to " shelters," the very places which most require supervision and regulation by the sanitary officers. Mr. Justice Wills said "the case was clearly one in which the Act ought to apply, but does not." On the other hand, Mr. Fowler, president of the Local Government Board, in answer to a question in the House of Commons, stated that the shelters were under the control of the Medical Officers of Health, and that if entry were refused these officers could gain admission on a magistrate's order. The importance of the subject treated of in the late appeal, which is considerable and far-reaching in its effects, has caused me to report somewhat frequently to your Vestry on the spread of small-pox in and from the Blackfriars Shelter, and also on its general management. In view of the recent judicial decision, and of the large amount of small-pox in London, as well as in the country, and, in the face of the more than probable increase of the complaint during the coming winter and spring (when small-pox is generally most rife), and of the proved spread of the disease by tramps, 4,000 of which class are nightly harboured in the unregulated metropolitan Salvation shelters alone, it is time, I think, for Parliament to repair a flagrant omission in the law, which, until amended, will continue to form a standing menace to the public health. The remedy I have to offer for the evil is that suggested at the commencement of the small-pox epidemic in 1892, when I advised that the best interests of both Salvationists and of the public would be served by the legislature promptly placing the managers of shelters under restrictions similar to those which apply to keepers of common lodging houses. Resolution passed by Vestry with regard to the fourth Special Report presented to the Vestry on December 19th, 1893, Resolved:— "That the attention of the President of the Local Government Board be called to a report of Dr. F. J. Waldo, the Medical Officer of Health for this Parish, on the subject of ' The Southwark Salvation Army Shelter, and the spread of small-pox,' and particularly to that portion of the report urging the necessity for further legislation for night shelters." Annual Report of the Medical Officer of Health,—1893. 39 Abstract of Report on a Proposed Increase of the Staff of Sanitary Inspectors. In 1892, I pointed out that a staff of two sanitary inspectors was quite inadequate to carry out the duties devolving on the Vestry. That the time of those officials was fully occupied by attention to complaints, the supervision of infectious cases, the visiting of works in progress, Court work, and various other pressing duties. Little time, therefore, was left for carrying out the provisions of the Public Health (London) Act, the Factory and Workshop Acts, the Housing of the Working Classes Act, to say nothing of other stringent Acts and Bye-laws. In another portion of the Report (Page 18) you will find it is recorded that "I would urge the great necessity which exists for enforcing the bye-laws for the registration and inspection, promotion of cleanliness, and prevention of overcrowding in lodgings, let or occupied by members of more than one family. Owing, however, to the insufficiency of the inspecting staff, these bye-laws have hitherto never been enforced. I would suggest after sufficient help has been provided to prevent the law from remaining a dead letter, that a house-to-house examination of the tenements let in lodgings, and coming within the powers of the bye-laws, should forthwith be made, and that the results be recorded in special registers for each district. "A list of those houses suggested as being the most appropriate to be placed under the operation of the bye-laws might then be submitted to the Public Health Committee for their approval, and handbills, setting forth, in a condensed form the powers and penalties in the bye-laws, be delivered to each of the owners and occupiers. " I have observed in Provincial towns, that the owners of tenement property have generally been very willing to bring their premises into conformity with the bye-laws, and have welcomed the assistance which the systematic inspection has rendered them in inculcating more cleanly habits amongst their tenants." To these words—carefully considered before they were committed to print—I have now little to add. Since they were written, the Bye-laws of the London County Council under the Public Health (London) Act, have become an established fact, and have already, in several instances, been acted upon and enforced by your Committee. In a Special Report I have stated that large numbers of underground rooms continue to be illegally occupied in this low-lying and densely crowded district. In order to obviate this evil effectually, it is absolutely necessary to keep up a regular and systematic inspection, just as in the case of the tenement dwellings. Unwieldly over-crowded " model " dwellings, thickly scattered over this district, also require a like attention before it is possible for them to justify their name. In the absence of legal powers to compel the owners of these "models " to exercise an efficient supervision over the tenants, the Sanitary Authority should, I think, themselves insist that Section 107—(1) of the Public Health (London) Act, be carried out. This section says :—Every Sanitary Authority shall appoint an adequate number of fit and proper persons as sanitary inspectors, and every such inspector shall be a person qualified and competent, by his knowledge and experience, to perform the duties of his office." Notwithstanding the fact that progress has been made during recent years in sanitary science, and new compulsory laws have been enacted, instead of a corresponding increase in the inspectorial staff, an actual decrease in their number has taken place. At the present date the Vestry have two inspectors as against three twenty-seven years ago. 40 Parish of St. George the Martyr, Southward. It is true that two of these inspectors of nuisances, in addition to their duties as such, had the roads and district sewers to look after, but on the other hand there has been an increase of population -within the parish. With the high death rate of 25.2 per 1,000, and the correspondingly excessive zymotic preventable death rate of 3.6 per 1,000, and 188 deaths under one year to 1,000 births for the year 1892, and with Asiatic cholera notified to me to-day, I respectfully submit to the Sanitary Authority that immediate steps should be taken to increase their staff by the appointment of two additional inspectors. If the Vestry think well to appoint these inspectors, subject to the approval of the Local Government Board, half of their salaries can be drawn through the County Council out of the Exchequer contribution account. If the Vestry choose to go further and re-appoint the present inspectors:— Messrs. Edwards and Anscombe—subject to the like approval of the Local Government Board, the Sanitary Authority will have four inspectors with the same outlay on the ratepayers money as they, at the present, expend on two, and will, in addition, be about £60 per annum in pocket. In my opinion more work and, what is of greater consequence, work of a better quality, can be accomplished if the Vestry finally decide that one of their inspectors shall devote the principal part of his time to the enforcement of the Adulteration, Workshop, and other Acts, and accompany and assist me in any special enquiries I may be asked to prosecute on behalf of the Sanitary Authority. The three remaining inspectors may, I think, with the sanction of the Vestry, keep each within the special sub-district allotted to him. Further details I leave the Public Health Committee or a Special Sub-committee of that body to deal with and report upon. Through the kindness of Mr. G. Gomme, Chief of the Loudon County Council Statistical Department, I have been enabled to confirm the estimate made in the foregoing Report as to the total cost of the increased staff of sanitary inspectors. His letter, which will be found appended, presents a clear view of the financial question involved. It is only fair, however, to add that as the Exchequer grant becomes more generally drawn upon by other local authorities, in like degree will there be an increase in St. George's proportion to be contributed towards the funds. Statistical Department, Spuing Gardens, S.W., 31s£ August, 1894. My Dear Sir, The position of the Vestry under the old arrangement and new arrangement respectively, would be as follows:— Old Arrangement: Two sanitary inspectors £360 0 0 New Arrangement: Four sanitary inspectors £600, of which the Vestry pay directly in salary £300 0 0 and the London County Council pay £300. A proportion of this payment, however, falls upon the Vestry rates, because the County Kate is increased by reason of the payment out of the County Fund. This Annual Report of the Medical Officer of Health,—1893. 41 portion is in accordance with the rateable value or sWiliST £300 2 10 0 Therefore, the total paid by the Vestry under the new arrangement would be £302 10 0 showing a profit to the Vestry of £57 10s. in money, together with increased efficiency. It must also be borne in mind that the Vestry contributes in its rates to the salaries of other local inspectors, and therefore, if it does not take advantage of the same privileges it is acting against its own interests. I cannot state the amount paid out of the Parish rates towards the salaries of the inspectors for all London paid for out of the County Fund, but it would not affect the principle of the above calculation. Being away from my office, I am only able to put the matter briefly, but I shall be glad to give any additional information, if required, when I return next week. Yours faithfully, G. GOMME. Dr. Waldo, Medical Officer, St. George's, Southwark. Now that the new arrangement has been adopted Mr. Gomme's letter has a special interest. 42 Parish of St. George the Martyr, Southwark. The Prevention of the Spread of Communicable Diseases through the Agency of Schools. By Section 55 of the Public Health Act, every medical officer is required, on the receipt of a certificate notifying a case of infectious disease, to send a copy thereof within 12 hours after such receipt to the Asylums Managers, and, in the case of children, to the head teacher of the school attended by the patient (if a child), or by any child who is an inmate of the same house as the patient. Within a few weeks of commencing my official duties in St. George's, in June, 1892, your Vestry adopted, on my advice, the use of the two following forms :— A.—Directed to the head teacher, as formerly, in accordance with the requirements of the law. In addition, a recommendation to prevent the patient or any member, who is an inmate of the same house from attending school until the head teacher be furnished with a certificate of the final disinfection of the premises having been effected. B.—A certificate to be called for at the Health Department stating that infected premises have been disinfected, signed by the Medical Officer of Health. From form A. it is understood that no child should be re-admitted to school from an infected house unless furnished with this certificate. Some months after the commencement of this sj stem in St. George's, the London School Board issued a circular letter advising all Metropolitan Sanitary Authorities to adopt the precautionary method as described. After a trial of the system, I found by the returns, that about one-half only of those who should have called for the certificate of final disinfection came for it. It followed, therefore, that there was either some misunderstanding or neglect on the part of the head teacher. Accordingly, I wrote a letter to the Londou School Board, and described my experience. The answer was as follows :— School Hoard for London, Victoria Embankment, W.C. 16th January, 1894. Sin,—Your letter of the 18th ult. has been laid before the School Management Committee of the Board. In reply, I am directed to inform you that the Board have recently decided to insert in the Code of Regulations for the Guidance of Managers and Teachers the following paragraph, with reference to the certificate of the Medical Officer of Health, stating that premises are free from infection:— " In the event of the head teacher not receiving this certificate, it becomes his duty to send to the office of the Local Authority in order that he may procure it." I am further directed to state that if it should be found that teachers do not get the certificates the School Management Committee of the Board will further consider the matter. I am, Sir, your obedient servant, G. H. CROAD, Clerk of the Board. Annual Report of the Medical Officer of Health,—1893. 43 Metropolitan Ambulance Service. Stations within or near the parish, containing litters and stretchers, and provided by the Street Ambulance Branch of the Hospitals Association, for the transfer of sick and injured persons (infectious cases excepted) are situated as follows:— Marshalsea Road, at the junction of Mint Street. Fire Brigade Head Quarters, Southwark Bridge Road. Fire Brigade Station, Waterloo Road. St. Thomas's Hospital. Guy's Hospital, Southwark. All metropolitan patients suffering from small-pox, fevers, and diphtheria, may, on application, be conveyed to and fro, and treated free, within the isolation hospitals of the Asylums Board. The Ambulance Station nearest the parish is the South-Eastern one, situate at the New Cross Road (near Old Kent Road Railway Station), S.E. Telephonic communication can be made from the Health Department (within office hours), to the chief office of the Asylums Board, and within a few minutes an ambulance will be on its way, for the conveyance of the patient to the South-Eastern Hospital (adjoining the South-Eastern Ambulance Station), if suffering from fever or diphtheria, or to the South Wharf, at Rotherhithe, if it be a case of small-pox. In the latter case, the patient will embark in one of the ambulance steamers for the hospital ships at Long Reach. The Convalescent Hospitals, belonging to the Asylums Board, are two in number. That for fevers and diphtheria is situated at Winchmore Hill, in the North-East of London; that for small-pox at Gore Farm, Darenth, distant about four miles from the hospital Bhips. Patients in a position to bear the expense of their support, and suffering from fevers and diphtheria, or small-pox, can be accommodated at the Loudon Fever Hospital, Liverpool Road, Islington, and at the Highgate Small-pox Hospital, respectively. Summary of Report of Sewage Flooding in Basements. In accordance with the request of the Chairman of the Main Drainage Committee of the London County Council, I furnished particulars of twenty cellars in which I had found evidence of sewage flooding. These basements were all situated in a main road in your district, and were brought to light in the course of a house-to-house visitation. Amongst them were the cellars beneath two large butcher's shops. In one of them I counted twelve large wooden tubs filled with salted pork and beef, besides two salting tanks which were in use. A quantity of meat, fresh and salted, lay about the cellar, or hung suspended from the beams. Sewage had risen to a height of 2ft., as plainly shown by the marks on the whitewashed cellar wall. Some of the tubs, I was informed by the occupier's son, had been floated off their wooden platforms, and a large meat safe at the dead end of the cellar had also been invaded. In the cellar belonging to the second butcher, I also found tubs containing salted meat and three sausage machines, one of which showed signs of recent use. The sewage in this case had left its mark 15 inches high, corresponding with the upper portion of the second step of the staircase leading from the cellar. 44 Parish of St. George the Martyr, Southwark. In the basements of two public houses, each of which contained casks of beer and spirits, the sewage had risen l£ft. and 6in. respectively. In a third public-house the beer cellar had escaped, but an adjoining chamber, used for storing pots, had been flooded to a height of 1ft. 9in. Below a milk shop I found a woman washing clothes in a cellar that had lately been flooded with sewage. Amongst other flooded cellars were those of a model dwelling, a sweetstuff shop, and a hank. Another was that of an auctioneer, in whose shop a couple of hundred people or more were in the habit of congregating together at one time. The concrete floor of the cellar was rent and cracked by the backward pressure from the surcharged and inadequate main sewer. A portion of a similarly damaged cellar in the next house was used as a kitchen, and in it a maidof-all-work and three young shop girls were in the habit of taking their meals. The last place I visited was a baker's shop, beneath which was a cellar used as a bakery. Here the master and his journeyman were actually working as best they could in a flood of sewage. In one corner of the workshop a row of sacks filled with flour rested on a wooden platform 3in. in height. The sewage had risen to a height of 4in., as shown by the stain on the wall, and, by the baker's own admission, had fouled the under surface of the sacks and caused a portion of the flour to cake together in lumps. At the same time it was admitted that the flour from those particular sacks had been made into bread. The special danger connected with this form of basement flooding is that the sewage is always more or less charged with the specific poison of typhoid fever, and is at any time liable to that of cholera and of other deadly diseases. It is obvious that such contaminated cellars are unfitted for the preparation of bread or other articles of food, and almost equally so for use as workshops or dwelling rooms. These facts have been recognised by Mr. Fowler, late President of the Local Government Board, who declared in the House that it was the duty of the London County Council to find a remedy for the grave dangers connected with the inadequacy of certain main sewers within this district. In reference to this Report a correspondence took place between your Vestry and the London County Council. The latter, as you are aware, suggested that the less costly remedy would be to fill up the cellars, rather than to enlarge the main sewer. No mention was made, however, of the question of compensation for disturbance to owners, nor did the Council state on whom it was proposed to lay the necessary costs involved by filling up the cellars. Further, no answer of any kind was given to my proposal contained in a previous Report that the Council should lay down a separate system of drainage for carrying off storm water. Annual Report of the Medical Officer of Health,—1894. 45 The Factory and Workshop Act, 1891. This Act, which came into operation on the 1st of Jaauary, 1892, has imposed on Sanitary Authorities and their officers new and important duties, for which previous to this date the factory inspectors were alone responsible. Occupiers are obliged to register their workshops within one month of occupancy. It then becomes the duty of the inspector under the Act to give notice forthwith to your Authority of all such occupied workshops. During 1893, I have caused 121 workshops to be entered in the register-book kept for the purpose. In several instances cleanliness and efficient ventilation have been enforced, overcrowding and other nuisances have been abated, and separate w.c. accommodation has been provided for the two sexes. By order of the Home Secretary, Section 27—(1.) of the Factory and Workshop Act, 1891, took effect for the first time, on the 20th of November, 1892. By this Section, which aims at the suppression of the evils of " sweating," occupiers and contractors, in certain trades, are bound henceforth to keep lists of outworkers according to a prescribed form. The lists of those employed in the manufacture of articles of wearing apparel, upholstery and furniture making (also file-making and electro-plating, which trades are in a few instances only followed in this palish) have to be kept accessible for the inspection of the officers of your Sanitary Authority. In a Special Report, I pointed out that the order, as it stood, could only be partial in its effect, since the larger portion (4-5ths) of the outworkers employed in St. George's lived in other metropolitan districts, or outside London altogether. For instance, of the outworkers employed by the large firms, the majority in the tailoring trade live in Whitechapel, and many in the boot business so far afield as Northampton. In my Annual Report for 1892, with a view to making the order workable, I suggested "the organisation, under the Home Secretary, of a staff of inspectors, whose duty it should be to inspect all the lists of outworkers, and, after extracting from them all requisite details, to forward them to the several medical officers of health." This suggestion has been adopted by Mr. Asquith, the Secretary of State for the Home Department, so that now Mr. Lakeman, the energetic Chief Inspector of Metropolitan Workshops, co-operates with the medical officers, and furnishes each with the addresses of those working in our particular district and appearing in lists prepared in other districts. To carry the order out thoroughly a special inspector will be required for your district. Customs and Inland Revenue Acts, 1890, S. 26 (2), and 1891, S. 4. Tenement property, occupied by about 515 persons, has been examined during 1893, at the request of the respective owners, with a view of the latter obtaining the certificate of the Medical Officer of Health, by which exemption from inhabited house duty can be claimed under the provisions of the above-mentioned sections. Much time was taken up in the inspection of these dwellings before certificates could be either given or refused. The Act of 1890 states that "before exemption from duty can be claimed the house must be so constructed as to afford suitable accommodation for each of the families or persons inhabiting it, and that due provision be made for their sanitary requirements." The Act of 1891 stipulates that the annual value of each separate dwelling within the house " shall not amount to £20." 46 Parish of St. George the Martyr, Southwark. The standard of sanitary requirements fixed by me was reached in the case of five houses, for which certificates were granted. The Inland Revenue Acts throw the burden of making a thorough inspection of houses, and of withholding or giving certificates exempting from the payment of imperial taxes, on the local authorities. There is no fixed and uniform standard of sanitary requirements. Mortuary and Coroner's Court. Two hundred and thirty-six bodies were removed to the mortuary during the year, as against 181 in 1892. Several of the bodies of those dying from infectious diseases serve to swell the list. They were removed at my request. Inquests were held in the new Coroner's Court, in Collier's Rents, on 134, and post-mortem examinations were made in 101 of the above cases. There were 20 more inquests held and 19 more post-mortem examinations made in 1893 than in 1892. A separate chamber is needed in the mortuary for the isolation of infectious diseases. In the event of a death from an infectious disease the body should forthwith be removed to the mortuary, in cases where it would otherwise be retained in a room used as a dwelling by others. It is also desirable that in any case where the body lies in a room which is used by other persons, the body should in the same manner be removed. The following is a list of those children suffocated whilst lying in bed with their parent or parents during the year 1893, together with the particular day of the week on which they died. Sunday 1 Monday 2 Tuesday 0 Wednesday 2 Thursday 1 Friday 2 Saturday 5 Total 13 Comment on this list is needless. The Notification of Infectious Diseases. The expression "dangerous infectious diseases," which have been compulsorily notifiable throughout London since 1889, means any of the following diseases:— Small-pox, cholera, diphtheria, membraneous croup, erysipelas, the disease known as scarlatina or scarlet fever, and the fevers known by any of the following names:— typhus, typhoid, enteric, relapsing, continued, or puerperal. The beneficial effect of notification has again been exemplified during the past year, when 2,557 cases of small-pox were notified. Patients were at once removed by the excellent ambulance service of the Asylums Board, to the floating hospitals on the Thames at Long Reach, and to the Gore Farm hospital at Darenth. Notification of such cases admits of concerted action between the medical practitioner, the medical officer, and the officials of the Asylums Board, and is thereby invaluable in the prevention of costly epidemics. I have no doubt that the general spread of small-pox in your parish during the year 1893 was prevented mainly by the precautions rendered possible by prompt notification. Annual Report of the Medical Officer of Health,—1893. 47 Its neglect entails delay which is apt to cause greater mischief than can be repaired by any subsequent effort. The Infectious Disease (Notification) Act, 1889, has been adopted by a large majority of Provincial Sanitary Authorities, urban and rural. The time has arrived, I think, when the Act should be made compulsory for the United kingdom, as it has been in London from the first. The sum in fees paid to medical practitioners for notifying infectious cases in St. George's, amounted in 1893, to £71 18s. 6d. This amount paid by your Vestry is recouped by the Asylums Board, and charged to the Metropolitan Common Poor Fund. 34 per cent. of the total number of cases notified in the Parish during 1893, as against 67 per cent. in 1892, were removed to the Asylums Board and other hospitals for infectious disease. The large decrease in the rate of admissions during the year under report was due to the insufficiency of the hospital accommodation. This forms a serious danger in so poor and densely-packed a district as St. George's. Removal of Destitute Patients suffering from Infectious Disease to the Asylums Board Hospitals. Dangerous delay has occurred in the removal of destitute infectious patients into hospital, owing to the refusal of relieving officers to furnish the requisite medical attendance. In a letter received from one of these officers, dated July 1st, 1893,1 was informed that my proposal that the officer in question should deal with a certain destitute case of scarlet fever, was "unprecedented." The officer went on to say that "the Sanitary Authorities are the ones who should remove infectious cases, paupers or non-paupers." Your Sanitary Authority, not feeling satisfied with the drift of this letter, forwarded it to the Guardians of Saint Saviour's Union. The latter supported their officer, and, after a long correspondence between the Guardians, your Sanitary Authority, and the Local Government Board, the last body, in a letter dated 11th December, 1893, said:—"When a person suffering from any infectious disease is destitute, it is the duty of the Guardians, or in the interval between their meetings, of the relieving officer, to give such relief as may be needed, and, if necessary, to give an order for the admission of the patient to a hospital in which he can properly be treated. The destitution here referred to does not necessarily depend upon the person being in the actual receipt of poor relief, but may consist in his being unable to obtain, at his own cost, the requisite medical attendance, nursing and accommodation, which his case requires. If it is proposed that the patient should be treated in one of the hospitals belonging to the Managers of the Metropolitan Asylums District, the removal should, if possible, be effected by means of one of their ambulances." The drainage of Institutions within the Parish. During the past year my attention has been especially directed to the drainage and general sanitary arrangements of the Parish Institutions, a term which includes places of public amusement. The following are among the principal works carried out, or suggested:—Evelina Hospital for children—newly drained by means of iron and stoneware glazed pipes, waiting room more efficiently ventilated. King Edward's School—the children were sent into the country and the school re-drained, at a cost of upwards of £2,000. 48 Parish of St. George the Martyr, Southwark. Yorkshire Schools—drains improved. Salvation Army Shelter, Blackfriars Road—a new system of drainage was carried out, on the enlargement of the building. Surrey Theatre and South London Music Hall—the sanitary arrangements of these places of public resort were considerably improved. Saint George's Workhouse, Mint Street—a defective state of the drains, as well as of the general sanitary condition of these premises, was reported by me to your Sanitary Authority. Among these defects, the drains, partly brick and partly pipe, are old and defective, and are ventilated by means of rainwater pipes and bell-traps. The whole system is, in my opinion, highly dangerous to the health of the inmates, and requires the immediate attention of those responsible for so unsatisfactory a state of affairs. So far nothing has been done to make the Workhouse habitable. The Cowhouses. The cowhouses (for list see page 61.) which are situated in populous back streets, have been regularly inspected. The following table gives the number of cows and cowhouses in 1882, 1892, and 1893:— TABLE XXI. Year No. of Cows. No. of Cowhouses. 1882 101 9 1892 46 5 1893 37 4 It is a well-known fact that stall-fed dairy cows in towns are very susceptible to "tubercle," popularly known as the "grapes," and that the same infectious cause produces this disease both in cows and in the human subject. A strong confirmation of the view that the "grapes" is transmissible to young children is contained in the fact that the mortality of children under five years of age from consumption of the bowels is very high. In the matter of dietary, there is one great distinguishing feature between this age-period and all others. It is that unboiled cow's milk forms the staple food of children under five years of age. All this points to the need of a more vigorous regulation of dairies, such as is in force in Copenhagen and Stockholm. It is hardly necessary to remark that the proper place for keeping cows is in the country. In July, 1893, I reported to the London County Council a breach of their regulations by a dairy keeper. This keeper had twenty-four cows in a shed adjoining his dairy and dwelling-house, and in the latter his child lay ill with fever. He objected to the removal of the patient to an isolation hospital, and had failed to report the infectious nature of the disease to the Council. The necessary steps were subsequently taken by the Council for the prevention of the contamination of the milk. Annual Report of the Medical Officer of Health,—1893. 49 The Slaughter Houses and Knacker's Yards. These (for a list of which see page 61) have been regularly inspected and found to be conducted satisfactorily. They number 7, against 10 in 1892. Meat inspection in Germany is carried out in an infinitely more systematic and thorough manner than in London. All cattle are inspected, both before and after slaughter, in public "abattoirs" by highly-skilled and specially-trained inspectors. In London large quantities of diseased meat, infectious in character, escape inspection, and are consumed daily. The wholesomeness of this meat is not improved by its occasional admixture with stale and sewer-tainted bread, and its subsequent conversion into sausage. Duriug 1893, 4,918 and 2,763 animals were either killed at or brought dead into Messrs. Harrison, Barber & Co.'s two knacker's yards, situated in Green-street and Westcott-street, near Tabard-street. Housing of the Working Classes Act, 1890. Summary of Representations, under Part II., made by the Medical Officer of Health during the year 1893. TABLE XXII. Premises. Date of Official Representation. Result. 1 to 11, Kell Street January 18th. Closed with costs. 22, 23, 24, 25, 26, 27, and 28, Brent's Court, Borough High Street February 9th. Closed with costs. Order since revoked by magistrate. 8, 9, 10, and 11, Green Street March 2nd Closed with costs. 34, Tower Street May 11th. Closed with costs. Since demolished. 29, Gerridge Street June 22nd. Closed with costs. Block II.—Nos. 1 to 28, Artizan's Buildings, Gun Street Case withdrawn owing to defective legal technicality. 1, 2, 9, 10, and 11, Adam's Place, Borough High Street October 10th. Works completed, and costs ordered to be paid. 8 and 10, Redcross Court, Borough High Street October 10th. Closed with costs. Summary. Houses and tenements, respecting which representations were made to the Vestry that they were in a state so dangerous or injurious to health as to be unfit for human habitation. Houses and tenements 59 Inhabitants 340 In addition to the above a closing order, with costs, was made under the Public Health (London) Act, 1891, in the case of the owner of the premises 55, Dodson Street. 50 Parish of St. George the Martyr, Southwark. Houses to Let in Lodgings. In accordance with the instructions of your Sanitary Authority I have prepared bye-laws for the registration and inspection, promotion of cleanliness, and prevention of overcrowding in lodgings, let or occupied by members of more than one family. Section 94 of the Public Health (Londou) Act, 1891, makes it imperative that every Sanitary Authority shall make and enforce bye-laws in furtherance of the abovementioned objects. The bye-laws, approved by your Vestry, now only await confirmation by the Local Government Board. Common Lodging Houses. On application to the Commissioner of Police for the Metropolis for information respecting the common lodging houses in this Parish, I was courteously supplied with a list of them, (see page 62.) 39 in number. They are mostly situated in the Borough Road sub-district, and are registered to accommodate 1,297 males and 316 females—in all 1,613 persons. At the end of 1891 the total number of registered common lodging houses under the control of the police was 863, with accommodation for 33,086 lodgers. On November 1st, 1894, the powers of the police over the common lodging houses, including the making and enforcement of regulations and bye-laws, are to be transferred to the London County Council. I have more than once expressed the opinion to your Vestry that a central body such as the London County Council might, with advantage, formulate uniform regulations and bye-laws for confirmation by the Local Government Board. Given, however, a sufficient staff of skilled and adequately-paid officers, the regulations could be more thoroughly enforced in the case of common lodging houses, slaughter and cow-houses, dairies, and bakehouses, by the Vestries and Local Boards, than by the Council alone, or in dual combination with any other authority. Bye-Laws under the Public Health (London) Act, 1891. This Act provides that every Sanitary Authority in the metropolis shall make bye-laws under the following sections :— Sec. 16. For the prevention of particular nuisances; Sec. 39. Water closets sufficiently supplied with water; Sec. 50. The cleansing of cisterns. The Vestry has made such bye-laws, and they have been approved by the Local Government Board. They may be found commencing at page 51. It now only remains for me, in bringing this Beport to a conclusion, to offer my thanks to all who have contributed, by their assistance, to whatever success may have attended our Public Health work during the past year. I have the honour to be, Your obedient Servant, F. J. WALDO, M.A., M.D., Cantab., D.P.H., Medical Officer of Health. 1, Plowden buildings, Temple. CHART SHOWING THE NUMBER OF CASES OF Scarlet Fever, Diphtheria. Small-Pox and Enteric Fever notified in St. George, Southwark, in each Week of the Year 1893. Annual Report of the Medical Officer of Health,—1893. 51 Public Health (London) Act, 1891 SECTION 16. BYE-LAWS, made by the Vestry of the Parish of St. George the Martyr, Southwark, in the Administrative County of London. Interpretation of Terms. 1. Throughout these bye-laws the expression "The Sanitary Authority" means the Vestry of the Parish of St. George the Martyr, Southwark, in the County of London. For the prevention of nuisances arising from any snow, ice, salt, dust, ashes, rubbish, offal, carrion, fish or filth, or other matter or thing in any street. 2. The occupier of any premises fronting, adjoining, or abutting on any street not repairable by the inhabitants at large shall, as soon as conveniently may be after the cessation of any fall of snow, remove or cause to be removed from the footways and pavements adjoining such premises and forming part of such street all snow fallen or accumulated on such footways and pavements in such a manner and with such precautions as will prevent any undue accumulation in any channel or carriageway or upon any paved crossing The person in occupation of, or having the charge, management, or control of the premises, or if there is no such person, then any person in occupation of or having the charge, management, or control of any part of the premises, and in the case of any premises the whole of which is let in tenements or to lodgers, the person receiving the rent payable by the tenants or lodgers, either on his own account or as the agent of another person, shall for the purposes of this bye-law be deemed to be the occupier. 3. Every person who shall remove any snow from any premises on to any carriageway shall deposit the same in such a manner and with suoh precautions as to prevent any accumulation thereof in any channel or upon any paved crossing. If in the process of such removal any snow be deposited upon any footway or pavement in any street, he shall forthwith remove such snow from such footway or pavement. • 4. Every person who shall throw any salt upon any snow on the footway of any street, shall do so in such quantity and in such manner as effectually to dissolve the whole of such snow, and he shall forthwith effectually remove from the footway the whole of the deposit resulting from the mixture of the salt with the snow. He shall not place any part of such deposit on the carriageway of such street elsewhere than in proximity to any channel at the side of such carriageway, and he shall not remove any part of the same into any such channel unless it is sufficiently liquid to flow along such channel. No person shall throw any salt upon any snow on the carriageway of any street, unless it shall be practicable forthwith effectually to remove the whole of the deposit resulting from the mixture of the salt with the snow. Every person who shall throw any salt upon any snow on any such carriageway, shall forthwith effectually remove the whole of the deposit, but he shall not place any part thereof on the footway of such street or any paved crossing, or on the carriageway in such a manner as to interfere with the carriage traffic, nor shall he place any part thereof in the channel at the side of the carriageway, unless it is sufficiently liquid to flow along such channel. 5. A person shall not throw, cast, or lay, or cause to be thrown, cast, or laid, any dust, ashes, rubbish, offal, carrion, fish, or filth, or other like matter, or thing, in or upon any part of a street. 52 Parish of St. George the Martyr, Southwark. Provided, always, that this bye-law shall not apply to any act which is for the time being an offence within the meaning of any public general statute, or of any bye-law made by the London County Council and in force in the place where such act is done. Provided, also, that it shall not be an offence against this bye-law to lay any ashes or other suitable material in any street in time of frost to prevent accidents. 6. Every person who shall lay or cause to be laid in any street any litter or other matter in case of sickness to prevent noise, shall lay the same so that it may be evenly distributed over the surface of the part of the street intended to be covered, and shall, when the occasion ceases, within forty-eight hours thereafter, remove or cause to be removed from such street the litter or other matter so laid in such street. For preventing nuisances arising from any offensive matter running out of any manufactory, brewery, slaughter-house, knacker's yard, butcher's or fishmonger's shop, or dunghill, into any uncovered place, whether or not surrounded by a wall or fence. 7. The occupier of a manufactory, brewery, slaughter-house, knacker's yard, butcher's or fishmonger's shop, or of any premises comprising a dunghill, shall not cause or suffer any offensive matter to run out of such manufactory, brewery, slaughterhouse, knacker's yard, butcher's or fishmonger's shop, or dunghill, into any uncovered place, whether or not surrounded by a wall or fence, so as to be likely to become a nuisance. For the prevention of the keeping of animals on any premises in such place or manner as to be a nuisance or injurious or dangerous to health. 8. The occupier of any premises shall not keep nor allow to be kept any animal on such premises in such a place or in such a manner as to pollute any water supplied for use or used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, or any water used or likely to be used in any daily. 9. Every occupier of a building or premises wherein or whereon any horse or other beast of draught or burden, or any cattle may be kept, shall deposit or cause to be deposited in a suitable receptacle all dung, manure, soil, filth, or other offensive or noxious matter other than urine and other liquid filth which may, from time to time, be produced in the keeping of any such animal in such building or upon such premises. He shall, likewise, provide in any connection with such building or premises a sufficient drain, constructed in such a manner, and of such materials, and maintained at all times in such a condition, as effectually to carry away all urine and liquid filth or refuse therefrom. Except where the Sanitary Authority, by notice duly given under the statutory provision in that behalf shall have otherwise required, he shall, once at least in every week, remove or cause to be removed from such building or premises all dung, manure, soil, filth, or other offensive or noxious matter produced in or upon such building or premises, and deposited in a receptacle as herein-before required. Provided that this requirement shall not apply to the occupier of any stable or cowhouse from which the Sanitary Authority remove or contract for the removal of manure and other refuse matter. Where for the purpose of preventing the keeping of any horse or other beast of draught or burden or any cattle on any premises so as to be a nuisance or injurious or dangerous to health, it is necessary that the floor of the building in which such animal is kept should be impervious to liquid matter, no person shall keep any animal in such building unless or until the floor thereof shall have been paved with a hard and impervious pavement evenly and closely laid and so sloped as to effectually carry off all liquid matter therefrom to a properly trapped inlet to the drain herein-before required to be provided. Annual Report of the Medical Officer of Health,—1894. 53 As to the paving of yards and open spaces in connection with dwelling-houses. 10. The owner of every dwelling-house in connection with which there is any yard or open space shall, where it is necessary for the prevention or remedy of insanitary conditions that all or part of such yard or open space shall be paved, forthwith cause the same to be properly paved with a hard, durable, and impervious pavement, evenly and closely laid upon a sufficient bed of good concrete, and so sloped to a properly constructed channel as effectually to carry off all rain or waste water therefrom ; and he shall cause such pavement to be kept in proper repair. Penalties. 11. Every person who shall offend against any of the foregoing bye-laws shall be liable for every such offence to a penalty of five pounds, and in the case of a continuing offence to a further penalty of forty shillings for each day after written notice of the offence from the Sanitary Authority. Provided, nevertheless, that the justices or court before whom any complaint may be made or any proceedings may be taken in respect of any such offence may, if they think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this bye-law. 54 Parish of St. George the Martyr, Southwark. Public Health (London) Act, 1891. SECTION 39. BYE-LAWS, made by the Vestry of the Parish of St. George the Martyr, Southwark. in the Administrative County of London. Interpretation of Terms. 1. Throughout these bye-laws the expression "The Sanitary Authority" means the Vestry of the Parish of St. George the Martyr. Southwark, in the County of London. With respect to the keeping of waterclosets supplied with sufficient water for their effective action. 2. The occupier of any premises in or for which any watercloset is for the time being provided, shall cause such watercloset to be at all times properly supplied with a sufficient quantity of water for securing its effective action. Where, however, any watercloset is provided for the use of persons occupying two or more separately occupied premises, and there is a person having the care and control of such watercloset, the foregoing requirement shall apply to such person. The person in occupation of or having the charge, management, or control of the premises, or if there is no such person, then any person in occupation of or having the charge, management, or control of any part of the premises, and in the case of any premises the whole of which is let to lodgers, the person receiving the rent payable by the lodgers, either on his own account or as the agent of another person, shall for the purposes of this bye-law be deemed to be the occupier. Penalties. 3. Every person who shall offend against the foregoing bye-law shall be liable for every such offence to a penalty of five pounds, and in the case of a continuing offence to a further penalty of forty shillings for each day after written notice of the offence from the Sanitary Authority. Provided, nevertheless, that the justices or Court before whom any complaint may be made, or any proceedings may be taken in respect of any such offence, may, if they think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this bye-law. Annual Report of the Medical Officer of Health,—1893. 55 Public Health (London) Act, 1891. SECTION 50. BYE-LAWS, made by the Vestry of the Parish of St. George the Martyr, Southwark, in the Administrative County of London. Interpretation of Terms. 1. Throughout these bye-laws the expression the "Sanitary Authority" means the Vestry of the Parish of St. George the Martyr, Southwark, in the County of London. For securing the cleanliness and freedom from pollution of tanks, cisterns, and other receptacles used for storing of water used or likely to be used by man for drinking or domestic purposes, or for the manufacturing drink for use of man. 2. The owner of any premises who shall provide thereon a tank, cistern, or other receptacle to be used for storing of water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, shall cause the 6ame to be so constructed and placed that it may conveniently be cleansed. 3. The owner of any premises on which a tank, cistern, or other receptacle not provided by the occupier of such premises is used for storing of water, used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, shall cause every such tank, cistern, or other receptacle which is erected outside a building, or which, being erected inside a building, is not placed in a suitable chamber, or otherwise constructed or placed so as to prevent the pollution of the water therein, to be provided with a proper cover. 4. The occupier of any premises on which a tank, cistern, or other receptacle is used for storing of water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, shall empty and cleanse the same, or cause the same to be emptied and cleansed, once at least in every six months, and at such other times as may be necessary to keep the same in a cleanly state and free from pollution. He shall cause every such tank, cistern, or other receptacle which is erected outside a building, or which, being erected inside a building, is not placed in a suitable chamber, or otherwise constructed or placed so as to prevent the pollution of the water therein, to be kept at all times properly covered. Provided that in every case where any tank, cistern, or other receptacle used for storing of water, used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, is used for supplying water to persons occupying two or more separately occupied premises, the foregoing requirements shall apply to the owner of such premises instead of to any occupier thereof. The person in occupation of, or having the charge, management, or control of the premises, or if there is no such person, then any person in occupation of or having the charge, management, or control of any part of the premises, and in the case of any premises the whole of which is let to lodgers, the person receiving the rent payable by the lodgers, either on his own account, or as the agent of another person, shall, for the purposes of this bye-law, be deemed to be the occupier. 5. The occupier of any premises or any other person shall not obstruct or interfere with the owner of such premises, or with any person duly authorised by him in that behalf, in the execution of any work to which the foregoing bye-laws relate. Penalties. 6. Every person who shall offend against any of the foregoing bye-laws shall be liable for every such offence to a penalty of five pounds, and in the case of a continuing offence to a further penalty of forty shillings for each day after written notice of the offence from the Sanitary Authority. Provided, nevertheless, that the justices or Court before whom any complaint may be made or any proceedings may be taken in respect of any such offence may, if they think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this bye-law. 56 Parish of St. George the Martyr, Southwark. Copy of Placard Distributed Within the Parish on Small-pox and its Prevention. The best means of Preventing the Attack of the Disease, and of Stopping it when it has Broken Out. It is required by Law that every child be vaccinated within three months of its birth; parents or persons in charge of infants are liable to prosecution and fines for omission. It cannot be too widely known that Vaccination is one of the best means of preventing an attack of Small-pox. All persons above twelve years of age should be Re-vaccinated. When Small-pox prevails in a family or neighbourhood, every person should be immediately Re-vaccinated. When an individual has Small-pox, everything should be done to separate the person attacked from those around. Since Small-pox is pre-eminently contagious in all stages of the disease every case should be at once removed to a Small-pox Hospital. If the patient be treated at home the sick-room should be cleared of all needless furniture, including woollen or other draperies, which serve to harbour the contagion. No person should be allowed to enter the room, except those who are attending upon the sick. Where persons have had Small-pox, whether they get well or die, the room in which they have been ill, and all articles therein should be disinfected. The inhabitants of the Parish who may at any time have any bedding or clothing which requires to be disinfected, are requested to give notice thereof, without delay, at the Vestry Hall, Borough Road ; such articles will then be removed by the Officers of the Vestry, disinfected and returned without any charge whatever. P. J. WALDO, M.D., D.P.H., Medical Officer of Health. PUBLIC VACCINATORS. Dr. MATCHAM, 9, St. George's Circus. Every Monday at 2 o'clock. Dr. WILLS, 216, New Kent Road. Every Wednesday at 2 o'clock. Dr. JONES, 61, Nelson Square, Blackfriars Road. Every Friday at 2 o'clock. Annual Report of the Medical Officer of Health,—1893. 57 Regulations for Bakehouses. Factory and Workshop Act, 1878, and Factory and Workshop Amendment Act, 1883. 1st.—All the inside walls of the rooms of such Bakehouse, and all the ceilings or tops of such rooms (whether such walls, ceilings, or tops be plastered or not) and all the passages and staircases of such Bakehouse shall either be painted with oil or varnished, or be limewashed, or be partly painted or varnished, and partly limewashed; where painted with oil or varnished, there shall be three coats of paint or varnish, and the paint or varnish shall be renewed once at least in every seven years, and shall be washed with hot water and soap once at least in every six months; where limewashed, the limewashing shall be renewed once at least in every six months. A Bakehouse in which there is any contravention of this Section shall be deemed not to be kept in conformity with this Act. 2nd.—A place on the same level with a Bakehouse, and forming part of the same building, shall not be used as a sleeping place unless it is constructed as follows:— that is to say, unless it is effectually separated from an external glazed window of at least nine superficial feet in area, of which at least four and a half superficial feet are made to open for ventilation. Any person who lets or occupies, or continues to let or knowingly suffers to be occupied, any place contrary to this Section, shall be liable to a fine not exceeding for the first offence, twenty shillings, and for every subsequent offence five pounds. The Factory and Workshop Act, 1883. 3rd.—It shall not be lawful to let or suffer to be occupied as a Bakehouse, or to occupy as a Bakehouse, any room or place which was not so let or occupied before the 1st June, 1883, unless the following Regulations are complied with:— (a) No water closet, earth closet, privy or ashpit shall be within or communicate directly with the Bakehouse. (b) Any cistern for supplying water to the Bakehouse shall be separate and distinct from any cistern for supplying water to a watercloset. (c) No drain or pipe for carrying off faecal or sewage matter shall have an opening within the Bakehouse. 4th.—Any room or place used as a Bakehouse (whether the same was or was not so used before the passing of this Act) is in such a state as to be, on sanitary grounds, unfit for use or occupation as a Bakehouse, the occupier of the Bakehouse shall be liable to a fine of forty shillings, and on a second or any subsequent conviction, five pounds. 5th.—Every person refusing or failing to allow the Sanitary Authority or their Officer to enter any premises in pursuance of those provisions, for the purpose of this Section, shall be subject to a fine of five pounds. FREDK. J. WALDO, M.D., D.P.H., Medical Officer of Health. N.B.—The Medical Officer of Health requests that the cleansing shall take place in April and October of each year. 58 Parish of St. George the Martyr, Southwark. Regulations as to the Removal of Persons suffering from Infectious Diseases, &c. The Metropolitan Asylums Board has published the following set of regulations as to the removal of persons suffering from infectious diseases:— 1. Apply on week-days between 9 a.m. and 8 p.m. to the chief offices. Postal address: Norfolk House, Norfolk-street, Strand, W.C. Telegraphic address: Asylums Board, London. Telephone number: 2587. (N.B.— Applications in the latter part of the day must be dispatched in time to reach the offices before 8 p.m.,) At night, between 8 p.m. and 9 a.m., and on Sundays, Christmas Day, and Good Friday, to the Ambulance Stations; Eastern Ambulance Station, Brooksby's Walk, Homerton, N.E.; SouthEastern Ambulance Station, New Cross-road (near Old Kent-road Bailway Station) S.E.; Western Ambulance Station, Seagrave-road, Pulham, S.W. 2. Removal to the Board's Hospitals:— (a) Only persons suffering from small-pox, fevers, or diphtheria are admitted into the Board's Hospitals. (b) Every application must state the name, age, and full address of the patient, from what disease suffering, and, in cases of fever, the particular kind of fever; and also the name of the person making the application. (c) Unless a medical certificate be handed to the ambulance nurse, the patient will not be removed. (d) Patients should leave all valuables, money, &c„ and all outside clothing at home; should wear body linen only, and be wrapped in the blankets provided for the purpose. (e) The ambulance nurse will leave at the house from which the patient is removed a notice stating the hospital to which the patient is to be taken, and a copy of the regulations as to visiting, &c. 3. Conveyance to other places:— (a) Persons suffering from any dangerous infectious disease may be conveyed by ambulance to places other than the Board's Hospitals. N.B.—Dangerous infectious diseases include the following: Smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlatina or scarlet fever, typhus, typhoid, enteric, relapsing, continued, and puerperal fevers, and measles. (b) Every application for an ambulance must state:— (i.) Name, sex, and age of patient. (ii.) Description of disease, and, in the case of fever, the particular kind of fever. (iii.) Full address from which the patient is to be conveyed. (iv.) Full address to which the patient is to be conveyed. (c) The patient must be provided with a medical certificate of the nature of the disease, to be handed to the driver of the ambulance. (d) The charge for the hire of the ambulance, including (when the patient is over ten years of age) the services of a male attendant, is 5s. This amount must be paid to the driver, who will give an official receipt for the same. Annual Report of the Medical Officer of Health,—1893. 59 (e) One person only will be allowed to accompany the patient, and such person may be conveyed back to the place from which the patient was conveyed. If desired, a nurse will be supplied at an additional charge 2s. 6d. for her services. (f) The ambulances may be sent outside the Metropolitan District only by special sanction of the Ambulance Committee, or of the Clerk to the Board, and in such cases an extra charge will be made of 1s. for every mile outside the metro.politan area. 4. The drivers of the Board's ambulances are not allowed to loiter on their journeys or to stop for refreshments on pain of instant dismissal. It is particularly requested that any breach of this regulation, or any neglect or incivility on the part of drivers, nurses, or attendants may be immediately reported. The servants of the Board are forbidden to accept any gratuities or refreshments. N.B.—PENALTY.—By Section 70 of the "Public Health (London) Act, 1891," it is enacted that—"It shall not be lawful for any owner or driver of a public "conveyance knowingly to convey, or for any other person knowingly to place "in any public conveyance, a person suffering from any dangerous infectious "disease, or for a person suffering from any such disease to enter any public "conveyance, and if he does so he shall be liable to a fine not exceeding TEN "POUNDS . . . ." 60 Parish of St. George the Martyr, Southwark. Regulations as to Furnishing Information Relative to the Condition of Patients, and as to the Visiting of Patients. Information as to Condition of Patients:— 2. Upon the admission of a patient, a letter will be sent to the nearest known relative or friend, setting forth the state of the patient. Should any serious change for the worse take place, a letter will be sent daily to the relative or friend, stating how the patient is progressing, which letter will be continued until the patient is in such a condition as to render further communications unnecessary; but should the patient become dangerously ill, notice will be sent to the nearest known relative or intimate friend, with an intimation that the patient may be visited; and, at the discretion of the Medical Superintendent, arrangements may be made for the conveyance of the visitor to and from the hospital. 3. Enquiries as to the condition of patients must be made in writing to the Medical Superintendent, who will reply by return of post. It is very undesirable that friends of patients should personally make enquiries at the hospital. Visiting:— 4. The visiting of patients is limited to the nearest relatives and intimate friends of patients dangerously ill. One visit only will be allowed daily to each patient. Visits, which will not be allowed xoithout the permission of the Medical Superintendent, are, as a rule, to be limited in duration to a quarter of an hour. In urgent and special cases, however, the Medical Superintendent is empowered to increase the number of visitors to two, and to extend the duration of the visit. 5. Visitors are warned that they run great risk in entering the hospitals. They are advised not to go into the wards of the small-pox hospitals without having been properly re-vaccinated, and if they reside where the case visited occurred, are earnestly requested to urge the remainder of the occupiers of such house to call at once on the Public Vaccinator (whose address can be obtained from any of the parish officers) for the purpose of being vaccinated. 6. Visitors are further advised not to enter the wards in any of the hospitals when in a weak state of health or in an exhausted condition, but to partake of a good meal before entering the hospital. They will be required when in the wards to carefully avoid touching the patient, or exposing themselves to his breath, or to the emanations from his skin; and will not be permitted to sit on the bed or handle the bed-clothes, but will be allowed to sit on a chair at the bedside at some little distance from the patient. 7. Visitors will also be required to wear a wrapper (to be provided by the Board) to cover their dress when in the wards, and to wash their hands and faces with carbolic soap and water before leaving the hospital, or to use such other mode of disinfection as may be directed by the Medical Superintendent. 8. Visitors are strongly urged not to enter any omnibus, tramcar, or other public conveyance, immediately after leaving the hospital. Annual Report of the Medical Officer of Health,—1893. 61 APPENDIX A. List of Slaughter-houses licensed by the London County Council, in October, 1893. Name. Situation. Farmer, John 264, Old Kent Road Eedman, Frederick 146, High Street, Borough Rowe, John 73, London Road Trask, William S. 11, Bermondsey New Road Waters, Arthur William 59, Old Kent Road Waters, Frederick S. 79, Old Kent Road List of Horse Knackers' Yards licensed by the London County Council, in October, 1893. Name. Situation. Harrison, Barber & Co., Limited 23, Green Street Harrison, Barber & Co., Limited Wescott Street. Tabard Street List of Cow-houses licensed by the London County Council, in October, 1893. Name. Situation. Adams, William 3, Little Lant Street Evans, John 89, Redcross Street Owens, John 143, Tabard Street Park, Isabella S. 30, Wellington Place List of Bakehouses under Inspection in St. George the Martyr, 1893. 126, Southwark Bridge Road 16, Borough Road 67, Long Lane 111, Great Suffolk Street 7, Westminster Bridge Road 44, „ 102, Lancaster Street 119, Waterloo Road 1, Tabard Street 70, London Road 28, Tower Street 49, „ „ 7, Great Suffolk Street 25, „ „ 155, „ „ 17, „ „ 5, „ „ 255, „ „ 126, „ „ 32, Earl Street 285, „ „ 119, „ „ 114, London Road 28, Clarendon Street 237, Scovell Road 10a, Hayles Street 15, Old Kent Road 51, Friar Street 60, St. George's Road 31, „ „ 26, „ „ 17, „ „ 33, „ „ 161, Blackfriars Road 21, Ontario Street 69, „ „ 27, Little Surrey Street 57 & 58, London Road 85, „ „ 45, Pocock Street 48, London Road 80, „ „ 14, Friar Street 233, Old Kent Road 146, „ „ Valentine Place 269, „ „ 168, „ „ 43, Webber Street 70, Red-cross Street 272, „ „ 76, „ „ 151, Borough High Street 304, „ „ 242, Borough High Street 108, „ „ 37, Warner Street 216, „ „ 90, „ „ 1, Cross Street 26, Lant Street 168, „ „ 62 Parish of St. George the Martyr, Southwark. RETURN showing the Registered Common Lodging Houses in the Parish of St. George the Martyr, together with the Number of Lodgers of each Sex for which the several Houses are Registered. Name of Keeper. Postal Address of Common Lodging House. Number of Single Lodgers for which Registered. Number of Double Beds authorised. Male. Female. Total. Hunter, Thomas Farm House, Harrow Street, Borough, S.E. 89 89 Willis, Ann E. 2, Quilph Street, Borough, S.E. 109 109 Ford, Alfred 7, Dorrett Street, do. 1 14 15 1 Longdon, William 15, Falcon Court, do. 45 45 Ford, Alfred 8, Dorrett Street, do. 7 29 36 7 Ford, Alfred 83, Mint Street, do. 19 12 31 Mayle, Thomas H. 97, Redcross Street, do. 3 25 28 3 Williams, Elizabeth 9, Lombard Street, do. 7 7 Williams, Elizabeth 8, Lombard Street, do. 6 6 Levy, Lewis 1, 2, 3, Disney Street, do. 77 9 86 1 Williams, Elizabeth 7, Lombard Street, do. 12 8 20 Williams, Elizabeth 5 & 6, Southsea Court, do. 7 13 20 7 Mayle, Thomas H. 99, Redcross Street, do. 39 55 94 18 Levy, Lewis 12, Marshalsea Road, do. 79 40 119 Morley, George 112, Southwark Bridge Road, S.E. 161 161 Roche, James 31, Tabard Street, Borough, S.E. 40 40 Wade, William 115, Tabard Street, do. 20 20 Allen, Frederick 12 & 14, Gray Street, Waterloo Road, S,E. 85 85 5 Childs, Harriet 2, Marcia Boad, Old Kent Road, S.E. 7 7 Levy, Henry 12, Lombard Street, Borough, S.E. 76 76 Levy, Henry 13, Lombard Street, do. 8 8 16 Mayle, Thomas H. 101, Red Cross Street, do. 28 10 38 Hogan, James 61, Borough Road, S.E. 68 68 Constantine, Denis 14, Great Suffolk Street, Borough, S.E. 15 15 Hogan, James 64, Borough Road, S.E. 36 36 Levy, Henry 56, Newington Causeway, S.E. 54 54 Levy, Henry 14, Lombard Street, Borough, S.E. 6 6 Williams, Elizabeth 7, Southsea Court, do. 8 8 Levy, Henry 95, Mint Street, do. 10 10 Levy, Henry 97, Mint Street, do. 6 6 Cavender, James 212, High Street, do. 142 142 Wane, William 113, Tabard Street, do. 13 4 17 4 Levy, Henry 101, Mint Street, do. 12 12 Levy, Henry 99, Mint Street, do. 14 14 Moore, Thomas 1, Surrey Buildings, East Street, Walworth, S.E. 30 30 Cavender, James 210, High Street, Borough, S.E. 39 39 Levy, Robert 131, Great Suffolk Street, do. 87 87 Steele, Charles S. 74 & 76 Newington Causeway 51 51 Annual Report of the Medical Officer of Health,—1893. 63 APPENDIX B. Special Reports on the Retail Bakehouses in the Parish. During the year 1893 I have made two Special Reports on the retail bakehouses within your district. Many references to the subject are also scattered throughout my general reports to the Vestry. My views and conclusions on the whole subject may be best gathered from the following paper, read before the Sanitary Institute on February 14th, 1894, which, together with the subsequent discussion, is here reprinted from the Journal of the Society:— "The subject upon which I have been invited to address you covers so much ground that it would be hopeless to attempt to deal with it exhaustively within the limits of time allotted to this paper. I, therefore, propose to confine my remarks more particularly to the consideration of the hygienic aspects of the bakehouses. At the same time, it may be broadly stated that many of the objectionable features met with in ill-regulated bakehouses are reproduced in bad kitchens. "After a prolonged consideration of this question, I have been forced to the conclusion that there is urgent need throughout the United Kingdom for enquiry and reform. Under the present system, the health of the workman often suffers, and in some instances the public health is also endangered. To remedy the evils, I would suggest—(1) that inspection under existing statutes should be more systematic and complete; (2) that legislation is needed to extend the powers of local authorities to deal with all aspects of the bakehouse question. Further, I am of opinion that a proper scheme of legislative action could be best initiated by a Select Committee of the House of Commons. "Too little attention has, I think, been devoted in the past to the wholesomeness of places where food is stored and prepared. Most practical sanitarians will agree with me that this neglect is likely te entail consequences more or less serious upon the food consumer, and in a still greater degree upon the food producers. "Turning to that portion of the subject with which I propose to deal more particularly, namely, to the question of bakehouses, this attitude of general apathy is especially remarkable. In bread, we have to deal with an article of prime necessity; it is the staple and essential factor in all dietaries, and every citizen is directly concerned in matters affecting its cost, its purity, and its methods of production. These being the circumstances, it seems hardly credible that, on a moderate estimate, 64 Parish of St. George the Martyr, Southwark. one-half of the bread supplied to Londoners is sent out from cellar bakeries or, in other words, is manufactured in underground places which violate the first principles of sanitation. This estimate, it may be at once acknowledged, is only approximate, as it is impossible to obtain anything like a comprehensive statement of facts and figures. In my own district of St. George the Martyr, Southwark, I find that out of sixty-seven bakeries, twenty-three are situated altogether, and nine partially in basements; a proportion which is exceeded in other metropolitan districts. In considering the source of the total output of bread, moreover, the fact must he taken into consideration that some of the above-ground bakeries carry on business on a very extensive scale. On the whole, however, I think we may take it as a fairly correct assumption that about one-half of the Londoners' daily bread is derived from underground bakeries. "According to the Census of 1891 there are no fewer than 18,029 bakers in London, and 84,158 in England and Wales.* These figures do not include the pastrycooks and confectioners, many of whom work underground, but whom I exclude as they are not directly concerned in the production of bread. The bakers, however, constitute a large and important class, and when we take into consideration the wives and children dependent on their exertions, it will be evident that our present discussion directly affects the interests of a large section of the industrial community. "The lot of the journeyman baker is neither a healthy nor an enviable one. From the nature of his occupation he is placed in an environment that saps his strength and too often makes him prematurely aged. His face is thin and pale, his shoulders are rounded, and his whole look is suggestive of chronic ill-health. Nor is this to be wondered at when we consider the fatiguing nature of his work, which is carried on through the night and far into the next day. He is exposed to damp and to great and sudden changes of temperature, and he habitually breathes an atmosphere which is charged with dust, with the fumes of coal, with the products of respiration, and not infrequently with actual sewage contamination. In consequence of the unhealthiness of the employment the young journeyman changes his occupation whenever he is able, and thus swells the mortality figure of some other trade. His place, however, is quickly filled up by a recruit from the country, or by an apprentice from Scotland or from the West of Englaud. "Dr. Ogle's tables of comparative mortality of males between twenty-five and sixty-five years of age, founded upon the Death Registers of 1880-1-2, offer some suggestive figures. Prom them we learn that in one hundred different occupations bakers occupy the following relative positions:—In suicide they come third, in alcoholism seventh, in liver disease eleventh, in diseases of circulatory system eleventh, and in diseases of the nervous system twelfth. Many of these diseases may be traced to the abuse of alcohol, an evil habit which is doubtless fostered by the fatigue consequent upon the overwork, the long hours, the want of sleep, and the poisonous atmosphere to which the journeyman baker is exposed. It may be remarked that Dr. Ogle's tables do not confirm the high rate of mortality from consumption and diseases of the respiratory organs testified to by other authorities. This apparent anomaly is possibly explained by the fact that a small proportion only of the total number of bakers included in his tables are exposed to the bad environment met with in London. In short, his figures deal with the state of the trade generally, as apart from the metropolis, and in this way they are diluted, so to speak, with the more favourable results obtained from provincial bakeries. "Among the diseases to which bakers are specially liable may be mentioned rheumatism, colds, erysipelas, and a form of eczema, due to the irritation of the flour, known as "bakers' itch." They are particularly liable to rupture; Malgaigne, indeed, states that their tendency to that affection is three times that of other trades. * Since the Census of 1881 the bakers have added 13,126 to their number. Annual Report of the Medical Officer of Health,—1894. 65 This observation is readily accounted for by the fact that the baker has to lift heavy sacks weighing 280 pounds. Another common affection of bakers is flat-foot, a deformity that produces a peculiar gait, and it is also due to long standing, and the habitual lifting of heavy weights. "As to the hours of work, from personal enquiries among the journeymen I find that seventy-two hours' work weekly is a fair average in the better class trade, with Saturday evening and Sunday free. Nor is it easy to see how, with the present system of making bread by hand, this time could be materially shortened. In the poorer neighbourhoods, where what is known as a " cutting" business is conducted, the baker works from eighty-four to a hundred hours weekly, and, in addition, frequently bakes dinners up till half-past one o'clock on Sunday. "Perhaps the best way to form an idea of the realities of a cellar bakehouse will be to draw a picture of such a place, sketching in the details from facts which have come under my own observation. "First of all we enter a baker's shop from the street, and descending a trap door, climb down a steep ladder into the bakehouse. We then find ourselves in a cellar some twenty or thirty feet in length, and ten or twelve feet in breadth. It is, in fact, an ordinary basement cellar, six or seven feet high, and is lighted by gas jets. Its roof is unceiled, and between the boards covering the warped rafters are many cracks, which open directly into the shop above. A portion of its floor-space is occupied by a slightly raised wooden platform, on which are ranged a number of sacks of floor. Along one of its sides are placed the kneading troughs, large wooden boxes which are fixed immoveably against the damp and whitewashed wall. The oven stands at one end of the bakehouse, away from the sacks of flour, and consists of a long, deep chamber built of unglazed bricks. Its furnace is fed with coal, a supply of which lies in a loose heap close by. In the darkest corner of this underground bakery stands a kind of open cupboard, in which a water-closet is placed. "In the cellar thus fitted up are carried on all the operations of mixing, kneading and baking the dough, in addition to which it often serves for storing the loaves of bread. "On descending the stairs, the visitor finds himself plunged into a hot and stifling atmosphere. Pursuing his investigations, he will find that the air is vitiated from many sources, for instance, there is the active contamination of the flaring gas-jets, while the furnace fills the place with sulphurous fumes, more especially when the journeyman economises fuel by closing the damper. The air is further charged with moisture and with other products derived directly from the baking of the bread. Sewer gas may enter through the drain openings in the floor, the more so as the grating traps are often worthless. It may enter, moreover, through a defective closet soil-pipe. Further pollution is caused by the ground air and damp which are sucked up into the heated cellar through the faulty flooring. But this is not all, for in low-lying districts there is the danger that in times of heavy rainfall the sewage may force its way through the drain-pipes into the bakehouse. It is easy to see that the introduction of a flood of sewage in this way may bring the germs of typhoid and other filth diseases into direct contact with the loaves of baked bread. "Ventilation, in any real sense of the term, is absent, and, indeed under the circumstances we have pictured, is impossible. An inlet grating usually exists at the level of the street, but as a rule it is kept carefully closed by the journeyman, who is morbidly susceptible to draughts. In most cases, again, there is another small inlet at the back of the cellar, but the second ventilator is almost invariably covered up by means of a sack. It will be seen, therefore, that not only is the air systematically poisoned from within, but also, that no provision is made for that constant renewal from without which is essential to health. We may safely assert that no man could habitually work in an atmosphere even approaching that which has been portrayed without sooner or later sustaining serious injury to his health. 66 Parish of St. George the Martyr, Southwark. "Our description, however, has by no means exhausted the evils incident to a bad underground bakehouse. In many of these places the unhappy journeyman is actually shut up for twelve hours or more at a stretch, and during that period adds his quota to the general impurity. At times he-smokes, or uses tobacco in the still more objectionable form of chewing. Now and then dogs and cats are found in the cellars. Other forms of animal life include rats, mice, black beetles, cockroaches, ants and spiders, the smaller insects often being present in almost incredible numbers. Then the moist and heated atmosphere is favourable to the rapid decay of vegetable matter, and this takes place in the scraps of dough and refuse flour which collect in the hollow sides of and beneath the kneading troughs. The same conditions act on the coal, and cause it to give off various injurious gases. "Bread, as everyone knows, is peculiarly liable to absorb moisture and gaseous substances. When stored in a badly arranged bakehouse, therefore, it can hardly escape deterioration. Moreover, when prepared under these conditions, it is liable to be injured at every step of its manufacture. The flour becomes damp, musty, and sour, the "sponge" and dough contaminated by the sweating arms of the journeyman, while on all sides it is exposed to the risk of sewage and of other noxious emanations. Lastly, the water with which the flour is mixed is often obtained from the same cistern which supplies the water closet, a system which is nothing less than an open invitation for the entrance of sewage matter into an important and universally used article of food. "In London there are between thirty and forty "model bakeries," that is to say, places where baking is carried on in a cleanly and scientific way, amid wholesome surroundings. This number does not include the wholesale factories, of which there are several of large size. It will be sufficient here if I briefly lay down the principles which should guide the construction and management of a sanitary bakery. "First, the building itself should be specially built for the purpose with strong walls and a plentiful supply of windows. Separate and lofty rooms should be provided for storing flour, for mixing and kneading the dough, for baking, and for storing the bread. The flour-loft should be placed at the top of the building, aud all the sacks should be conveyed thither by means of a lift, so as to spare the workmen as much as possible from the laborious and dangerous work of hauling about heavy weights. The mixing and kneading room should be provided with movable iron troughs, the kneading as well as the mixing to be conducted by means of machinery wherever possible, in order to avoid the handling of the dougb or flour by the workmen. Then a special provision should be made for thoroughly cleansing the empty sacks before they are returned to the miller. "These various rooms should be light, airy aud lofty, and be kept with the most scrupulous regard to cleanliness. Much will depend on the construction of the rooms. The walls, ceiling aud floor of each room should be of smooth and nonabsorbent material, such as glazed tiles for the walls and roof, and hard wood or tesselated pavement for the floor. The windows should reach to the ceiling, and be kept permanently open at the top. Additional ventilation could be provided by means of Tobin's tubes and other appliances, but in all cases it is imperative that all such apparatus should act automatically and be beyond the control of the workmen. As much daylight as possible should be admitted to every part of the building, and no part of the bakehouse must be below the ground level. Where artificial light is wanted, it would be best obtained from electric lamps. The water used for mixing the dough must be provided from a special and separate cistern, or better still, direct from the main. All sanitary conveniences, including wash-basins and baths, should be placed in a basement, or in some place quite apart from the main building. "The ovens themselves may be heated in various ways. Some of the most cleanly and convenient means are by gas or by wrought iron tubes containing superheated steam. If coal or coke be used, it is important to insist that the furnace room be freely ventilated, and that on no account is the flue to be closed by a damper. Annual Report of the Medical Officer of Health,—1893. 67 "Let us glance briefly at the state of legislation with regard to bakehouses. "Before 1863 no special legislation existed. In that year, however, the Bakehouse Regulation Act was passed. The measure in question was introduced at a time when public attention had been pointedly drawn to the unhealthy conditions under which baking was carried on. The duty of inforcing this first Act of 1863 was imposed on the local authorities. As a result of the report of a Royal Commission on Factories and Workshops in 1876, the Factory and Workshop Act of 1878 became law, and at the same time the Bakhouse Act was repealed. For some unaccountable reason, and against the advice of the Commission, the regulation of bakehouses was transferred from the local authorities to the already over-burdened factory inspectors, who numbered six only for the whole of London. In 1883, on the passing of the Factory and Workshops Amendment Act, the duties were re-transferred from the factory inspectors to the local authorities. "The present law regarding retail bakehouses, as far as London is concerned, is incorporated in Sections 26 and 27 of the Public Health (London) Act, 1891. The provisions of the Act of 1878 are contained in Sections 34, 35 and 81. These Sections repeated in Section 26 of the Public Health (London) Act, apply to such bakehouses only as are situated in any place that contains, according to the last published Census, a population of more than 5,000 persons. Section 34 runs as follows:—'Where a bakehouse is situate in any city, town, or place containing, according to the last published Census for the time being, a population of more than 5,000 persons, all the inside walls of the rooms of such bakehouse and all the ceilings or tops of such rooms (whether such walls, ceilings, or tops be plastered or not) and all the passages and staircases of such bakehouse, shall either be painted with oil or varnished, or be limewashed, or be partly painted, or varnished and partly limewashed; where painted with oil or varnish there shall be three coats of oil or varnish, and the paint or varnish shall be renewed once at least in every seven years aud shall be washed with hot water and soap once at least in every six months; where liinewashed the limewashing shall be renewed once at least in every six months. A bakehouse in which there is any contravention of this Section shall be deemed not to be kept in conformity with this Act.' "Section 35 of 1878 Act states that a place on the same level with the bakehouse and forming part of the same building shall not be used as a sleeping place, unless it is constructed as follows:—that is to say, 'It must be effectually separated from the bakehouse by a partition extending from the floor to the ceiling, and unless there is an external glazed window of at least nine superficial feet in area, of which at least four-and-a-half superficial feet are made to open for ventilation.' There is no apparent reason why the operation of this Section should have been confined to urban districts. Surely, in the interests of the sleeper and the bread consumer— whether rustic or cockney—it is desirable that the Section should be of general application. Section 81 of 1878 Act provides that if Section 34 be contravened the occupier of the bakehouse shall be liable to a fine not exceeding £10. "The sections of the Act of 1883 applicable to bakehouses, and repeated in Section 26 of the Public Health (London) Act are Sections 15 and 16. Section 15 relates exclusively to places which were not let or occupied as bakehouses before the 1st of June, 1883. This Section provides that it shall not be lawful to let or to suffer to be occupied as a bakehouse, or to occupy as a bakehouse any such place, unless the following regulations are complied with: (1) No water closet, earth closet, privy, or ashpit, shall be within, or communicate directly with the bakehouse; (2) Any cistern for supplying water to the bakehouse shall be separate and distinct from any cistern for supplying water to a water closet; (3) No drain or pipe for carrying off faecal or sewage matter shall have an opening within the bakehouse. "It is to be regretted that this Section is not applicable to bakehouses let or occupied as such before, as well as after, the 1st of June, 1883. 68 Parish of St. George the Martyr, Southwark. "Section 16 relates to all bakehouses whatever may be the date of their construction or first occupation. It provides that where a court of summary jurisdiction is satisfied on the prosecution of a Local Authority that any place used as a retail bakehouse is in such a state as to be, on sanitary grounds, unfit for use or occupation as a bakehouse, the occupier of the bakehouse shall be liable, on summary conviction, to a fine not exceeding forty shillings, and on a second or any subsequent conviction, not exceeding £5. The Court, in addition to, or instead of, inflicting such fine, have it in their power to order means to be adopted by the occupier within a time named in the order for the purpose of removing the ground of complaint, and may on application enlarge the time so named; but if after the time so originally named or enlarged by subsequent order, the order is not complied with, the occupier will be liable to a fine not exceeding £1, for every day that such non-compliance continues. "The Vestry of St. George the Martyr, Southwark, is the first Sanitary Authority that has gained a conviction, and this quite recently, under the 16th Section of the 1883 Act, without asking the Court to order means to be adopted by the occupier for the purpose of removing the ground of complaint. In the case cited, the prosecution did not apply for this order, since the Medical Officer of Health was of opinion that the premises were incapable of being made fit for use as a bakehouse. "The magistrate inflicted the full peualty with costs, and made no order for removing the ground of complaint for the reason stated above. "Sub-sections 1 and 2 of the 17th Section of the 1883 Act have been repealed— so far as London is concerned—by Section 142 (vide fourth Schedule) of the Public Health (London) Act, 1891. "Sub-section 3 of the same 17th Section has been repealed by Section 39 (vide second Schedule) of the Factory and "Workshop Act, 1891. "The present law for the regulation of the metropolitan bakehouses, summarised and reproduced in the following two Sections of the Public Health (London) Act, 1891, reads as follows:— " 'Section 26.—(1). Sections 34, 35, and 81 of the Factory and Workshop Act 1878, and Sections 15 and 16 of the Factory and Workshop Act (Amendment Act), 1883 (which relates to cleanliness, ventilation, and other sanitary conditions), shall, as respects every bakehouse which is a workshop, be enforced by the Sanitary Authority of the district in which the bakehouse is situate, and they shall be the local authority within the meaning of those sections. " '(2). For the purpose of this Section, the provisions of this Act with respect to the admission of the Sanitary Authority and their officers into any premises for any purpose in relation to nuisances shall apply in like manner as if they were herein re-enacted and in terms made applicable to this Section; and every person refusing or failing to allow the Sanitary Authority or their officer to enter any premises in pursuance of those provisions for the purposes of this Section shall be subject to a fine. " 'Section 27.—If any child, young person or woman is employed in a workshop, and the medical officer of the Sanitary Authority becomes aware thereof, he shall forthwith give written notice thereof to the factory inspector for the district.' "By Section 96 of the Factory and Workshop Act, 1878, 'child' means a person under the age of fourteen years; 'young person' signifies a person of the age of fourteen years and under the age of eighteen years; and 'woman' is defined as a female of eighteen years of age and upwards. "The only remaining special legislation affecting retail bakehouses is to be found under Section 26, Sub-sections 1 and 2 of the Factory and Workshop Act, 1891. This Section obliges every person within one month after opening a bakehouse to serve a writien notice on the district factory inspector, acquainting him of the fact. Annual Report of the Medical Officer of Health,—1893. 69 The Section further imposes upon the inspector the duty of forwarding the notice forthwith to the Sanitary Authority of the district in which the bakehouse if situate. "The chief conclusions at which I have arrived may be stated somewhat as follows:— (1). That it is advisable, by means of a Select Committee of the House of Commons, to enquire into the bakehouse question. (2). That in case the Committee advise fresh legislation they shall prepareas Bill incorporating their recommendations with the Public Health (London) Act, 1891. (3). That it should be rendered an offence to occupy as a bakehouse any cellar or place almost or altogether below the level of the street, unless it had been so occupied before and up to a certain fixed date. (4). That all bakehouses be compulsorily licensed, and that such license be renewable annually. (5). That the granting of licenses be vested in the London County Council. (6). That uniform Metropolitan bye-laws regulating the conduct of the retail bakeries be made by the County Council, and be confirmed by the Local Government Board; and that the duty of enforcing these bye-laws devolve upon the various Sanitary Authorities. (7). That such bye-laws shall cover: (a) The regulation of the conduct of the business; (b) The regulation of the structure of the premises; (c) The regulation of the mode in which application is to be made for sanction to establish anew the business of a baker in the County of London. (8). That the bye-laws relating to structure and comprised under heading (b) do not apply to existing bakeries until after the lapse of a certain number of years. (9). That the question of compensation for disturbance of existing right in bakeries be taken into consideration by the Parliamentary Committee. (10). That no dealing with the question of the regulation of bakehouses will be complete unless it investigates the relations between the millers and the retail bakers. At present the small tradesmen are often completely under the thumb of the capitalist millers. (11). That inspection of bakehouses should be more systematic and thorough. To fulfil this condition an increase of the staff of sanitary inspectors is imperative. (12). That a more intelligent knowledge of the whole question of their bread supply is desireable on the part of the public. (13). That the weight of sacks of flour should be reduced from 280 to 140 lbs. "To my mind, the ill-health of the baker is, in the main, the result of the bad surroundings in which he works. If baking be carried on in well-ventilated places, with a perfect sanitary environment, there is no reason why it should be a particularly dangerous or unhealthy trade. It is open to question how far the State should be called upon to fix the hours of labour of the journeyman baker. Without entering, however, into the discussion of that difficult and complex economical problem, it may, I think, on the other hand be emphatically asserted that there is much in the present condition of the retail bakehouses which calls for stringent legislative interference." 70 Parish of St. George the Martyr, Southwark. "Prof. W. H. Corfield (London) said that if underground bakehouses were as they had been described, and he knew that, many were, everybody would agree that they ought to be abolished. In Dr. Waldo's scheme notice was to be given to bakers to reform their bakehouses within a certain period; but he was of opinion that not too much notice should be given them. As a case in point, he referred to the Act passed for the abolition of private slaughter-houses. This Act allowed a period of forty years for all private slaughter-houses to be abolished. Thirty-eight years after the passing of this Act. as no steps whatever had been taken to abolish private slaughter-houses, a Bill was brought in exempting them from abolition. So that in this case after forty years' notice things remained just the same as ever. Although the duty of inspecting bakehouses was in the hands of the Home Office, for three years there was, so far as he had been able to ascertain, practically no bakehouse inspection whatever. Many improvements had now been introduced into some underground bakehouses, but he thought it was far better to get rid of them altogether than to try and improve them. "Dr. Louis C. Parkes (London) thought that the proportion of underground bakehouses in London was more like seven-eighths than that mentioned by Dr. Waldo— viz., a half. He thought that underground bakehouses were liable to be unhealthy, and although much had been done to remedy their insanitary conditions still a great deal of dampness and bad ventilation remained. Where food was being prepared it was most important that there should be no dampness, and, moreover, he thought it impossible to ventilate underground rooms without immediately creating a draught, which bakers very naturally objected to. He expected it would be found that the comparative mortality of lung diseases among bakers would be high. It was impossible to do much with underground bakehouses, and their gradual abolition would probably be the best course. He agreed with Dr. Waldo that bakehouses should be licensed, and that the London County Council should have power to make regulations in regard to them, regulating them similarly to slaughter-houses The insanitary conditions of bakehouses no doubt affected the public health to a certain extent, but it should not be lost sight of that the process of baking sterilised the bread, and therefore destroyed all germs of disease. After being baked the crusts of the loaves might become contaminated under unwholesome conditions, and in epidemic times it was advisable to have bread re-baked at home. All bakehouses should be made sanitary, and the work commenced at once and done gradually. Kitchens were also important, as some were in a still worse condition than bakehouses. The audience would recollect the correspondence in the newspapers some time ago about the kitchens of foreign restaurants. Atone of the large London exhibitions he went over one of the kitchens, and found in it two bell traps with steam issuing from the drains and a water-closet situated in close proximity to the kitchen. If this was the state of affairs in a highclass establishment, what must it be in a low-class one ? He thought it very desirable that there should be a special inspection of all kitchens, and that this was almost more important than that of bakehouses, as the act of baking tended to sterilise or destroy the germs, whereas from kitchens many things were served up in a raw state. "Mr. W. G. Lakeman (H.M. Superintending Inspector of Workshops for London) thought that Dr. Waldo's paper had been read opportunely, at a time when public thought was being exercised for the good of humanity. County Councils and local authorities were being awakened to a sense of their duties, and were beginning to assist the heads of the Government in carrying out the measures so wisely introduced. In 1863 a Commission was appointed to enquire into the bakehouse question, and as a result of their report an Act of Parliament was passed appointing the local authorities inspectors of bakehouses. They did nothing, and at the end of twenty years instead of an improvement things were worse. They had no time and no one else had any time, because no one was paid to do the work. In 1879 the inspection of bakehouses was transferred to factory inspectors, with the result that in fifteen months from 2,000 to 3,000 bakehouses were inspected and reported to the Government. In some instances the reports showed that large cesspools had been found situated immediately under the kneading troughs. As a result of these reports the Act of 1883 was passed, but he would ask what was the use of this Act and what good had it done? The local Annual Report of the Medical Officer of Health,—1893. 71 authorities found they could not undertake the work as they had too much to do already, so that from 1883 till quite recently no thorough inspection of bakehouses had been made, and now although the Home Office Inspectors work in harmony with the local authorities in carrying out the work of inspection, he was of opinion that until the Act of 1883 had been abolished and a new one passed on the lines suggested by Dr. Waldo the result would not be entirely satisfactory. He pointed out that in Glasgow and Belfast the sanitary condition of bakehouses was all that could be desired, and yet in London there was scarcely any underground bakehouses that could be said to be so. The master of a bakehouse was frequently a representative of the miller or contractor under whose thumb he was. He submitted that the hours were too long. Why should the men work 16, 17, and 18 hours out of the 24? In this matter inspectors had power to prevent young persons being overworked but they could do nothing for the men, who, if they refused these hours, must in consequence suffer a loss of wages. He hoped that we should soon have such legislation for bakehouses as would ensure their being built on hygienic principles. "Mr. John Blandy (London) objected to the lecturer's use of the word cellars as applied to underground bakehouses, he considered they should be termed basements. If basement bakehouses were done away with, why not also basement kitchens and basement factories and workshops? And if all basement establishments were abolished, how would the owners manage as to rent, having regard to the great value of land in London? He believed that attention was wisely directed to pure air and good ventilation, but thought it would be a great mistake to abolish basements; far better retain them and make their sanitary condition proper and clean. He could not agree with Dr. Parkes as to germs being killed by being sterilised in the baking. He considered that cleanliness was to be aimed at, whether above ground or below. "Mr. T. A. Garniot (London) said that the case mentioned by the lecturer was not the first action under the Act. The Vestry of St. Marylebone closed a bakehouse some time ago for a period of six weeks, and obtained penalty under the Section; and in September last they obtained a closing order under the Public Health (London) Act 1891, until the Vestry's notice to put the premises in a sanitary condition had been carried out. He thought that everybody would agree to the abolition of underground bakehouses, especially if they could see the unhealthy conditions under which the men employed in them had to work, in comparison to the advantages obtained in those built above ground. "Mr. B. A. Prain (London) said that cellar bakehouses, or as he preferred to call them, basement bakehouses, contained the oven and were not damp. He entirely disagreed with the assertion that a great deal of the baking business was in the hands of the millers. He said that in London want of room was a great difficulty, and that if underground bakehouses were done away with, he failed to see where the necessary ground for the bakehouses was to be obtained. Under the present system of short leases, a baker could not afford to build above ground, as the landlord would in consequence raise the rent after the expiration of the lease. He had done his best to advocate cleanliness, but if underground bakehouses were done away with, the baking trade, except the large factories, would be done away with also. "Mr. Thornton (London C.C.) asked the lecturer if he had suggested to his local authority to communicate with the Local Government Board, urging the amendment of the law relating to bakehouses, as he knew Dr. Waldo had taken more interest and trouble in the matter than anyone else. The evils were only too apparent, even bakers themselves deplored them. He could not agree with Mr. Lakeman as to the Act of 1883. It was not a matter for surprise that the Vestries had taken no action. They were largely composed of interested property jobbers and those interested in the business, and it was owing to this that nothing was done, and not from want of time. There was not sufficient interest taken in the representation of the Vestries. He did not think the matter should be handed over to the London County Council, but rather that the Local Government Board should provide regulations which should be enforced 72 Parish of St. George the Martyr, Southwark. by District Councils. If this were done thoroughly and properly, and the country possessed more medical officers like Dr. Waldo, the bakery business would become as healthy as any other. "Dr. Walsh (London) said that the assertion as to landlords confiscating the leases of bakehouses was an argument against the law of landlords and not against sanitation. If you reformed the bakehouses you would no doubt drive out the small baker. The public would gain in the end, but, as a class. the journeyman baker would suffer. He would venture to ask if the conversion of an ordinary house into a bakery increased the value of the property? Also whether Dr. Waldo was aware that many insanitary bakehouses belonged to the City or other Corporations, and whether they were taking any steps to remedy their condition, and if not, why were they not prosecuted ? "Mr. Viokers (London) said that ordinary people would conclude from the lecture that bakers were the blackest of sinners, and he thought the lecturer had drawn greatly on his imagination. No doubt there were dirty bakehouses, and no trade could show a clean sheet, but bakers had too much at stake to allow their premises to be in such a condition as that described. If such a state of affairs became known, their trade would be ruined. One might conclude from the lecture there was no inspection of bakehouses, but he could say from experience, both as the owner of a bakehouse and a member of the Health Committee of a Vestry, that inspection was both systematic and regular. He submitted that inspectors did perform their duty and the trade had no right to be blackballed. The Vestries were quite able to cope with the evils, and he counselled people not to be afraid to eat their bread. "Mr. James Priestley (London) quite agreed with Dr. Waldo that there was urgent need for reform in the matter of the sanitary arrangements and condition of bakehouses; need for suitable bye-laws and for the licensing of bakehouses. Dr. Waldo's description of the "typical" bakehouse as it occurred in his parish would not apply to the average bakehouse in the parish of Paddington. He had visited all the bakehouses in the latter parish, and only two or three could be passed as requiring no amendment. The average height of the ceilings was about eight feet. He did not see how underground bakehouses were to be done away with, but the erection of any new underground bakehouses could be stopped. He was opposed to the handing over of the control of bakehouses to any other authority ? let the supervision remain with the medical officer of health. "Dr. Waldo (London), in reply, said that there was much to answer, but he would endeavour briefly to meet the chief points raised. Dr. Parkes had given seven-eights as the proportion of underground bakehouses to the total number of bakeries in London. This was an over-estimate, and calculating from data in his possession, he thought three-fifths would fairly express the correct proportion. Ninety-nine per cent. of the master bakers in the metropolis were Germans. With regard to bread made in cellar bakeries not being injurious to the public, he would point out that in various parts of London reflux of sewage accompanied heavy rainfalls. In one day, in October last, he had entered twenty cellars—situated in a main road leading to the Kentish capital— and had found them all flooded with sewage. "He considered that such conditions were highly dangerous. The bread—after it came out of the oven—lay about the filthy bakery and was very liable to be contaminated. Another source of danger was contact with the hands of the men, which were frequently soiled. There was rarely—if ever—any provision for washing save in the same utensils as used for bread-making. "With regard to kitchens, he had not bad time enough to go into the subject. He agreed that kitchens were too often quite as bad as or worse than bakehouses, but the work in them was less by night and in length of hours than in bakeries. "Mr. Lakeman had struck at the root of the evil when he charged the millers with sweating and vested interests. The influential millers, so far as legislation was concerned, were masters of the situation, and they could block or pass a Bill by appealing to the owners of the land upon which the corn was raised, who sat in the Houses of Parliament. Annual Report of the Medical Officer of Health,—1894. 73 "He saw no difference between the terms "basement" and "cellar," as applied to retail underground bakeries. Call them by what name you will it is absolutely impossible to efficiently ventilate or render healthy these places which were never constructed or intended for the manufacture of bread. He did not see why the bakehouse should not be removed to the top of the house—as was the case in so many kitchens—where there was no room to erect one on the ground floor. This would not entail great extra expense, and would besides render the house a much healthier one to live in. "In answer to Mr. Thornton, L.C.C., he had suggested in his reports to the Vestry of St. George-the-Martyr, that there should be more frequent inspection, and on his recommendation their staff of inspectors had recently been doubled. Inspection was now made once every three months. This was a step in the right direction. He had also suggested legislation to do away with cellar bakeries, but had received little encouragement from the Local Government Board. He believed in the distribution of Local Government. He said the London County Council should make the bye-laws, subject to the approval of the Local Government Board, and that the Local Authorities should carry out the work, not the London County Council to do everything. "Dr. Walsh had pertinently asked whether the City Corporation possessed insanitary bakehouses. As a matter fact, some of the worst bakehouses in Southwark did belong to the City of London. He was of opinion that the establishment of a bakery on any premises raised the value of such property. "More than one gentleman—in the trade, he presumed—had stated their opinion that he had drawn somewhat on his imagination. He could, however, vouch for everything he had said, and all his remarks were made from personal observation, not on mere hearsay. He was not so well acquainted with the West-end, but he had lived in the South and East-end and visited many of the bakeries. There the state of things was so bad that it called, in his opinion, for immediate attention at the hands of the Legislature." 74 Parish of St. George the Martyr, Southwark. APPENDIX C. Table I. Corrected Return of Cause of Death in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road London Road Kent Road. I.—Specific, Febrile, or Zymotic Diseases. 1.—Miasmatic Diseases. Small-pox ... ... ... Measles 5 3 14 Scarlet Fever (Scarlatina) 3 12 7 Diphtheria 10 6 4 Whooping-Cough 24 24 ... Typhus Fever ... ... ... Enteric or Typhoid Fever 1 4 2 Simple Continued and Ill-defined Fever ... ... ... Influenza 3 3 1 Asiatic Cholera 1 Other Miasmatic Diseases ... ... ... 2.—Diarrhœal Diseases. Simple Cholera ... ... ... Diarrhoea, Dysentery 11 87 37 3.—Malarial Diseases. (e.g., Remittent Fever, Ague) ... ... ... 4.—Zoogenous Diseases. Cowpox and effects of Vaccination ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, and Splenic Fever) ... ... ... 5.—Venereal Diseases. Syphilis 2 1 1 Gonorrhoea, Stricture of Urethra ... ... ... 6.—Septic Diseases. Erysipelas ... 4 1 Pyaemia, Septicæmia ... ... ... Puerperal Fever 1 2 2 II.—Parasitic Diseases. Thrush 2 1 2 Hydatids and other Animal Parasitic Diseases ... 1 ... III.—Dietic Diseases. Starvation and Want of Breast Milk ... ... ... Scurvy ... ... ... Chronic Alcoholism, Delirium Tremens 3 3 1 IV.—Constitutional Diseases. Rheumatic Fever and Rheumatism of the Heart. 2 2 2 Rheumatism 3 6 5 Gout 1 ... 4 Rickets 11 17 6 Cancer, Malignant Disease 12 19 13 Tabes Mesenterica 18 17 26 Tubercular Meningitis, Hydrocephalus 9 21 29 Phthisis 25 29 1 Other Tubercular and Scrofulous Diseases 16 24 21 Purpura, Hæmorrhagic Diathesis 4 2 2 Anæmia, Chlorosis, Leucocythæmia ... 3 4 Glycosuria, Diabetes, Mellitus 5 2 3 Other Constitutional Diseases 3 6 6 Carried forward 174 215 194 Annual Report of the Medical Officer of Health—1893. 75 Table I.—(Continued.) Corrected Return of Cause of Death in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 174 215 194 V.—Developmental Diseases. Premature Birth 15 17 2 Atelectasis 1 1 ... Congenital Malformations 5 3 5 Old Age 5 13 13 VI.—Local Diseases. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes 3 ... 3 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis 5 7 11 Insanity, General Paralysis of the Insane ... 5 ... Epilepsy ... 1 1 Convulsions 20 14 20 Laryngismus Stridulus (Spasm of Glottis) 1 ... ... Paralysis Agitans. Paraplegia, Disease of Spinal Cord 4 ... 2 Other Diseases of Nervous System ... 2 ... 2.—Diseases of Organs of Special Sense. (e.g., Ear, Eyes, and Nose) ... ... ... 3.—Diseases of Circulatory System. Endocarditis, Valvular Diseases of Heart 3 6 ... Pericarditis 16 23 30 Other Diseases of Heart ... ... ... Aneurism ... ... ... Embolism, Thrombosis ... ... ... Other Diseases of Blood Vessels 1 1 ... 4.—Diseases of Respiratory System. Croup 1 5 1 Laryngitis l ... 2 Bronchitis 48 73 75 Pneumonia 30 31 30 Pleurisy 1 ... 2 Emphysema, Asthma 8 4 2 Other Diseases of Respiratory System 19 13 4 5.—Diseases of Digestive System. Dentition 7 15 9 Tonsillitis, &c. ... 2 ... Diseases of Stomach 3 ... 5 Enteritis 2 4 8 Peritonitis 4 1 2 Obstructive Diseases of Intestines 7 1 6 Ascites ... ... ... Cirrhosis of Liver 2 2 1 Jaundice and other Diseases of Liver 2 2 ... Other Diseases of Digestive System 2 3 8 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) ... ... ... 7.—Diseases of Glandlike Organs of Uncertain Use. (e.g Bronchocele, Addison's Disease ... ... ... Carried forward 385 364 446 76 Parish of St. George the Martyr Southwark. Table I.—(Continued). Corrected Return of Cause of Death in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 385 364 446 8.—Diseases of Urinary System. Nephritis 4 9 16 Blight's Disease, Albuminuria 6 11 9 Disease of Bladder and of Prostrate 1 5 11 Other Diseases of Urinary System 10 13 6 9.—Diseases of Reproductive System. (A) Of Organs of Generation). Male Organs ... ... ... Female Organs ... ... ... (B) Of Parturition. Abortion, Miscarriage ... ... ... Puerperal Convulsions ... ... ... Placenta Prævia, Flooding ... 1 1 Other Accidents of Child-birth 2 4 ... 10.—Diseases of Locomotive System. Caries, Necrosis 4 7 4 Arthritis, Ostitis, Periostitis 6 16 6 Other Diseases of Locomotive System ... 5 2 11.—Diseases of Integumentary System. (e.g., Carbuncle, Phlegmon, Cellulitis) ... ... ... Other Diseases of Integumentary System ... ... ... VII.—Violence. 1.—Accident, Negligence, &c. Fracture and Contusion 1 3 2 Gunshot Wound ... 1 ... Cut, Stab ... ... ... Burn and Scald 1 ... ... Poison ... ... ... Drowning ... ... ... Suffocation 6 4 5 Hernia 7 1 ... Deaths consequent on Surgical Operation 1 ... ... Otherwise ... ... 1 2.—Homicide. Murder and Manslaughter ... ... ... 3.—Suicide. Gunshot Wound ... 1 ... Cut, Stab ... ... ... Poison 1 1 1 Drowning ... ... ... Hanging ... ... ... Otherwise ... ... ... 4.—Execution. Hanging ... ... ... Carried forward 435 439 467 Annual Report of the Medical Officer of Health—1893. 77 Table I.—(Continued.) Corrected Return of Cause of Death in the Registration Sub-District during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 435 439 467 VIII. —Deaths from Ill-defined and not Specified Causes. Dropsy 9 5 16 Debility, Atrophy, Inanition 29 31 30 Mortification 4 ... 7 Tumour 4 8 17 Abscess 3 1 12 Hæmorrhage ... 2 5 Sudden Death (cause not ascertained) ... ... ... Found Dead (cause not stated) 1 ... ... Other Causes not Specified or Ill-defined 2 14 4 Totals 489 600 568 TABLE II. Summary of Return of Cause of Death (Corrected.) Cause of Death. Total. I.—Specific Febrile, or Zymotic Diseases:— 1. Miasmatic Diseases 126 2. Diarrhœal Diseases 56 5. Venereal Diseases 4 6. Septic Diseases 10 II.—Parasitic Diseases 6 III.—Dietic Diseases 7 IV.—Constitutional Diseases 374 V.—Developmental Diseases 80 VI.—Local Diseases:— 1. Diseases of Nervous System 99 2. Diseases of Organs of Special Sense 70 3. Diseases of Circulatory System — 4. Diseases of Respiratory System 423 5. Diseases of Digestive System 98 8. Diseases of Urinary System 66 9. Diseases of Reproductive System:— Parturition 4 10. Diseases of Locomotive System 3 VII. —Violence:— Accident, Negligence, &c. 30 VIII.—Deaths from ill-defined and not specified causes 177 Total 1,657 78 Parish of St. George the Martyr Southwark. Table III. Corrected Return of Cause of Death of Infants under One Year in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road London Road Kent Road. I.—Specific, Febrile, or Zymotic Diseases. 1.—Miasmatic Diseases. Small-pox ... ... ... Measles ... ... 2 Scarlet Fever (Scarlatina) 1 ... ... Diphtheria 1 ... ... Whooping-Cough 7 10 3 Typhus Fever ... ... ... Enteric or Typhoid Fever ... ... ... Simple Continued and Ill-defined Fever ... ... ... Other Miasmatic Diseases ... ... ... 2.—Diarrhœal Diseases. Simple Cholera ... ... ... Diarrhoea, Dysentery 8 7 28 3.—Malarial Diseases. (e.g., Remittent Fever, Ague) ... ... ... 4.—Zoogenous Diseases. Cowpox and effects of Vaccination ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, and Splenic Fever) ... ... ... 5.—Venereal Diseases. Syphilis 1 2 1 Gonorrhoea, Stricture of Urethra ... ... ... 6.—Septic Diseases. Erysipelas 2 ... ... Pyaemia, Septicæmia ... ... ... Puerperal Fever ... ... ... II.—Parasitic Diseases. Thrush ... ... ... Hydatids and other Animal Parasitic Diseases ... ... ... III.—Dietic Diseases. Starvation and Want of Breast Milk ... ... ... Scurvy ... ... ... Chronic Alcoholism, Delirium Tremens ... ... ... IV.—Constitutional Diseases. Rheumatic Fever and Rheumatism of the Heart. ... ... ... Rheumatism ... ... ... Gout ... ... ... Rickets 1 2 ... Cancer, Malignant Disease ... ... ... Tabes Mesenterica 6 4 6 Tubercular Meningitis, Hydrocephalus 5 2 3 Phthisis 2 4 ... Other Tubercular and Scrofulous Diseases 4 3 4 Purpura, Hæmorrhagic Diathesis ... ... ... Anaemia, Chlorosis, Leucocythæmia ... ... ... Glycosuria, Diabetes, Mellitus ... ... ... Other Constitutional Diseases ... ... ... Carried forward 38 34 47 Annual Report of the Medical Officer of Health,—1893. 79 Table III.—(Continued.) Corrected Return of Cause of Death of Infants under one Year in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 38 34 47 V.—Developmental Diseases. Premature Birth 15 17 4 Atelectasis 3 2 1 Congenital Malformations ... 3 ... Old Age ... ... ... VI.—Local Diseases. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes ... ... ... Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis ... ... ... Insanity, General Paralysis of the Insane ... ... ... Epilepsy ... ... ... Convulsions 15 15 11 Laryngismus Stridulus (Spasm of Glottis) ... ... ... Paralysis Agitans. Paraplegia, Disease of Spinal Cord ... ... ... Other Diseases of Nervous System ... ... ... 2.—Diseases of Organs of Special Sense. (e.g., Ear, Eyes, and Nose) ... ... ... 3.—Diseases of Circulatory System. Endocarditis, Valvular Diseases of Heart ... ... ... Pericarditis ... ... ... Other Diseases of Heart ... ... ... Aneurism ... ... ... Embolism, Thrombosis ... ... ... Other Diseases of Blood Vessels ... ... ... 4.—Diseases of Respiratory System. Croup ... ... ... Laryngitis ... ... ... Bronchitis 8 16 26 Pneumonia 10 9 5 Pleurisy ... ... ... Emphysema, Asthma ... ... ... Other Diseases of Respiratory System 2 ... ... 5.—Diseases of Digestive System. Dentition 6 3 5 Tonsillitis, &c. ... ... ... Diseases of Stomach ... ... ... Enteritis 3 ... 5 Peritonitis ... ... ... Obstructive Diseases of Intestines 2 1 ... Ascites 1 ... ... Cirrhosis of Liver ... ... ... Jaundice and other Diseases of Liver 1 ... ... Other Diseases of Digestive System ... 1 6 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) ... ... ... 7.—Diseases of Glandlike Organs of Uncertain Use. (e.g Bronchocele, Addison's Disease ... •• ... Carried forward 106 101 109 80 Parish of St. George the Martyr Southwark. Table III.—(Continued). Corrected Return of Cause of Death of Infants under one Year in the Registration Sub-Districts during the 52 Weeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 106 101 109 8.—Diseases of Urinary System. Nephritis ... ... ... Bright's Disease, Albuminuria ... ... ... Disease of Bladder and of Prostrate ... ... ... Other Diseases of Urinary System ... ... ... 9.—Diseases of Reproductive System. (A) Of Organs of Generation). Male Organs ... ... ... Female Organs ... ... ... (B) Of Parturition. Abortion, Miscarriage ... ... ... Puerperal Convulsions ... ... ... Placenta Prævia, Flooding ... ... ... Other Accidents of Child-birth ... ... ... 10.—Diseases of Locomotive System. Caries, Necrosis ... ... ... Arthritis, Ostitis, Periostitis ... ... ... Other Diseases of Locomotive System ... ... ... 11.—Diseases of Integumentary System. (e.g., Carbuncle, Phlegmon, Cellulitis) ... ... ... Other Diseases of Integumentary System ... ... ... VII.—Violence. 1.—Accident, Negligence, &c. Fracture and Contusion 1 ... ... Gunshot Wound ... ... ... Cut, Stab ... ... ... Burn and Scald ... ... ... Poison ... ... ... Drowning ... ... ... Suffocation 6 2 4 Hernia ... ... ... Deaths consequent on Surgical Operation ... ... ... Otherwise ... ... 1 2.—Homicide. Murder and Manslaughter ... ... ... 3.—Suicide. Gunshot Wound ... ... ... Cut, Stab ... ... ... Poison ... ... ... Drowning ... ... ... Hanging ... ... ... Otherwise ... ... ... 4.—Execution. Hanging ... ... ... Carried forward 113 103 114 Annual Report of the Medical Officer of Health—1893. 81 Table III.—(Continued). Corrected Return of Cause of Death of Infants under one Year in the Registration Sub-Districts during the 52 Weeeks ending December 31st, 1893. CAUSE OF DEATH. Borough Road. London Road. Kent Road. Brought forward 113 103 114 VIII. — Deaths from Ill-defined and not Specified Causes. Dropsy ... ... ... Debility, Atrophy, Inanition 31 31 24 Mortification ... ... ... Tumour ... ... ... Abscess 1 ... ... Hæmorrhage ... ... ... Sudden Death (cause not ascertained) 1 ... ... Found Dead (cause not stated) ... ... ... Other Causes not Specified or Ill-defined 2 2 2 Totals 148 136 140 82 Parish of St. George the Martyr, Southwark. TABLE IV. Comparative Analysis of Population, Density. Deaths, and Notification Rate in London, and the undermentioned South London Districts, during the year 1893. Sanitary Area. Estimated Population middle of 1893. Persons to an Acre. Annual rate per 1,000 living. Deaths of Infants under 1 year of age to 1,000 Births. Notification rate per 1,000. Deaths from all Causes. Deathsfr'm principal Zymotic Diseases. St. George, Southwark 59,924 211 27.6 4.0 213 17.7 St. Saviour, Southwark 26,854 132 24.2 3.1 154 14.6 Newington 117,672 185 24.3 3.7 176 17.0 St. Olave, Southwark 12,903 103 24.2 2.2 141 15.7 Bermondsey 84,246 135 23.8 3.3 168 13.0 Rotherhithe 40,020 53 23.2 3.4 165 15.3 Lambeth 280,284 71 20.5 2.7 149 14.4 Battersea 158,105 71 18.9 3.6 169 18.1 Wandsworth 172,143 18 15.2 2.5 142 13.4 Camberwell 245,143 54 19.3 2.5 161 12.8 Greenwich 171,120 49 20.5 3.5 165 15.4 Lewisham (excluding Penge) 77,473 15 14.6 1.7 128 13.2 Woolwich 41,864 37 20.1 2.4 160 10.2 Plumstead 94,596 9 16.4 3.0 137 13.2 London 4,306,411 57 21.3 30 164 15.6 The foregoing table shows that St. George's—the most densely-populated district in the United Kingdom—had among the South London Sanitary areas in 1893:— (1) The highest general death rate. (2) The highest zymotic or preventable deathrate. (3) The largest number of deaths of infants under one year of age. It also had the highest notification-rate of infectious diseases, with the single exception of Battersea. Annual Report of the Medical Officer of Health,—1893. 83 TABLE V.—Zymotic Diseases, 1893. Street List of Cases and Deaths from the undermentioned Diseases. Locality. Small Pox. Erysipelas. Scarlet Fever. Diphtheria. Puerperal. Fever (Mostly Enteric or Typhoid.) Locality. Small Pox. Erysipelas. Scarlet Fever. Diphtheria. Puerperal. Fever (Mostly Enteric or Typhoid.) Amicable Place ... ... 2 ... ... ... Grotto-place ... ... ... ... ... ... Ann's'Place ... ... ... ... ... ... Goldsmith's-place ... ... ... ... ... ... Angel's Place ... ... 1 ... ... ... Goodwin Buildings ... ... 1 ... 1 1* Aldams Place ... ... 1 ... ... ... Alfred Place ... ... ... ... ... ... Henshaw Street ... ... 3 ... ... ... Afreton Street ... ... 2* ... ... ... Hayle's Street ... ... 7** 3* ... ... Austral Street ... 2 ... 1* ... ... Henry Street ... ... ... ... ... ... Bangor Court ... ... ... ... ... ... Hendre Road ... ... ... ... ... ... Hunter's-place ... ... ... ... ... High Street 4 1 6 1 ... ... Blackfriars Road 14* ... 2* 4** ... ... Herberts-place ... ... ... ... ... ... Bath Street ... ... 1 ... ... ... Hill Street ... ... ... ... ... 1 Barron's-place ... ... 2 ... ... ... Harrow Street ... ... 1 2 ... ... Bermondsey New Road ... ... ... ... ... ... Borough Road 4 ... 2 1 ... 1 Ilfracombe Buildings ... 3* 1 2 ... ... Buckenham Street ... ... 1 ... ... ... Brent's Court ... ... ... ... ... ... John's-place ... ... ... ... ... ... Brown's Buildings ... ... ... ... ... ... Joiner Street ... ... ... ... ... ... Bean Street 2 ... 3 1 ... ... John Street ... 1 1 ... ... ... Buckenham Square ... ... 1 1 ... ... Jubilee Buildings ... ... 2 ... ... ... Belvedere-place ... ... 1 1 ... ... James Street ... ... ... 1 ... ... Brook Cottages ... ... ... ... ... ... Boutcher's-place ... ... ... ... ... ... Kell Street ... 1 2 ... ... ... Burman Street ... ... ... 1 ... ... King's Bench Walk ... ... ... ... ... ... Blackhorse Yard ... 1 ... ... ... 2 King Street ... ... 2 ... ... ... Bethlera Hospital ... ... ... ... ... ... King Edward Street ... ... ... ... ... ... King's Court ... ... 2 ... ... ... Collinson Street ... ... 9** 11** 1* ... Kingslake Street 1 ... 1 ... ... ... Collier's Rents ... 1 ... ... ... 1 Castle Street ... ... ... 1 ... ... Lant Street ... ... 4 1 ... ... Chatham Street 1 1 1 ... ... ... Lancaster Street ... ... ... ... ... 4 Cornbury Street ... l ... ... ... ... Lambeth Road ... 1 1* 2 ... ... Clarendon Street ... 2 2 ... ... ... Long Lane ... 1 3 ... ... ... Charles Street 1 ... 1 ... ... ... London Street ... 1 3* 1* ... ... Cleghorn Cottages ... ... ... ... ... ... Lansdowne Place ... 1 1 1 ... ... Crispin Street ... ... ... ... ... ... Little Frederick Place ... ... ... ... ... ... Chapel Court ... ... ... ... ... ... Lant-place ... 1 3 ... ... ... Cook's Cottages ... ... 2 ... ... ... Leyton Grove ... ... ... ... ... ... Cross Street ... ... 2 ... ... ... Lant Street ... 2 3 ... ... ... Cavendish Street ... ... ... ... ... ... London Road ... ... 4 ... ... ... Clifton Buildings ... 1 3** ... ... ... Lombard Street ... ... ... ... ... ... Chester Street ... ... ... 1 ... ... Little Surrey Street 2 ... ... ... ... ... Clarence Street ... ... 5 ... ... ... Mardyke Street ... ... 31 ... ... ... Darwin Street ... 2 3 ... ... ... Montague Street ... ... ... ... ... ... Duke Street ... 5 1 3** ... ... Mansfield Street ... ... ... ... ... ... Delph Street ... ... ... ... ... ... Marshall Street ... ... 4 ... ... ... Dover Buildings ... ... 3 ... ... ... Market Street ... ... ... ... ... ... Dobb's Cross ... ... ... ... ... ... Mason Street ... 2 6 4 ... ... Douglas Buildings ... 1 5* ... ... ... Marshall Buildings ... ... 1 ... ... ... Disney Street 1 ... ... ... ... ... Marshall-place ... ... ... ... ... ... Mint Street 16** ... 1* ... ... ... East Street ... ... 3** ... ... ... Martin Street ... 1 ... ... ... ... Earl Street ... ... ... 1 ... ... Marcia Road ... ... ... ... ... ... Elliott's Row ... ... 8*** ... ... ... Mina Court ... ... ... ... ... ... Evelina Hospital ... ... 18*** 5** ... ... Maypole Alley ... ... ... ... ... ... Etham Street ... ... ... ... ... ... Mina Road ... ... ... ... ... ... Elizabeth Cottages ... ... ... ... ... ... Madron Street ... ... ... ... ... 1 Mermaid Court ... ... ... ... ... ... Fox's Buildings ... ... 4 1 ... ... Marshalsea Road 3 ... ... ... ... ... Falstaff Yard ... ... 4 ... ... ... Milton Terrace 2 ... 1 ... ... Falcon Court ... 2 1* 1 ... ... ... Francis-place ... 1 ... ... ... ... Newington Causeway ... 1 ... ... ... ... Friar Street 2 1 4* ... ... ... New Kent Road ... ... 1 ... ... 1 Flint Street ... ... ... 1* ... ... North Street ... ... ... ... ... ... Friar's-place ... ... ... ... ... ... New Street ... ... ... ... ... ... Nelsou-place ... 1 ... ... ... ... Gable Cottages ... ... 1* ... ... ... Northampton Street ... 1 ... ... ... ... Gilbert Street ... ... ... ... ... ... Noel Street 1 ... ... ... ... ... Gladstone Street ... ... 1 1 ... ... Garden Row ... ... 2 ... ... ... Old Kent Road ... 3 12*** ... ... ... Gray Street ... ... 4 1* ... ... Orient Street ... ... 3 ... ... ... Green Street ... 1 1 ... ... 1 Orphanage, Austral Street ... ... ... ... ... ... Gun Street ... ... 2 ... ... ... Oswin Street ... 3 3* 2 ... ... George Street ... 1 ... ... ... ... Gay wood Street ... 3 4 4 1* ... Providence-place ... ... 1 1 1 ... Gilbert Court ... ... ... ... ... ... Peter Street ... ... ... ... ... ... The asterisks represent deaths and the numerals the total cases in each street. 84 Parish of St. George the Martyr, Southwark. TABLE V.—Zymotic Diseases, 1893.—(Continued.) Street List of Gases and Deaths from the undermentioned Diseases. Locality. Small Pox. Erysipelas. Scarlet Fever. Diphtheria. Puerperal. Fever (Mostly Enteric or Typhoid). Locality. Small Pox. Erysipelas. Scarlet Fever. Diphtheria. Puerperal. Fever (Mostly Enteric or Typhoid). Peabody Square ... 1* 11** 1* ... ... Tennis Court ... ... ... ... ... ... Pocock Street ... ... 2 ... ... ... Tabard Street ... ... 5 ... ... ... Princess Street ... 1 3 ... ... 1* Tower Street 2 ... ... ... ... ... Parliament Street ... ... ... ... ... ... Townsend Street ... ... 1 ... ... ... Pitt Street ... ... ... ... ... ... Temple Street ... ... 1 ... ... ... Pleasant-place ... ... ... ... ... 1 Toulmin Street ... ... 2 ... ... ... Potier Street ... ... 4 ... ... ... Trinity Buildings ... ... ... ... ... ... Paragon ... ... 1 1 ... ... Thomas-place ... ... ... ... ... ... Quinn Square 2 ... 7* 1* ... ... Queen's Buildings ... 2* 24*** ... ... ... Upper Green Street ... ... 2 ... ... ... Queen Street ... ... 1 ... ... ... Union Street ... ... ... ... ... ... Queen's Court ... 1 5 ... ... ... Upper Mill Street ... ... ... ... ... ... Upper Grange Road ... ... 4 ... ... ... Red Cow Alley ... ... ... ... ... ... Red Cross Square ... 1 4 ... ... ... Regent Street ... ... ... ... ... ... Vine Yard ... ... ... ... ... ... Rephidim Street ... ... ... ... ... ... Valentine-row ... 1 ... ... ... ... Rodney Street ... ... ... ... ... ... Victoria-place ... ... ... ... ... ... Red Cross-place 2* ... 1* 1 ... ... Russell-place ... 1 ... ... ... ... Richmond Street ... ... 1* ... ... ... Waleran Buildings ... ... 8 ... ... ... Westminster Bridge-road ... 1 8*** 2** ... ... Warwick Street ... 1 1 1 ... ... St. George's Circus 1 ... 4* ... ... ... Weston Street ... ... 8* 1 ... ... Spiller's Court ... ... ... ... ... ... Webber Street ... 1 2 ... ... ... Stephen-place ... ... ... ... ... ... Warner Street ... 1* 1 ... ... ... Stephen's Square ... ... 1 ... ... ... William Street 1 1 2 1* ... 2 Suffolk Street 1 2 9** 1 ... 1 Warwick Square ... ... ... ... ... ... St. George's Road ... ... 2 ... ... ... Waterloo Road 2 3 1 ... ... ... St. George's-place ... ... ... ... ... ... Wellington-place ... ... ... ... ... ... Southwark Bridge Road 2 3 10** 3 ... ... Westcott Street ... ... ... ... ... ... Smyrk's Road ... ... 3 3* 1 1 Wickham-place ... ... 1 ... ... ... Sterry Street ... ... 1 ... ... ... Wilmott's Buildings ... ... ... ... ... ... Staple Street ... ... 2 ... ... ... Walker Street ... ... ... ... ... ... Surrey Street ... ... 1 ... ... ... West Square ... ... 11 ... ... ... St. George's Market ... ... ... ... ... 1 West-place ... ... ... ... ... ... Stamford-place ... ... ... ... ... ... Webber-row ... 1 4 ... ... ... Sturge Street ... ... 1 1* ... ... Whitecross Street ... ... ... 1 ... ... Swan-place 3* ... 3* ... ... ... Wickham Place ... 1 ... ... ... ... St. George's Buildings 1 ... 3 3 ... ... Surrey Buildings ... ... ... ... ... ... Scovell Road 1 ... 7 ... ... ... Young's Buildings ... ... ... ... ... ... Surrey Square ... ... 1 ... ... ... York Street ... ... 1 ... ... ... St. Mary's Place ... ... ... ... ... ... Sussex House ... ... 6 ... ... ... The asterisks represent deaths and the numerals the total cases in each street. Annual Report of the Medical Officer of Health,—1893. 85 PUBLIC HEALTH DEPARTMENT. The Streets and Houses therein, on the Parish Boundary. Alfreton Street 1 to 31 odd Nos.; 2 to 32 even Nos. Ann's Place (now Falka Place) Tower-st. 17 and 18. Austral Street 1 to 15 and Orphan's Home. Bermondsey New Road 1 to 19 odd Nos.; 2 to 14 even Nos. Blackfriars Road 96 to 172. Bland Street No. 46. Boro' High Street 151 to 221 odd Nos.; 74 to 302 even Nos. Bowling Green Lane 1, 3 to 6. Chatham Street 113 to 159 odd Nos.; 94 to 118 even Nos. Darwin Street 1 to 71 odd Nos.; 22 to 42 even Nos. Deverill Street 1, 2, and 3. East Street 301 to 323 odd Nos.; 334 to 354 even Nos. Elliott's Row 7 to 67. Gloucester Street 29 and 30. Great Guildford Street 49, 50, 53, and 55. Great Suffolk Street 1 to 141, odd Nos.; 2 to 142a even Nos. Great Dover Street 107 to 110. Henshaw Street 79, 80, 81, and 82. Hayles Street 1 to 52. John Street (now Leroy Street) 4 to 20. Kinglake Street 1 to 21 odd Nos.; 2 to 8 even Nos. Lamlash Street 1, 2, 3, 4, 10, 9, 8, 11, 12. Lambeth Road 2 to 92 & Blind School & Bethlem Hospital. Long Lane 1 to 67 odd Nos.; 16 to 54 even Nos. Mason Street 1 to 31. Mina Road 1 to 17 odd Nos.; 2 to 28 even Nos. Newcomen Street No. 70. New Kent Road 211 to 597 odd Nos.; 182 to 246 even Nos. Newington Butts 2 to 22 even Nos. Newington Causeway 2 to 140 even Nos. Old Kent Road 1 to 279 odd Nos.; 2 to 308 even Nos. Oswin Street 2 to 52 even Nos.; 1 to 43 odd Nos. Peter Street 1 and 2, and 8 to 29. Potier Street 9 to 19. Redcross Street 79 to 103 odd Nos.; 64½ to 80 even Nos. Short Street (now Emery Street) 1 and 2. Smyrks Road 1 to 21 odd Nos.; 2 to 26 even Nos. 2, Staple Street 70 to 28. 1 Southwark Bridge Road 115, 131 to 157, 191 to 197, 201, 205 to 223 231 to 273 odd Nos.; 68 to 94, 98 to 130, 134 to 140, 144 to 162a, 164 to 228 even Nos. Orient Street 2 to 16 even Nos.; 1 to 47 odd Nos. Surrey Square 1a, 2, and 3½. Tabard Street All odd Nos. and 302. Temple Street 3 to 41, and 1 to 34. Townsend Street 1 to 34. Union Street 1 to 25 odd Nos.; 2 to 18 even Nos. Upper Grange Road 94 to 106 even Nos. only. Waterloo Road 169 to 275 odd Nos.; 226 to 300 even Nos. Westminster Bridge Road 4 and 6, 10 to 82 even Nos.; 1 to 59 odd Nos. Weston Street 219 to 235, 263 to 293 odd; 174 to 210 even. White Cross Street 1 and 2. 86 Parish of St. George the Martyr, Southwark. REMOVAL OF NUISANCES. IN THE SANITARY DEPARTMENT. Mr. JOHN EDWARDS, Inspector. Number of Cases. Apartments disinfected 456 Dust Bins provided or repaired 66 Yards paved or repaired 91 Interior of Houses cleansed throughout 67 „ „ partly cleansed 90 Water Receptacles cleansed or repaired 53 Service Pipes repaired 39 Sinks in Yards trapped or otherwise repaired 50 Sinks and Stack Pipes disconnected from House Drains 93 Pans in water Closets cleansed, or New pans provided 55 Roofs repaired 55 Drains opened and cleansed 112 Offensive accumulations removed 13 Water Gutters and Pipes provided and repaired 121 Water Closets repaired and soil Pipes ventilated 12 Walls of Yards limewashed 93 Supply of water provided to closets and water waste preventers repaired 95 Cases not otherwise classified 32 Ventilation provided Underground Floors 43 New Drains Constructed and Ventilated 42 Cat Gut premises inspected 1 Bone Boilers' premises inspected 1 Horse slaughterers' premises inspected 1 Tallow Melters premises inspected 2 Cases of Overcrowding or Indecent Occupation abated 18 Slaughter Houses inspected 1 Bakehouses inspected 36 Cowsheds inspected 3 Disinfected Bedding, &c., lots 355 Houses closed as unfit for human habitation 16 Occupation of underground rooms as dwellings discontinued 7 Smoke abatement 4 Overcrowded Workshops abated 6 Workshops inspected 47 2176 During the year 1 Bushel of Apples, and 220 Boxes of Grapes were seized and destroyed, as unfit for human food. [Continued over.] Annual Report of the Medical Officer of Health—1893. 87 ADULTERATION ACTS, 1875—1887. and MARGARINE ACT, 1887. SAMPLES SUBMITTED TO THE PUBLIC ANALYST. Name of Sample. Adulterated. Unadulterated. Total. Milk 12 24 36 Butter, or imitation of Butter 7 15 22 Bread — 6 6 Whiskey — 3 3 Vinegar — 1 1 Olive Oil — 1 1 Pepper — 1 1 Sweets, Aniseed Balls — 1 1 Coffee 1 1 2 Arrowroot — 1 1 Chocolate Candy — 1 1 Lard — 1 1 Oatmeal — 1 1 Flour — 1 1 Total 20 58 78 The above Table shows 25.6 per cent. of the samples to be to the prejudice of the Purchaser. Fines inflicted for adulteration during the year £89 10 0 Recovered costs 13 15 6 Total £103 5 6 SUMMONSES ISSUED DURING THE YEAR. Adulteration 20 Contravention of Margarine Act 2 Various Nuisances 17 Housing Working Classes Act 15 Obstruction 1 The Factory and Workshops Act 3 58 JOHN EDWARDS, Assoc. San. Inst., Inspector. 88 Parish of St. George the Martyr Southwark. REMOVAL OF NUISANCES. IN THE SANITARY DEPARTMENT, Continued. Mr. JOSEPH A. ANSCOMBE, Inspector. Number of Cases. Interior of Houses cleansed, repaired and put into proper order 169 „ „ partly „ „ „ 150 Exterior of Houses repaired, &c. 101 Boundary Walls and Forecourts limewashed, &c. 320 Hoofs repaired, &c. 55 Rain Water Pipes, Gutters, &c., repaired & new, & disconnected from Drains 115 Closets supplied with Water and New Apparatus, &c. 54 „ New Structures 41 „ repaired, cleansed and unstopped 157 Water closets Ventilated and New Soil Pipes 35 Payings (new and old) to yards repaired 125 Traps to yard drains repaired and new supplied 150 Sink Pipes and Traps disconnected from drains 102 Drains, new to houses 31 „ amended 70 „ cleansed, unstopped and repaired 130 Dust Bins, new, supplied to houses 103 „ old repaired „ 51 Water Cisterns cleaned out and repaired 140 „ „ new supplied 25 Water Service Pipes repaired 46 Water supplies to houses 32 Cases of Overcrowding or Indecent Occupation abated 35 Animals improperly kept 5 Removal of offensive matter 35 Bakehouses inspected 30 Miscellaneous Cases 60 Slaughterers' Houses inspected 5 Cowsheds inspected 2 Horse Slaughterers' inspected 1 Occupation of Underground Rooms as discontinued 3 Houses and Premises closed as unfit for human habitation 15 Smoke Abatement (Public Health (London) Act, 1891) 17 Summonses issued during the year, Abatement of nuisance, &c. 29 Water laid on to Houses and from Main 28 Ventilation to floors and Houses—and damp corners 31 Total 2498 N.B.—During the year, the following Articles were seized as being unfit for food and were destroyed, viz.:—2 Boxes of Tomatoes, 3 Lots of Oranges, quantity of Fish, about 84 Barrels of Herrings, 12 cwt. of Pickled Pork, 23 pieces of Pickled Pork, and Turkeys, &c. J. A. ANSCOMBE, Inspector. Annual Report of the Medical Officer of Health,—1893. 89 CONTENTS. SECTION I.—STATISTICAL:- Facts concerning the Sanitary District 3 Houses 4 Number of Occupants of Tenements 4 Population 5 Births and Birth Rate for 1893 6 Death Rate per 1000 for 1893 6 Deaths and Death Rate for 1893 7 Deaths in Public Institutions 8 Death Rate of Sub-Districts 8 Density of Population 8 Poverty 9 Zymotic or Preventable Death Rate 11 Zymotic Disease Mortality 12 Cases admitted to Hospital Ships 18 Vaccination of Children 21 Cholera 24 Respiratory Diseases 28 Alcoholic Excess 29 Mortality of Infants and Children 29 Table of Deaths during 1893 32 Table of Population, Births, and New Cases of Infectious Sickness, 1893 33 SECTION II.—GENEBAL:— Water Supply of the Parish 34 Salvation Army Shelter and Small-pox 37 Increase of Sanitary Inspectors 39 Prevention of the Spread of the Communicable Disease through the Agency of Schools 42 Sewage flooding in Basements 43 Metropolitan Ambulance Service 43 Customs and Inland Revenue Acts, 1890 45 Factory and Workshops Act, 1891 45 Mortuary and Coroner's Court 46 Notification of Infectious Diseases 46 90 Parish of St. George the Martyr, Southwark. CONTENTS-(Continued.) Removal of Destitute Patients 47 The Drainage of Institutions 47 The Cowhouses 48 Slaughter Houses and Knacker's Yards 49 Housing of the Working Classes Act, 1890 49 Common Lodging Houses 50 Houses Let in Lodgings 50 APPENDIX A:— Bye-Laws under the Public Health (London Act, 1891) 51 Small-Pox and its Prevention 56 Public Vaccinators 56 Regulations for Bakehouses 57 Regulations for the Removal of Persons suffering from Infectious Diseases 58 List of Slaughter-houses 61 List of Horse Knacker's Yards 61 List of Cow-houses 61 List of Bakehouses 61 Registered Common Lodging Houses 62 Regulations as to Furnishing information Relative to the Condition of Patients, &c. 60 APPENDIX B:— Special Report on Retail Bakehouses 63 APPENDIX C:— Return of Cause of Death in the Registration Sub-Districts 74 Summary of Return of Cause of Death 77 Return of Cause of Death of Infants in the Registration Sub-Districts 78 Comparative Analysis of Deaths in the South London District 82 Zymotic Diseases—Street List of Cases and Deaths 83 Street Boundaries 85 Inspector Edward's Report 86 Adulteration Acts, &c. 87 Inspector Anscombe's Report 88