HAN 43 City of Westminster. PARISH OF ST. GEORGE, HANOYER SQUARE. REPORT of the MEDICAL OFFICER OF HEALTH for the Year ended 29th December, 1900. London: WIGHTMAN & CO., Ltd., OLD WESTMINSTER PRESS, Regency Street, S.W. 1901. REPORT ON THE SANITARY CONDITION of the Parish of St. Hanover Square. IN THE CITY OF WESTMINSTER, FOR THE YEAR 1900. by W. H. CORFIELD, M.A., M.D. (Oxon.), FR.C.P. (Lond.), Hon. A.R.I.B.A., Consulting Sanitary Adviser to H.M. Office of Works, and Honorary Sanitary Adviser to University College Hospital; Professor of Hygiene and Public Health at University College, London; Past-President oj the Society of Medical Officers of Health; Vice-President of the Sanitary Institute ; " Membre d'honneur" of the Royal Society of Public Health of Belgium; Honorary Member of the Society of Hygiene of France, and of the Hungarian Society of Public Health; Honorary Corresponding Member of the Royal Academy of Medicine of Belgium, of the Imperial Society of Medicine of Constantinople, and of the Royal Society of Hygiene of Italy ; Felloio of the Medical Society of Sweden ; MEDICAL OFFICER OF HEALTH (Being his Twenty-ninth Annual Report). To the Council of the City of Westminster, Mr. Mayor, My Lords and Gentlemen, In presenting this my twenty-ninth and last Annual Report on the Sanitary condition of St. George's, Hanover Square, I wish to express my regret at the severance of a connection which has lasted for over a quarter of a century, and the sense of my obligation to the members of the late Vestry of St. George's, and more especially to the Committee of Works, at whose hands I have always received the kindest and most considerate treatment. This severance is ilue to circumstances over which I have had no control, and although I should have been glad to continue my work at St. George's, I did not apply for the post of Medical Officer 4 of Health for the City of Westminster, as I was not able to comply with the condition requiring that Officer to devote his whole time to the duties of the office. In my Annual Report for 1896 I gave a Table showing the Census Populations of the Parish, and of the two Sub-Districts, from 1891 to 1896, and stated my reasons for believing that the populations, as enumerated at the Censuses of 1891 and 1896, were too low ; estimating, however, from them, I calculate that the population of the Parish at the middle of 1900 was as follows :— Mayfair 23,906 Belgravia 57,458 * Whole Parish 81,364 The total number of deaths registered in the Parish during the 52 weeks ending December 29th, 1900, was 1,654 (Table I.). Of these deaths 657 were those of NonParishioners (Table II.), leaving 997 deaths of Parishioners. To these, however, must be added 143 deaths of our Parishioners in Public Institutions in the Metropolis outside of the Parish, and in the extra Metropolitan Asylums, so that the corrected total of deaths of our Parishioners during the 52 weeks was 1,140, or 32 less than the average during the preceding ten years. This gives a corrected death-rate of 14'06 per thousand per annum on the estimated population. It will be seen from Table I. that the death-rate of the Parish during 1900 was lower than in 1899, but rather higher than in 1896, 1897 and 1898, and that it was one per thousand lower than the average of the ten years, 1890-99. * For the estimated populations of the various Wards see Addendum at the end ot this Report. 5 Table I. Year. Gross Total of Deaths. Deaths in Public Institutions. Proportional ghare of Deaths in Public Institutions Corrected Total of Deaths. Corrected Death-rate per 1,000 per annum. 1890 (53 weeks) 1,986 997 340 1,329 16.46 Deaths of NonParishioners in the Parish. Deaths of Parishioners in Public Institutions outside the Parish. 1891 1,877 904 144 1,312 16.22 1892 1,751 564 147 1,334 16 .97 1893 1,716 654 155 1,217 15.38 1894 1,510 554 140 1,096 13.80 1895 1,675 603 113 1.185 14.98 1896(53 weeks) 1,541 569 145 1,117 13.74 1897 1,577 630 120 1,067 13.32 1898 1,568 615 119 1,072 13.33 1899 1,753 726 129 1,156 14.31 Average during ten years, 1890-1899 1,680 1,172 15.07 1900 1,654 657 143 1,140 14.06* Average during ten years, 1891-1900 1,662 648 136 1,170 14.64 * Applying the correction for age and sex distribution (factor= 1 "10438), given by Mr. Murphy in his Annual Report to the London County Council for 1898, the death-rate of the Parish for 1900 would be 15'53. Table II. Deaths in Public Institutions in the Parish. Parishioners. NonParish ioners. Mayfair. Belgravia. SubDistrict not stated. St. George's Infirmary, Fulham Road 13 99 75 295 Union Workhouse, Wallis's Yard 1 ... ... 1 St. George's Hospital 11 50 1 323 Belgrave Children's ditto ... 16 ... 19 Gordon Hospital for Cancer ... ... ... ... Other Places in the Parish ... 5 8 18 Total in the Parish 25 170 84 657 In Public Institutions in London, outside of the Parish, and in the Extra Metropolitan Asylums 23 98 22 ... 6 Table III. Death-rates per 1,000 per annum. 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 33 Large English Towns . 22.3 20.7 21.6 18.1 20.7 18.9 19.1 19.0 20.2 19.5 London 21.4 20.6 21.3 17.8 19.9 18.6 18.2 13.7 19.8 18.8 Greater London 19.8 19.3 19.7 16.4 18.3 17.0 16.7 17.2 18.3 17.3 St. George's, Hanover sq. 4.65 16.97 15.38 13.80 14.98 13.74 13.32 13.33 14.31 14.06 From Table III. we see that the death-rate of London proper, with an estimated population of 4,589,129, amounted to 18 8, the average rate in the previous ten years having been 19'8 (or equal to the death-rate in 1899). The death-rate of Greater London, with an estimated population of 6,652,145, was 17'3, the average rate in the previous ten years having been 18.3 (or equal to the deathrate in 1899). The death-rate of the 33 largest English Towns was 19'5. The death-rate of this parish was lower than that of any one of the 33 largest English towns except Cardiff (with only 13'8), the others nearest to it being:— Croydon 14.6 West Ham 15.9 Burnley 16-3 Bradford 16.4 and the highest being :— Sheffield 22.6 Preston 24.0 Manchester 24.l Salford 25.1 Liverpool 25.7 7 The death-rate of Edinburgh was 19 4, that of Glasgow 22 0, and that of Dublin 27"6. The two first were nearly the same as in 1899, but Dublin was 3'2 per thousand lower. No Colonial or Foreign city mentioned in the Registrar- General's Annual Summary had as low a death-rate as this parish, the lowest death-rates among Colonial and Foreign cities being those of:— Christiania ... ... ... ... 15'5 Amsterdam ... ... ... .. 164 Brussels ... ... ... ... 16-4 The Hague ... ... ... ... 164 Stockholm ... ... .. ... 16"8 Rotterdam ... ... ... ... 176 Copenhagen ... ... ... ... 17'8 Hamburg .. ... 17'8 and the highest being :— Breslau ... ... ... ... 26 4 St. Petersburg ... ... ... 270 Trieste ... ... ... ... 28'9 Moscow ... ... ... ... 312 Alexandria ... ... ... ... 32*2 Cairo ... 392 Madras .. ... ... ... 46-2 Calcutta .. ... ... ... 50"6 Bombay ... ... ... ... 96*4 In Berlin the rate was 19 0, in Paris 20"6, and in Vienna 20-5 ; the two former being higher and the last a little lower than in 1899. 8 Table IV. YEAR. Registered Births. Birth-rate per 1.000 per annum. Deaths of Children under 1 Year. Total. Percentage to Registered Births. Percentage to Total Deaths of Parishioners 1891 1,610 17-96 216 13-41 16-45 1892 1,519 19-31 220 14-48 16-49 1893 1,496 18-90 204 13-64 16-76 1894 1,499 18-88 177 11-81 12-78 1895 1,470 19-02 204 13-88 17-22 1896 (53 weeks)... 1,407 17-30 211 15-00 18-87 1897 1,365 17-04 183 13-40 17-24 1898 1,411 17-54 172 1-2-12 16-05 1899 1,348 1669 177 13-13 15-31 1900 1,295 15-97 146 11-27 12-81 From Table IV. we see that the number of births in the Parish was 1,295, and that the birth-rate was 15*97 per thousand per annum, as against 16.69 in 1899. The birth-rate for London proper was 28 6, " the lowest London birth-rate on record," as against 29*4 in 1899 and 29-5 in 1898. The average birth-rate of the 33 largest English towns was 29 4 against 30 2 in 1889; the highest being those of Bolton 34 7, Sunderland 35*8, Liverpool 36 0, and Gateshead 36'3; and the lowest those of Croydon 24 9, Oldham 24'1, Brighton 23'6, Bradford 23'1, Halifax 23'1, and Huddersfield 22 8. The number of deaths of Parishioners under one year of age, including those dying outside the Parish (see Table A at end of report) was 146 ; the percentage of such deaths to registered births was 1127, and to total deaths of parishioners, 12'81 ; thus the mortality of children under one year of age was only 113 to a thousand births, while in London generally it was 160, and the average for the 33 9 largest English towns was 172, the highest being Wolverhampton and Burnley with 205, Manchester 207, Blackburn 220 and Preston 236 deaths of children under one year of age to a thousand births. Table V. YEAR. A. Persons aged sixty years and upwards. B, Injuries. C. Inquest Cases. D. Uncertified. Percentages to Gross Total of Deaths. A. B. O. D. 1890 650 94 130 22 32-73 4-73 65 1 10 1891 627 95 144 17 33-38 5*05 7-6 097 1892 581 115 159 15 3318 6-57 91 0-87 1893 541 98 145 15 31 53 5-42 8-4 0-87 1894 465 70 120 9 30-79 4-63 7-9 059 1895 586 87 147 3 34-98 5-19 8-8 0 18 1896 434 114 156 2 28-16 7-40 101 013 1897 518 97 151 4 32-85 6-15 9-6 0-25 1898 495 101 172 6 31-59 6-45 11-0 0-38 1899 595 108 186 8 33-94 616 10-6 046 1900 557 79 146 7 33-68 4-78 8-8 0-42 London 1900 21,837 3,668 8.093 495 25:39 4-26 9-4 0-58 From Table V. it appears that there were 557 registered deaths of persons aged 60 and upwards, giving a percentage of 33'68 of the gross total of deaths, as against a percentage for London generally of only 25"39. No fewer than 322 parishioners (see Table VI.), lived to the age of 65 years and upwards, giving a percentage of 28'25 of the corrected total of deaths. From Table V. we also see that 79 deaths from injuries were registered in the Parish, being 4 "7 8 per cent, of the total deaths, but of the 79 deaths registered under this heading only 26 were those of parishioners,and 6 parishioners died from injuries outside of the Parish, making a total of 32 deaths of parishioners from "Injuries" (see Table VI.)> 10 and giving a percentage of 2'8 of the corrected total of deaths, as against 4'26 for London generally. The Inquest cases held in the parish numbered 146. They were equivalent to 8'8 per cent, of the gross total of deaths, as against 9 4 in London generally. Table VI. Non-Parishioners excluded. Year. A Persons aged sixty-five years and upwards. b Injuries. Percentages to corrected Total of Deaths. a b 1891 *405 37 30-85 2-8 1892 *396 50 29-66 3-7 1893 307 56 25-23 4-6 1894 257 43 23-45 3 0 1895 333 46 28-10 3-9 1896 (53 weeks) 250 48 22-36 4-3 1897 305 55 28-58 5-2 1898 278 53 25-93 4-8 1899 342 49 29-58 4-2 1900 322 32 28-25 2-8 *60 years and upwards. The number of registered deaths uncertified as to cause was only 7, and equivalent to 0'42 per cent, of the gross total of deaths, that of London generally being 0'58 per cent. Table VII. SUB-DISTRICT. Population at middle of 1900. Births. Birth-rate. Deaths of Parishioners. Deaths (corrected). Death-rate (corrected). Mayfair 23.906 208 8-72 217 248 10 41 Belgravia 57.458 1,087 19 32 817 892 15-85 Sub - district not stated 106 "Whole Parish ... 81,364 1,295 15-97 1,140 1,140 14 06 11 Table VIII. birth-rates. death-rates. 1891. 1892 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1891. 1892. 1893. 1894. 1895. 1896 1897. 1898. 1899. 1900. Mayfair 8-95 11-32 10-87 11'26; 11*39 I 9-17 10-98 1059 9-37 8-72 10-08 11-62 10-74 10-53 10-16 7-93 9-38 9-12 8-85 10*40 Belgravia 22-59 22-71 22-27 22 02 21-50 20-30 19-60 20-46 19-75 19-32 17-00 19 25 1 5 £ 15-16 16-94 16-20 14-78 15-10 16*58 15*85 Whole Parish 17-96 19-31 18-90 18-95 18-58 16-98 17-04 17-54 16-69 15-97 14-65 16-97 15-38 13-80 14-98 13-74 13-32 13-33 14 31 14*06 12 From Tables VII. and VIII. it appears that the birthrate of the Parish was only 151)7, and that of the Mayfair Sub-District was 8 72, as against 937 in 1899, while that of the Belgravia Sub-District was 19 32, as against 1975 in 1899; and that the corrected death-rate of the Mayfair Sub-District was 10'40, as against 8'85 in 1899, and that of the Belgravia Sub-District was 15 85 as against 10 58 in 1899. From the birth and death-rates in Table VII., I have calculated, as usual, " the mean length of life." I use the term "mean length of life" instead of "mean duration of life " (as I explained in my Annual Report for 1890), in order to prevent confusion, as the term " mean duration of life" is a technical expression which means the length of life as calculated by the life-table method. The "mean length of life " stated in this report is calculated by means of Dr. Bristowe's formula. The birth-rate in the Mayfair Sub-District is so abnormally low, and the death-rate at the same time so low, that it is of no use attempting to get any correct approximation of the mean length of life in that Sub-District. I therefore merely give it for the whole Parish, for which I calculate it was *67 32 years. This is the highest mean length of life yet recorded in the Parish, being over 12 years more than in 1899, when it was exceptionally low. Table IX. Mean Length of Life. Y ear. St. George's, Hanover Square. London. 1875 46-67 — 1876 47-96 — 1877 49-52 — 1878 48-03 34-24 * This figure seems very high, and so it is, but even if correction for age and sex distribution be made, and the death-rate taken as 15*53, the mean length of life works out at no less than 63*87 years. 13 Year. St. George's, Hanover Square. Londoi 1879 48-55 34-23 1880 5801 35-17 1881 50-26 35-87 1882 52-56 36-82 1883 5509 37-88 1884 53-78 38-08 1885 56-11 39-29 1886 54-46 39-31 1887 56-49 39-98 1888 57-71 41-77 1889 61-43 43-27 1890 62-67 4110 1891 61-62 38-28 1892 55-27 39-58 1893 59-58 38-61 1894 66-19 43-81 1895 59-96 40-60 1896 65-49 42-03 1897 66-69 42-61 1898 65-35 42-45 1899 55-04 41-37 1900 67-32 43-01 N.B.—These figures for London are too high, being calculated from erroneous estimates of the population. N.B.—These figures for London are probably too high for the same reason as those from 1882 to 1890, Table IX. shows the mean length of life in this Parish for the last 26 years, and in London for the last 23 years, and from it we find that the mean length of life in this parish during the last 26 years has averaged 57 years, while during the last ten years it has averaged 62J years, and that the mean length of life in London has averaged over 39£ years during the last 23 years, and nearly 41 £ years during the last 10 years. Table X. shows that the total number of Parishioners dying from the principal infectious diseases and from diarrhoea, including 12 dying in Public Institutions outside of the Parish, was only 71, the lowest number yet recorded, as against an average of 109 during the preceding 10 years, 14 which is equivalent to the very low zymotic death-rate of only 0'88, as against 110 in 1898, the rate for London being 2 22, and that for the 33 largest English towns 2'50. No large town had as low a zymotic death-rate as this Parish, the nearest to it being Halifax, with 1*32. and Croydon, with 144. The highest zymotic death-rates in the large towns were those of Salford 3"98, Sheffield 433, and Preston 4 37. Table X. Deaths of Parishioners from the principal Infectious Diseases and from Diarrhoea and Influenza :— Disease. 1890. 1891. 1892. 1898 1894. 1895. 1896. 1897. 1898. 1899 Average from 1890 to 1899. 1900. Small-Pox 0 0 0 3 1 1 0 0 1 0 1 0 Jleasles 45 13 48 2 29 10 32 18 35 18 25 6 Scarlet Fever 2 6 12 24 10 8 11 7 4 6 9 6 Diphtheria... 12 19 23 26 18 23 24 20 10 12 19 9 Whooping Cough ... 48 21 19 12 20 25 16 13 16 14 20 11 Typhus Fever 0 0 0 0 0 0 0 0 0 0 0 1 Enteric(Typhd.)Fvr. 5 9 8 11 8 8 9 11 9 9 9 11 Simple Contd. Fvr. 2 1 0 2 2 1 0 0 0 0 1 0 Diarrhoea ... 29 31 21 28 10 33 16 25 29 30 25 27 Cholera 0 0 1 0 0 0 0 0 0 0 0 0 Total 143 100 132 108 98 109 108 94 104 89 109 71 Influenza 27 40 75 13 15 67 7 17 29 39 34 38 Taking these diseases separately, according to the order in which they are placed in Table X., we find that:— Small-Pox caused no death in the Parish, and no deaths of Parishioners in Public Institutions outside of the Parish. Measles caused 6 deaths of Parishioners, or 19 less than the average of the last ten years. It also caused 4 deaths of Non-Parishioners in the Parish. Scarlet Fever caused only 6 deaths of Parishioners, being 3 below the annual average. 15 Diphtheria : Nine deaths were caused by this very fatal disease, as against 12 in 1899, and an annual average of 19 during the preceding 10 years. This disease also caused 4 deaths of Non-Parishioners in the Parish. This disease is still very prevalent in London and in some of the other great towns, but while the average deathrate from it in the 33 largest English towns in 1900 was 6 per cent, above the average of the preceding ten years, that of London was no less than 30 per cent, below its average for the same period. Whooping Cough: 11 deaths of Parishioners were registered, the annual average of the previous 10 years having been 20. This disease also caused 4 deaths of NonParishioners in the Parish. Typhus Fever was said to have caused 1 death during the year, the first that has been recorded from it in the parish since 1884. My report on this case was as follows:— The death certified as Typhus Fever is the first certified under that name since 1884. The case, which occurred in the Peabody Buildings, Ebury Bridge, was that of a woman who had moved there from Peabody Buildings, Chelsea, and who, six days later, was certified as suffering from Enteric (Typhoid) Fever, and was removed to the Tooting Hospital. Her husband had died a fortnight before she left Chelsea, the death having been certified as from Capillary Bronchitis, and I am assured by the Medical Officer of Health for Chelsea that no case suggestive of Typhus Fever has occurred in the Peabody Buildings there. The woman's case was a doubtful one throughout, and was only certified as Typhus Fever on account of a rash which was developing when she died, 10 and on account of the absence of the lesions characteristic of Enteric Fever, as shown by the post-mortem examination. I have taken all the necessary precautions, and no further cases have occurred. Enteric (Typhoid) Fever : 11 deaths of Parishioners were recorded, being 2 above the annual average. Five Non-Parishioners died of this disease in the Parish. Simple continued Fever : No death from this disease was registered. Diarrhoea : This disease caused 27 deaths of Parishioners as against 30 in 1899, and an annual average of 25. It also caused 14 deaths of Non-Parishioners in the Parish. The mean temperature of the first quarter was slightly, that of the second nearly half a degree, that of the third two degrees, and that of the fourth nearly four degrees above the average of 129 years. The mean temperature of the year was 50 4° F., or r6° F. above the average of 129 years, and 1"0° above the average of the last 59 years. No death from English Cholera was registered. Influenza : 38 deaths of Parishioners were recorded from this disease as against 39 in 1899. Six Non-Parishioners died from it in the Parish. 17 Cases of Infectious Diseases. The following Table shows the number ol cases certified by Medical Attendants in the ten years 1891 to 1900:— Table XI. Name of Disease. Number of Cases" certified. Average during 10 years 1891-1900. 1891. 1892. 1893. 1894. 1895. 189c. 1897. 1898. 1899. 1900. Scarlet Fever 122 318 567 255 298 339 178 218 194 167 266 Enteric Fever ... 26 42 62 65 37 52 39 40 46 54 46 Continued Fever 2 1 *2 4 3 1 2 0 0 3 2 Diphtheria 74 118 111 97 92 119 119 113 85 88 102 Erysipelas 41 57 76 45 67 56 50 43 73 47 55 Membranous Croup ... 2 1 7 3 4 0 0 1 0 3 2 Small-Pox 0 1 21 10 2 1 0 0 0 2 4 Puerperal Fever 2 2 3 3 1 3 1 2 2 1 2 English Cholera 0 1 2 0 0 0 0 0 0 0 0 269 541 851 482 504 571 389 417 400 365 479 w 18 Cases of Infectious Diseases. Table XI. shows the number of cases certified by Medical Attendants in the ten years 1891-1900, and the average number for each disease. Of the 365 cases certified last year, only 3 were also notified by householders. One of the cases of Small-pox was that of a woman whose husband had been working at a Small-pox Hospital in Hull, and the other that of a woman whose husband had died of a disease certified as '' Malignant Measles," but which no doubt was Hsemorrhagic Small-pox. A case supposed to be "Small-pox," I found on examination to be one of Chicken-pox. Four other cases certified as Scarlet Fever, one as Diphtheria and three as Enteric Fever turned out not to be cases of those diseases. One of the cases certified as Enteric Fever was afterwards thought to be Typhus Fever. (See p. 15.) There were two instances in which Scarlet Fever was contracted from children recently discharged from Fever Hospitals. Of the 54 cases of Enteric Fever, 10 were certified in November and December, and 13 in the three previous months, so that the monthly average for the last two months of the year (5'0) was higher than that of the three previous months (4'3). 19 Cases of Enteric Fever. year. Aug., Sept. and Oct. November and December. No. of Cases. Average per month. No. of Cases. Average per month. 1891 6 2-0 12 6-0 1892 15 5-0 15 7 5 1893 16 5-3 18 9 0 1894 14 4'6 29 14-5 1895 11 3-7 10 5 0 1896 15 5-0 15 7-5 1897 16 5-3 6 3-0 1898 7 2-3 18 9 0 1899 14 4-7 11 5'5 1900 13 4'3 10 50 It will be seen from the Table that this has been the case in every year except 1897, and I have already pointed out in previous reports that this excess of Enteric Fever in November and December is coincident with the increase of organic matter in the drinking water due to the flooded state of the river. (See correspondence on pages 29 to 41 of my Report for 1898.) During the year, 37 examinations of specimens sent by Medical Attendants of Parishioners were made; viz., 26 for Diphtheria and 11 for Enteric Fever; of the 26 for Diphtheria, 9 yielded the Diphtheria Bacillus, one was doubtful, and 16 gave negative results; of the 11 for Enteric Fever, 3 gave the Widal (Typhoid) reaction, one was doubtful, and 7 i>ave negative results. Of the examinations for Diphtheria 3 were made for one case, and 2 each for three other cases; and of those for Enteric Fever, 2 each were made for 2 cases. Five other specimens were sent to be examined in cases of Non-Parishioners ; four for Diphtheria (one positive and three negative results), and one for Enteric Fever (negative result); the fees were paid by the Medical Attendants. b 2 20 A medical practitioner having sent three successive specimens from the same case to be examined in order to ascertain when the patient was free from the bacilli of diphtheria, I brought the matter before the Committee, who authorised me to sanction such repeated examinations when I considered it advisable. Dr. W. J. Simpson having been appointed by the London County Council to investigate " Returned Cases " of diphtheria and scarlet fever alleged to prove sources of infection on returning home, and having prepared an important Report on the matter, the Royal College of Physicians appointed a Committee to consider it, and their Report is so important that I think it advisable to insert it in full:— 1. The Committee have carefully considered Dr. Simpson's Report and the documents referring thereto, for the purpose of expressing an opinion as to whether, and if so under what conditions, the present period of detention of patients in the Hospitals of the Metropolitan Asylums Board could consistently with public safety be shortened. 2. The Committee are impressed with the small percentage of those cases which, on investigation, were found to have given rise to fresh infection, viz., 1*1 per cent, on the total cases discharged from hospital of diphtheria and scarlet fever taken together. They also note that of these no fewer than 80 per cent, were suffering from some mucous discharge, either during their stay in hospital, or shortly subsequent to their return home. 3. The total number of return cases of diphtheria was 21, equal to a percentage of "5 on the cases of diphtheria discharged. With reference to the length of detention in diphtheria, the Committee are of opinion that this can only be left to the discretion of the several medical superintendents. The importance of the question of return cases mainly turns on the length of detention of scarlet fever 21 cases, which are most numerous ; the proportion of the return cases in diphtheria is a small one, viz., *5 per cent, of the patients discharged after suffering from that disease; and apart from the difficulty which is occasionally experienced in respect to the recognition of the specific bacillus, a difference of opinion exists as to the practicability of regulating a patient's detention by bacteriological examination alone. 4. The total number of return cases of scarlet fever was 90, giving a percentage of 1*3 of the total number discharged. In endeavouring to arrive at a definite conclusion as to the necessary length of detention in scarlet fever, there are two points on which elucidation is required: The degree of infectivity attaching to (a.) The desquamation of the skin. (b.) Any mucous discharge occurring during convalescence. In respect of the infectivity of the later desquamation of the skin in scarlet fever, it is to be observed in Dr. Simpson's investigation that in only 2 7 per cent, was there any reason to suspect desquamation of the skin as the cause of secondary infection. The relatively high degree of infectivity of the mucous discharges as compared with the later desquamation of the skin in scarlet fever, as shown in the report, is one which is obtaining an increasing support among those of the profession who have had much to do with infectious diseases. It would suggest that possibly too much importance has been hitherto attached to the infectivity of the skin during the later weeks of scarlatinal convalescence. The Committee have communicated with the Authorities of a number of hospitals in other large towns in this country and abroad, and have ascertained that the period of detention insisted on is of somewhat shorter duration than is practised in those of the Metropolitan Asylums Board. Unfortunately, no corresponding record of the incidence of return cases is available 21 for comparison with that recently obtained for the Metropolitan Asylums Board. In respect of the infectivity of the mucous discharges, the question raised by the Managers of the Metropolitan Asylums Board is of the highest importance, as on its solution depends the practice which it would be advisable to adopt. If it can be proved that the discharge after a time constitutes simply the vehicle, as suggested by Dr. Simpson, and is not in its nature infective, as is usually believed, it is obvious that the practice of removing the patient from an infective environment for a short period before return to his home is one which should be adopted. But on this point the Committee are unable to express a decided opinion with the evidence at present available. 5. In order to arrive at a satisfactory conclusion, the Committee are of opinion that information should be obtained as to whether (a.) The mucous discharges in themselves are infectious from patient to patient. (;b.) Their infectivity quickly dies out on removal of the patient to an uninfected environment. And further, in order to place the inquiry on a firmer basis than at present, that the investigation should extend over a longer period than six months, so that not only all seasons of the year may be included in the scope of the investigations but that the data available should be more numerous. The Committee are of opinion that there is not sufficient evidence at present before them to enable them to lay down any definite period of time as necessary for the detention of patients recovering from scarlet fever. With the object of obtaining further evidence the Committee recommend— I. That in each hospital a couple of wards identical in respect to cubic space per bed, &c., should be set aside and administered on a different principle, the sex of the children being the same, and the age as far as possible. •» In one ward the cases subject to mucous discharges from nose or ear be rigorously excluded; that immediately on the appearance of any such discharge the patient should be removed from it; and that all nozzles of syringes should be kept in antiseptic solutions. In the other ward no special attention should be paid to these discharges other than that hitherto adopted. The incidence of either rhinorrhoea or ottorrhoea should be compared. Cases of " septic scarlet fever " should be excluded from both. II. That, if possible, in certain hospitals, with the approval of the Medical Superintendents, two or more rooms, previously disinfected, be reserved for the isolation, after six or eight weeks' detention, of single patients who are suffering from rhinorrhoea or ottorrhoea, but whose desquamation is completed. Each patient so secluded should be kept for ten days or a fortnight before returning home. During this period of detention the affected parts should be regularly irrigated or syringed with some reliable antiseptic, and great care be taken that the nozzle of the apparatus be kept in a germicidal solution. That on the expiration of the quarantine the patient should be sent home whether the discharge has ceased or not, and that the room should be disinfected prior to the reception of another patient. The subsequent history of the case should be investigated. III. That the inquiry into the facts connected with the incidence of the return cases at the Managers' Hospitals should be continued for a further period of twelve months, and that the scope of the inquiry should include the history of the cases discharged under the conditions mentioned. July 19 th, 1900. 24 A case of small-pox having been imported into the Parish from Hull, I investigated the matter and submitted the following Report to the Committee of Works:— With regard to the letter from the Medical Officer of Health of Hull, in respect to the man Robinson, whose wife was attacked with small-pox at 3, Whittaker Street, I beg to report as follows :— I visited the case in question with the Medical Attendant, who requested me to do so, on Saturday, January 27th, and finding that it was a case of small-pox, I had the woman removed the same day. I ascertained that the husband had been employed on some buildings in the precincts of the Small-pox Hospital at Hull, which he left on December 23rd, 1899. It appears that he had some sort of eruption on his skin, but was not laid up, and shortly afterwards he went to work at Orset, near Grays. I have very little doubt that he was suffering from a mild attack of modified small-pox and that his wife caught it from him. He states that he was not re-vaccinated before he went to Hull, nor when there, as he refused to have the operation performed. He has also stated to the Chief Sanitary Inspector that while at work he was on the roof and within hand reach of the ventilators of a ward in which there were small-pox patients. He, moreover, states that the persons bringing small-pox patients to the hospital and the persons engaged in the removal of infected bedding freely associated with the workmen, and that no steps were taken to prevent it. The Medical Officer of Health of Hull, in his letter, states that Robinson and others on the completion of their work suddenly left " without the knowledge of the Resident Medical Officer or Inspector of Nuisances." From this it is 2n evident that no proper precautions were taken to prevent the workmen leaving the premises or the city. I may point out to you in this connection that this is not the only case in London that has been derived from the same source. On the 22nd January, a woman was removed from a house in Fulham, having contracted small-pox from her husband, who was employed at the same place as Robinson and returned with him to London on the same day. He also had " an eruption of spots," but saw no doctor. I think that in each case the man contracted modified small-pox at Hull, and that the wife took it from him on his return to London. Certain memoranda with respect to plague, having been forwarded to the Vestry by the Secretary of the Local Government Board, were referred to ine by your Sanitary Committee, and I prepared the following Report thereon :— I have considered the " Memoranda with respect to Plague " forwarded by the Secretary of the Local Government Board, and find that they consist of— 1.—" General Memorandum on the Proceedings which are advisable in places attacked or threatened by Epidemic Disease." This has no special reference to plague, but refers generally, as its title indicates, to the means of preventing epidemic disease. 2.—A special memorandum, by Mr. Power, the Chief Medical Officer, on the plague. In this memorandum, although it is pointed out that u Local Authorities should be on their guard against plague, it is not intended to suggest that there exists any cause for alarm." 26 It is anticipated that if this disease obtains a foothold in any district it will especially affect "insanitary areas such as are peopled by the poorest class, and where overcrowding of persons in houses, and dirt and squalor of dwellings and of inhabitants tend to prevail." It is also pointed out that the hygienic conditions in this country and the methods of dealing with infectious diseases have been improved to so great an extent that there has been a large diminution in the mortality from most infectious diseases, and that typhus fever, " which as regards the conditions under which it becomes prevalent most clearly resembles plague," has been almost exterminated, and it is anticipated that the same measures will be equally effectual against plague. The four following facts are insisted upon— " (1) Plague has an incubation period of 3 to 5 (in exceptional cases of perhaps 8 to 10) days. " (2) Plague is wont, especially in its earlier manifestations, to assume a mild form, or even to present anomalous symptoms, tending to confound it with other and more innocent diseases. " (3) Plague in all its forms must needs be regarded as personally infective. "(4) Plague affects rats as well as the human subject; it may, indeed, be found causing mortality among these lower animals antecedent to its definite invasion of the population. There can be no doubt that the rat and man are, as regards plague, reciprocally infective." Plague is made a notifiable disease, and with a view to assisting medical attendants in its diagnosis the symptoms of the disease are described in detail. Besides the general methods of precaution set forth in the General Memorandum, " the prompt destruction of all 27 rats in districts threatened or invaded by plague, care being taken that their carcases are collected and burnt without being unduly handled," is advised as an essential measure of precaution. It is also announced that the Local Government Board is prepared to issue Professor Haffkine's plague prophylactic "in limited amount to the Medical Officers of Health of districts actually infected by plague for the protection therein of Doctors, Nurses, and other persons that are, under the conditions of the invaded area, being subjected to sustained exposure to plague infection." 3.—Directions for obtaining and forwarding for bacteriological examination material from suspected plague cases." The testing of material from the earliest suspected case or cases will be done without cost to the Local Authority, but the material for examination ''can be received only from the Medical Officer of Health" who is to send full particulars in each instance with the material forwarded. The London County Council has provided for the examination of material from any suspected cases of plague by Dr. Klein, and has also retained the services of Mr. James Cantlie, formerly Medical Officer in one of the plague hospitals in Hong Kong, to give advice as to the diagnosis of suspected cases. The Council has also issued a Report by Mr. Cantlie on the signs and symptoms of plague. I may add that I am making arrangements with medical men to attend cases should they arise in the parish, similar to the arrangements I made for cholera in 1893. In response to a representation made by the Incorporated Society of Medical Officers of Health, the Royal College of Physicians appointed a Committee, of 28 which I was a member, to consider the certification and classification of deaths from diarrhoea. That Committee issued the following Report, which was subsequently adopted by the College, and which it is desirable should be as widely disseminated as possible:— (1) We find on enquiry, and especially from evidence furnished by Dr. Tatham, of the General Register Office, and by other Members of the Committee, that many different terms are employed to designate the disease officially known as "Epidemic Diarrhœa," whereby its specific character is in danger of being ignored and great confusion ensues. (2) The results of this confusion are serious and important, since this form of diarrhoea causes a large portion (about one-fourth) of the deaths attributed to zymotic diseases. We gather, from a statement furnished to us by Dr. Tatham, that his main difficulty lies in the impracticability of picking out, from the long list of fashionable but unauthorised synonyms, all the deaths which in their nature are indistinguishable from deaths by diarrhoea, and which ought to be called by the authorised name. At present he classes as diarrhœa (and therefore under zymotic disease) deaths certified as follows Diarrhœa Epidemic diarrhœa Dysentery and dysenteric diarrhœa Intestinal (or enteric) catarrh Gastro intestinal (or gastro-enteric) catarrh. But the following he classes not as diarrhoea, but as diseases of the alimentary canal (thus excluding them from the zymotic class):— Gastro-enteritis Muco-enteritis Gastric catarrh This second group of cases ought, he points out, for the most part, to be regarded as identical with epidemic diarrhcea, inasmuch as their age, incidence, fatality-curves and general epidemiological character correspond closely with those of that disease. 29 In London, during the thirteen weeks ending with September last, the deaths medically certified as due to diarrhoea numbered 3,798; but in addition, there were registered 2,289 deaths from enteritis (of which 1,880 were from gastro-enteritis) the bulk of which ought certainly to be attributed to epidemic diarrhoea. The different counties of England vary very widely in the proportions of deaths returned respectively as due to diarrhoea and to enteritis, presumably in accordance with local fashion. Thus, for England and Wales as a whole, the diarrhoea death-rate amongst infants appears as 25 per thousand births, the enteritis death-rate as 12 per thousand. But in East Yorkshire, the proportions are 35 per thousand from diarrhoea, and 9 per thousand from enteritis while in Cumberland they are 10 per thousand from diarrhœa, and 14 per thousand from enteritis. Dr. Tatham further points out that the fashion of discarding the familiar name "diarrhœa" in favour of such unsatisfactory and unauthorised names as "gastroenteritis," "gastric catarrh," &c., is of comparatively recent growth. But during the last fifteen, and especially during the last ten years, the fashion has prevailed so extensively as entirely to vitiate the diarrhoea mortality returns, which, for sanitary purposes, are of exceptional importance. We therefore consider that the present confusion of terms renders it impossible to determine accurately the prevalence of the disease in special places or at special times, the extent to which it influences public health in general, and the effects produced by sanitary measures. (3) We find that there is a widespread objection on the part of medical practitioners to the employment of the term "diarrhœa" in certifying the cause of death. The term is generally held by the public to imply a mild disease, insufficient by itself to cause death. This fact explains the reluctance of the practitioner to employ it on the death certificate, since it may be conceived to imply a stigma upon his own capacity. It is therefore desirable, if possible, to substitute for it some name equally accurate, but conveying to the public the idea of a more serious affection, but we regard it as essential that the idea of specificity intended to be conveyed by the term "epidemic" should be retained. 30 {4) Hence we would recommend the College to authorise the use of the term "epidemic enteritis" (or, if preferred by the practitioner, "zymotic enteritis") as a synonym for epidemic diarrhœa (Nomenclature of Diseases, p. 9, ed. 1896). And we would further recommend that the College should urge the entire disuse, as synonyms of epidemic diarrhoea in medical certificates of death, of such terms as "gastroenteritis," "muco-enteritis," or "gastric catarrh." A letter from the Vestry Clerk of the Parish of Plumstead with reference to "Coroner's Inquests and Uncertified Deaths" having been referred to me by your Committee of Works, I reported as follows:— I have carefully considered the above letter and also the Report of the Public Health Control Committee of the London County Council on Coroner's Inquests, dated 18th January, 1895, and referring to the Report of the Select Committee of the House of Commons on Death Certification made in 1893, and am of opinion that it is desirable that a Bill on the lines proposed by the Select Committee of 1893 should be introduced into Parliament, and that the four requirements mentioned in the letter from the Plumstead Vestry should be put most prominently forward:— 1.—That Medical Practitioners should be required to send certificates of death to the Registrar instead of handing them to the representatives of the deceased. 2.—That a Medical Practitioner in attendance should be required before giving a certificate of death to personally inspect the body and identify it as the body of the person he has attended. In the present state of the law a medical man is not required to certify to the fact of death. 3.—That certified Medical Practitioners should be appointed to enquire into all uncertified deaths, make post-mortems when required, and report to the Coroner. 4.—That in no case should a death be certified without production of a certificate of the cause of death signed either by a registered Medical Practitioner or by a Coroner after satisfactory enquiries by the Medical investigator or inquest. 31 Your Committee of Works having referred to me a letter from the Clerk of the London County Council forwarding copy of a Report made by the Public Health Committee and adopted by the Council on the subject of the proposed amendment of By-law No. 1 made by the Council under Section 16 of the Public Health (London) Act, 1891, with regard to the removal of offensive matter, I reported as follows:— That the hours proposed for the removal of "any faecal or offensive or noxious matter or liquid" in the morning, viz.:-between the hours of 5 a.m. and 10 a.m. during the months of March to October, inclusive, and between 6 a.m. and 11 a.m. during the months of November to February, inclusive, are in my opinion satisfactory, but I consider that instead of "two hours before sunset to one hour after sunset all the year round," it would be preferable to fix definite times for the evening as is done for the morning, as mistakes would be less likely to arise. I am also of opinion that two hours before sunset is too early for such materials to be removed in many parts of this Parish. With regard to the removal of horse-manure, our experience in this Parish does not coincide with the view that it is necessary that "peat moss litter" should be removed in covered receptacles. The Vestry adopted my views and so informed the London County Council. With regard to a letter from the Clerk of the Board of Works for the Limehouse District with regard to the condemnation of unsound food, which was referred to me by your Committee of Works, I reported as follows:— The case mentioned in that letter is a very important one and will no doubt act as a precedent in future cases. Some strawberries which had been sent out from Holland were refused as being unfit for use by the Jam Manufacturers to whom they had been sent. The Medical Officer of Health, acting under Section 47 of the Public Health (London) Act, 1891, had the fruit brought before one of the Police Magistrates, who refused to condemn it "on the ground that there was no evidence that the same was intended or the food of 32 man, or sold or exposed for sale or deposited for the purpose of sale at the time of the seizure." This decision was appealed against, and two Judges in the Queen's Bench Division of the High Courts of Justice decided that "the question whether the articles were intended for the food of man was at this stage of the proceedings immaterial, and did not become material until Sub-section 2 of Section 47 came into operation, and the person exposing the food for sale was charged on a summons for an offence under the Act," and they remitted the case to the Magistrate with the intimation that he ought to have condemned the strawberries. In future, therefore, Magistrates will have no doubt about condemning unsound food which is brought before them, apart from any technical question as to whether it was exposed for sale or not. Under the instructions of the Committee of Works I prepared the following circular on the sale of low-priced tinned milk, which was distributed throughout the Parish by means of handbills and posters:— Tinned Milk. As a large amount of low-priced tinned milk is being sold to the public, some of which is prepared from skimmed milk and some from separated milk, the Food and Drugs Committee consider it desirable that a cautionary notice should be given to the inhabitants of this Parish, directing their attention to the low nutritive properties of such preparations. The proportion of fat in natural milk is that which is necessary in it as a complete food for an infant, and if that amount is reduced the preparation is no longer a complete food. By skimming, two-thirds of the fat in the milk may be removed, and the remainder, known as skimmed milk, no longer contains a sufficient proportion of fat to make it a proper food for an infant. Separated milk is milk from which practically the whole of the fat has been removed by means of a centrifugal machine, and as fat is a necessary food substance in all diets, an infant fed upon separated milk alone is subjected to a process of slow starvation, and is as certainly starved to death as if it were given no food at all. Such preparations are, therefore, not suitable foods for infants, and when given to young children they should be accompanied by other foods, such as butter, containing fat. 33. The Parliamentary Committee having referred to me an extract from the Report of the Health Committee of the Strand District Board of Works, referring to the Census of 1901, I considered the matter and reported on it as follows:— I consider it very desirable "that the Census Act of 1900 should provide for an Intermediary Census in 1906," and that the Census should not be taken on Easter or Whit Monday, but I think it also desirable that the Census should not be taken on the Sunday next following Easter Sunday, as a great number of people are away from this Parish, at any rate, on that Sunday also, and the Census Return of 1891 was, in my opinion, quite erroneous and worthless for statistical purposes, because it was taken on the Sunday next following Easter Sunday. I also agree that the Census Act should be passed as early as possible in order that there may be time for proper arrangements to be made, and "that the Census Returns should not be primarily based on Poor Law areas, but on the areas of Municipal and Sanitary Authorities; and that the age and occupation of the inhabitants of every sanitary area, and sub-districts of the larger areas, be separately tabulated and published." With regard to the last suggestion, that a sort of day census should be taken to ascertain the number of persons employed in the district during the day, although there is a large number of such persons in this Parish, I certainly do not think that they ought to be included in our population, neither do I see much advantage in obtaining their numbers and the other particulars suggested. At the request of the Parliamentary Committee I considered the By-law "To amend the Law as to the qualifications and tenure of office of Sanitary Inspectors, C 34 and to make other relative provisions." I reported as follows:— I have carefully considered it and think that all of its provisions are advisable, but under section 4 (c. 2) I think that some condition is necessary for the qualification of an Inspector who holds no certificate besides the mere fact of having been "for three consecutive years an Inspector within the meaning of this Act," as there are many trivial Inspectorships which can hardly be considered as qualifying for the post of Sanitary Inspector under the Act. Such a further condition would be, for instance, to require that he had been for the period named a Sanitary Inspector or Inspector of Nuisances of a District of say at least 5,000 people. As a precedent for this I may point out that it is provided by the Public Health (London) Act, 1891, that a Medical Officer of Health not holding a Diploma in Public Health must, in order to bo qualified, have been for three consecutive years preceding the year 1892 a Medical Officer of Health of a District or combination of Districts of not less than 20,000 inhabitants. Some such further condition is far more necessary in the case of a Sanitary Inspector than it is in that of a Medical Officer of Health, for the former, if he has not got a certificate, has probably passed no examination at all, whereas the latter, even if he has not got a Diploma in Public Health, is of necessity a fully qualified medical man. Under the instructions of the Committee of Works I prepared, in conjunction with Mr. Livingstone, the Surveyor, the following Report, "On a Report made by the Public Health Committee of the Vestry of St. Georgethe-Martyr, Southwark, upon the case of Gover v. St. George's Vestry, argued at the Newington Quarter Sessions":— In this case, on account of the insanitary condition of the premises, a closing order was obtained and enforced, 35 but no repairs were done to the premises, and the Sanitary Authority then made an Order under the Housing of the Working Classes Act, 1890, "for the demolition of the premises .... in consequence of the same not having been rendered fit for human habitation and being dangerous or injurious to the health of the inhabitants of the neighbouring houses." The owners of the property appealed against this order to the Court of Quarter Sessions, who decided that the premises were then dangerous or injurious to the health of the surrounding population, but under Section 33 of the Act the words "dwelling house" meant an "inhabited" dwelling house in accordance with the definition contained in Section 29. At the request of the Vestry of St. George-the-Martyr, a case was stated for the decision of the Queen's Bench Division of the High Court on the point of law then raised. That Court decided that the words "dwelling house "under Section 33 applied not only to an "inhabited" but also to an uninhabited dwelling house (a decision which we consider of great importance), but remitted the case to Quarter Sessions "for re-hearing and determination for the purpose of ascertaining whether the whole of the five houses above mentioned or some and what part of any or all of them is dangerous or injurious to the health of the public." But in the meantime the owners had removed the water-closets and sealed up the drains, and when the case came on for hearing they alleged that there was then no nuisance and that the buildings were mere ruins. The Chairman of the Court of Quarter Sessions visited the premises in company with a Medical Officer of Health and a Surveyor chosen by himself, and the Court of Quarter Sessions decided that there was then no nuisance to the inhabitants of the neighbouring buildings, nor C 2 36 likely to be any such nuisance, and they therefore declined to "order now any further demolition or work to be done on the property." The result of this case appears to us merely to show that before a Public Authority issues a notice for demolition it must be satisfied that the nuisance cannot be abated by merely removing the water-closets and sealing up the drains, or, we may add, by any other partial improvements. And also the following:— We have considered the revised draft of the By-laws made by the London County Council as to the deposit of plans with reference to pipes, drains, and other means of communicating with sewers, under the Metropolis Management Acts Amendment (By-laws) Act, 1899, and are of opinion that they meet the necessities of the case. We would merely suggest that the words "and form" should be omitted from line 7 of paragraph 2 of By-law 1, as it is not necessary that the form" of every bath, water-closet, apparatus, slop-sink, urinal, lavatory basin or apparatus sink (not being a slop-sink), and trap in connection with the foregoing," should be shown on the plans and sections ; and that instead of this the detailed description required in paragraph 3 should include the form of the appliances. Mr. Livingstone and I also prepared at the request of the Committee of Works, the following Report on a letter received from the London County Council re Streets and Street Traffic. QUESTIONS. REPLIES. (1) The best method of removing house refuse ? (1) By properly constructed covered vans hauled either by horse or mechanical power. We may observe with regard to this question that there is little difficulty in dealing with 37 QUESTIONS—continued. REPLIES—continued. the removal of house refuse; the problem to be solved is how best to ultimately dispose of it. (a) The best kind of portable receptacle for use by householders? (a) Galvanized iron bins provided with close fitting covers, easily removable. (b) The best contrived vehicle for the conveyance of house refuse through the streets, so as to avoid nuisance ? (b) Speaking generally, perhaps the best description of vehicle would be a covered fourwheeled van of approved design, and preferably a motor. (2) The best method of cleansing and sprinkling the roads? (2) Undoubtedly the best method of cleansing streets is by thoroughly washing them by an abundant use of water supplied by hose and hydrant. Such a system, however, is rendered almost impracticable in consequence of the restriction of the London County Council who (except, I believe, in one district of London) prohibit the washings of the streets entering the sewers. Failing washing by water, the only other alternative is the one at present generally adopted throughout the metropolis, namely, sweeping the roads by hand or horse brooms, and removing the sweepings by carts to be subsequently disposed of. A very costly process. With regard to street watering, the present methodof sprinkling by water carts is perhaps as good as any, having regard to the excessive and ever increasing traffic in the London streets. (3) The best means of preventing, so far as possible, the casting of objectionable litter or dangerous substances in the streets ? (3) By having the existing police regulations and additional, if necessary, strictly enforced. 38 QUESTIONS—continued,. REPLIES—continued. (4) The best means of indicating the names of thoroughfares, not only at the ends, but at the intersections of streets ? (4) By fixing name plates on the building at each angle of the street, and also transparent tablets on the gas lamps at the corners of the streets. When, however, electricity has become more general for public lighting, it would be a simple matter for the names of the streets, both at the ends and the intersections, to be so arranged as to be easily seen at night as well as by day. (5) As to suggesting regulations for the further suppression of street cries, railway whistles, and other objectionable and unnecessary noises, within the County of London ? (5-9) We are of opinion that these are matters which more particularly concern the police, who ought to have authority to enforce such regulations as may be considered necessary. (6) The question of better police regulations being made for the protection of the public while building operations contiguous to foot pavements are being carried on ? (7) The question of police regula tions being made for the disuse of vans so constructed with blind hoods as to prevent drivers from seeing passing vehicles, to the common danger of vehicular traffic ? (8) The practicability of making further arrangements for slow traffic ? (9) As to suggesting more stringent police regulations, so as to prevent serious hindrances to vehicular traffic, occasioned by prolonged and unnecessary stoppage of vehicles at the sides of crowded thoroughfares ? 39 It is obvious that the consideration of these subjects must be governed by the circumstances and conditions affecting the particular locality to be dealt with. It is difficult, therefore, to suggest any scheme of reform with regard to any of the matters referred to which would be universally applicable to London. Any scheme, for example, which might be adopted in one district with advantage might be quite unsuitable for another. We have, therefore, confined ourselves to replying to the various questions in as brief and concise a manner as possible, more especially as we are of opinion that in view of the near amalgamation of this and other adjoining parishes under the Local Government Act, the subjects in question would be more fittingly dealt with by the new municipality, which they will then more particularly concern. I have received and answered a number of communications from the Medical Officer of Health of the London County Council, and from other Medical Officers of Health, on various sanitary matters connected with the Parish. One of the letters I received from the Medical Officer of Health of the London County Council was with reference to house-to-house inspection and the systematic inspection of schools, to which I made the following reply:— It is not the practice of the Sanitary Authority to carry on a system of house-to-house inspection without waiting for complaints as to insanitary condition, unless under special circumstances such as the outbreak of disease in any particular street or district, when a house-to-house inspection is made; as I have for years past advised the Authority that a house-to-house inspection except under special circumstances is illegal, and that opinion was last year confirmed by the judgment given by Messrs. Justices Lawrence and Channel (in the case of "Vines v. North London Collegiate and Camden School for Girls," High Court of Justice, Queen's Bench Division, January 18th, 1899), on which I prepared a special Report, which is to be found in my last Annual Report to the Vestry, pages 25-26. For the same reason the schools in this district are not periodically inspected by the Officers of the Sanitary Authority, hut as a matter of fact all the schools are inspected from time to time whenever any cases of infectious disease are reported in them or any complaint received with respect to them. 40 Sanitary Legislation. A Bill to amend Part III. of the Housing: of the Working Classes Act (1890) was passed and received the Royal assent; it is known as the Housing of the Working Classes Act (1890) Amendment Act. Various other Bills, mostly amendments to previous Acts, were brought before Parliament, but were all withdrawn or dropped. Sanitary Work. For the Year ending December 29th, 1900. The following report prepared for me by Mr. Albert Taylor, your Chief Sanitary Inspector, shows the amount of sanitary work done. I have added the figures for 1899 for comparison:— Table XII. 1899. 1900. Houses and Premises inspected 1,686 2,337 ,, „ re-inspected 6,689 7,702 References to Surveyor 17 38 Notices issued (preliminary) 562 754 „ (statutory) 45 72 Summonses taken out 6 6 Convictions obtained 6 6 Table XIII. Nuisances dealt with:— 1899. 1900. Soil Pipes fixed 317 201 Soil Pipes ventilated 211 107 Bath, Sink, and other Waste Pipes disconnected 298 374 Drains unstopped or repaired 136 170 Defective Drains re-constructed 182 249 Trapped Gullies fixed 384 616 Water Closet apparatus cleaned and repaired 111 131 Water Closets fixed 352 361 Water Waste Preventer Cisterns fixed 310 353 Carried forward 2,301 2,562 41 Nuisances dealt with—continued. 1899. 1900. Brought forward 2,301 2,562 Drinking Water Cisterns cleaned and repaired 111 132 Houses provided with water 5 41 Water Supply of W.C.'s separated from drinking water 12 13 Dustbins repaired 3 1 ,, provided 37 73 Yard surfaces paved or repaired 17 28 Cesspools abolished 3 4 Overcrowding abated 23 20 Houses and premises cleansed 91 190 Roofs and rain-water pipes repaired 20 22 Offensive accumulations removed 44 63 Wire manure cages provided 11 11 Nuisances from the keeping of animals 2 5 Underground rooms discontinued for use as sleeping apartments 3 - Smoke nuisances 14 41 "Removal of Hogs' Wash in unsuitable receptacles 8 6 Miscellaneous nuisances 47 43 2,752 3,255 Examination of Drains:— 1899. 1900. Drains tested and found defective 407 364 ,, ,, satisfactory 488 721 Drains of New Buildings, or Premises undergoing alteration, superintended and tested 263 288 It was necessary to take legal proceedings in 8 cases to enforce the abatement of nuisances, and for contravening Bye-laws; convictions were obtained in five of these cases, work being done and costs paid; the summonses were withdrawn-in the three remaining cases. The defendant appealed to Quarter Sessions in one case, but the conviction was upheld. 42 There are 153 registered houses let in lodgings. They have been inspected, and the regulations as to cleansing complied with. The total number of applications for the removal of house refuse were:—In the In-Wards, 982; in Grosvenor Place District, 387; and in South Belgravia District, 728. Notices have been served where necessary, to abate overcrowding, and to enforce the provisions as to cleanliness, ventilation, drainage, &c. There are 41 bakehouses on the register, of which 40 are in use; these have been inspected twice each during the year, and the regulations as to cleansing observed. Two bakehouses were transferred on the 9th November, to the Borough of Chelsea, viz., 3, Pont Street, and 84, Westbourne Street. The provisions of the Factory and Workshops Acts have been carried out, and cards showing the number of persons who may be employed in each factory or workshop, and in each room, have been distributed and hung up in conspicuous places in the factories and workshops, and in most cases in each room where work is carried on. "The number of workshops and work-places inspected was 112 and 436 visits made; of these, the sanitary arrangements of 86 were found defective, the drains of 18 were repaired, and the drains of 36 reconstructed, the w.c. apparatus of 45 premises were cleaned or repaired, and 14 additional w.c.'s were constructed. "These 112 premises contained 260 work-rooms, 37 of which were overcrowded, and 57 in a dirty and unwholesome condition. There were 963 persons found employed in these work-rooms, or 61 in excess of the accommodation, taking 250 cubic feet as the minimum amount of cubic space allowed for each person in such places." There are now no cowsheds in the Parish. There is now only one licensed slaughterhouse in the Parish, and this has been regularly inspected and found to be satisfactorily conducted. 43 The street stalls and butchers' shops have been frequently visited, but it has not been necessary to seize any article of food as unfit for human consumption. The Mewses in the Parish have been regularly inspected, and are generally in a satisfactory condition, except during the summer months, when there is a great difficulty in getting rid of the dung, because the farmers are too busy to fetch it away. Table XIV. Infectious Diseases and Disinfection. 1898. 1899. 1900. Infectious cases reported 417 409 365 Medical certificates received 464 468 392 Certificates of infectious cases sent to School Teachers 315 389 354 Houses in which infectious disease occurred 386 366 316 Visits made to infected houses 1,210 1,084 946 Patients removed to the Hospitals 319 317 262 Houses disinfected 319 291 342 Rooms disinfected 344 320 324 Articles of clothing, bedding, &c., disinfected 8,675 9,266 7,016 Certificates have been sent to the Head Teachers of Schools after disinfection has been carried out in houses where there are children who go to school, so that the Head Teachers may know when to re-admit the children from those houses, and to the Chief Librarian of the Public Libraries belonging to the Vestry to prevent the issue of books to infected houses. The Public Shelter, provided by the Vestry for housing families temporarily displaced during the disinfection of their homes and bedding, has not been occupied during the year. Disinfectants have been distributed to the public when required, and personal instructions given as to their proper use. 44 Mortuary. The following Table shows the number of bodies received in the Mortuary during the 12 months ending December 29th, 1900, as compiled from the returns furnished to me monthly by the Mortuary-keeper, Mr. Birch. Table XV. Returns showing the number of bodies received into the Mortuary, Ebury Bridge, during the 12 months ending December 29th, 1000. Cause of Death. Number. Post-Mortems. Inquests. Found Drowned 0 0 0 Found Dead 0 0 0 Born Dead 1 0 0 Murder 0 0 0 Suicide 2 0 0 Natural Causes 86 1 0 Accidents 3 0 0 Infectious Diseases 0 0 0 Totals 92 1 0 Of the 92 bodies, 91 were brought to the Mortuary because there was insufficient accommodation for them at home. In the month of May, 1899, the Coroner made arrangements for all bodies taken to the Ebury Bridge Mortuary to be removed to the Mortuary at Westminster to await inquest. This has since been done, so that the bodies admitted since that date have been almost all of them removed by the relatives on account of insufficient accommodation at home. I have given evidence in support of your Public Analyst, in various cases relating to the adulteration of foods, although this is not strictly part of my duty. The results of the analyses of the water supplied to the Parish by the two companies during each of the twelve months have been submitted to me by your Public Analyst, Mr. Charles E. Cassal, and are summarised in Table XVI. Table XVI. Showing the results of Mr. Cassal's Analyses of the Water supplied by the Grand Junction and Chelsea Water Companies, from January to December, 1900:— Date of Collection Jan. 16 th Feb. 17th March 23rd April 23rd May 18th June 21st July 31st Aug. 23rd Sept. 20th Oct. 30th Nov. 22nd Dec. 10th Average j Grand Junction Company's Water Total Solid Matters 32.0 30.0 36.0 36.0 30.0 31.0 32.8 28.0 30.0 28.0 28.0 32.0 31.2 Parts per 100,000. Chlorine 2.0 1.9 1.08 1.8 1.8 1.8 2.0 1.8 2.0 1.85 2.1 1.9 1.89 Equivalent to Common Salt 3.29 3.13 2.96 2.96 2.96 2.96 3.29 2.96 3.29 3.04 3.46 3.13 3.12 Saline Ammonia 0.010 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 Parts per Million. Organic Ammonia 0.118 0.102 0.106 0.092 0.090 0.088 0.106 0.098 0.092 0.082 0.10 0.090 0.089 Chelsea Company's Water Total Solid Matters 32.0 28.0 36.0 32.0 28.8 29.0 31.2 28.4 28.0 28.0 26.0 34.0 30.1 Parts per 100,000. Chlorine 2.0 1.9 1.8 1.8 1.8 1.8 2.0 1.8 2.0 1.85 2.1 1.9 1.89 Equivalent to Common Salt 3.29 3.13 2.96 2.96 2.96 2.96 3.29 2.96 3.29 3.04 3.46 3.13 3.12 Saline Ammonia 0.010 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 0.008 Parts per Million. Organic Ammonia 0.100 0.102 0.108 0.094 0.088 0.086 0.094 0.090 0.090 0.084 0.092 0.088 0.085 46 The samples were all clear and had a "slight greenishyellow tint" when looked at through a depth of two feet, except in the months of January, February, March and July, when the tint is described as "marked greenishyellow." The appearance of the Solid Matters on ignition is described as "marker! browning" for the same four, and "slight browning" for the other eight months. The indications of Organic matter were highest in the months of January, February, March, July and November, and were due to the flooded state of the river. With regard to this matter I may refer to the correspondence between Sir William Crookes and Professor Dewar on behalf of the Water Companies and myself on behalf of the Vestry, which was published in my Report for 1898, in which I showed that the increase of Typhoid Fever in the Parish, and in London generally, during the winter months, when it ought to be decreasing, was coincident with the impure condition of the water supply, which was described by Sir Edward Frankland as containing "an excess of Organic Matter," and also that in the month of April, when the water supply was much purer, the number of cases of Typhoid Fever in London had very considerably diminished, and the death-rate from it gone down to its normal amount. For the information of the Parishioners, I may mention that the ambulance belonging to the Metropolitan Asylums Board is kept at Seagrave Road, Fulham; but those who are in a position to bear the expenses of their support should apply at the London Fever Hospital, Liverpool Road, Islington (or, in case of Small-pox, at the Highgate Small-pox Hospital), where they can be accommodated on favourable terms. Also that a refuge has been provided 47 at No. 1, Pimlico Road, for the use of persons during the disinfection of their rooms. I have the honour to be, My Lords and Gentlemen, Your obedient Servant, W. H. CORFIELD. 19, Savile Row, London, W. ADDENDUM. Populations of the Wards of the Parish. The populations of the various Wards of the Parish, according to the Census of 1896, are given below, with the estimated populations for the middle of 1900. Ward. Population 1896. Estimated population middle of 1900. Dover 3,013 3,285 Conduit 4,898 4,610 Grosvenor 4,491 4,047 Brook 6,188 6,392 Curzon 5,237 5,573 Knightsbridge 16,367 16,591 Out 39,773 40,866 79,967 81,364 48 49 (A)TABLE OF DEATHS during the Year ending December 29th, 1900, in the Metropolitan Sanitary District of St. George's, Hanover Square, classified according to Diseases, Ages, and Localities. Localities. Mortality from all causes, at subjoined ages. Mortality from subjoined causes, distinguishing deaths- of children under five At all ages. Under 1. 1—5. 5—15. 15—25. 25—65. 65 & upwards. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Smallpox. Scarlatina. Diphtheria. Membranous Croup. Typhus, Fevers. Cholera. Erysipelas. Measles. Whooping Cough. Diarrhoea and Dysentery. Rheumatic Fever. Influenza. Phthisis. Bronchitis, Pneumonia, and Pleurisy. Heart Disease. Injuries. All other Diseases. Total. Enteric or Typhoid. Continued. Relapsing. Puerperal. (a) (b) (c) (d) (e) (f) (g) (h) (i) Mayfair 169 11 5 5 8 79 61 Under 5 ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... 3 3 ... 1 7 16 5 upwds ... 1 ... ... ... 1 ... ... ... ... ... ... 1 1 1 13 10 35 19 5 66 153 Belgravia 549 98 40 13 19 225 154 Under 5 ... ... ... ... ... ... ... ... ... ... ... 5 10 13 ... ... 18 28 1 1 61 138 5 upwds ... 1 2 ... ... 2 ... ... ... ... 1 ... ... 3 1 23 62 116 49 8 143 411 St. George's Infirmary (Fulham Road) 187 13 4 1 2 81 86 Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... 6 ... ... 1 3 ... ... 7 17 5 upwds ... ... ... ... ... 1 ... ... ... ... 1 ... ... 1 ... ... 28 38 19 1 81 170 Union Workhouse 1 1 ... ... ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 5 upwds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... St. George's Hospital 62 6 7 5 5 36 3 Under 5 ... ... 2 1 ... ... ... ... ... ... 1 ... ... ... ... ... 2 3 ... 1 3 13 5 upwds ... ... 2 ... ... 4 ... ... ... ... 2 ... ... ... ... ... 7 12 5 3 14 49 Belgrave Children's Hospital 16 6 8 1 ... 1 ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 6 2 ... 1 4 14 5 upwds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 2 Other places in the Parish 13 4 ... 1 1 6 1 Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... 4 5 upwds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 8 ... 9 Net Total 997 139 64 26 35 428 305 Under 5 ... ... 2 1 ... ... ... ... ... ... 2 6 10 21 ... ... 30 39 1 8 83 203 5 u pwds ... 2 4 ... ... 8 ... ... ... ... 4 ... 1 5 2 36 107 202 92 26 305 794 The subjoined numbers have also to be taken into account in judging the above records- of mortality. Parishioners dying outside parish 143 7 8 2 17 92 17 Under 5 ... 4 3 ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 2 ... ... 4 15 5 upwds ... ... ... ... 1 3 ... ... ... ... ... ... ... ... 1 2 lb 10 19 b 70 128 Non -Parishioners dying in parish. 657 38 49 21 34 395 120 Under 5 ... ... 4 ... ... ... ... ... ... ... ... 3 4 13 ... ... 11 15 1 5 31 87 5 upwds ... ... ... ... ... 5 ... ... 1 ... 3 1 ... 1 2 6 91 98 81 43 238 570 d 50 51 (B) TABLE OF POPULATION, BIRTHS, AND OF NEW OASES OF INFECTIOUS SICKNESS, coming to the knowledge of the Medical Officer of Health, during the year, January to December, 1900, in the Metropolitan Sanitary District of St. George, Hanover Square, classified according to Diseases, Ages, and Localities. Names of Localities Population at all Ages. Registered Births. Ages, New Cases of Sickness in each Locality. Number of such Cases removed from Home to Hospitals, Census 1896. Estimated to middle of 1899. 1 2 3 4 5 6 7 8 9 10 ii Totals. 1 2 3 4 5 6 7 8 9 10 11 Totals. Smallpox. Scarlatina. Diphtheria. Membranous Croup Fevers. Fevers. Cholera. Erysipelas. Smallpox. Scarlatina. Diphtheria. Membranous Croup. Fevers. Cholera. Erysipelas. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal. (a) (b) (c) (d) (e) Mayfair 23,827 23,906 208 Under 5 ... 4 3 ... ... ... ... ... ... ... ... 7 ... 3 3 ... ... ... ... ... ... ... ... 6 5 upwards ... 27 19 ... ... 11 ... ... ... ... 5 62 ... 19 16 ... ... 7 ... ... ... ... 1 43 Belgravia 56,140 57,453 1,087 Under 5 ... 29 23 2 ... 2 ... ... ... ... 2 58 ... 28 20 1 ... 2 ... ... ... ... ... 51 5 upwards 1 106 45 1 i 31 3 ... 1 ... 31 220 1 96 32 1 1 24 ... ... ... ... 7 162 Fulham Rd Workhouse ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards 1 ... ... ... ... 2 ... ... ... ... 8 11 1 ... ... ... ... 2 ... ... ... ... 7 10 Buckingham Palace Rd. Workhouse ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... 1 ... ... ... ... ... ... ... ... 1 2 ... 1 ... ... ... ... ... ... ... ... ... 1 St. George's Hospital ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... ... 1 ... ... 3 ... ... ... ... ... 4 ... ... 1 ... ... 2 ... ... ... ... ... 3 Belgrave Children's Hospital ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... St. Gabriel's do. ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Orthopædic Hospital (Hanover Square) ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Gordon Hospital for Cancer ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5 upwards ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Total 79,967 81,364 1,295 Under 5 ... s3 26 2 ... 2 ... ... ... ... 2 65 ... 31 23 1 ... 2 ... ... ... ... ... 57 5 upwards 2 134 65 1 1 47 3 ... 1 ... 45 299 2 116 49 1 1 35 ... ... ... ... 15 219 "Notification of Infectious Disease" has been compulsory in the District since October 31st, 1889. The Isolation Hospitals are the Hospitals of the Metropolitan Asylums Board, and occasionally the London Fever Hospital and the London Small-pox Hospital. Cases of Diphtheria and Enteric (Typhoid) Fever are also received into St. George's Hospital.