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A DECADE OF PUBLIC HEALTH WORK INTHE ADMINISTRATIVE COUNTY

OF LONDON.

I. WE have received from the medical officer of health of the

administrative county of London a copy of his ninth annual ,report, which contains, in addition to an elaborate set ofstatistical tables with appropriate comments relating to theyear 1900, a carefully written and most interesting history ofsanitary administration in the metropolis during the firstcomplete decade of the County Council’s existence-a periodwhich corresponds with the last 10 years of the nineteenth.century.

Were we writing for Londoners alone we should at once proceed with our notice of this report, but inasmuch I.as so many of our readers reside outside the metro-

politan area, and are consequently less familiar than our-selves with sanitary progress in London, we think it well to- preface our review of the document before us with the

following explanatory remarks.The London County Council was constituted by Act of

Parliament in the year 1868, and under the guidance of anillustrious chairman the first elected members of that bodypromptly set themselves to lay the foundation of that vast.administrative system which has its present centre at

,Spring-gardens, and which ever since that year they haveincessantly laboured to perfect for the benefit of their fellow-citizens.At this stage it will be useful to recall the fact that up to

the year 1888 the sanitary government of London had been.distributed among 43 vestries, each of which exercised itsfunctions (or refused to exercise them) according to its ownwill, exclusively and without regard to the welfare of.adjoining districts and, indeed, without regard to the generalwelfare of the metropolis. Consequently, epidemics were freeto spread from one metropolitan district to another simply- from lack of suitable coördinating and supervisory machinerysuch as it is the principal function of a county authority to.supply. Although for certain purposes of self-governmentLondon is subdivided under many independent authorities,nevertheless it is obvious that from a public health stand-point it must be regarded as one vast community, no part ofwhich can suffer, either from epidemic visitation or from:sanitary shortcomings, without imminent danger to all its’other parts.From the nature of the case it will readily be understood

that many important preliminaries had to be arranged beforethe County Council could with propriety address itselfto the formation of a public health department which shouldfully satisfy the requirements of London. For it is obviousthat in order to meet such requirements a central healthdepartment must be so constituted that by successive de-velopments it may be adapted to supervise, and where neces-sary to control, the sanitary functions of the various localbodies within its jurisdiction as supreme authority. Accord- Iingly it was not until late in the year 1889 that the CountyCouncil took its first and most important step in thisdirection by appointing a superintendent medical officer of..health.

On his appointment Mr. Shirlev F. Murphy was unprovidedeither with office accommodation or with clerical staff.

Terhaps fortunately’for him, he was left to construct the newdepartment mainly according to his own judgment, the

inecessary medical and clerical assistants and other requisites,for the conduct of business being furnished at his specialrequest. From the firt his constant care has been to culti-vate friendly relations with the local medical officers in

.charge of the 43 districts of the county, and by degrees hehas built up what is practically an intelligence departmentor central bureau, to which communications may be.addressed by his local medical colleagues, and from which theymay derive expert advice or assistance in cases of difficultyor doubt.

It is only necessary to refer to the interesting series ofreports already issued from Spring-gardens in order to showhow completely Mr. Shirlev Murphy has succeeded in his’projects, as well as to indicate the thoroughly practicalcharacter of the work which is being done in connexion with

the central bureau by the county medical officer of healthand his able staff of professional assistants.Coming now to an examination of Mr. Shirley Murphy’s

annual report for 1900, we find that as it is the latest so alsoit is in many respects the most interesting of the series ofwhich it forms the ninth number. That this should be so isnot surprising when we reflect that it treats of the health andsanitary condition of the largest urban community in theworld-not for a single year only but for an entire decennium.The administrative county of London is not only the largest ;it is likewise, from a sanitary standpoint, the most perfectlyequipped urban community of which we have knowledge.For more than 10 years past it has enjoyed the protection ofcompulsory powers for the notification of infectious diseasesupplemented by a very complete system of hospital pro-vision for the infectious sick. The arrangements forthe isolation of small-pox are perhaps the most perfect atpresent existing within the British isles, for, instead of

being treated in hospitals where they may readily becomea source of danger to others, the small-pox patients areremoved to hospital ships moored in the estuary of theThames and at a safe distance from human habitations.London is divided into a large number of sanitary areas,each possessing its own medical officer of health and acomplete sanitary staff, and so great is the importance whichnow attaches to accuracy of statistical method that for 10years past every death occurring in a hospital, either inLondon or in a Metropolitan Asylums Board establishmentin the suburbs, has been referred in the registers to the areain which the patient or inmate originally resided. Mr.Shirley Murphy therefore enjoys exceptional advantages forthe preparation of trust worthy vital statistics and for the com-pilation of sanitary reports, and we think that he has availedhimself of those advantages very fully.

In the present report the annual rates of birth, marriage.sickness, and death for each year of the last decennium areset forth in great detail, the rates having been carefullvcorrected by the help of the census returns of populationrecently published. As in the earlier reports, so in the

present, the statistical tables relate to the old sanitarydistricts of London. As a matter of fact, these district,ceased to exist and were replaced by the new metropolitanboroughs on Nov. 9th, 1900, but for the purposes of this

report it was obviously impracticable to do otherwise thanassume that the old sanitary areas had continued in existenceup to the end of the year.

In the county of London as a whole the rate of increase ofthe population has rapidlv declined during the last 30 years;in the decennium 1871-80 the rate of increase had been 17.4 per cent., in the following decennium it fell to 10’4 per cent.,and in the decennium just completed the increase did notexceed 7 ’4 per cent..The space at our disposal will not admit of our following

Mr. Shirley Murphy in his detailed examination of the metro-politan general death-rates for the year 1900 ; but we maynote that the mean mortality of London during the de-cennium just completed was below that of 1881-90 at all

periods of life from infancy to old age. Mr. Shirley Murphyreproduces a table, given in previous reports, by which heshows the mean annual number of deaths occurring in 1891-1900, as compared with the annual number that would haveoccurred had the death-rates of the previous decennium beenmaintained throughout 1891-1900. The number of lives

gained and the number of lives lost at the several ages inthe later period are also shown. This gain or loss is expressedin terms of "life capital," the figures being obtained byapplying the mean future life time " values, as ascertainedfrom a London life table, to the number of lives gainedor lost at each age-group. According to this calculationwe find that in the 10 years 1891-1900, as compared withthe previous decennium, there accrued a saving of 3664 livesper annum, representing an annual salvage of 118,483 yearsof life capital. It is, however, important to observe thatthis reduction in the mortality has by no means beenmanifested in the death-rate from all causes alike. Thus.for example, there has been in the later decennium, as com-pared with the earlier, a marked increase in the death ratefrom diphtheria, cancer, and influenza, and a slight increasein the death-rates from a few other causes. On the otherhand, there has been marked reduction in the mortality fromphthisis and also from non-tuberculous respiratory diseasesand diseases of the nervous system, as well as a less stronglymarked decrease in the death-rates from several othercauses. Perhaps the most important of these changes for

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the worse is that which concerns that terrible malady lcancer, the death-rate from which has increased during the Ilast decennium by little less than 27 per cent. As His I

Majesty the King has publicly expressed a desire that thequestion of the causation of cancer should be investigated by i

competent persons, with a view, if possible, of checking its 1

ravages, we can only express our astonishment that the iGovernment has not as yet taken active steps with thisobject in view.There is no single test of the healthiness of a com-

munity which is so generally trustworthy as that furnishedby the rate of infantile mortality-i.e., the death-rate ofchildren under one year of age in each 1000 registeredbirths. Infant life is peculiarly sensitive to the sort ofinsanitary conditioos which generally abound in greatcentres of population. It is accordingly satisfactory to findfrom the present reporr, that throughout the decennium

ending with the year 1900 London experienced the lowestinfantile mortality of any of the principal Englith townssave one-viz., Bristol, which has enjoyed an enviable

notor:ety in regard to low infant mortality for many pistyea’s. During the year 1900 the eastern group of metro-politan districts suffered the highest infantile mortality-namely, 175 per 1000 births ; the northern group experiencedthe lowest, 145 per 1000 ; whilst the southern, the central,md the western groups experienced a rate of 158 per 1000.Among individual sanitary districts Holborn showed the

highest rate (240 per 1000) and Hampstead the lowest ra’e-viz., 100.

THE SANITARY CONDITION OF LEICESTERINFIRMARY.

As the result of a joint conference between the weeklyboard and the honorary medical staff of the LeicesterInfirmary with respect to the recommendations of ProfessorW. H. Corfield as to the sanitary condition of the institution 1a report has just been issued of the decisions arrived at ]and it will be presented at the quarterly meeting of the

governors to be held next week. The report candidly admitsthat the central block of the infirmary is old and structurallyunsuitable for hospital wards, but urges that it is capable ofconversion for administrative purposes. In regard to thewards the members of the conference agree with Pro-fessor Corfield that "certain re-arrangements and improve-ments are required," and that "the building would be

greatly improved for the purposes of a hospital if it weredivided into sections by means of cross-ventilated lobbies,as suggested in the plan prepared by Mr. Pick." " The

report states that the members of the conference agreewith Professor Corfield’s recommendations in reference tothe nurses’ bedrooms-that the nurses should be providedwith a separate building- as." adds the report, "entireseparation from the wards must be beneficial to thehealth of the nurses." The report also supports ProfessorCorfield’s recommendations for separate accommodation forinfectious cases and for the out-patient department. In

regard to the latter Professor Corfield stated that a separatebuilding for out-patients "would considerably lessen theintroduction of infection into the infirmary." With regard tothe infirmary building in general Professor Corfield reportedthat " the floors are in most cases old and much worn " andthat they required to be replaced with new ones, or coveredwith a parquet flooring, but the report of the confer-ence points out that although in many parts of the house thefloors require renewal none of the wooden floors are olderthan 1862, except possibly in the central block. Dealing withthe question of the sanitary annexes and offices the reportstates that a a personal inspection of the various annexes andoffices throughout the building shows that with the exceptionof St. Mary’s Ward all the water-closets and slop-sinks areeither new or have been renewed within the last 10 years.In most cases the iron and lead sinks in the ward scullerieshave been replaced by sanitary earthenware ones, and theold baths have been replaced by new ones and others havebeen added. The particular pattern of the water-closetapparatus now in use has ’been called in question in thereports, but expert opinion appears to be divided as to therelative superiority of ’wash-downs’ and wa8h-out;;,’ somemodern institutions preferring one and some the other.

In each case much depends upon their being properly fixedand receiving systematic attention. The same remarkapplies to the question of ’tip-up’ wash-basins." The"borough pattern" " gully-traps. largely in use at theinfirmary, are strongly disapproved of by Professor Corfield,but, adds the report, they have some distinct advantagesfor hospital purposes. Coming to the most important part,of Professor Corfiel<l’s report-the state of the drains ofthe infirmary-the report says that the drains, bothinternal and external, have been carefullv tested, and inseveral cases faults have been discovered in the latter,and later investigation has disclosed that some of thesefaults were due to imperfect workmanship in fitting thedrain-pipes to the iron outlets of the traps, thus allowing theescape otf smells not through, but by the side of, the traps.There can be little doubt that in this way the atmosphere ofthe wards has from time to time been vitiated. The upperlength of the drain most responsible for this state of thingshas already been entirely removed. Cases of imperfect con--nexion between iron and earthenware pipes were found intwo instances on the western side of the building, which mayhave contaminated the hot-water duct near the nurses’

dining-room windows. The escape from these faulty cor-nexions has doubtless been injurious to the sanitary conditionof the house, and instructions have been given to test, andif necessary to re-set, the whole of the gully-traps aroundthe infirmary, and also to put additional ventilation pipeson the eastern block as recommended by Professor Cor-field, and to make any other minor alterations in the

existing upper connecting drain - pipes which may be

thought advisable. The gully-traps have been regularlyexamined and cleansed and their satisfactory conditionhas been reported on from time to time at the weekly meet-ings. The drains have been systematically and thoroughlyflushed. Those in immediate connexion with the buildingsare receiving, and will continue to receive, careful attention.Sufficient cause has not been shown to justify Professor Cor-field’s opinion that the whole of the present drainagearrangements must be condemned and removed entirely andnew rlrains laid on concrete ...... preferably throughout ofheavy iron pipes, coated inside and outside with Dr. AngusSmith’s solution and having the joints caulked with metalliclead.’ This could only be carried out at a great expanse cwhich urgent need alone would justify." The concludingportion of the report of the joint conference sets out inbrief the recommendations made by Professor Corfieldand states that although doubtless many alterationsand additions are desirable the weekly board and thegovernors will have to consider what is most urgent andreally practicable, for to carry out the recommendationsenumerated would entail an expenditure far in excess of anyfunds at present at disposal. The surgical staff havingcalled attention to the utter inadequacy of the presentoperating theatre and the great difficulties under whichthe important and critical work of that c1epartment jf’carried on, the weekly board have ordered plans to be

prepared for a new surgical wing, to comprise all the

arrangements and appliances that the experience ofthe most modern hospitals has proved to be valuable.These plans have been adopted and the work is now

making rapid progress. The new wing will contain twooperating theatres (with anaesthetic, sterilising, and nurses’rooms), a waiting hall, a new surgery and two examinationrooms adjoining, a dispensary and ample store-room, a roomfor special night cases, a sitting-room and bedrooms for thehouse surgeon and resident surgical staff, an entrance hall,a clerk’s office, a porter’s room, and sanitary and other

requisite accommodation. The cost of the new wing will beabout R 12,000.

ASYLUM REPORTS.

The Retreat, I-or7. (Annnal Report for 1900).-The YorkRetreat was founded early in the nineteenth century by theSociety of Friends for the care and treatment of insanepatients and is one of the oldest institutions for the treat-ment of mental disease in England. The average number ofpatients resident during the year was 162 and comprisecl60 males and 102 females. The admissions during the yearamounted to 39-viz., 17 males and 22 females. Of these,31 were first admissions. Dr. Bedford Pierce, the medical

I superintendent, states in his report that from a miancial