1858. STGIL 6 SANITARY PROGRESS IN ST. GILES. A REPORT ON THE SANITARY CONDITION OF THE DISTRICT IN 1858; AND ON THE MEANS THAT HAVE BEEN TAKEN FOR ITS IMPROVEMENT DURING THE YEAR ENDING MARCH 25th, 1859; ADDRESSED TO THE LOCAL BOARD OF WORKS. BY GEORGE BUCHANAN, M.D., Medical Officer of Health. London: printed by t. penny, leman street, whitechapel, and london terrace, hackney road. 1859. 1858-9. ANNUAL REPORT of The Medical Officer of Health. Gentlemen, An enquiry into the sanitary history of St, Giles's, in 1858, may be fitly prefaced by some observations on the health of the metropolis at large, during the year. Proceeding to investigate the statistics of our own district, we shall have to observe, as usual, an excess in its mortality beyond the rate which has prevailed in London as a whole; but we shall also discover that the number of deaths which occurred in St. Giles's in 1858, presented a remarkable fall below the average of the district in former years. An examination of the real significance of this apparent improvement in the public health, will require much caution, and will unavoidably involve a good deal of detail: as, however, definite results of a cheering character will be arrived at, the length of the enquiry may be more easily forgiven. A very short notice will suffice of those diseases in the district which did not contribute to the death-returns, and I shall then have the satisfaction of enumerating the various measures that have been taken for the improvement of the sanitary condition of the district. Such will be the chief topics of this report. While we acknowledge how much scope there is for improvement in the health of our district, and how little of our great task has yet been accomplished, still we shall find that sufficient progress has already been made to serve as a strong incentive to our future exertions. Chapter I.—Mortality and Death-rate of the Metropolis in 1858. The year 1858 was not so salubrious to London as its predecessor. Comparing equal periods of fifty-two weeks, 4869 more persons died in the later than in the earlier year. Still, in 1858, the mortality did not reach up to the average rate (24 per 1000) which had prevailed in the town for the ten preceding years. The death-rate of 1858, per thousand persons then living, was 23.5, while in 1857, it was only 22.2 per thousand. The increase of deaths affected all five groups of the metropolitan districts, the southern presenting the largest rise, and the central districts—among which St. Giles is placed—the smallest amount of increase. (See Table I. Appendix.) 4 The diseases which in London produced the surplus of deaths in 1858 over 1857, belonged chiefly to two great orders; the miasmatic order of zymotic complaints* on the one hand, and on the other hand, disorders of the organs of respiration. To the excess in the former group, small-pox, measles, scarlatina, indeed every important member contributed, with the exception of diarrhoea and typhus fever. Scarlatina, however, was the complaint which was found in chief and increasing amount during the year. It caused death in upwards of 4000 cases, more than 3000 of which occurred in the last six months of the year, the total number of the year 1857 having been only 1500. The other group of diseases, those of the breathing apparatus, were, of course, mainly represented by their chief members, bronchitis and inflammation of the lungs, which produced upwards of a thousand more deaths in 1858 than in the preceding year. Assuming then the inevitable town death-rate to be 17 per thousand annually, the excess above this for London was 6.56 in 1858, while in 1857 it was but 5.20. In the year which has just ended, therefore, more deaths occurred from preventible causes than in 1857, in the proportion of five to four. Besides the table in the Appendix before referred to, there will be found on page 26 a comparison of the aggregate death-rate of the metropolis, both in 1857 and 1858, with that of St. Giles's and the districts bordering on St. Giles's; and on page 28, the diseases which produced the mortality of last year in London are exhibited, and their prevalence is compared with that of the same diseases in St. Giles's. Chapter II.—Mortality from all Causes in St. Giles's District, in 1859. The deaths registered in the entire district numbered 1331. They are returned by the Registrar General at 1334, but an average was inserted on one occasion instead of the true number certified to the local Registrar. This would bring the total to 1347, but of these no fewer than sixteen were registered twice over; so that the real number of deaths which occurred in the district was 1331, the number above given. The mention of these sources of error shows the care which is needful to avoid fallacy in the most elementary points of a statistical enquiry. But the registered mortality of a district, however accurately determined, does not represent the true amount of deaths among the inhabitants. Public institutions, whose doors are open for the reception of the sick poor from all quarters, swell unduly the registered mortality of the districts in which they are situated, and take away from other districts a portion of the deaths which would be assigned to them under a more perfect system of registration. St. Giles's being dependent on the hospitals of all neighbouring districts for the relief of its sick poor, and having no similar establishment within its own limits, is peculiarly affected by this source of discrepancy. In 1858, seventy-one persons left St. Giles's district, and died in the hospitals of the neigh- * In the class "zymotic diseases" of the Registrar General, are comprised those disorders which are generated in the system of the individual, or spread from the individual through the community, in the manner of ferments. Where the poison of such disease is conveyed through the atmosphere, the zymotic disease, belongs in the classification of the Registrar General to the "miasmatic" order. Plenty of examples of these diseases will be exhibited in the pages of this Report. 5 bourhig parishes; the distribution of these cases in the several metropolitan hospitals, is shown in the Appendix, Table II. Adding these 71 deaths to (he total registered mortality, it appears that the actual number of St. Giles's residents who died within the year was 1402. For certain purposes of comparison, the registered deaths must be taken; but wherever it is possible, the corrected number 1402 will be adopted. This number represents a death-rate in the population of St. Giles of 25.8 in the thousand, or 258 per ten thousand, living. Of the 1402 deaths, 700 were in females, and 702' in males, the preponderance in males being to a much less degree than is ordinarily witnessed. The ages of the 1402 persons averaged twenty-seven-and-a-quarter years, at the period of death. 138 infants died before they were three months old, and 165 others below the age of one year; the total mortality under two years was 450, and under five years, 603. These deaths among children, though much more numerous than in the average of the town, form a smaller proportion of thei total mortality than in the preceding year. Thus, of a thousand persons who died in St. Giles's in 1858, 821 were below the age of two, and 430 below five years of age, the corresponding numbers for 1857 being 360 and 477. The average ago at death of those who had passed their fifth year, was something under forty-seven years. Six persons are recorded to have passed their ninetieth year at the time of their death, and three of them were upwards of ninety-five. Four out of these six old persons were females. The ages at which deaths occurred are shown at more detail in the third Table of the Appendix, along with the diseases which produced the fatal result at each age. The 1402 deaths were distributed over the four quarters of the year thus:— the first quarter showed 399, and the second 312 deaths; while, in the September quarter, there were 302, and in the December quarter, 389 deaths. In my last Annual Report, for 1857, I compiled, with some care, a table of comparison between the gross mortality of St. Giles's, and that of the districts surrounding it, and of the metropolis generally. Having made allowance for all artificial disturbing influences, I found the result was strikingly unfavourable to St. Giles's. I have made a similar table for the year 1858. (See next page.) In one point of view, the comparison on this table is still unfavourable to St. Giles's, for this district continues to present a higher death-rate than any of those among which we should expect it to rank, upon consideration of its natural and social features. Its death-rate is still higher than that of Holborn, and is considerably greater than in the Strand or St. Martin's. But in another point of view, the figures of these tables are extremely gratifying:— London, it has been shown, was less healthy in 1858 than in 1857. In the last column of the above table, the increase in mortality is represented by the number 13½ in the 10,000; the rise in Marylebone, on the same population, was 6.7; in Holborn it was 11.3; and in St. Pancras it reached to as many as 28 in the 10,000. On the other hand, so far from participating in the increase of mortality, the Strand, St. Martin's, and St. Giles's show an actual fall in the death-rate, and that to a very considerable extent. This fall is represented in the first district by 13, in St. Martin's by 24½, and in St. Giles's by 22½ in the 10,000. MORTALITY IN 1858.* Districts. Population. Registered Mortality. Column A. Column B. (see Note.) Total Mortality in 1858, corrected for Cols. A & B. Rise or Fall from rate of 1857, per 10,000. (See Report of 1857.) Districts. 1st Quarter, 13 Weeks. 2nd Quarter 13 Weeks. 3rd Quarter 13 Weeks. 4th Quarter, 13 Weeks. Whole year, 52 Weeks. 1851 Corrected for 1858 Actual number. per 10,000 Actual number. per 10,000 Actual number. per 10,000 Actual number. per 10,000 Actual number. per 10,000 († add.) (—subtract.) Actual number per 10,000 Rise. Fall. St. Pancras 166,956 201,080 1288 64.0 1023 50.9 986 49.0 1415 70.6 4712 234.5 96 Hospitals, 144 4524 224.9 280 — St. Pancras. Work. Strand 140 284 St. Marylebone 157,696 173,600 1111 64.0 869 50.1 808 46.5 1120 64.5 3908 225.1 112 Hospital, 131 3889 224.0 6.7 — St.Marylebone Metropolis. 2,362,236 2,720,600 17308 63.3 14541 53.4 14345 52.7 17688 65.0 63882 234.4 — — 63882 234.4 13.6 — Metropolis \ Holborn 46,621 48,200 314 65.1 251 52.0 250 52.0 371 77.0 1186 246.1 62 Hospital, 54 1194 247.7 11.3 — Holborn. 44,460 45,090 278 61.6 229 50.8 192 42.5 25.5 56.6 954 211.5 Workh. 140 Hospital, 113 1022 226.6 — 12.9 Strand. Hosps 41 181 St, Martin 24,640 24,700 174 70.5 130 52.0 146 59.1 148 59.9 598 242.1 15 Hospital, 73 540 218.6 — 24.6 St. Martin. St. Giles 54,214 54,300 386 71.2 298 54.8 286 52.7 374 69.7 1344 247.5 71 Subtract 13 (Deaths registd twice over.) 1402 258.2 — 22.5 St. Giles. * Col. A, gives the number of Inhabitants of each District who expired in 1857, in the Public Institutions of other Districts. These figures must be added to the Registered Mortality. Col. B, gives the number of Inhabitants of other Localities who died in the same year in the Public Institutions of the Districts named. These Figures hav3 to be subtracted from the Registered Mortality. (See Appendix Table 2.)—In estimating the Rise or Fall since 1857, the two years must be reduced to periods of equal duration. 7 Had St. Giles's, in 1858, maintained the same amount of excess that it exhibited in 1857, over the average death-rate prevailing in town, 37 more lives in every 10,000 persons living would have been sacrificed in the year. It is plain, then, that there has been some intrinsic agency at work within the district, which has produced an amelioration in it, instead of permitting that deterioration which has characterized the year 1858, in the metropolis at large. The nature and extent of this agency will be best examined after the consideration of the prevailing causes and of the localization of the mortality of the year. Chapter III.—Causes of Death in St. Giles, in 1858; Comparative prevalence of various Diseases in that Year, and in its predecessor. The several diseases which produced the mortality of St. Giles's, in 1858, are exhibited in Table III. appended to this Report. They are grouped into classes and orders in the following table, which shows their relative prevalence in our own district, and in the metropolis, and indicates those diseases which has been less frequent in St. Giles, as well as those which have been in excess of the quota for its population. (See next page.) Compared with 54,300 persons taken by hazard from the whole of London, the population of St. Giles's registered fifty-four more deaths from all causes than would have been found if the ordinary metropolitan death-rate had existed during the year; and including the deaths of St. Giles's patients in hospitals, the excess rises to 125. Instead of fifty-four, 232 was the amount of excess in the registered mortality of 1857, similarly calculated. It was chiefly in the cold quarters* of the year, the first and the last, that the deaths in St. Giles's were in excess over the rest of London. Indeed, in the autumn quarter there were actually fewer deaths registered in our district than the quota. For three whole months St. Giles's was healthy up to the average of the town, a very exceptional circumstance. These facts hint at the nature of the diseases which produced the excessive mortality. Consumptive disease, that constant scourge of our district, killed 62 or 63 persons more than would be assigned to it for our population; or, adding those cases which died in hospitals, the number in excess becomes seventy-five. Lung diseases, other than consumption, and represented of course by their principal members, bronchitis and inflammation of the lungs, were fatal to 44 persons above the quota. Adding the hospital deaths, 54 is the number which represents the excess in lung diseases. Ten cases of premature birth and infantile debility were fatal in St. Giles's, beyond the number which should have died from these causes, according to the population. Diseases of the nervous system were in a similar excess of fourteen. Thus far, the diseases which especially scourged St. Giles's in 1858, are identical in nature with those of 1857, discussed in my former report. In amount, however, consumption is the only disease which maintained its former standard of excess. All the other kinds of disease just mentioned, although still in excess in 1858, were notably less so than in the previous year. * The details of this investigation for the four quarters of the year are given at Table IV. of the Appendix. Comparison of Mortality from various causes in London and in Saint Giles. Whole Year, 1858. Classes. Classes and Orders of Disease. London. Popln. 2,720,600 St. Giles's. Population 54,300. Estimated Quota. Actual Registered Mortality. Corrected for Deaths. ill Hospitals All Causes 63882 1277.7 1331 1402 Specified Causes 63027 1260.6 1316 1386 (Classes.) I Zymotic Diseases 16704 334.1 276 284 II Constitutional ,, 12309 246.2 297 317 III Local „ 25053 501.1 545 578 IV Developmental „ 7045 140.9 157 158 V Violent Deaths 1916 38.3 41 49 (Orders.) I 1 Miasmatic Diseases 15554 3111 256 263 2 Enthetic „ 305 6.1 8 8 3 Dietic „ 670 13.4 9 10 4 Parasitic „ 175 3.5 3 3 II 1 Diathetic Diseases 2182 43.6 32 39 2 Tubercular „ 10127 202.6 265 278 III 1 Diseases of Nervous System 6571 131.4 145 149 2 „ ,, Organs of Circulation 2521 50.4 49 59 3 „ „ Respiratory Organs 11908 238.2 282 292 4 „ ,, Digestive Organs 2573 51.5 54 58 5 „ „ Urinary Organs 831 16.6 8 12 6 „ „ Organs of Generation 205 4.1 5 5 7 „ „ Organs of Locomotion 182 3.6 1 2 8 „ „ Integumentary Organs.. 262 5.3 1 1 IV 1 Dev: Dis. of Children 1771 35.4 40 40 2 „ „ Adults 270 5.4 6 6 3 „ „ Old People 2413 48.3 55 55 4 Diseases of Nutrition 2591 51.8 56 57 V Sudden Deaths 1622 32.4 38 45 Cause unspecified 238 4.8 3 4 All other Violent Deaths 56 1.1 Sudden Deaths 476 9.5 3 3 Cause unspecified 379 7.6 12 13 Certain Special Diseases of Zymotic Class and of Miasmatic Order. I.1. Small Pox 247 5.0 7 7 Measles 2383 47.7 25 25 Scarlatina 4118 82.4 70 71 Diphtheritis 9 10 Whooping Cough 2700 54.0 51 51 Diarrhoea 2093 41.8 35 35 Typhus & other Fevers, continued and remittent. 1996 39.9 35 39 9 Deaths from simple old age, it will be seen, were happily still rather more common in St. Giles than would be anticipated. Violent deaths were considerably more frequent last year than they should be; the quota for the population of St. Giles is 38, the registered number is 41. Eight persons dying in hospitals being added, there is an excess of eleven such deaths. These, however, are accounted for in a mass, by the loss of sixteen lives, in the Gilbert-street fire, in the first quarter of the year. Passing from diseases in excess to those which have been less prevalent in St. Giles than elsewhere, we have the great satisfaction of meeting with the important class of zymotic diseases. These diseases, it will be remembered, have been in strange excess in London generally: they are in defect in St. Giles's. Thus the case of 1857 is precisely reversed. In lieu of a quota for its population of 100 deaths from these complaints, St. Giles, in 1857, gave 124. In lieu of a similar quota for 1858, St. Giles's gives only 83. Relatively to the metropolis, the mortality from this class of maladies has fallen from one year to the other, in the proportion of three to two. Even in actual numbers, the decrease is considerable, from 332 in 1857, to 276 in 1858. The diseases whose subsidence has produced this fall in the relative zymotic mortality of St. Giles's, are measles, whooping-cough, and diarrhoea, all of which were unduly fatal in 1857. Measles n that year killed 59 children; in 1858, only 25. The former number represents twice the quota of deaths for its year, while the 25 deaths of 1858 were little more than half the estimated number of deaths for the St. Giles population.* Whooping-cough destroyed 98 and 51 children in the two years respectively, the estimated number in each case having been 52 and 54. Diarrhoea fell from 78 deaths to 35, while the population of St. Giles would have afforded in the two seasons, 64 and 42 deaths. Scarlatina, on the other hand, has increased in St. Giles's, from 32 to 79, (or, with two hospital cases, 81); but this increase is strictly proportionate to that which has characterized the year 1858, in the whole of London. Among these 81 deaths are included 10 from diphtherias, a disease whose epidemics have long been known to the world of medicine. Distinct from scarlatina on the one side, and from croup on the other, this disease is nevertheless liable to be confounded with these complaints. By the Registrar General, it was last year included with scarlatina and perhaps little is gained at present by separating them in his returns. Continued fever, including under this head, typhus, typhoid, and infantile remittent fever, has been a little under the estimated number in the two years alike. There was remarkably little of this disease in London in 1858, and what there was, was nearly all typhoid— the Paris type of continued fever—which is believed to be especially generated by bad drainage. One disease of the zymotic class, however, has been very prevalent in St. Giles's, as well as in other parts of London. Seven deaths from Small-pox, in St. Giles's, are notably more than its share of the 247 which occurred in the metropolis in * Measles attained its maximum prevalence in London in the early months of 1858; in St. Giles's it culminated earlier than in other districts, whence the chief explanation of the above. 10 the year; this number itself, though not above the average, is nearly a hundred larger than in the preceding year. But there ought to be no single death from small-pox, and in proportion to our means of preventing the disease, rather than to the actual ravages that it commits, is our responsibility to blot out this cause of death from future registers. To recapitulate: the zymotic class of diseases was considerably less fatal to St. Giles's in 1858, than in 1857. All the other groups of disease which have usually been unduly rife in the district, continued to be in some excess, but none of them maintained the same amount of excess which they exhibited in 1857. To this rule, the persistence of consumptive diseases formed the only exception. We have next to inquire what the localities were that experienced, in 1858, the undue mortality above demonstrated to have existed in St. Giles's beyond the rest of London. We shall also ascertain the portions of the district which suffered less mortality than in 1857, and we shall observe whether any spots, on the other hand, appear to have had more deaths than in the preceding year. Chapter IV.—Localization of Disease and Death, in St. Giles's, in 1858. I have become more and more impressed with the importance of accurately determining the parts of our district, which contribute most deaths to the register, and of marking the spots affected with certain diseases and classes of disease. Last year I undertook this investigation up to a certain point. I am now prepared with more accurate information, which may be applied to 1857 as well as to 1858, and the facts elicited will possess a peculiar interest in determining the effect of sanitary work in various localities. The registered mortality of 1858, from all causes, after being subjected to certain corrections, has been shown to be 1331. The deaths were divided as follows, among the registration sub-districts:—Bloomsbury, 317—153 males, and 164 females; St. Giles's South, 612—males and females in equal number; St. Giles's North, 402— 199 males, and 203 females. [Appendix, Table V.] Corrected for twelve deaths in hospitals, and twelve occurring in the workhouse, the death-rate of Bloomsbury was 203 in the 10,000. From the registered deaths of St. Giles's South, we must exclude 67 cases which had been brought from the other two sub-districts, and died in the workhouse; 36, however, must be added for deaths in hospitals, so that the death-rate of the district is 291 per 10,000. Taken from St. Giles's North to various hospitals, 23 persons died; and 55 persons from this subdistrict ended their days in the workhouse. The death-rate, therefore, becomes 275 in the 10,000. These three death-rates are to be compared with those of the preceding year, remembering that 1857 was shown to be, as nearly as possible, an average year in its fatality to the district as a whole. In Bloomsbury, 181* of 1857, rose to 203 in 1858. On the other hand, the parish of St. Giles's shows a fall in each of its chief divisions. In the northern sub-district, the deaths were 283 in 1857, and 275 *The registration year 1857, has been reduced from 53 to 52 weeks, for comparison with 1858. Hence, at first sight, a discrepancy between the above figures and those given in my report for the former year. 11 in 185S, per 10,000 living. The southern sub-district, however, shows the most striking improvement, the deaths having fallen from 357 to 291 in the 10,000. I have before insisted on the unsuitableness of the registration sub-districts, for the purposes of an accurate investigation into the localization of disease. They are too large, and too compound in their nature; and the existence of the workhouse, with its peculiar kind of residents, in one sub-district, produces a disturbing influence which needs to be eliminated. In my General Report of 1857, I sketched out a division of our district, which I afterwards employed in examining the mortality of that year; the practical advantage of this minuter analysis was considerable even last year, but it is incomparably greater now, as it will enable us to institute a trustworthy and exact comparison between the two years, in every group of streets, both in respect of their total mortality, and of the chief diseases prevailing in them. The boundaries of these ten sub-divisions are indicated on the diagram which accompanies this report; and in this diagram a summary of the following facts is readily presented to the eye. The population, and the number of bouses of each locality, has been ascertained since last year, and is shown on the diagram. The greater accuracy which has thus become possible, has been extended to 1857, by a review of the corresponding facts of that year. The order of the ten sub-divisions, in regard of their general healthiness, may be tested by the relative number of deaths from all causes occurring in each. The following table is arranged in this order for 1858; the total number of deaths in each locality being shown, with the mortality on equal populations calculated for 1857, as well as for the year more immediately under review. Ten Sub-Divisions of St. Giles's; their Order of Mortality from all causes, 1858.* Order of Sequence, 1858. Locality of Actual number of Deaths, 1858. Per 10,000 In Houses. In Works. In Hosps. 1857 1858 Best 1st. L Lincoln's Inn Fields 33 0 3 220 144 2nd. B Russell Square 74 0 5 132 166 3rd. A Bedford Square 61 0 3 187 179 4th. D Bloomsbury Square 121 2 3 192 189 5th. C Coram Street 120 9 4 195 207 6th. K Southern Drury Lane 113 12 7 241 261 7th. E Church Lane 118 21 5 281 283 8th. G Short's Gardens 152 27 14 349 295 9th. 11 Northern Drury Lane 105 37 11 404 303 Worst 10th. F Dudley Street 225 36 15 377 355 Workhouse Inmates — 65 1 — — Total District 1122 209 71 286 258 * In this and the following tables, a correction of small amount should have been made, for the different duration of the two years. It is well worth remark in the above table how closely the arrangements of these sub-divisions, according to their total death-rate, coincides with the order in which they furnished deaths to the Workhouse death-book. The trifling exception formed by the precedence of the Northern Drury Lane locality over Dudley Street and its neighbourhood, is accounted for at once by the numbers of common Lodging Houses in the former district. 12 An enormous difference in the mortality of the various parts of St. Giles's, is shown in the figures of the foregoing table, and the results are more absolute and valuable than those derived from the sub-districts of the Registrar Genera), as the divisions are less artificial and compound in their characters. Making all allowance for the different proportion of children living in each locality as in some measure accounting for variations in the death-rate, still the existence of a vast mass of preventible disease is established beyond dispute. If in large portions of the district only 14, 1G, or 18 persons in the 1000 die annually, how can a mortality of 28, 30, or 35 in the 1000 be regarded as inevitable in other localities ? Evidence of the preventible character of the disease which kills the population of St. Giles's will be found also in a comparison of the columns for 1857 and 1858. A few only of the most rudimentary propositions of sanitary science are yet known to us. Some of these have been acted on in 1856 and 1857. In these years, measures of cleanliness and drainage were effected in many parts of the district, but most systematically and extensively in the localities which I have marked F, G, and II, on the diagram, and on the foregoing table. In each of these divisions, the year 1858 discovers a notable diminution of mortality. Let us be wary of assigning the whole of such improvement to sanitary measures; much will be attributable to circumstances which we can at present only call accident, fluctuations from year to year, and of these the changed position of Lincoln's Inn Fields is an example.* Much again may have to be explained away by other considerations, which will appear in their due place. But after every deduction, looking at the broad facts in the two columns for 1857 and 1858, remembering the greater unhealthiness of the town at large in the later year, we shall observe a fall in the mortality of St. Giles's, just in those very districts where the most active sanitary measures were taken—a fall of no trifling extent, but 2, 6, 10, in the thousand—other localities the while following, with hardly an exception, the rule of the town at large, and being either without improvement, or having actually deteriorated. Without venturing on a numerical estimation of the lives that have been saved by the vigilance of the local government, we cannot reasonably doubt that some portion of the improvement that we witness in the rate of mortality of St. Giles's, is to be ascribed to the removal of unhealthy conditions from the district. We are further warranted in this belief by the fact before stated, that it is the class of zymotic complaints which has been less fatal than usual to St. Giles's in 1858, these diseases being of all others the most dependent on unhealthy conditions within our controul. And stronger corroborative evidence still of the real influence of our sanitary measures will be presently afforded by a comparison of the localization of these zymotic diseases, in 1857 and 1858. The mortality among children which prevails in St. Giles's, beyond other parts of London, requires in this report, as in my last, to be closely scrutinized. A knowledge of the spots where this infantile mortality is greatest, gives no inconsiderable due to its cause. I have therefore ascertained, in the ten sub-divisions of our district, the mortality of children under two, and under five years of age, and I have examined * Lincoln's Inn Fields locality has the smallest population of all the ten, and hence, small variations in the numbers of deaths registered, are apt to assume undue importance. 13 their death-rate in each locality. These facts for 1858, with a column for comparison with the previous year, are thrown into the following table; in deducing inferences from it, the different numbers of children in the population of the several parts of the district, must be had in mind.* Order of Mortality among Children, † Order of Sequence, 1858. Locality of Children dying in 1858 Mortality per 10,000. Under Two years. Between Two & Five 1857. 1858. Best 1st. B. Russell Square 15 8 38 49 2nd. L. Lincoln's Inn Fields 12 4 108 64 3rd. D. Bloomsbury Square 30 16 82 69 4th A. Bedford Square 21 6 75 75 5th. C. Coram Street 44 15 73 92 6th to 9 th. E. Church Lane 53 13 123 129 K. Southern Drury Lane 50 18 140 138 H. Northern Drury Lane 46 23 196 137 G. Short's Gardens 69 21 197 138 Worst 10th. F. Dudley Street 102 28 199 167 Workhouse Inmates 8 1 — — Total District 450 153 130 111 The fall in the infantile death-rate since 1857, as disclosed by this comparison, appears to have followed in its distribution much the same course as the fall in the entire death-rate. Of course, the poorest localities have not all at once given up their character of fatality to children, and they still remain much the worst in the actual infantile deathrate. But these localities, especially those before adverted to, F, G, & H, have experienced the most remarkable relative reduction of the mortality of children under five years old. On the other hand, two localities which presented a slight rise in the general deathrate, are shown here to owe that increase to a larger mortality among children. Lincoln's Inn Fields neighbourhood again presents the same anomalous change in position. In our next inquiry—into the distribution of zymotic disease in 1858—we shall find the explanation of the chief distinctions which have hitherto appeared between this year and 1857. In the following arrangement, the relative mortality of the ten districts, in regard of their total miasmatic diseases,§ has determined their sequence. The chief members of this group of diseases are given separately. The places affected by the prevailing diseases are here sufficiently indicated; Scarlatina, the disease of the group, which chiefly assumed an epidemic form, was in force enough to impress on the total miasmatic mortality the order of its own prevalence. It culminated in amount and virulence in the latter half of the year, in and * In my General Report of last year, it was shown that, at the census of 1851, St. Giles's as a whole, and each of its three sub-districts, possessed fewer children for its population than the average of London, and that the deficiency was most conspicuous in Bloomsbury. † A hundred and forty-four deaths occuring in the Workhouse, and all the deaths in the Hospitals, are. in this and the following tables, uniformly referred to the houses whence the patients were brought. The remaining sixty-five deaths arc attributed to imitates of the Workhouse, and arc considered by themselves. § See note, page 24. 14 Order of Mortality from Zymotic Class of Disease —Miasmatic Order. Order of Sequence, 1858. Locality of Deaths from Miasmatic Diseases in 1858. Per 10,00 All Miasmatic Piseases. Small Pox. Measles. Scarlet Fever. Diphtheritis. Whooping Cough. Diarrhoea Contind. Fever. 1857 1858 Best 1st & 2nd. A. Bedford Square 10 — 1 5 1 — 2 1 36 28 L. Lincoln's Inn Fields 8 — — 4 — 2 1 — 56 32 3rd to 5th. D. Bloomsbury Square 26 — 5 6 2 5 — 4 47 39 B. Russell Square 19 1 — 4 1 6 — 4 25 40 K. Southern Drary Lane 21 — — 4 2 8 3 2 77 41 6th to 9th. G. Short's Gardens 35 — 5 7 2 5 7 5 98 53 C. Coram Street 35 2 8 5 1 7 5 5 27 55 H. Northern Drury Lane 28 — 3 7 — 4 7 4 89 55 F. Dudley Street 44 3 2 11 — 10 8 8 99 56 Worst 10th. E. Church Lane 34 1 2 17 1 3 1 5 65 66 Workhouse 1 — — — — — 1 — — — Omitted by error 2 — — — — 1 — 1 — — Total District 263 7 26 70 10 51 35 39 64 48 around the High Street. Cases of Small-pox were widely scattered through the district; in two spots becoming almost epidemic, about St. Giles's Church, and in and about Keppel Mews North. Deaths occurred from this disease in these places as well as in the Coram Street locality, where it first appeared in 1857. With one exception, wherever the point could be determined, it appeared that the victims were not protected by vaccination. It deserves also to be recorded that in the great majority of cases, glaring sanitary evils were also apparent on the premises in which small-pox had occurred. The largest number of cases of Measles occurred in the Coram Street locality. This and kindred diseases have combined to produce a much greater mortality in this district, in 1858 than in 1857. Measles was comparatively absent from the southern parts, about Drury Lane, which were ravaged by the disease in the earlier year. It is to be remembered, that such a malady occurring one year in an epidemic form, is pretty sure to be less fatal than usual in the following year, even without any improvement whatever in the material conditions which foster the disease. Whooping-cough and Continued Fever maintain their ground in the Dudley Street subdivision, but though still fatal here more than elsewhere, the actual number of deaths from these diseases has fallen to almost one-half of that observed in 1857. The amount of mortality from all zymotic diseases together, in the ten localities being compared for the two past years, we find that some very remarkable changes have taken place. In two of the ten localities there has been a decided increase in the prevalence of these diseases, viz: about Russell Square and Coram Street: after allowing for the unusual prevalence in London at large, there remains a surplus of zymotic diseases in 1858 over 1857, which is, perhaps, as much attributable to a deficiency below the average in the earlier year, as to an excess in the other. Certainly, the 15 ditions which favour the production of epidemic diseases were not wanting in the Coram-street locality, and I have reason to know that our b?st neighbourhood, about Russell-square, is by no means free from similar defects. In three others of the ten localities, there is a slight fall in the zymotic mortality. In the remaining five, a great and unmistakeable decrease has been experienced in spite of the prevalence of epidemic disease which signalized the year. Around Lincoln's Inn Fields, the zymotic deaths —represented in 1857 by the proportionate number 56 — have sunk, in 1858, to 32. In the southern parts of the district, about Drury Lane, the number 77 falls to 41; in the northern locality of Drury Lane, the deaths sink from one year to the other in the proportion of 89 to 55; while, in the two localities which were most affected by zymotic disease in 1857, and which continued to be singularly bad in this respect, namely, around Short's Gardens and Dudley Street,* the figures 98 and 99, of the earlier year, are replaced by 53 and 56 in the year following. In 1858, the worst locality for disorders of this class, was that enclosed between Oxford Street, High Street, Broad Street, and Holborn. The lowest position was attained by this locality, however, not by an actual increase in the numbers of these diseases, but only because zymotic diseases did not here experience the same fall as in the surrounding portions of St. Giles's. This resulted from the local prevalence of scarlatina, before mentioned. This examination of the distribution of zymotic disease through our district, in 1857 and in 1858, has shown that these spots have made most progress towards a better standard, which had been subjected to the most vigorous measures for the removal of their known insalubrious conditions. So undeniably are zymotic diseases dependent on such conditions, that the fact here established appears to me to complete our title to claim some of the improvement in the public health of our district as the result of our own endeavours. And we may venture to hope for a considerable reduction of the present rate of mortality in those localities, such as around Coram Street, which have more recently come under supervision, as well as a further amelioration in those which, like the neighbourhood of Dudley Street, and Drury Lane, have been steadily under inspection from the outset. Consumptive diseases : It has already been stated that these maladies exhibited no decline in our district since 1857. The localization of fatal cases, however, was remarkably different in this year and in 1858, as will be seen in the following arrangement. * With regard to Dudley street itself, itshigh death-rate in 1857, will not have been forgotten; the mortality among its children, and especially the great excess of deaths from zymotic diseases, were attributed to dirt, bad drainage, and overcrowding. This last condition has continued to exist until lately; but systematic measures were taken for improving the cleanliness and drainage of the Street as early as the year 1857. Of these operations, what has been the result? In the year of dirt and cesspools thirty-eight children were cut off before they had reached their fifth year, and there are twenty fatal instances of fever and its allied diseases in this single Street. In the year of comparative cleanliness and improved drainage, the deaths among the young children numbered only twenty-eight; and there were but ten deaths from the zymotic class of diseases, just one half the number of the previous year. On the other hand, consumptive diseases, and those affecting the lungs, had not fallen in 1858, nor was this to be expected until wholesomer air to be respired had been secured to the dwelling-rooms. The recent proceedings against over-crowding and cellar-occupation have had this for their object. We may look forward to the success of these measures in reducing for subsequent years the deaths from Bronchitis and Consumption, as well as in further diminishing the zymotic mortality. 16 The Ten Localities in the order of their Mortality from Tubercular Diseases. * Order of Sequence, 1858. Locality of Deaths in 1858, from Tubercular Diseases. Per 10.000. 1857. 1858. Best 1St. L. Lincoln's Inn Fields 2 28 8 2nd. B. Russell Square 8 27 17 3rd & 4th. A. Bedford Square 9 17 25 D. Bloomsbury Square 17 22 25 5th. C. Coram Street 20 29 31 6th to 8th H. Northern Drury Lane. 32 124 63 K. Southern Drury Lane 32 45 63 G. Short's Gardens 45 67 68 9th & 10th. E. Church Lane 41 65 80 F. Dudley Street 69 46 88 Workhouse Inmates 9 — — Total District 284 50 52 Let it still be borne in mind, that these numbers are based upon small populations, and represent the facts for short periods; and it will be sufficient to observe, that the deaths of 1858 are much more uniformly distributed than in the preceding year, localities which correspond in their other chief features being more similarly affected by consumption. In my last report, for 1857, I confessed my inability to explain the relative position of the different parts of St. Giles, in respect of these diseases. We are only beginning to learn the degree of dependence of consumption and allied maladies upon local conditions, and interpretations are less to be sought at present than accessions to our knowledge by accumulations of facts. Lung diseases, other than consumption, which produced death in St. Giles's, last year, were a little less fatal than previously, instead of being, as in the town at large, distinctly in excess over the preceding year, 1857. The localization of the fatal diseases of the respiratory organs is shown in the following, to which the remarks just made on the former table are equally applicable. The order of Mortality from Diseases of the Lungs. Order of Sequence, 1858 Locality of Deaths from Lung Diseases, 1858. Acute Lung Disease, Per 10,000. Total Lung Disease, Per 10,000. Acute. Chronic. 1857 1858 1857 1858 Best 1st & 2nd. D. Bloomsbury Square 11 6 13 16 25 25 B. Russell Square 9 4 17 19 21 28 3rd to 7 th. G. Short's Gardens 16 13 29 24 47 44 C. Coram Street 18 11 22 29 39 45 E. Church Lane 16 8 33 32 70 47 A. Bedford Square 14 3 20 39 42 48 L. Lincoln's Inn Fields 9 4 16 36 32 52 K. Southern Drury Lane 22 11 23 43 49 63 8th & 9th. H. Northern Drury Lane 18 15 44 35 79 63 Worst 10th. F. Dudley Street 46 19 54 58 76 83 Workhouse Inmates 4 15 — — — — Total District 183 109 30 33 55 53 * These include, in this place, consumption affecting the lungs or lymphatic glands, scrofula, and water-on-the-brain in children. Six of the last kind of cases arc included with brain diseases in Table III appendix. Hence an apparent in consistency, 17 There is but little interest in the difference of the two years, with respect to these diseases. In some localities the mortality has risen, in some it has subsided. The sequence of the ten sub divisions, in their fatality from acute lung disease, conlinues to present a certain correspondence to their mode of arrangement in regard of zymotic disease; suggesting a similarity in the two classes of complaint, as to the mode in which they are influenced by local conditions. Before quitting the subject of the localization of disease, violent deaths deserve a minute's notice. Of 49 such deaths in the year, 8 took place in hospitals, 6 in the workhouse, 3 of the latter being among inmates of the house. Fifteen lives were lost in the Gilbert Street fire, in March, 1858, and 4 persons committed suicide. Deducting these deaths, there remain 30 from accidents of various kinds, and of these 23 occurred in the four southernmost localities of St. Giles's parish, (lettered F, O, H, and K.) Thirteen infants (3 boys and 10 girls), met with their deaths from suffocation in one way or another. A summary of the foregoing statistics, relative to the localities chiefly affected by the diseases of St. Giles's, is given in the diagram which accompanies this report. The amount and nature of the improvement or deterioration of the public health, within each of the ten sub-divisions, is there indicated. My examination of the mortality statistics of St. Giles's, in 1858, is now completed. In the course of it, I have had occasion to ind'cate several sources of possible error, which made it necessary to use caution in our deductions from mere figures. I have now to direct attention to a circumstance of a very enigmatical nature, which if not distinctly noticed, might be held to invalidate several of my conclusions. Throughout the whole enquiry, the population of the district has been presumed to be known, and every calculation has had reference, directly or indirectly, to this knowledge. If it should turn out that the population has notably altered its numbers, not according to any law of progression hitherto experienced, but in some entirely new and anomalous manner, doubt may reasonably be thrown on the accuracy of statements which assume the number of inhabitants for their basis. Now, it appears from my enquiries, that in the year 1858, the number of Births in St. Giles's district was very remarkably below the average. In former years they had exhibited a tolerable constancy, though showing some disposition to fall off in numbers : Thus, in 1851, there were 1862 Births. In 1852, „ 1849 „ In 1854, „ 1826 „ In 1857, (corrected to 52 weeks) 1814 „ In the year 1858, therefore, we should expect to find the births, about or not much below the last figure, 1814. Some cause, however, was in operation over the whole metropolis, to depress the birth-rate of the year. Making further proportionate allowance for this, theestimated number of children to be born into St. Giles's, in 1858, would become 1800. It is ascertained, however, that sixteen fewer births occurred in 1858, among the stranger-patients at the Lying-in Hospital, than in 1857; so that after every possible correction for artificial and extrinsic sources of fallacy, we look for 1784 births, on the books of the registrars during the past year. 18 But the truth is, that there were only 1G77 births registered in the ycai, showing a deficiency of 107 below the smallest number at which they could be reckoned. It must be mentioned, that the registration of births in England is imperfect, and it is only from the steadiness of the numbers actually recorded during several years, that we venture to consider the registered births as a fair exponent of the number of children actually born. So that, in drawing any deduction from the birth returns, two assumptions are involved: that the same proportion of parents take the trouble to register their children at one time and at another, and that these returns are correctly transmitted by the registrars. If we are fairly warranted, as I think we are, in taking these two points for granted, then the fall in births which St. Giles's presented in 1858, must either be accepted as an anomaly for which we can at present assign no explanation, or else we must regard the diminution in births to the number of 107, as indicating a corresponding emigration* from the district. I may at once confess that I know of no such emigration, nor do I see that any special inducement has existed for removal from St. Giles's during the year. Any sanitary measures which can have had for their effect a thinning of the population, were not taken till the very end of 1858, or the beginning of the present year, whereas the fall in the births dates from the earliest months of last year. (Appendix, Table VI.) Supposing, however, such a movement can have taken place, it would have this great interest for us : that a population which diminishes to the extent of losing 107 births, ought also to present 87 fewer deaths. If the fall in the births, then, is to he thus accounted for, two-thirds of the fall in mortality of the year 1858, is also explained, and proportionately less credit is to be taken for the influence of other causes in reducing the death-rate. Probability is added to the above hypothesis also, by the circumstance that the decrease in mortality and the decrease in births affect, as far as we can see, the same sub-districts; the greatest decrease by far, in both birth and deathrate being in South St. Giles's; while Bloomsbury exhibits an increase, both in one and the other. It has only been honest to give its full value to a possible disturbing influence of this magnitude, but if its existence were much more clearly demonstrated than it really is, the main conclusions which have been drawn as to the improvement of the public health in St. Giles's remain unimpugned. The exact significance of the particular figures might be drawn in question, but I have throughout guarded myself from making any statement on too narrow a basis. If the emigration in question could be proved for certain, I should, indeed find ground for much congratulation in the removal of some three thousand persons from the very overcrowded parts of South St. Giles. Chapter V.—Diseases and Deaths of 1858, in the Public Institutions of St. Giles's. The Workhouse practice of 1858 has had considerable interest for the Officer of Health, in indicating the local prevalence of disease, and where sanitary measures were therefore most required. The information derived from a record of sickness comes * An emigration to the extent of 3000 persons, if an average sort of population had moved. It is of course unlikely that child-bearing women should go in a different proportion to the rest of the people; and there certainly has been no new inducement for such women to Amigrate. 19 earlier than that of a death-register, and is therefore more available for many practical purposes. But the returns of the Registrar-general are from their nature more comprehensive, and hence form a more reliable basis for sanitary investigations. Still the books of the workhouse will be found to furnish valuable corroboration to the statements and inferences which have been founded on the mortality returns. The table on the following page exhibits the cases of disease which came newly under treatment by the Medical Officers of the workhouse, in the year 1858. It also distinguishes those diseases to which chief interest attaches, either from their being more preventible than others, or from their especial prevalence in St. Giles's. The mortality from all causes, and from each of these diseases, is also given. Within the workhouse itself, only 864 new cases of disease came under treatment, and almost the whole of these originated out of the house. The corresponding number in 1857, was 1037, and it was 1149 in the year 1856. The mortality among these 861 persons was 209, or 24 per cent. For the explanation of this enormous mortality, we must as usual look to the peculiar class of the patients, and the incurable nature of many of their diseases. Nearly half the deaths occurred from old bronchitis and consumption, though these diseases were not more fatal than usual. Twenty-three persons died from apoplexy and paralysis, and 18 from mere old age. Among the residents in the workhouse, there were 66 deaths, chiefly from the diseases just mentioned. Of zymotic diseases, singularly few cases were received from without into the infirmary. Among the inmates of the house, a few cases of diarrhæa occurred among the old people and infants, and four persons become affected with erysipelas. A good many cases of ophthalmia are found on the registers, and the disease appears to have prevailed among the inmates of the house in the latter part of the year. Among the out-door poor who apply for medical relief at the workhouse, bronchitis in the cold months, diarrhoea in the autumn, and febrile attacks of small importance all the year round, are always the principal complaints. In 1858, there were only three - quarters of the cases of bronchitis, and one-half the cases of diarrhoea that were seen in 1857. In part this arose from an excess of these complaints is the earlier year. But in the case of diarrhoea, the fall of 1858 is of very singular and exceptional extent, and corresponds with the very reduced mortality from the complaint which we have before noticed with satisfaction. The patients visited at their homes, in 1858, were more numerous than in 1856, but fewer by 118 than in 1857. In this list, scarlatina has risen, and measles has fallen from their respective amounts in 1857. Less bronchitis, and less diarrhoea were met with, in about the same ratios here as in the other class of patients. The diseases recorded as "Fever," and "Febricula," have slightly risen in numbers, but as heretofore it is impossible, though most desirable, to separate the true idiopathic fevers from the mass of diseases grouped with them under these two designations on the workhouse books. Two diseases appear in the foregoing table, for the first time this year. Of the one, ophthalmia, I have already made sufficient mention. The other is Ague—of which 43 cases came under observation among paupers in St. Giles's. It has been ascertained by the Association of Medical Officers, that a proportionate number Cases of Disease and Deaths, occurring in the Practice of the Workhouse, in the Four Quarters of 1858. Cases occurring— Within Walls of Workhouse, (Infirmary and Inmates) Among Out-Patients attending at Workhouse. Among Patients visited at their own homes. Quarters of the Tear. First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Whole Year. First. Second Third. Fourth Whole Year. First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Whole Year. Cases. New Cases. Deaths New cases Deaths New cases Deaths New cases Deaths New cases Deaths New cases. No deaths. New cases Deaths New cases Deaths New cases Deaths New cases Deaths New cases. Deaths 236 74 194 35 193 37 241 62 864 208* 988 973 1334 1392 4687 465 37 321 27 383 28 499 36 1668 128 Small Pox — — — — — — — — — — — — — — — 3 — 2 — 3 — 5 — 13 — Measles 1 — — — 1 — — — 2 — 3 1 5 13 22 9 — 5 — 2 — 23 — 39 1 Scarlet Fever — — — — 2 — — — 2 — — — 6 7 13 4 — 1 — 37 3 38 1 80 6 Hooping Cough — — — — 1 — 1 — 2 — 1 9 40 32 82 4 1 1 — 4 — 5 3 14 3 Diarrhœa 2 — 2 — 6 1 — — 10 1 28 84 387 94 593 5 — 12 — 29 1 7 2 53 1 Fever † and Febricula — — 4 2 3 2 6 — 13 4 129 116 145 116 506 76 — 71 1 54 — 66 — 267 1 Ague 2 — 2 — 3 — — — 7 — 5 8 5 4 22 5 — 5 — 5 — 1 — 16 — Bronchitis (acute and chronic) 68 19 15 5 19 4 43 13 145 41 290 117 104 379 950 99 5 21 2 14 2 61 5 195 14 Inflammation of the Lungs & Pleura 6 3 5 — 2 — 5 5 18 8 7 1 1 7 16 16 12 8 5 4 1 22 6 50 24 Consumptive diseases 26 21 13 8 14 5 33 18 86 52 7 12 18 25 62 36 6 20 10 23 6 21 5 100 27 Ophthalmia 4 — 1 — 7 — 9 — 21 — 7 3 8 7 25 — — — — — — — — — — * In the Registrar General's returns, this number is stated at 209, from the registration of a case in which two inquests were held. † The term "Fever," here includes symptomatic as well as idiopathic fevers. It is impossible to separate the one class from the other in the Registers of the Workhouse. There is a large proportion of idiopathic cases in the first and last divisions of the table; while in the middle division the so called fevers are for the most part only symptomatic. 21 existed in the other parts of London. As a rule, of course, these cases are only manifestations of a poison received during a residence elsewhere; but it seems probable that some of them are actually generated in the town. The question is one of importance, but can only be solved by a careful cross-examination of the patients themselves. I have thought it advisable to ascertain how far the diseases which do not go on to a fatal issue, correspond in their localization with those returned by the Registrar of deaths. A partial investigation of this kind for the workhouse cases, has produced the following table, which gives the numbers of the chief zymotic diseases that come from each of the ten localities into which I have divided St. Giles's. Distribution of Zymotic Diseases in the Out-Patient practice of the Workhouse, in the Ten Localities of St. Giles's.* Zymotic Diseases in Locality of Small Pox. Chicken Pox. Measles. Scarlet Fever. Whooping Cough. Fevers, including cases of febricula visited at home. Diarrhoea. Erysipelas. Ague. Rheumatic Fever. Total of foregoing Diseases. A. Bedford Square — — — — — — — — — — 0 B. Russell Square — — — — — — — — — — 0 C. Coram Street 5 2 1 1 1 9 4 1 — 3 27 D. Bloomsbury Square — — 1 — 2 2 10 — — — 15 E. Church Lane — 3 14 16 12 56 58 1 8 3 171 F. Dudley Street 5 11 19 29 31 92 118 11 1 11 328 G. Short's Gardens 1 17 8 1 5 11 74 99 9 6 8 248 H. Northern Drury Lane — 7 9 15 5 70 94 3 4 3 210 K. Southern Drury Lane 1 1 2 1 9 49 47 5 7 4 126 L. Lincoln's Inn Fields — — — — — 5 1 1 — 2 9 Total District as far as Classified 12 41 51 77 71 357 431 31 26 34 1134 Making allowance for the relative pauperism of the different parts of the district, and for the circumstance that the sick poor who go to the workhouse for relief, will be more or less numerous as they dwell nearer or farther from the house, we find that little new information is given us by this table, beyond what we have already gained from the returns of the Registrar-general. The very large number of cases coming from Dudley Street and the streets around, will not surprise us, when we remember the large mortality there. In the northern parts of St. Giles's, and in the parish of Bloomsbury, the totals are fewer, from there being fewer poor, and from these localities being relieved by the Bloomsbury Dispensary, and other institutions. The extreme southern parts are in like manner relieved by the Brewers's Court Dispensary, and by King's College Hospital, and the Carey Street Dispensary. Hence the small numbers in the two districts at the end of the list. Any deductions from this table, as to the relative frequency of the various diseases in the several parts of St. Giles, would be vitiated by the circumstance just * The totals of this table will not be found to agree with those of the preceding table, as in some few occasions I omitted to procure the addresses of the patients, especially of those coming to the Workhouse with Diarrhoea But though not complete in its totals, yet relatively to the ten districts the table may be considered perfectly correct. 22 stated, or else would be only a repetition of what we have already learned from the death-returns. But in the case of Ague the Workhouse practice furnishes cur only guide. This disease is rarely registered as a cause of death, and its localization cannot therefore be studied from the Registrar General's records. It appears that in 1858 Ague was confined to the very poorest places, Church Lane and Lincoln Court being the two chief; for this we should be prepared, by what has gone before. A few, but nowise the majority, of the cases were among the inmates of common lodging houses The diminution which I have been able to record, in the number of patients admitted into the parish infirmary, taken with the fall we have seen in the death rate of the district, must be regarded as a most satisfactory circumstance in an (Economic as well as in a purely sanitary point of view. It may be roughly stated that one quarter of the whole number of paupers are thrown upon the poor's rates, as the direct result of illness, and more than another quarter of the whole by the loss of the heads of families by death. To diminish sickness, therefore, is at once to diminish pauperism. I should disdain to calculate the money amount which is saved to the rate-payers by every decrease in the disease and in the mortality of St. Giles's, and I know that in this district, no such inducement to a humane and far-sighted policy is needed. Rut it is worth while to point out how, in acting energetically from unselfish and higher motives, we are practising the most direct œconomy to ourselves, as well as fulfilling a sacred duty to our poorer fellow men. The Bloomsbury Dispensary, in 1858, afforded relief to 2618 patients, 1895 of whom were attended by the physician, and 723 by the surgeon. Of these, 49.1 were visited at their own homes, and of the whole number only 54 died. A statement of the number and nature of the principal zymotic diseases, in the practice of this dispensary, with the localities in which they occurred, is given in the following table, in which, as before, allowance must be made for patients seeking relief at the source nearest to them. Zymotic Diseases in practice of Bloomsbury Dispensary, 1858.* In locality of Total Zymotic Diseases. Small Pox. Chicken Box. Measles. Scarlatina. Whooping Cough. Fevers. Diarrhœa. Erysipelas. Rheumatie Fever. A. Bedford-square 2 — — 1 — — — — 1 — B. Russell-square 11 2 — 1 — — 5 3 — — C. Coram-street 36 3 1 2 4 1 14 9 2 — D. Bloomsbury-square 53 — 1 3 7 2 21 15 3 1 E. Church-lane 24 — — — 3 — 14 6 — 1 F. Dudley-street 46 2 — 3 4 4 17 14 1 1 G. Short's-gardens 26 — — — 2 1 11 10 1 1 H. Northern Drury-lane 18 — — 2 4 3 5 3 — 1 K. Southern Drury-lane 7 — — — — — 4 2 1 — L. Lincoln's Inn-fields 1 — — — — — 1 — — — Out of District or not Classified 68 — 2 9 3 3 17 28 3 3 Totals as far as ascertained 292 7 4 21 27 14 109 90 12 8 * Under scarlatina are included three cases where the disease resembled diphtheritis. A ease of ague occurred in Charles Street (H), not in a common lodging house. 23 In the model lodging houses for families, in St. Giles's district, there were in 1858, several zymotic diseases, and some of them were fatal to the children. Though the number of cases was unusually large for these establishments, still the actual amount was not so large as in the poor streets in the neighbourhood where less attention is paid to the means of health. Whooping-cough, measles, and scarlatina, were the diseases which produced death in the various model houses. I have not this year made a particular examination of the diseases affecting the inmates of common lodging houses. The number of registered houses in the district has been increased by five, since the date of my general report, in 1857. Chapter VI.—Sanitary operations of the Year 1858, comprising the Returns of the Sanitary Inspector. The sanitary work of 1858-9 has, of course, consisted in the main of improvemen s in and abo it the houses of the district. Other measures have been taken for the safety of the public health, and these will also he related. But none are so important as those which relate to the dwellings of the people—and none have engaged such unremitting attention. Section I.—Improvement in the sanitary condition of houses has been of course most needed in the poo'.er portions of the district, but very considerable scope for amendment has been found in the mews adjoining the better streets and squares. Moreover, in several instances, the services of the Sanitary Inspector has been required in our very best houses. He has been in trumental in preserving the health of Russell-square and Montague-place, as well as of Church-lane and Lincoln-court. I am very anxious that the Insptctor should be more often applied to by the upper classes. The sanitary defects most likely to exist about their dwellings is bad drainage. When their homes were built the cesspool was, usually, the only m ans of drainage, and in several very good streets it has not yet been wholly supe seded. People trouble themselves too little about the drainage of their houses,— bad smells are not noticed, or are satisfactorily accounted for by "the wind being in a particular quarter." But there are found inexplicable ailments in the house; servants lose their healthy looks and children droop. Or scarlatina, generated in the unknown mews close by, affects the children, and assumes a serious type. Another year diphtheritis is heard of, or typhoid fever appears—is called by some gentle name of slow or bilious fever—and there are speculations how the disease can have been "caught," and fears lest it should be "given" to others. It is important for peopleto be well assured that, in he great majority of cases, such diseases as these only exist, or only become serious by reason of some defective condition in the dwelling house or n ighbourhood. In a poor locality the existence of epidemic disease is used by the sanitary officers as a guide to the existence of cesspools, Imperfect drainage, or other defective arrangemen's. Very rarely, indeed, does the Inspector fail in discovering some such cause for the prevailing disease. The wealthler and more intelligent classes should provide for themselves the same security that we are attempting to obtain for the poor, and should make themselves sure that the conditions which surround their dwellings are the best adapted to health. House improvements in the several Localities of St. Giles's, effected under the Superintendence of Inspector Webb, between March 25th, 1858, and March 25th, 1859. House improvements in localities. A. Around Bedford Square. B. Around Russell Square. C. Around Coram Street. D. | Around Bloomsbury-sq. E. Around Church Lane. F. Around Dudley Street. G. Around Short's Gardens H. Around Northern part of Drury Lane. K. Around Southern part of Drury Lane. L. Around Lincoln* Inn Fields. Whole District of St. Giles. Unclassified house improvements, and Remarks. Number of houses for the improvement of which measures were taken. 10 29 157 36 37 49 28 32 46 8 432 Many house-works in progress at date of report. Improvements in Drainage. Number constructed 7 11 32 15 5 13 19 13 7 — 122 N.B.-New Sewers made by Board in Woburn Mews, East, (C.) Bury Ssreet, (D.) Bronlow Street, (G.) Coal Yard, & Smart's Buildings, (H.) Improved or constructed 1 2 19 1 5 15 3 4 6 8 64 Traps fixed 8 13 91 13 12 38 20 22 15 7 239 Cesspools abolished 8 12 31 14 4 5 10 9 5 3 101 Cesspools cleaned only — 1 — — — 1 — — — — 2 In Water Closets. Pan, trap, and water provided 5 6 29 10 3 4 11 10 9 1 88 Three Water Closets abolished, one in each of the localities E, F, and K. Water and apparatus only provided 1 8 69 5 5 26 14 20 9 2 159 Cleaned or repaired 1 2 9 — 2 6 5 6 5 — 36 Newly constructed or re-built 2 2 11 1 1 — 3 5 1 — 26 In Dust Bins. Newly constructed — — 13 2 1 5 5 3 1 — 30 Repaired or covered — — 18 — — 3 1 3 1 — 26 In Paving. Constructed — — — — — — — — — — — Re-laid — — 19 3 1 3 3 11 2 — 42 In General Water Supply. Receptacles provided 1 2 23 4 — 9 10 4 3 — 56 Very few houses are without some supply of water. Receptacles repaired — — 8 — — 3 1 2 1 — 15 Water supply provided where none in house before — — 1 — — — — — 1 — 2 In Cleanliness and Repair. Generally repaired — 1 6 2 — 2 4 5 2 — 22 Five houses shut up by Magistrate. One in C, four in K. Cleansed and Lime-whited 3 4 92 11 6 36 29 22 21 4 228 Various accumulations removed from Cellars, &c. — — 7 2 — 7 2 3 2 — 23 In Ventilation &c. Ventilation improved — 12 — — 1 — 1 — — 14 Great part of Church-lane, (E.) and whole of Lincoln Ct.,(K) among other places in course of radical improvement at date of report. Overcrowding reduced — — — — 5 2 3 1 7 — 18 Kitchens, disused or made legally habitable — — 8 — — 23 2 — 1 — 34 Proceedings taken. First notices 10 29 152 28 16 72 28 25 25 7 392 Excluding handbills distributed. Second notices, letters, &c. Totals only given. — — — — — — — — — 52 Summoned 25 Reported to Police or District Surveyor 15 Total improvements 37 64 498 83 50 202 145 144 99 25 1347 25 The foregoing table exhibits the nature of the house improvement, effected under the supervision of Inspector Webb, and it shows (this year for the first time) the localities in which the several works have been carried out: (See last page.) As far as the totals of this year admit of comparison with those of 1857, they appear to show a numerical decrease in some kinds of improvement and an increase in others. The truth is that, in 1857, the numbers were swelled by a great deal of rapid work to meet a threatened emergency. This is indicated by the large number of notices served, many of which related only to cleanliness and limewhiting. In 1858, our operations have been more systematic and thorough; and thus it will be seen that works of drainage have been more numerous. At the time, too, that this enumeration is brought down to—March 25th, 1859—an unusually large number of extensive and important sanitary works remain in hand. The improvements in Lincoln and Orange courts, in and around Church-lane and Hampshire Hogyard, are not in luded in the foregoing table, as they were not complete in March. These places however, received a very large amount of time and attention during the year. A very complete examination was male of them, and. among other points enquired into, the dimensions of some hundreds of rooms, and the numbers, ages, and sex of their inmates were ascertained. The most glaring violation of the laws of health, and of the requirements of civilized life, was found.* In obtaining effectual improvement in these localities, great weight was given to the demands of the Board, and most valuable assistance rendered to the sanitary officers by the laborious personal attention given by influential members of the Sanitary Committtee. Thus we have been enabled to obtain many concessions from the freeholders of prope; ty, on the occasion of the expiration of leases; alterations of magnitude have been made, and stringent provisions introduced, into subsequent leases for the maintenance of the premises in a healthful state. Church-lane and its purlieus have, time out of mind, been the portion of the district which has most urgently demanded fundamental improvement. To particularise here, the defects of this locality, would be a needless and unwelcome task. Those who have visited the place need not be told how rankly every noxious con- * For instance: There are several small rooms in the back yards of Church-lane, in close proximity to the privy, which is common to twenty or thirty persons, without water, and filthily dirty. Each of the rooms measures about ten feet by eight, and between six and seven feet high. Each of them serves a family for sleeping, cooking, and all domestic needs. At the time of examination, four, five, or six persons were the ordinary numbers residing here; the water for household and drinking purposes, if there was any at all, was stored in some tub or pan in a corner, or under the bed. The air of these rooms was unbearable to a visitor, and to open the window was only to exchange one foul emanation for another. Another case: In Orange-court, a man of fifty was dying of consumption; his wife and eight children, mostly grown up, occupied with him a space of 1500 cubic feet only. Seven persons above the age of puberty, with three young children, were found in Church-lane, living in a room whose dimensions were about 1000 cubic feet, or just the allowance for one individual in our modern prisons; there were but two beds for them all. It would be easy to find many other such instances. To avoid the operation of the Common Lodging-houses Act, the residents in such cases always profess to be "of the same family," reserving to themselves the utmost latitude in the use of the word. Thus, father, mother, and children of all ages, are to be found, sharing their miserable accommodation, by night and day, with the son's wife, or the mother's sister, and their children, An extension of the provisions of the Common Lodginghouses Act is much to be desired, to meet these and other cases. Still more urgently needed, are cleaner and more spacious rooms for the use of the poor, and I believe these could be provided for little more than the rent of their present abodes. 26 dition has flourished, and how systematically every provision for health and decency has been neglected or abused. Repeated attempts have been made to improve this locality, but they have almost all failed from being imperfect and ill adapted to the wants and habits of the pecullar class of residents. The only real improvement which Church-lane has hitherto witnessed, has been in the houses registered under the Common Lodging Houses' Act. The houses, whose rooms are occupied by single families, were last year in a condition of squalor and overcrowding which it is difficult to conceive surpassed.* (See Note on preceding page.) The portion of this locality to the south of Church-lane, comprising half the houses in the lane, Welch's and Kennedy courts, and Hampshire Hog-yard, was held on lease from Sir John Hanmer, Bart., M.P., and it was ascertained that the leases were to expire in the winter of 1858-9. The Sanitary Committee at once entered into communication with Sir John Hanmer and his agent, and at frequent interviews made urgent representations on the m'serable state of the property. The views of the committee met with attention, and, a though the whole of their suggestions have not been adopted, a great amount of good will have been effected. The houses in the places mentioned were, in March last, in process of repair and cleansing. New water cisterns were being built, and new closets erected; ventilation was being improved, not in the rooms and staircases only, but by the removal of one or two tenements which greatly hindered the free circulation of air round the houses. A series of cow-sheds in Hampshire Hog-yard, which had long been a nuisance to the district, were to be rebuilt, with proper provisi ns for drainage and cleanliness. With all these improvements, however, the Sanitary Committee felt that the advantage would be of a very temporary nature, if they did not also impress on the leaseholder his responsibilities to keep the premises in a decent state, and to prevent overcrowding. It has been necessary with this view, to summon the chief leaseholders of Church-lane, under the Nuisances' Removal Act, Magistrates' orders have been obtained in each case, and in one instance a fine was inflicted. The most important sanitary measure of the year has certainly b en the diminution of overcrowding. This has been applied, not to Church-lane only, but to other parts of the district. A decision was obtained from the magistrate, on physiological evidence of a very positive kind, by which a cubical space of 400 cubic feet is secured to every member of a family in the lower class of houses; extremely small is this allowance of space, but it is three times what was found to be granted to each person in many rooms of the district. I do not think it is possible to overrate the good results which will follow on this decision, This regulation of the number of inmates will not only ensure a purer air for each, but will allow of a remedy being applied to many other sanitary defects which result inevitably from the condition of overcrowding. In my former annual report, I have insisted very strongly on the good that must flow directly and indirectly from forbidding overcrowding. Measures, such as I there recommended, have now begun to be adopted; handbills,* giving information and warning, have been freely circulated throughout the district, and owners of overcrowded houses have * A copy of this hand bill will be found in the appendix. 27 been convicted. I am very hopeful now that this serious sanitary error, on which hang so many others, will be corrected, and that we shall soon find the effect of our measures on the health of St. Giles's. Lincoln-court † is another locality where works were in progress at the date of the foregoing table. Here the leaseholder was repeatedly summoned, for his prem'ses being overcrowded, and otherwise very unhealthy, but little effect was produced. At last the leaseholder was ejected, and the court was then shut up and repaired, throughout, at the expense of the freeholder. Some six or seven hundred people were turned out of the twenty-two houses of this court in January, 1859, and it is still empty (June 1st). In this place it may be well to record that, during 1858, two little courts were permanently emptied of their inhabitants. Star-court, near the workhouse, which has been pulled down, and Linney-court, leading from Museum-street, which has been absorbed by Mr. Mudie's new buildings. Of a kindred nature to the prevention of overcrowding are other proceedings which have been taken in 1858, and which are destined to make that year an era in our district. "A cellar in St. Giles's" has been the by-word for centuries to express a wretched habitation, unworthy of humanity. Dating from the time of Charles I., the underground dwellings of our distiict attained the acme of their miserable notoriety from the pen and pencil of Fielding and Hogarth. The parish authorities have habitually objected to the use of these cellars, but with little or no practical result. The Building Act of 1844, contained stringent clauses against the use of underground rooms, unless they possessed requisites of area and ventilation, such were out of the question in the cellars of St. Giles's. No effective measures, however, were taken to empty them until the present time. The Metropolis Local Management Act, under which this Board is constituted, repeated the prohibitions of the Act of 1844, and in defence of the public health, as well as in pursuance of their commission, the Board have lately put this statute in force. This has been done without compromise; it has been insisted that the cellars be simply and absolutely emptied of their tenants, and permission has been refused * to the owners of the houses to make those alterations, which would permit of the cellars being used as dwellings. They may still be employed as shops or store-rooms, but as separate habitations, for occupation by human beings at night, "a cellar in St. Giles's," is no longer to exist. It would be hard to estimate the value of this bold and admirable measure of the Board of Works, on the moral and physical well-being of their district. I subjoin a list of 34 houses, whose cellars were previously illegally occupied, and in respect of which measures had been successfully taken, at the instance of the Board, up to Lady-day last. Since that d .te many others have been disused : Dudley-street (locality F of diagram,) Nos. 8, 9, 12, 13, 15, 19, 20, 23, 24, 27, 28, 30, 37, 59, 61, 63, 64, 65, 66, 67, 68, 70, 87. Now wholly disused, or only occupied during the day. † Between Drury-lane and Great Wild-street, in sub-division K of the diagram. *Except in one or two instances, where the alterations were made before this resolution was come to. 28 Great Wild-street (locality K of diagram), No. 28. Emptied. Short's-gardens (G), Nos. 3 and 20. Altered so as to possess the legal requisites, (see note on preceding page). Little Coram-street (C), Nos. 14 and 19, disused. Nos. 3, 24, 25, 28, altered to meet the law. The kitchens here are of a different class from the cellars of Dudley-street—twenty-one out of the total twenty-seven were found to be legally habitable. Little Guilford-street C), Nos. 11 and 32 disused. In concluding my account of the House improvements effected in 1858, it is within my province to repeat, here, a statement which will doubtless appear in the Surveyor's report. In several streets, the Sanitary Inspector has reported the house drainage to be imperfect, and that it could not be made effectual on account of insufficient public sewerage. In these cas s the facts have been reported to the Board by the Sanitary Committee, and, in consequence, several new sewers of considerable length have been constructed, and others are under consideration. The principal new sewers have been made in Bury street (locality D of diagram), Smart's-buildings and Coal-yard H), Woburn Mews east (C), and Brownlowstreet (G). I wish also to find place for an observation which has been forced on me, though my facts are not yet in number sufficient to allow absolute deductions to be drawn. In a few instances, children have died of malignant zymotic diseases, during the execution of considerable drainage works in their houses. I cannot doubt that many others have fallen ill, but I am unwilling to wait for further experience of this sort, before expressing an opinion that houses ought not to be tenanted during extensive alterations in their drainage. Section II.—The proceedings of the Medical Officer of Health, in other matters than House improvement, have been, from time to time, brought before the Sanitary Committee at their monthly meetings, but only a few need to be here repeated. The slaughter-houses of the d strict have been several times carefully examined. Their condition has been found, on the whole, satis actory, but it is still impossible to impress upon butchers the necessity of keeping the blood entirely away from the drains. Some portion of it almost invariably gets down the drains and is found clogging their entrances to the public sewer. A good deal of improvement has been made in the cow-houses, in spite of strenuous opposition from their proprietors, several of whom have needed compulsion by the orders of the magistrates. Messrs. Gibson, of Drury-lane, and Delano, of Hampshire Hog-yard, have in great measure, rebuilt their premises. The worsekept cow-shed in the district, is now, Mr. Evans's, of Goldsmiths'-alley. Early in the summer of 1858, complaint was made to the Board of Works by residents in Holborn, of the nuisance created by the tallow-melting factory of Messrs. Cook, in Smart's-buildings. Frequent visits and special reports were made on the cause of the nuisance, and the means of remedying it. At my suggestion the boiling vessels were provided with covers and flues, so as to pass the vapours of 29 the tallow through the fire place, and thus to consue them. For a while, and during the winter, the effluvia was less disagreeable to the neighbours, but with the warm weather of 1859, it appears that they are again the subject of complaint. In my report for 1867, I gave an account of the preliminary measures which had been taken in reference to the vaults under places of worship in the district, together with the order in council which had been issued for their improvement. The alterations specified in this order were effected in the autumn of 1858, under the supervision of the Surveyor and myself. As the nature of the works performed will be stated to you in the Surveyor's Report, I shall make no remark on them, beyond stating that the manner of their execution elicited the strong approval of the Government Medical Inspector, Mr. Grainger, who visited the vaults after the alterations. I wish, however, to record the precautions taken to preserve the health of the workman, as our experience on this point may be useful to others. At the outset the walls were limewhited, and the coffins sprinkled freely with Mc Dougal's powder, a disinfectant of which sulphurous acid is the most active ingredient. This substance answered its purpose admirably, and the "dredger" was in great favour with the labourers. Thick gloves were worn to protect the hands from scratches, and the recesses of the vaults where foul air might stagnate, were well ventilated by jets of gas. With these precautions, the men experienced remarkable immunity from illness throughout their hazardous work. In Bloomsbury Church, where a re-arrangement of the coffins was found necessary, a dozen or more of them were met with, from which there was some leakage, and the effluvia were horrible until the use of the disinfectant. The black foetid fluid escaping from these coffins could not always be avoided, and in one case it was received into a cut in a workman's hand, yet happily no bad result followed. Diarrhœa affected all the men; it was easily checked by treatment, and there was no more s rious ailment. The completion of the entombment of the coffins under the churches is another proceeding which will make the past year a date in our parochial history. Since the present churches were built, in the first quarter of the eighteenth century, not one of the 1700 coffins has been deposited in their vaults except in virtual violation of the Act of parliament under which they were erected. It has been for the ratepayers of 1858 to rectify the errors of their fathers, and to take the final step in the extinction of the system of vault sepulture in St. Giles's. The prevention of small-pox in the district, has engaged a gocd deal of anxious attention. In the summer of 1858, circulars were extensively dist ibuted, informing parishioners of the state of the law with regard to vaccination, and of the places where the operation would be performed for their children. In October, I addressed a letter to the Board of Directors, calling their attention to the Public Health Act of 1858, and inviting them to appoint officers to put in force the laws relating to vaccination. Mr. Bennett, the public vaccinator, and the Overseers, were accordingly appointed. I believe that these gentlemen have enquired into the circumstances attending all cases of small-pox that have come under their notice, but that they have met with no case in which it appeared to them advisable to enforce the provisions of the Compulsory Vaccination Acts, 30 I take this opportunity of making my acknowledgments to the Board of Directors, for their acquiescence in my proposal, and of assuring them that the facilities for obtaining information, peculiar to the Medical Officer of Health, shall be very much at their service. The following analyses of water, made during the year, may be added to those given in a former annual report. The water from the pump in King's Arms Yard, supplied from the New River Company, but believed to be contaminated from the position of the tank underground, was analysed in March, 1859, with the following result. For the sake of comparison 1 have given the mean of two analyses of the same Company's water made bv Dr. R. D. Thomson in December and January:— Water of New River. Hardness ° or grains per gallon. Solid Impurities, grains per gallon Temporary Permanent. Total. Organic. Inorganic. Total. King's Arms Yard tank 8.1 6.5 140.6 1.76 19.44 21.20 Mean of samples examined by Dr. R. D. Thomson — — — 1.66 19.28 20.94 Hence the inference was, that in spite of its objectionable situation, the water of this tank had not become notably contaminated. Two of the public pumps of the district, have, on my advice, been closed for all purposes but watering the roads; they are the pumps in Denmark Street, near St. Giles's Church, and that in Broad Street. Former analysis of these waters had shown their great impurity, and in March last, the wells not having been used during the winter, the impurities were found to have accumulated. On opening the wells for watering the roads, in the spring, it was a question whether the water was good enough for this purpose. That of both wells was offensive to the smell, and in Broad Street was of a deep olive-green colour, from the abundance of vegetable life. On analysis, this latter well-water yielded 10.12 grs. organic; 96.12 grs. inorganic; total 106.24grs. of solid impurity per gallon, including the suspended and dissolved portions together. Facts such as these continually presenting themselves, in corroboration of the opinion formerly expressed of the unfitness of these well waters for internal use, induced the Sanitary Committee, at their meeting in March, 1859, to give their active sympathy to the movement in favour of the erection of Free Drinking Fountains in the metropolis. This Committee instructed the Medical Officer of Health and the Surveyor, to prepare a report on the most appropriate sites for such fountains, and on the best mode of supplying them with pure water. Though not strictly within the year which it is now my business to consider, it may be stated that such a report has been presented, and that the Board have decided to adopt its main suggestions. The munificence of individuals, the co-operation of the Metropolitan Free Drinking Fountains' Association, and the honest ardour of working men in aiding the cause, are matters too pleasant for their record to be delayed. In these various ways, there will be borne a very large share of the cost of establishing Free Drinking Fountains in St. Giles's. 31 In conclusion, Gentlemen, it is my grateful duty to acknowledge the ality and confidence which I continue to experience from your Board. The permanent appointment of a special Sanitary Inspector, and the adoption of the various measures which have been enumerated, are proofs of the earnest and increasing attention that you are bestowing upon the public health of your district. To the Sanitary Committee my more especial acknowledgements are due; but I feel that any thanks of mine would only weaken the testimony to their untiring zeal, which is afforded by the facts of this report. I rely confidently on a continuance of your active co-operation, until we have placed St. Giles's in the position, as to healthiness, which it should occupy among the districts of London. GEORGE BUCHANAN, B.A., M.D., Londin., Lic. Roy. Coll. of Physicians, Medical Officer of Healh. 75, Gower Street, June 14th, 1859. APPENDIX TABLE I.— Mortality per Thousand in London, in the Divisions of London, and in St. Giles, in 1857, and in preceding Years. Note.— The numbers are computed on the population of the period named, and comparison made throughout from the printed returns of the Registrar General. Mean of Ten years, 1847 to 1857. 1857, corrected to 365¼ days. 1858. Similarly corrected. London 24.46 22.20 23.56 West Districts.—(Kensington, Chelsea, St. George, Hanover-square, Westminster, St. Martins, St. James) 22.76 20.81 21.77 North Districts.—(Marylebone, Hampstead, Pancras, Islington, Hackney) 22.15 21.22 22.48 Central Districts — (St. Giles's, Strand, Holborn, Clerkenwell, St. Luke, East London, West London, London City) 24.35 22.93 23.16 East Districts.— Shoreditch, Bethnal Green, Whitechapel, St. George's East, Stepney, Poplar) 25.84 24.35 25.30 South Districts.—(St. Saviour, St. Olave Bermondsey, St. George, Southwark, Newington, Lambeth, Wandsworth, Camberwell, Rotherhithe, Greenwich, Lewisham). 26.28 21.60 24.26 St. Giles's 26.89 26.58 24.89 TABLE II.— Deaths in Hospitals among Patients brought from St. Giles's and neighbouring Districts, 1858. Districts. Total ascertained Deaths in London Hospls. King's College Hospl. (Strand.) Middlesex Hospl. (Marylebone.) Charing Cross Hospl. (St Martins) University College Hospl.(St.Pancras) Children's Hospl. (Holborn.) St. Bartholomew's Hospl. W(London ) Royal Free Hospl. (St. Pancras.) London FeverHosp (Islington.) Westminster Hospl (Westminster.) St. Mary's Hospl. (Paddington.) Deaths in Hospls. out of the district. St. Pancras 191 7 42 4 74 14 17 21 12 ... ... 96 St. Marylebone 170 4 58 3 11 1 3 2 13 ... 75* 112 Metropolis 3094 169 189 95 150 62 575 89 105 ... ... • • • Holborn 70 15 5 0 1 8 29 5 7 ... ... 62 Strand 97 56 17 12 1 2 4 2 3 ... ... 41 St. Martin's 37 11 2 22 0 0 0 0 0 2* ... 15 St. Giles's 71 18 18 14 10 4 6 1 0 ... ... 71 The figures in the above table were obtained by personal inspection of the books of the several Hospitals, with the exception of those marked with a star, and for these I have to thank Dr. Thomson and Mr. Beale, the Officers of Health of the respective districts. TABLE III.— Causes of Deaths in St. Giles's, 1858, with the Ages at Death. Class. Causes of Death. At all Ages. Under 2 years. 2 and under 5. 5 and under l0. 10 and under 20. 20 and under 30. 30 and under 40. 40 and under 50. 50 and under 60. 60 and under 70. 70 and under 80. 80 and under 90. 90 and upwards. All causes 1402 450 153 60 57 104 83 113 124 126 78 48 6 Specified causes 1386 442 152 59 57 103 83 113 122 123 78 48 6 (Classes.) I. Zymotic Diseases 284 112 81 32 17 15 4 7 6 9 ... 1 ... II. Constitutional „ 317 46 28 8 19 55 48 54 41 16 2 ... ... III. Local „ 578 175 36 15 12 30 25 46 70 89 63 17 ... IV. Developmental „ 158 93 3 ... 1 2 4 ... 1 7 13 28 6 v. Violent Deaths 49 16 4 4 8 1 2 6 4 2 ... 2 ... (Orders.) I. 1. Miasmatic Diseases 263 102 79 32 17 13 2 5 3 9 ... 1 ... 2. Enthetic „ 8 6 1 ... ... ... ... ... 1 ... ... ... ... 3. Dietic „ 10 2 ... ... ... 2 2 2 2 ... ... ... ... 4. Parasitic „ 3 2 1 ... ... ... ... ... ... ... ... ... ... II. 1. Diathetic „ 39 ... 4 ... ... 4 3 14 6 6 2 ... ... 2. Tubercular „ 278 46 24 8 19 51 45 40 35 10 ... ... ... III. 1. Diseases of Nervous System 149 61 9 3 1 9 7 9 12 21 11 6 ... 2. „ of Organs of Circulation 59 ... 1 2 2 8 2 13 10 16 4 1 ... 3. „ of Respiratory Organs 292 110 26 7 4 6 9 10 34 37 42 7 ... 4. „ of Digestive Organs 58 4 ... 3 5 4 4 11 11 10 3 3 ... 5. „ of Urinary Organs 12 ... ... ... ... 2 1 ... 2 5 2 ... ... 6. „ of Organs of Generation 5 ... ... ... ... ... 2 3 ... ... ... ... ... 7. „ of Organs of Locomotion 2 ... ... ... ... 1 ... ... ... ... 1 ... ... 8. „ of Integumentary System 1 ... ... ... ... ... ... ... 1 ... ... ... ... IV. 1. Dev. Diseases of Children 40 40 ... ... ... ... ... ... ... ... ... ... ... „ of Adults 6 ... ... ... ... 2 4 ... ... ... ... ... ... „ of Old People 55 ... ... ... ... ... ... ... 1 7 13 28 6 4. Diseases of Nutrition 57 53 3 ... 1 ... ... ... ... ... ... ... ... V. 1. Accident or Negligence 45 16 4 4 8 1 1 4 4 1 ... 2 ... 3. Homicide ... ... ... ... ... ... ... ... ... ... ... ... ... 4. Suicide 4 ... ... ... ... ... 1 2 ... 1 ... ... ... 5. Execution ... ... ... ... ... ... ... ... ... ... ... ... ... Violent Deaths not classed ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Deaths, cause unascertained 3 2 1 ... ... ... ... ... ... ... ... ... ... Causes not specified 13 6 ... 1 ... 1 ... ... 2 3 ... ... ... TABLE III.—(continued.) Class. Causes of Death. At all Ages. Under 2 years. 2 and under 5. 5 and under 10 10 and under 20. 20 and under 39. 30 and 1 under 40.' 40 and under 50 50 and under 60 60 and under 70. 70 and under 80. 80 and under 90. 90 and upwards. 4. Ascites 7 ... ... 1 ... 1 ... 2 ... 1 1 1 ... 5. Ulceration of Intes. 2 ... ... ... 1 ... ... ... ... ... 1 ... ... 6. Hernia 2 ... ... ... ... ... ... ... 1 1 ... ... ... 7. Ileus 3 ... ... ... 1 ... 1 ... 1 ... ... ... ... 8. Intussusception 2 1 ... ... ... ... ... ... 1 ... ... ... ... 9. Strict. of Intestines. 2 ... ... ... ... ... ... ... 1 ... ... ... ... 10. Fistula 4 ... ... ... ... 1 ... ... 1 1 1 ... ... 11. Stom. Disease, &c. 11 1 ... ... 1 ... ... 4 1 3 ... ... ... 12. Pancreas Disease. ... ... ... ... ... ... ... ... ... ... ... ... ... 13. Hepatitis 1 ... ... ... ... ... ... ... ... 1 ... ... ... 14. Jaundice 2 1 ... ... ... ... ... ... 1 ... ... ... ... 15. Liver Disease, &c. 10 ... ... ... ... ... 1 4 3 2 ... ... ... 16. Spleen Disease &c. 1 ... ... ... ... ... ... ... 1 ... ... ... ... Order 5. 1. Nephritis 1 ... ... ... ... ... ... ... 1 ... 1 ... ... 2. Ischuria ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Nephria 4 ... ... ... ... 1 i ... 1 ... 1 ... ... 4. Diabetes 1 ... ... ... ... ... ... ... ... 1 ... ... ... 5. Stone ... ... ... ... ... ... ... ... ... ... ... ... ... 6. Cystitis l ... ... ... ... ... ... ... ... ... ... ... ... 7. Kidney Disease &c. 5 ... ... ... ... l ... ... ... 3 1 ... ... Order 6. 1. Ovarian Dropsy 2 ... ... ... ... ... 1 1 ... ... ... ... ... 2. Uterus Disease, &c. 3 ... ... ... ... ... 1 2 ... ... ... ... ... Order 7. 1. Arthritis ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Joint Disease, &c. 2 ... ... ... ... 1 ... ... ... ... 1 ... ... Order 8. 1. Phlegmon 1 ... ... ... ... ... ... ... 1 ... ... ... ... 2. Ulcer ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Skin Disease, &c. ... ... ... ... ... ... ... ... ... ... ... ... ... IV. Order 1. 1. Premature Birth 22 22 ... ... ... ... ... ... ... ... ... ... ... 2. Cyanosis 3 3 ... ... ... ... ... ... ... ... ... ... ... 3. Spina Bifida ... ... ... ... ... ... ... ... ... ... ... ... ... 4.Other Malformations 2 2 ... ... ... ... ... ... ... ... ... ... ... 5. Teething 13 13 ... ... ... ... ... ... ... ... ... ... ... Order 2. 1. Paramenia ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Childbirth see Metria 6 ... ... ... ... 2 4 ... ... ... ... ... ... Order 3. 1. Old Age 55 ... ... ... ... ... ... ... 1 7 13 28 6 Order 4. 1. Atrophy & Debility. 57 53 3 ... 1 ... ... ... ... ... ... ... ... V. Order 1. (Accident or Negligence) 1. Fractures & Contu. 9 ... 1 ... 1 ... 1 2 2 1 ... 1 ... 2. Wounds 1 ... ... ... ... 1 ... ... ... ... ... ... ... 3. Burns & Scalds 19 2 3 4 6 ... ... 2 2 ... ... ... ... 4. Poison 1 1 ... ... ... ... ... ... ... ... ... ... ... 5. Drowning ... ... ... ... ... ... ... ... ... ... ... ... ... 6. Suffocation 13 13 ... ... ... ... ... ... .. ... ... ... ... 7. Otherwise 2 ... ... ... 1 ... ... ... ... ... ... 1 ... Order 3. (Homicide.) 1. Murder and Manslaughter ... ... ... ... ... ... ... ... ... ... ... ... ... Order 4. (Suicide.) 1. Wounds Gunshot, 1 ... ... ... ... ... 1 ... ... ... ... ... ... Cut, Stab 1 ... ... ... ... ... ... ... ... 1 ... ... ... 2. Poison 1 ... ... ... ... ... ... 1 ... ... ... ... ... 3. Drowning ... ... ... ... ... ... ... ... ... ... ... ... 4. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... 5. Otherwise 1 ... ... ... ... ... ... 1 ... ... ... ... ... Order 5. (Execution.) 1. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... Violent Deaths (not classed) ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Deaths (Cause unascertained) 3 2 1 ... ... ... ... ... ... ... ... ... ... Causes not specified or ill-defined 13 6 ... 1 ... 1 ... ... 2 3 ... ... ... TABLE III.—(continued.) Class. Causes of Death. At all Ages. Under 2 years. 2 and under 5. 5 and under 10. 10 and under 20. 20 and under 30. | 30 and | under 40. 40 and under 50 50 and under 60. 60 and under 70. 70 and under 80. 80 and under 90. 90 and upwards. I. Order 1. 1. Small Pox 7 3 2 ... ... 2 ... ... ... ... ... .. ... 2. Measles 25 15 9 1 ... ... ... ... ... ... ... ... ... 3. Scarlatina 81 17 37 18 7 ... ... 1 ... ... ... 1 ... 4. Quinsy 2 1 ... 1 ... ... ... ... ... ... ... ... ... 5 Croup 10 2 8 ... ... ... ... ... ... ... ... ... ... 6. Whooping Cough 51 30 15 6 ... ... ... ... ... ... ... ... ... 7. Typhus & Infte.Fvr. 33 1 2 5 8 9 ... 1 1 6 ... ... ... 8. Erysipelas 5 1 ... ... ... ... 1 1 ... 2 ... ... ... 9. Metria ... ... ... ... ... ... ... ... ... ... ... ... ... 10. Carbuncle 1 ... ... ... ... ... ... 1 ... ... ... ... ... 11. Influenza ... ... ... ... ... ... ... ... ... ... ... ... ... 12. Dysentery 3 ... 1 ... ... ... ... 1 1 ... ... ... ... 13. Diarrhœa 35 29 3 ... ... 1 1 ... ... 1 ... ... ... 14. Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... 15. Ague ... ... ... ... ... ... ... ... ... ... ... ... ... 16. Remittent Fever 6 3 2 1 ... ... ... ... ... ... ... ... ... 17. Rheumatism 4 ... ... ... 2 1 ... ... 1 ... ... ... ... Order 2. 1. Syphilis 8 6 1 ... ... ... ... ... 1 ... ... ... ... 2. Stricture of Urethra ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Hydrophobia ... ... ... ... ... ... ... ... ... ... ... ... ... 4. Glanders ... ... ... ... ... ... ... ... ... ... ... ... ... Order 3. 1. Privation ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Want ofBreast-milk 2 2 ... ... ... ... ... ... ... ... ... ... ... 3. Purpura and Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... 4. Alcoholism— a Del Tremens 5 ... ... ... ... 1 2 1 1 ... ... ... ... b Intemperance. 3 ... ... ... ... 1 ... 1 1 ... ... ... ... Order 4. 1. Thrush 2 2 ... ... ... ... ... ... ... ... ... ... ... 2. Worms, &c 1 ... 1 ... ... ... ... ... ... ... ... ... ... II. Order 1. 1. Gout ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Dropsy 9 ... 2 ... ... 1 ... 4 ... 1 1 ... ... 3. Cancer 26 ... 1 ... ... 2 3 8 6 5 1 ... ... 4. Noma 1 ... ... ... ... 1 ... ... ... ... ... ... ... 5. Mortification 3 ... 1 ... ... ... ... 2 ... ... ... ... ... Order 2. 1. Scrofula 5 2 1 ... ... 1 1 ... ... ... ... ... ... 2. Tabes Mesenterica 18 10 7 1 ... ... ... ... ... ... ... ... ... 3. Phthisis 218 10 8 3 18 50 44 40 35 10 ... ... ... 4. Hydrocephalus 37 24 8 4 1 ... ... ... ... ... ... ... ... III. Order 1. 1. Cephalitis 14 4 4 1 ... 3 1 ... ... 1 ... ... ... 2 Apoplexy 30 ... ... ... ... ... 3 4 5 9 5 4 ... 3. Paralysis 26 ... ... ... ... 1 2 1 7 8 6 1 ... 4. Insanity ... ... ... ... ... ... ... ... ... ... ... ... ... 5. Chorea ... ... ... ... ... ... ... ... ... ... ... ... ... 6. Epilesy 10 ... 2 ... ... 5 ... 1 ... 1 ... 1 ... 7. Convulsions 58 55 2 1 ... ... ... ... ... ... ... ... ... 8. Brain Disease &c. 11 2 1 1 1 ... 1 3 ... 2 ... ... ... Order 2. 1. Pericarditis 5 ... ... 1 ... 1 ... ... 1 2 ... ... ... 2. Aneurism 5 ... ... ... ... 1 1 1 ... 1 1 ... ... 3. Heart Disease &c. 49 ... 1 1 2 6 I 12 9 13 3 1 ... Order 3. 1. Laryngitis 6 3 1 ... ... ... 2 ... ... ... ... ... ... 2. Bronchitis 149 26 6 l 1 3 4 5 25 34 39 5 ... 3. Pleurisy 3 ... ... 2 1 ... ... ... ... ... ... ... ... 4. Pneumonia 121 78 19 3 2 3 2 5 5 2 1 1 ... 5. Asthma 5 ... ... ... ... ... ... ... 2 1 2 ... ... 6. Lung Disease, &c. 8 3 ... 1 ... ... 1 ... 2 ... ... 1 ... Order 4. 1. Gastritis 2 1 ... 1 ... ... ... ... ... ... ... ... ... 2. Enteritis 2 ... ... ... 1 ... 1 ... ... ... ... ... ... 3. Peritonitis 7 ... ... 1 1 2 1 1 ... 1 ... ... ... TABLE IV.— Comparison of Mortality from various causes in London and in St. Giles's. Four Quarters, 1858. Class. Classes and Orders of Disease. first Quarter. Second Quarter. Third Quarter. Fourth Quarter. London. St. Giles. London. St. Giles. London. St. Giles. London. St. Giles. Estimated Quota. Actual Number. Estimated Quota. Actual Number, Estimated Quota. Actual Number. Estimated Quota. Actual Number All causes 17308 346.2 379 14541 290.8 295 14345 286.9 284 17688 353.8 373 Specified causes 17042 340.8 374 14376 287.5 289 14160 283.2 282 17449 349.0 371 (Classes.) I. Zymotic Diseases 3382 67.7 46 3604 72.1 45 5032 100.6 90 4686 93.8 95 II. Constitutional 3251 65.0 93 3187 63.7 75 2785 55.7 60 3086 61.7 69 III. Local 7992 159.8 186 5377 107.5 113 4153 83.1 84 7531 150.6 162 IV. Developmental „ 1965 39.3 41 1715 34.3 38 1690 33.8 45 1675 33.5 33 V. Violent Deaths 452 9.0 8 493 9.9 18 500 10.0 3 471 9.4 12 (Orders.) I. 1. Miasmatic Diseases 3114 62.3 38 3358 67.2 39 4688 93.8 88 4394 87.9 91 2. Enthelic „ 75 1.5 3 77 1.5 2 65 1.3 1 88 1.8 2 3. Dictic „ 155 3.1 3 140 2.8 4 217 4.3 ... 158 3.2 2 4 Parasitic „ 38 .8 2 29 .6 ... 62 1.2 1 46 .9 ... II. 1 Diathetic „ 580 11.6 10 517 10.7 8 491 9.8 6 574 11.5 8 2. Tubercular „ 2671 53.4 83 2650 53.0 67 2294 45.9 54 2512 50.2 61 III. 1. Dis. of Nervous System 1817 36.3 40 1572 31.4 31 1461 29.2 31 1721 34.4 43 2. „ Organs of Circulation 723 14.5 14 554 11.1 13 544 10.9 8 700 14.0 14 3. „ Respiratory Organs 4140 88.8 115 2226 44.5 52 1167 23.3 24 4075 81.5 91 4. „ Digestive ditto 631 12.6 13 632 12.7 12 668 13.4 19 642 12.8 10 5. „ Urinary ditto 210 4.3 1 217 4.3 3 179 3.6 2 219 4.4 2 6. „ Organs of Generation 54 1.1 2 60 1.2 2 40 .8 ... 51 1.0 1 7. „ „ Locomotion 42 .8 1 56 1.1 ... 44 .9 ... 40 .8 ... 8. „ Integumentary System 69 1.4 ... 60 1.2 ... 50 1.0 ... 83 1.7 1 IV. 1. Dev. Dip. of Children 467 9.3 13 464 9.3 12 405 8.1 9 435 8.7 6 2. „ „ Adults 63 1.3 1 62 1.2 ... 74 1.5 1 71 1.4 4 3. „ „ Old People 804 16.1 17 598 12.0 12 466 9.3 16 545 10.9 10 4. Diseases of Nutrition 631 12.6 10 591 11.8 14 745 14.9 19 624 12.5 13 V. 1. Accident 401 8.0 7 413 8.3 18 412 8.3 3 396 7.9 10 4. Suicide 39 .8 1 69 14 ... 67 1.3 ... 63 1.3 2 All other Violent Deaths 12 .2 ... 11 .2 ... 21 .4 ... 12 .2 ... Sudden Deaths 138 2.8 ... 113 2.3 3 86 1.7 ... 139 2.8 ... Cause unspecified 128 2.6 5 52 1.0 3 99 2.0 2 100 2.0 2 Certain-Special Diseases I.1 Small Pox 41 .8 ... 34 .7 1 54 1.1 4 118 2.4 2 Measles 714 14.3 2 679 13.6 1 466 9.3 7 524 10.5 15 Scarlatina 473 9.5 7 588 11.8 12 1243 24.8 22 1814 36.3 29 Diphtheritis 3 2 2 2 Whooping Cough 757 15.1 10 870 17.4 7 514 10.3 12 559 11.2 22 Diarrhœa 152 3.0 2 316 6.3 8 1391 27.8 20 234 4.7 5 Typhus & other Fev. continued and remittent 444 8.9 9 432 8.6 6 518 10.4 10 602 12.0 10 TABLE V.— Registered Deaths in 52 Weeks of 1858. Sub-Districts of St. Giles's Deaths in Sub-Districts. [Population, 1851.] First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Whole Year, 1858. M. F. M. F. M. F. M. F. M. F. Both Sexes. St George, Bloomsbury. [16807] 37 41 38 46 39 34 39 43 153 164 317 St. Giles's South. [19951.] 91 91 60 63 62 56 93 96 306 306 612 St. Giles's, North. [17456.] 53 66 51 37 47 46 48 54 199 203 402 Whole District. [54214.] 181 198 149 146 148 136 180 193 658 673 1331 TABLE VI-- Registered Births in 52 Weeks of 1858. Sub-Districts of St. Giles's. Births in Sub-Districts, First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Whole Year, 1858. M. F. M. F. M. F. M. F. M. F. Total Childn St. George, Bloomsbury 73 54 38 24 51 52 51 60 213 190 403 St. Giles's South 94 92 102 96 100 83 85 65 381 336 717 St. Giles's, North 83 79 76 59 63 62 70 65 292 265 557 Whole District 250 225 216 179 214 197 206 190 886 791 1677 Appendix VII to Report of Medical Officer of Health: 1859. OVERCROWDED HOUSES. CAUTION 10 OWNERS & OCCUPIERS OF HOUSES WITHIN THE SAINT GILES'S DISTRICT. The Board op Works for the above District, desire to direct the attention of Landlords of Houses to the state of the Law with regard to Overcrowded Hodses, and to a recent decision of the Magistrates thereon. By the Nuisances Removal Act, (18 & 19 Vict, cap 121, s. 29,) it is provided, that 29. " Whenever the Medical Officer of Health, if there be one, or if none, whenever Two qualified Medical Practitioners shall certify to the Local Authority that any House is so overcrowded as to be dangerous or prejudicial to the Health of the Inhabitants, and the Inhabitants shall consist of more than one family, the Local Authority shall cause proceedings to be taken before the Justices to abate such overcrowding, and the Justices shall thereupon make such order as they may think fit, and the person permitting such overcrowding shall forfeit a sum not exceeding Forty Shillings." It is held by the Magistrates that any House occupied by more than One Family, and not being a Common Lodging liouse under the supervision of the Police, is overcrowded within the meaning of this Act, if the cubic space available for each inmate fall short of Jour hundred eubic feet. The Board desire it to be well understood, and they hereby give Notice, that in all such cases of overcrowding, they intend to take proceedings before the Magistrates without other warning, in order to abate such overcrowding and to recover penalties. Any information on this subject can be obtained by applying to the Surveyor, or the Sanitary Inspector, between the hours of Nine and Ten, a.m., at the Office of the Board, Stone Yard, 199, Holborn. By order of the Board, i 1th day of January, 1859. ROBERT FINNIS, Clerk. Note,—As an illustration of the space required, it may be observed that a room 16 feet long, by 15 feet wide, by 10 feet high (16 X 15 X 10 gives 2400 cubic feet) cannot lawfully be occupied by more than Six persons ; and that a Room 15 feet long by 10 feet wide by 8 feet high (15 X 10 X 8 gives 1200 cubic feet) cannot lawfully be occupied by more than Three persons. Two Children, under the age of 12, are allowed to count as one person.