Sanitary progress during the last twenty-five years-and in the next

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SANITARY PROGRESS DURING THE LAST TWENTY-FIVE YEARS--AND IN THE NEXT. BY 5. SPOTTISWOODE CAMERON, M.D., B.Sc, Medical Officer of Health of the City of Leeds, President of the Society. ~ENTLEMEN,

The altogether unexpected honour which you conferred upon him at your last meeting I)3' choosing him as your President for the year has compelled the person so highly honoured to inquire of himself as to what he might have done to earn a distinction which he values so highly. Modesty, unfortunately, compels him to the conclusion that it is chiefly because mere lapse of time has promoted him to a position amongst the senior medical officers of health in the country. While, therefore, thanking you for the honour which you have thus done to the branch to which he belongs, to the town in which he works, and to himself personally, it has occurred to him that it might not be inappropriate if he were to ask your consideration for a short time of some of those points connected with the sanitary progress of the country which have necessarily come under his personal observation in the quarter of a century during which he has been officially connected with the department of public health. When, in the autumn of 1877, the Council of the borough of Huddersfield chose me as their medical officer of health, I found myself acting for a comparatively young borough, which had received its incorporation so recently as 1868. One of the main factors inducing some seven or eight local boards, who had formerly exercised jurisdiction in the same area, to combine and ask the Queen to make them into a borough was the desire of procuring a better water-supply. The Improvement District of Huddersfield, placed by an Act of 1848 under the control of Commissioners, lay entirely within the township bearing the same name, and along with the remainder of that township obtained for the time being a fairly sufficient water-supply from the springs and streams on the side of Scapegoat Hill, Longwood. This water was sufficiently hard to give a coating of lime-salts to the inside of the lead service pipes, and sufficiently soft to form a good domestic supply. Coming as most of it did from springs in the hill side, and as surface water from a sparsely inhabited district, it was looked upon as fairly pure. It had, however, been necessary, as the

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district increased in population, to supplement the original supplies by tapping springs and conducting them to subordinate tanks, and occasionally collecting a larger proportion of the surface water than was altogether desirable. In one or two of the other districts limited water-works existed. But with a large manufacturing area and an increasing population, it was felt desirable to go further afield for supplies; and the amalgamation of the districts was followed at a short interval by an Improvement Act and a Waterworks Act. This activity is typical of a like activity in regard to the same matter in other towns. Notification and Isolation of I~fectious Disease.--In 1877 I found myself, amongst other things, one of the two medical officers of health in whose districts compulsory notification of disease was enforced. We had also a small Fever Hospital, adapted from buildings deserted by the Guardians of the Huddersfield township when they erected their larger workhouse for the Union. The usability of part of this building as a temporary small-pox hospital it had been my duty a few years earlier, at the request of the overseers, to report upon when small-pox was prevalent in the new borough. The outbreak of small-pox in 1879, had been followed in tIuddersfield, as in other towns, by the desire to isolate cases in hospital, and the possession of a temporary building for that purpose had suggested, when the outbreak passed away, the use of the extemporized hospital for the isolation of other infective diseases. Of the two towns which at that time had compulsory notification, ttuddersfield had thus a somewhat small, but at the same time not unworkable, hospital, while Bolton had none at all. On the other hand, while Bolton had no hospital, it required the dual notification of every case of certain infectious diseases, but Ituddersfield was content in the first instance with asking for the notification by the householder of such cases of these diseases as were in the opinion of the medical man in attendance insufficiently isolated. Some curious difficulties arose from this provision. A form had been prescribed in the Act for a certificate, which the medical practitioner was to hand to the guardian of the child to forward to the authority. One medical man was confronted with the fact that no such certificate had been received by the authority in a case where it was undoubtedly necessary, and it turned out that he had given the certificate, but that the parents had not forwarded it. The inconvenience to this practitioner was sufficiently obvious. The sanitary inspector informed me of another case where, as he alleged, the medical man in attendance told the parents that unless

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they could pay him half a crown for his visit he would be compelled to notify the case as without proper lodging or accommodation~ which it certainly was. An even more troublesome class of case was illustrated by the following: The child of a milk-dealer was attacked by scarlet fever. The mother washed the cans and nursed the child. The medical man did not notify on the ground that the room in which the patient lay was a large one and that he had it to himself. These cases were, of course, exceptional, and as a rule medical men were anxious to assist me in every way. They themselves, however, soon found the inconvenience of having to be the judges as to whether their patients ought or ought not to be removed, and were anxious in most cases to shift this responsibility from their own shoulders to mine. Accordingly, when in 1880 we went again to Parliament we obtained, with the consent of the medical practitioners in the town, who had opposed it in that form in the original Act of 1876, what was practically the dual notification. Two modifications in the proposed clause were made, either by Parliament or in the Council, which I did not altogether approve of. One of these made the practitioner directly responsible for sending the certificate ; the other reduced the fee for notification from 2s. 6d. to ls. Although Ituddersfield and Bolton led, in the course of a few years a very large number, chiefly of manufacturing towns, followed suit, and by 1886 very many towns with a very large population had adopted the compulsory notification of disease. In 1889 the Government proposed the present Notification Act, which was made in the first instance compulsory in London, and adoptable by any other urban, rural, or port sanitary district. Since that time a further Act of 1899 has made the notification of infectious disease necessary throughout the country. The extension of notification to various towns was not carried out without a considerable amount of opposition. One gentleman proved conclusively to his own satisfaction that the result of notification was to increase the number of cases of, and the mortality from, notifiable diseases in the towns where Acts existed. That the value of his statistical researches was not regarded as very great is shown by the circumstance that the Local Government fathered the Act of 1889, and approved of the one of ten years later. Isolation Hospitals.--One great benefit which resulted from notification was the impression it produced upon the authorities where it was enforced of the necessity of providing a larger amount of

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accommodation for the separating of such eases. As already said, even amongst those towns which had urged the necessity of notification, the provision for isolation was very meagre. The almost universal result of the adoption of notification was the demand for more accommodation of this kind. Again, in the close of the eighties and in the beginning of the nineties, small-pox reasserted itself even in vaccinated communities, and again the urgency of dealing with cases of this disease produced a crop of temporary hospitals, some of which were retained when the outbreak passed away for the isolation of other infectious diseases. These were, however, seldom so good as hospitals deliberately built to supply the need of ordinary fever accommodation. The Isolation Hospitals Act of 1893 has furthered greatly the provision of hospitals of this latter kind by enabling County Councils to secure the combination of small districts to this end. Retu~m Cases of Scarlet Fever.--But the inevitable reaction has set in, and there are statisticians at the present day who are prepared to prove tha~ the natural effect of hospitals for the isolation of scarlet fever is to increase, rather than to diminish, the amount of the disease. Like all oppositions, while the retarding influence of these views is probably not inconsiderable, the probability is that the direction of attention strongly to what are commonly called return eases must result in the improvement of our methods of dealing with those interned. It seems not improbable that many of these so-called return cases are the result of actual infection from the patient himself after his return home. A few of them are probably due to the difficulty of insuring the complete disinfection of the articles at home which have been in contact with the patient before his removal, and which in some cases are put away till his return, on the supposition that they have not been exposed to infection. A not inconsiderable number are probably due to infection from outside; for the mere fact that a patient has been removed to hospital does not protect other members of his family from infection from without. Is it not also possible that there may in a few cases have been some inefficiency in the disinfection at the time of discharge ? Most hospitals are now provided with a steam disinfecting apparatus. It was not so in 1877; but even a steam apparatus does not necessarily insure efficient disinfection of clothing. Another danger to be guarded against lies in the home-going, especially of young children, and in the redressing of the little patient. The nurse who receives him from the bath and dresses him in uninfected garments should have no communication with

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the nurse who takes him to the bath and undresses him there. This is not always easy to secure. After allowing, however, for these outside causes, there probably remain a small number of cases in which the infection is actually conveyed by the convalescent, and it seems not improbable that a child living for six weeks in an infected atmosphere may carry in his nasal sinuses, in discharges from the ear, or throat, the materies morbi of scarlatina. My own experience leads me to think that in the great majority of cases where a fresh infection has occurred there has been some slight discharge from nose, ears, or throat, or even occasionally from a broken-down pimple, which may have been the efficient cause of the infection. If the streptococcus of Klein be the same as the streptococcus conglomeratus of Kurth, and be the efficient cause of scarlet fever, then Klein's researches and those of Dr. Gordon seem to indicate that it is to these discharges rather than to the desquamating cuticle that we must look for the cause of the disease. A cultivation of this bacterium in such uncleansed discharges is not impossible. The conditions under which the patient lives at home are often such as to reinduce a catarrh which had entirely disappeared before he left hospital, and, if this be so,-is it not the natural thing to remove the patient from the infected wards for some weeks before his return home; to place him in healthy conditions, as much exposed as possible in the open air; to repeatedly disinfect his clothes during this period of quarantine; and to pay special attention to the sterilization of the aural, nasal, pharyngeal, and buccal membranes? This method of isolation before discharge was attempted--so far as the accommodation at my command allowed-in Huddersfield during the middle and later years of the 1881.90 decade. My successors, Dr. Kaye and Dr. Annis, I believe, continued the practice. Disinfection.--The evolution of the disinfecting apparatus during the last quarter of a century is not without interest. A stove much in favour in the North of England in the earlier portion of the period was an iron chest with a weighted lid, manufactured by Nelson of Leeds. Underneath was a row of gas-jets, which, by directly heating the bottom and, by conduction, the sides, secured, by radiation, a very high temperature of the air and articles in the chest. A wire netting a few inches from the heated bottom and hooks on movable bars near the top were used for protecting and suspending infected articles. A thermometer was supplied, and it was usual to insist that it should register a temperature of 220 ° F. There was some danger where the air of the chamber was heated

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to this amount that articles within a short distance of the radiating floor and sides might be scorched, and there was a considerable danger that the attendant, who would in that case be blamed for carelessness, might sometimes contrive to escape such blame altogether by the simple process of not heating the chamber to the required degree. The inequalities in the temperature in the different parts of the oven were minimized by the hot-air apparatus of Dr. Ranson, of Nottingham ; but it was largely to Mr. Washington Lyon that we are indebted for a convenient apparatus for disinfection by steam. The advantages of steam over hot air for disinfection of certain suitable classes of articles are that the danger of burning is entirely removed, and that the period of exposure is considerably lessened. An unfortunate use or misuse of the word "superheated" in regard to the steam used in this machine indicates a possibility of danger. If Mr. Washington Lyon really superheated his steam--by which I mean increased its temperature after it had been removed from immediate contact with the water from which it was generated--he would have produced a gas with conducting powers not very dissimilar from those of air at the same temperature. It is not superheated steam, but saturated steam, which is required for rapid disinfection, and it is only as the molecule of steam in becoming water gives up its latent heat to the article with which it is brought into contact that steam as a disinfecting agent has any great advantage in this respect. Another danger--and it is the one which was specially in my mind in speaking of inefficient disinfection--is that the air may not have been entirely expelled from the apparatus, and that the penetrating power of the partly gaseous and partly vaporous contents may be less than that of pure saturated steam. The failure of Koch to destroy bacteria in a Papin's digester is thus accounted for. The operator has therefore not only to see that his steam is saturated steam, not superheated, but he has to secure an entire absence of air from the chamber. If this be done, it is better, I think, to use the steam under pressure, as a higher temperature in the infected articles is thereby secured; but i t is safer to use current steam than to risk the interference of residual air. There is no practical difficulty in having current steam along with increased pressure. Confidence in chemical disinfectants has varied considerably during the quarter of a century. Personally I was much inclined in 1877 to trust to oxidizing agents, such as Condy's fluid, but the great wave of influence in favour of the phenol compounds carried

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one away with it. One of your late Presidents, Dr. Seaton, impressed me long ago with the necessity--which I have preached ever since--of securing intimate mixture of the disinfectant with an infected motion and of keeping them some time in contact. At that time, as I have already said, I used permanganate of potash in preference to any other disinfectant. When I began to use so-called carbolic acid, I was struck at once with the danger of hardening--or, if you like, cauterizing--seybalous motions and leaving protected germs within uninfluenced by the chemical. For this purpose, following Dr. Seaton, I impressed upon all with whom I came in contact the necessity of breaking up the masses in a sufficiently dilute solution and keeping the discharge in contact with the disinfectant for some length of time. A serious outbreak of typhoid in the autumn of 1880 (due, as I afterwards found, to a pollution of a tributary carrying a small quantity of water to one of our distributing tanks) led me to investigate very carefully the influence of tubs in which the excreta from cottage-houses in Huddersfield were collected, and I was at the time inclined to regard them as in part the cause of the spread of the disease. A further consideration, however, led me to think that they had not much to do with the outbreak, but suggested the desirability of having special tubs, specially coloured, to receive the motions of such typhoid patients as were left at home. Accordingly, a large number of tubs were painted red, and one of these was sent to every house at which a typhoid or doubtful typhoid case was being treated. The tub was charged with a 10 per cent. solution of a crude carbolic acid, and the nurse was directed, after having disinfected the motion in the manner already described, and left it for some time in the vessel, to empty the whole of the contents of the latter into the tub. An air-tight lid, fitted with a rubber ring, pressed strongly by a curved lever upon the wrought-iron lid of the tub, and made the latter air-tight and water-tight. When the tub was removed it was again charged with a further quantity of disinfecting solution, and set aside in the sanitary yard to stand for a week before its contents were mixed with the general refuse of the town. On coming to Leeds, where destructors were in full working order, the same system was adopted, but the contents of the tubs were sent at once to the destructor. Owing to the greater timidity of the Leeds public, we had, after a few months' use of the tubs, to substitute a green for a red paint. With these changes the system of collecting the typhoid motions from the houses continues in Leeds, although the tub system is not in general use in the town.

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The choice of disinfectants already spoken of is not unimportant. The experiments of Koch and others led many of us t o doubt the value of carbolic acid as a disinfectant, although it seemed probable that the higher homologues of phenol, and perhaps some of their metameric comrades, were more efficacious. It is probably these higher homologues and their allies that are chiefly present in the commercial carbolic acid. I am credibly informed that what is called " p u r e commercial carbolic acid" contains practically none of the crystalline phenol. It is the oily acid from which all the true carbolic acid has been crystallized out which is sold under this name, and it consists largely of a mixture of cresylic and higher carbon so-called acids, and only remote traces of the primary phenol to which it owes its name. Numerous other preparations are now on the market, many of which have a more powerful germicidal effect than carbolic acid ; but I submit for your consideration whether we are not on the wrong tack in introducing in any large quantities into our sewers a powerful germicide. Any strong oxidizing agent--and I am inclined to think that few, if any, surpass our old friend chloride of lime--will kill the bacteria with which it is brought into contact, if sufficient time be given it; but having been brought into relation with an oxidizable material, it presently exhausts itself, and when it gets to the sewer has little or no restraining influence upon the other bacteria naturally found there. After all, is not this what we want ?--immediate action upon the peccant germ sufficiently strong to kill him, but dying with his death, and not interfering with the harmless bacteria in the sewage into which it is afterwards introduced. We cannot disinfect a sewer any more than we can disinfect a cesspool, but can we not to a very large extent keep the bacillus typhosus out of both ? The Study of Germs.--In 1877 the doctrine of a contagi:um viwm was not exactly a modern one, but it belonged to the region of hypothesis. The researches of Pasteur, the epoch-making work of Lister, and the exact and careful study of wound infection by Koch, prepared the way for many enthusiastic workers in the field of bacteriology. Koch's own rigid demonstration of the necessity of his bacillus for the production of tubercle, and his use of solid media for cultivation, led to much progress in this direction, and it is during these twenty-five years that it has been successfully demonstrated that the presence of Eberth's bacillus typhosus, Koch's Comma bacillus, and the Klebs-L5f~er bacillus are respectively necessary antecedents to enteric fever, cholera, and diphtheria. Klein's streptococcus scarlatince and some others may still be considered as being on their trial, but it may now be confidently asserted that

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in these diseases, as well as in relapsing fever, tetanus, erysipelas, and several other maladies, a definite bacterium is the essential cause of the disease. Still more recently infection by protozoa parasitic in insects has been shown to be capable of causing malaria and yellow fever, and larger hopes of grappling with these diseases now that their chief, if not their only, cause is known, can be reasonably entertained. The examination of potable waters bacteriologically promises great things for preventive medicine, while the harnessing of the beneficent bacteria to the work of splitting up the wastes from our cities adds a new element of usefulness to this portion of botanical science. Bacteriological Examination of the Sources of our Water-supplies. - - I have already said that the desire for a more extensive and purer water-supply was one of the principal causes in inducing certain local authorities to form themselves into a single borough. This, it was true, was earlier than the period I have selected for consideration, but during that period many large towns have acquired rights for collecting water over great areas of the country, and have presented Bills to Parliament to that end. The controlling influence of that High Court has been on the whole wisely and fairly exercised, but many of us doubtless feel that some central co-ordinating influence ought to be at work in controlling the selection of gathering grounds, and that some central Board might with advantage take cognizance, if not absolute possession, of the unappropriated areas capable of being utilized for the watersupply of our great towns. There has been a growing tendency in connection with watersupply, especially from catchment areas, to pay greater attention to the numerous small pollutions which are apt to occur in these districts. The Town Council of Torquay have acquired the absolute possession of the greater portion of their catchment area on Dartmoor. The Leeds Corporation are at present acquiring the absolute possession of a great part of their gathering ground in the Washbourn Valley. It is also becoming the frequent practice to supplement the chemical examination of waters by a bacteriological one; but I fear we are a long way yet from requiring, not only that the water in the tap shall not be so grossly polluted as to yield positive chemical and bacteriological evidences of the same, but that the contributory rills shall individually pass this test. It is exceedingly difficult to convince the public, and even the members of water committees, that negative evidence of pollution of a large supply proves little or nothing. The continued presence of typhoid in London, and even

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in those northern towns where waters naturally purer are used, suggests very strongly that there may be polluting influences at work. Such pollutions are not, in all probability, usually sufficiently concentrated to produce the disease in persons of normal resisting power, but where--say from the partial failure of a filtering bed-a local increase in the number of bacilli has occurred., and particularly where such accident has carried them to specially susceptible individuals, may they not account for some of those sporadic cases of typhoid which are seldom absent from our large towns ?

Infautile Diarrheea.--The continuance of diarrhoea in cities, notwithstanding the greater attention given to sanitation, is a serious matter. In trying to account for it several possibilities present themselves. In the first place the term used is not a definite one, and though during the whole of the quarter of a century in review the efforts of the Registrar-General have been directed to securing from practitioners the return of all deaths from this complaint which should come under the zymotic category, there is still a great deal of difference on the part of practitioners in the certifying of death from this disease. On the whole, probably the tendency has been rather during these years to include more and more correctly under this heading the cases which properly belong to it. If this be so, an apparent increase in the deaths might be to some extent discounted. There has not been, however, any such marked improvement in the mortality, from all causes, of children under one year, estimated by the ratio of deaths at this age to births, as would lead one to suppose that this circumstance entirely accounts for the continued amount of the disease in our death returns. The diminution in the birth-rate, which has been going on since 1874, suggested to me in 1886, when considering the matter in Huddersfield, where the change was, even at that time, very marked, the possibility that the apparent non-diminution, if n o t actual increase, in infantile mortality measured per thousand births might be in part accounted for by the fact that the diminution in the birth-rate was to some extent due to the postponement amongst the middle class and the more intelligent of the working classes of the age of marriage, throwing the responsibility for an increased proportion of the births which took place upon the less provident classes, whose care for the nurture of the children they bring into the world is often inversely proportionate to the readiness with which they continue to produce them. But even this mode of looking at the matter would not altogether account for t h e

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apparently non-diminished death.rate per thousand of the estimated population in many of our large towns. One active member of our Society, Dr. Waldo, now coroner for the City of London, has insisted strongly upon the importance of animal deposits in the streets as a cause of summer diarrhoea. We are all, I think, agreed that high temperature and drought, when together, are factors in increasing mortality from this cause. A cool and wet summer such as we have had this year, such as we had also in 1877, is usually attended by a low autumn death-rate, the saving of life from this special cause conducing largely to the result. It is difficult, however, to think that the scavenging of our streets is worse now than it was five-and-twenty years ago. It is possible, perhaps, that the increased traffic in the central districts of our large towns, the extension of our absorbent wooden pavements, and during the few special dry summers the restrictions placed upon the free use of water for scavenging purposes, may together have had a good deal to do with the continuance of this opprobrium of sanitary administration. One cannot shut one's eyes to the further possibility that, as towns grow in size and the distances which milk has to be conveyed to the consumer increase, there is some danger of the milk-supply being older, of putrefactive changes in it having commenced, or, where that has been prevented by artificial means, of poisonous drugs having been used to secure this end. Preservatives in Food.--The increased use of preservatives in articles of diet has been the subject of a very thorough inquiry by a Departmental Commission. Our means of preserving foods from putrefaction without the use of chemicals are greater than they ever were, but the addition of poisonous chemicals to our foodsupplies appears to be continually on the increase. Disposal of Sewage.--The disposal of sewage during the last fifteen years has become a much more important subject with sanitary authorities than formerly. There can be very little doubt, especially in the manufacturing districts, that the pollution of streams flowing through large centres by the sewage and manufacturing effluents of towns above is a serious cause of illhealth i~ the riverine populations of these communities. Fortuna~ely, owing to the action of county councils, river boards, and local authorities, much is now being done to lessen this evil, but the process seems to many of us, living in the towns described, exceedingly slow. The work, however, of Dibdin, of Cameron, of Whittaker, and of others, will, it is to be hoped, before long bear more abundant fruit than has yet been possible. But again comes in the great question of vested interests. When we see towns like

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Bradford and Leeds defeated in Parliament in promoting sanitary schemes to secure the treatment of their sewage by the opposition of landowners, many of whom would actually benefit by the improvement brought about in the stream flowing through their land, some of us wish that the High Court of Parliament would ~eonsider the advantages of the public a little more and the prejudices of proprietors a little less. There are other points indicating progress which perhaps it is only necessary to hint at. Since 1875 there have been several small additions to our legislative powers. There have been, of course, a large number of decisions modifying our views of powers already existing, and amongst these none more confusing and none more absurd from a sanitary point of view than those dealing with the difference between sewers and drains. This matter may possibly be referred to again. House.to-House Examination.--One department of our work has been gradually more thoroughly carried out. Although the Public Health Act, 1875, following the Sanitary Act of 1866, requires that every authority shall make from time to time inspection of their distric~ for the detection of nuisances, the opinion yet lingers in some remote places that it is only the duty of the inspector to go where he is sent for. Some colour is lent to this position by the fact that compulsory inspection can only be enforced on a declaration in oath. But compulsory entry is not the usual practice of inspectors, and most large towns now make a systematic inspection of dwellings, house to house, street to street, the inspector taking note of the conditions as to ventilation and overcrowding, cleanliness of the rooms, the state of the drains (which are usually tested in some way), and the presence or absence of neighbouring nuisances. Notification of infectious disease gave us occasion to visit many houses which migh~ not otherwise have been examined, and the raison d'etre of the examination was usually sufficient to satisfy the occupiers. But in places where a systematic examination of houses has been carried on the occupier is generally pleased, rather than otherwise, that the Sanitary Authority should take the trouble to satisfy themselves that his house is in a healthy condition, instead of waiting till some disease or manifest nuisance declares that it is not. Enlightenment of PuSlic Opinion.--But of all the forces which have contributed to sanitary progress, during the quarter of a century we are considering, by far the most powerful has been that of an intelligent public opinion. Penal legislation in advance of public opinion is largely inoperative. Had the Public Health Act

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of 1875 been passed a century earlier, many of its enactments would have remained a dead-letter. It was the cholera scares of 1830 and 1832 which produced the first real Public Health Act, that of 1848, and the large mass of local legislation which took place from 1840 onwards, and which gave rise to the various Improvement Clauses Acts of 1846 to 1848. The Health of Towns Commission helped to guide public opinion in the right direction, The Common Lodging-Houses Acts of 1851 and 1853, the Disease Prevention and the Nuisance Removal Acts of 1855, were followed by an important Administration Act in 1858, amended in 1861 and 1863, by which populous places were enabled to secure for themselves a measure of local government. The Sanitary Acts of 1866, 1868, and 1870, were followed by the important Public Health Act of 1872, the effect of which was to place every part of the country under the care of an urban or rural authority, and to provide that every authority should have the advice of a medical officer of health. Other officers had existed before, but, except in the Metropolis and in a few large towns, the medical officer of health did not exist till 1872. We are apt in the country to date the commencement of the modern sanitary period from 1875, when, so far as the English provinces were concerned, the Acts I have already mentioned were consolidated into one great Public Health Act. While outbreaks of cholera, as has been said, led to a strengthening of our legislative powers, the drawing of public attention to sanitary matters by the serious illness of His Majesty the King, when Prince of Wales, had a most powerful effect in increasing the vigilance of sanitary authorities. For weeks the whole nation waited breathless for the daily bulletins as to the condition of the Prince, and a great sigh of relief went up throughout the whole land when at length these became more and more reassuring. The great object-lesson presented to the nation by the illness of the heir-apparent had a most powerful effect in bringing ink) line laggards within the sanitary authorities, and strengthening the hands of those less apathetic. But the great moving force was that of a more and more educated public opinion. The fact that men were appointed to administer sanitary powers was often an education to these men themselves, and the very existence of the Sanitary Acts has been one of the most powerful influences in creating the sanitary administrator. The extension of the franchise in large towns, followed by the Education Act, has gradually educated the electors to demand the enforcement of sanitary legislation by their representatives on the local authorities. At first the progress was more

November, 1902]

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rapid in the large towns, most of which had already administrative machinery, and in many of which capable sanitary inspectors already existed ; but in the smaller districts much apathy prevailed. The stimulating effect, however, of the County Councils, formed after the Act of 1888, and the energizing influence of the extension of the franchise in the smaller urban and in the rural sanitary districts by the Act of 1894, have still further increased the rate of progress throughout the land; nor has the legislation creating sanitary officers been without effect upon ourselves. The clause in the 1888 Act requiring a health qualification for medical officers in large districts has stimulated the scientific study of hygiene in the schools. The action of the Sanitary Institute in pressing upon authorities the desirability of requiring some examination test of their inspectors has resulted in the legal requirement of such a test for the Metropolitan boroughs. The influence of the Sanitary Institute and of the l~oyal Institute of Public Health in promoting conferences throughout the country has been of great benefit, notwithstanding that the almost immediate result was the extinction of the Social Science Congress, which had to a large extent covered some of the same ground. The practice, originated I believe by the Royal Institute, but followed almost immediately by the older Sanitary Institute, of getting the Mayors of the towns in which the conference was to be held to officially invite authorities throughout the country to take part in the autumn congress has been attended with the best results. Esoteric teaching in sanitary matters may have a certain value. There are many points which it is desirable to discuss almest in camera in societies like our own. The more important scientific developments are likely to be best matured by work in laboratories and discussion in professional conclaves; but the great force of public opinion must be trained by the bringing together of the practical administrators and the sanitary exponents of hygiene. The immense interest shown by members of sanitary authorities in the discussions in the municipal section at Exeter and Manchester this autumn, the interesting contributions which many of these laymen have made in other sections of the conference, not less, perhaps, than the friendly chats on practical points in the corridors of the colleges and in the smoke-rooms of the hotels, have done much to make common property of knowledge which might have otherwise remained more or less professional--to smooth over difficulties of administration and to stimulate our desire for further progress. Lessened D e a t h . r a t e . - - Y o u will ask, Is there any means of measuring the progress of this quarter of a century ? T h e most 6

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ordinary mode of doing so is by comparing the rates of mortality. From the last decennial report of the l~egistrar-General I find that in the decennium 1841-1850 the death-rate in England and Wales was 22 per thousand. In the following decennium, 1851-1860, it was again 9.2 per thousand. In the ten years following, 1861-1870, the mortality in round numbers was again 22 per thousand--that is, for the thirty years, 1840 to 1870, the mortality in England and Wales remained persistently 92 per thousand. In other words, there was one death in every 45½ of the inhabitants every year. During the decennium 1871-1880 the rate fell to 21"3 ; during the following decennium, 1881-1890, to 19"1 ; and during the decennium just concluded, ~hat for 1891-1900, it has been 18"1 ; the average for the three decennia being 19"5 deaths per thousand, or 1 death in every 51¼ persons. Put in another way, the death-rate in the last thirty years has been more than 11 per cent. lower than in t h e previous thirty. Since these words were written, however, through the kindness of Dr. Tatham, I have been able to obtain the figures to one decimal place for every quinquennium since 1851, and these - - a s they enable me to compare the rate in the last twenty-five years of the past century with the twenty-five immediately preceeding t h e m - - I print in the accompanying ~able. Table showing the Annual Mortality at all Ages per 1,000 Persons living during each Five.year Period of the Latter Half of the Last Century, and the Mortality amongst Infants under One Year of Age per 1,000 Children born in each Similar Period. Years included.

at all Agesper 1,000 Living.

Deaths

Deathsunder One Year per 1,000 Births,

1851-1855 1856-1860 1861-1865 1865-1870 1870-1875

22"7 21"8 22 "6 22 "4 22"0 Average 9,2"3

157 152 151 157 153 Average 154

1876-1880 1881-1885 1886-1890 1891-1895 1896-1900

20"8 19 "4 18"9 18 "7 17"7 Average 19"1

144 139 145 151 156 Average 147

I am indebted to my friend Dr. Tatham for the quinquennial rates, which he has kindly himself calculated for me for the purposes of this address.

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It will be noticed, on comparing these rates, that in the five quinquennia, from 1851 to 1875, the rate only in one of these periods fell below 22, and that the average of the five was 22"3. On the other hand, in the five succeeding quinquennia, from 1876 to 1900, the concluding quarter of the nineteenth century, in only one of these periods was the rate above 20, and the average of the whole five was 19"1, four points below that of the thirty years' period just given. In comparing these twenty-five years with the twenty-five which immediately preceded them, the improvement is therefore one of more than ]4 per cent. Not only is the actual improvement one of 14 per cent., but every successive quinquennium has shown a rate lower than that which preceded it. I have already mentioned the subject of infantile mortality. I am again indebted to my friend Dr. Tatham for the mortality of children under one year during this same half-century, estimating in each case the number of deaths at this age to a thousand children born. I have placed these figures in the same table, and you will again notice that the mortality has been considerably less during the second as compared with the earlier period of twenty-five years. Dut~ng the five periods of five years each, from 1851 to 1875, the rate was only once so low as 151. During the second period, from 1876 to 1900, in only two lustra did it reach that number. The average of the five earlier quinquennia was 154 per thousand, of the five later 147, an improvement of a little Iess than 5 per cent. The remarks already made on the subject of infantile diarrhoea, and in relation to the diminished birth-rate, are borne out by these figures, which I received after those remarks were written. It must be remembered, however, that in a small group of years a single cause, like that of diarrhoea, may by its presence or its absence determine to a large extent the mortality at a limited age, and it is probable that the two or three dry, warm summers of the latest lustrum have to some extent accounted for the higher rate of infantile mortality during that period. It might, however, be urged that this improvement in the rate with a diminished birth-rate is to some extent fallacious. In the last two decennial reports Dr. Ogle and Dr. Tatham have furnished us with life-tables, which are comparable with those prepared by Dr. Farr from the statistics of the years 1838-54. Doubtless in due course we shall have from Dr. Tatham a new life-table based upon the data in the most recent censuses and the mortality returns in the intercensal permd; but this laborious work will naturally not be completed for some little time. Meantime a comparison between the life.tables last published and those of Dr. Farr, 6--2

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although not covering exactly the period of our retrospect, is worth making. A diagram has been worked out from these life-tables which shows graphically the excess of persons living according to the rates of mortality at each age period during the decennium 1881-90, and the period 1838-54, for which Dr. Fart's original life.table was constructed. This table may, perhaps, require a few words of explanation. The 1,000 persons are supposed in each case to be born at the same time, and the period of comparison might be supposed to consist of 100 years. During that hundred years the C h a r t s h o w i n g the Survivors out of 1,000 C h i l d r e n born at t h e End of Each Five Y e a r s according to t h e Life.table of Dr. Farrin Solid, and of Dr. T a t h a m O u t l i n e d . ooo

tO 15 20 25 30 32; 40 4~ 50 5S 60 63 ";0 "~ 8 0 8~ SO 9 5

t000

9oo

9oo

8oo

8oo

qoo

"too

6oO

ooo 4oo

400

3OO

3o0

0

Q

The dotted line in the last three colums represents the survivors according to Dr. F a r r ' s table, the solid black being the smaller number of survivors . according to the 1881-90 returns.

rates of mortality at the several age groups are supposed to be those prevailing between 1881-90 in the one case, and 1888-54 in the other. At the end of each five years' period in each case a certain number survive, and it will be noticed that the numbers surviving when the mortality is estimated at the rates which obtained in the middle of the quarter of a century we are considering are greater at each age period up to eigh~y-five than of those who would have survived out of the same number born had the rates been those existing in the earlier part of the century. At the very close of the table, indeed, it will be noticed that the lines cross, * and that there See note to ehar~.

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are fewer survivals in the later decades amongst the very old persons at the rates now obtaining; but (1) it will be noticed that this change does not take place until the age period eighty-five to ninety--that is, till after the most active period of life--and (2) it may. be sur. raised R a t the accuracy with which the age of old persons is stated is much greater now than it was in the earlier part of the century, and the tendency to exaggerate the longevity of survivors less.

THE NEXT TWENTY-FIVBYEARS. When thesecretary asked me to give him the subject of my address, having already decided to review the sanitary progress of the period we have been considering, and to forecast, if possible, what might be hoped for in the next twenty-five years, I found a little difficulty in putting the title of the paper into anything like epigrammatic form. The difficulty was that I could not find a Saxon word corresponding with retrospect. Forecast has a sort of Saxon flavour. The rootword, if not Saxon, at least belongs to the Teutonic family, and I began to wonder whether the difficulty of finding a corresponding word suggesting a look back was because our Teutonic forefathers were always so engaged with the present and the future that it was not worth their while to find a word for dealing with the immediate past. If this be so, perhaps I may have myself been guilty of dwelling too much upon the " h a s been," and shall hasten at once to complete my paper with a short anticipation of what " m a y be." Public Opinion with Us.--There is good ground for hoping that public opinion, which has become recently so much more enlightened in sanitary matters, will continue to enforce upon our rulers 4he necessity for progress. Five-and-twenty years ago, when notification was first made compulsory in Huddersfield, it was often most difficult to persuade parents to allow their children to be sent into hospital. In most of our large towns we have now changed all that. For many years past my difficulty has not been to persuade parents to send their children to us for isolation, but to ~ d room for the cases where the demand for isolation came from the parent. Altho%h, in proportion to the size of the town, our hospital accommodation is greater in Leeds than it ever was, its insufficiency for the growing demands of the public has become year by year more manifest. What has occurred in Leeds is occurring in all large towns, and the possibility of carrying out these improvements is largely due to the pressure of public opinion. Are Hospitals Necessary ?--But it may be asked, Is the provision

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of extended hospital accommodation a necessary item of sanitary progress ? Is it not rather a sign of failure that we should have so many cases of illness to isolate ? The answer, I think, to this important question lies in the consideration of the fact that all infectious disease is due to two essential factors: the presence Of the poecant germ, and the condition of receptivity on the part of the individual. I do not myself see any immediate prospect of such an improvement in sanitary conditions as would insure that no child exposed to the contagion of scarlet fever should contract that disease. The chances of recovery are enormously increased by favourable sanitary surroundings. Probably, also, insanitary surroundings increase the infectivity of the poison ; but so long as the exigencies of civilized life bring large numbers of people 5n to a small area of land, so long as the necessities of education require the bringing together of many children into the limited area of schools, there will be a danger that this disease will spread amongst our juvenile population. There is no reason to think that any improved sanitary conditions that are likely to be present during tL~ next quarter of a century will so strengthen the health of the rising generation that they shall be insusceptible to the contagion of this disease, but it is perfectly possible to remove the contagion. This, however, is only possible, at least, in a working-class community where the isolation of the sick is promptly and efficiently carried out in hospital. The child of a working man--one of a family, say, of seven living in a four-roomed house--can hardly ever be efficiently isolated at home. To isolate such a child would mean the giving up to its use entirely one of the four rooms in the house, the separation of this room from a~rial communication with all the others, the telling off of a nurse to remain in this room, and the prohibition of communication between such nurse and any other member of the family. Even if an attempt to carry out this isolation be made, I do not think that any medical officer of health would advise that other children from that ~amily should attend school. This would mean the loss of educational advantages to these children for a period of at least two, and probably, if the thing was to be done thoroughly, at least three months. For I do not believe that the infectiveness of scarlet fever necessarily disappears at the end of that mysterious period, forty days. Not only is it desirable to keep the other children away from school, but it will be necessary to prevent their intercourse in the streets with the members of neighbouring families. Not only so, but is it safe to allow the father to assist in the distribution of goods from a warehouse, or the eldest daughter to engage in the manufacture

November, 1902]

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of ready-made clothes ? And yet these things are done. It is only, I contend, by the more complete isolation of cases of this disease that we can hope to lessen it, and it is only from an enlightened public opinion amongst the working class themselves, and a desire on their part to protect, not only other members of their own families, but the children of their neighbours, that we c a n hope to acquire a mastery over this disease. Even when all this is done, in order that we may stamp out scarlet fever, we must have in addition to the wards for undoubted cases of the disease a very much larger provision than has ever been thought of yet for doubtful cases. Most of you will agree with me that it is to the doubtful cases chiefly that the spread of scarlet fever is due, but if isolation be carried out more thoroughly in the undoubted cases, and the spread of the disease f r o m them prevented, there will be less difficulty in tracing back the infection of these cases to the doubtful ones, from which they have often sprung, than there is at present, when the disease in all its forms is so prevalent. I have already spoken on the subject of return cases, and how they might be almost, if not entirely, prevented. It seems to me that it is no less the duty of the authority to provide ample wards for convalescents than to supply the observation wards already spoken of. But this means a large immediate increase in our hospital accommodation. Once we acquire something like mastery over the disease, a smaller provision would probably suffice, but if we are to be able to do with the smaller provision in the future, we must have the larger provision now. If I may be allowed to repeat what I have years ago said elsewhere, I would add that there is no hospital so expensive as one too small for the needs of the community. Educate the Educators.--No~ only must we look to an enlightened public opinion to force the hands of the authorities in making the necessary accommodation for cases of fever, but, again, to quote from old reports, we must educate the educators. We must teach the teachers. The community "equires, and quite rightly, the attendance of every child at school. Some school authorities have discovered that by procuring the attendance of children below the compulsory age they can enormously increase their educating influence, but if children are to be brought together in large numbers, the older ones by compulsion, the younger ones by persuasion, it is the bounden duty of the school authorities to train the teachers, who stand to the children for the time being in loco parentis, to a recognition of the earlier symptoms of such diseases as measles, diphtheria, and scarlet fever. It should be as necessary

84

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for the teachers in charge of infant schools to be able to discern the earlier symptoms of these diseases amongst their little pupils as to know the multiplication table, and it ought to be as much a part of their training. Many teachers are conscientiously anxious to do their duty in this respect, but I fear their systematic training in these matters is absolutely nil. On the other hand, the difficulty of insuring anything like regular attendance, the readiness of parents to find excuse for absenteeism, and, above all, the pressure on their time, makes it exceedingly difficult even for the most anxious amongst the teachers to send home all children suffering from doubtful symptoms. Should there not be attached to every school a medical man, who should call as a matter of course within, say, about an hour of the morning assembly, and who should have statutory power to examine ~ny child about whose condition the teacher was suspicious? Were this a matter of daily routine, would not the attendances ut our elementary schools be considerbly increased by promptly sending home children with suspicious symptoms ? This might involve in some cases the dedication of a small room to the use of the medical officer, and in this room the suspected patient might, generally speaking, be allowed to wait until he called. Improved Disinfection.- A more enlightened public opinion should also assist in insuring more complete disinfection of infected articles. It has been already hinted that some of the so-called return cases may be due to the setting aside of articles infected at the time that the patient is removed. One conspicuous instance occurs to me. A small boy had a doll which he was allowed to nurse in the interval between his attack and his somewhat promp~ removal to hospital. After his return the doll was brought out of its drawer, and his little sister helped him to play with it, and a few days later developed scarlet fever. It is difficult i t present to get the public to understand that scarlet fever is infectious from the very momen~ of the attack. So much stress has been laid upon the subject of desquamation that an idea has become prevalent, even amongst medical men, that the later stages of scarlet fever are more infective than the earlier ones. It is possible that the convalescent may be more frequently the cause of infection; but the exposure of a susceptible person to contact with him for a certain definite period is less likely to cause the disease than a similar contact for a like time with a patient in the acute stage of the malady. Sunday clothes are often a grea~ difficulty. A child is taken slightly ill on Saturday morning; on Monday the rash comes out, and the doctor is sent for; but the

sovember, loo~

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Sunday clothes of the rest of the family are not disinfected, unless specially asked for by the officer in charge. The mother tells him, of course, that the rest of the family were never in contact with the child, and that the clothes they wore were never in the room with him, all of which she believes to be true, but she forgets. Inquiry Necessary,--In an appreciable number of cases, it must be admitted, the convalescent is himself the source of the infection. This matter is so important as influencing our action, and even the very continuance of the practice of isolation, that it cannot be passed over as indifferent. I have already hinted how I think such cases can be almost entirely prevented; but the matter is too important to be left to individual opinion. It is true that the London County Council have done something in the way of enquiring into this matter ; that the College of Physicians has been asked to make suggestions ; and that the medical staff of the Local Government Board have been carrying out bacteriological investigation upon this subject of return cases. In our own society the pros and cons have been very carefully gone into, and I suggest to you whether the time has not now arrived when we might, as a society, look into the whole question, asking a small committee of our members to undertake the collation and consideration of the facts. Much of the improvement that we may expect to see in the course of the next twenty-five years will depend upon our grappling thoroughly with the subject of infectious disease, and if it shall be proved upon unmistakable evidence that fever hospitals properly conducted promote, instead of diminish, the amount of infection, it will be our duty as medical officers of health to recommend their disuse. On the other hand, if it can be shown that there are means whereby these accidents can be reduced to a vanishingpoint, and diseases like scarlet fever postponed to a more resisting period of life, if not absolutely prevented, it will be our duty to see that the necessary measures are pressed upon the authorities whom we advise. The overcrowding of hospitals no one will defend. The difficulty which most of us experience is to get our corporations to understand that the large amount of air-space that we ask for our patients is absolutely necessary, and that the frequent cleansing of infected wards, which some of us have been in the habit of demanding, is not a useless expenditure of money. The Open Window.--We have also to persuade the public, and perhaps even a few members of our own profession, that fresh air in the sick-room is not the deadly danger they imagine. I remember well the death of a ease of scarlet fever, which I should have regarded as due to septicmmia, being described by the medical

86

Sanitary Progress

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attendant as caused by cold ; and I have a vivid recollection in the Children's Hospital at Edinburgh of remarking to the resident physician on the closeness of a scarlet-fever ward. He assured me that it was necessary to prevent kidney complications, and certainly he had plenty of them in the ward. In my own practice I found that kidney complications much more frequently arose where the ward was overcrowded and foul than where it was freely ventilated. In fact, during the later years of my charge of the Fever Hospital at Huddersfieid, I scarcely saw such a thing as anasarca in my wards. Attention to diet, the use of flannel underclothing, the avoidance of too much exertion, and the absolute discontinuance of the internal use of chlorate of potash, combined with plenty of fresh air in the wards, had, perhaps, something to do with this result. Fortunately, the belief in the curative effect of fresh air is reviving. It may seem strange in the country of Sydenham, of the Combes, of Neil Arnott, and of Hughes Bennett, that the openair treatment of phthisis should have had to come back to us from Germany. Some of us were taught in the North that the most important point in the selection of a wintering-place for phthisical patients was the amount of time it was possible for them to spend in the open air, and that sunlight and fresh air were essentials in the successful treatment of the disease. Even cod-liver oil, with the use of which one of the names I have mentioned is specially associated, was looked upon, not as a drug, but as a food, and it was the hygienic rather than the medicinal treatment of the disease that was impressed upon us in these early days; but reminiscences of the old methods, when they came back improved from Germany, caught on with the public, and fortunately the wave of enthusiasm in favour of the open-air treatment has overcome the prejudice on the part of patients and their relatives against free exposure to fresh air. I look forward during the next twenty-five years to an even greater diminution in the death-rate from consumption than has been going on during the past half.century, great as that has been. But may we not hope in regard to all diseases that the impetus derived from this enthusiasm will enable us to get rid of that fear of exposure and dread of draughts which was one of the great difficulties that the medical man of the nineteenth century had to encounter ? One eminent professor of the Yorkshire College, when asking me if I felt any inconvenience from the window in his study, remarked to me that he thought a great many people were so unaccustomed to the smell of fresh air that they did not recognise it and thought it must be something baneful, and therefore shut it

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out. By all means let us, if we can, prevent sudden draughts of cold air from playing on unprotected surfaces ; by all means let us arrang~ the ventilation of our rooms and our sick-rooms so that ~je~ of fresh air do not impinge upon their occupants ; but do not let us, to avoid this, go back to the old-%line heresy of shutting up all windows and doors and rebreathing the used-up air charged with the waste products of the occupants. ltemoval of Wastes.--Not only must we admit outside air freely to our sick-rooms and our habitations, not only must we abolish narrow streets and lanes which impede the circulation of air, but in our large towns we must still further secure the rapid removal of wastes. The introduction of electric cars and automobiles may perhaps tend to lessen the quantity of horse manure collecting on the streets of our towns, but we should not on that account cease to urge on our authorities further improvements in our methods of scavenging, including the freer use of the watercart, the hose-pipe, and the street-sweeper. All these things cost money and rates are high, and if we are to get them done we must speak out loudly and with no uncertain sound. Why do our Sewers Smell ?--Another source of pollution to our atmosphere arises from our sewers. The modern sewer is a barrel placed deeply in the street, receiving branches from the street gullies and the house-drains. It is generally constructed with such a gradient that the liquid it contains can run easily towards the outfall, depositing a minimum of sediment. Were this liquid fresh sewage and were these barrels occasionally flushed with clean water, the air from the sewers should be comparatively innocuous. They are deep, not exposed to the rays of the sun or the h e a t of the atmosphere; they are what engineers call selfcleansing. But the liquid they contain is not fresh sewage: it is sewage which has been kept fermenting about the premises probably for hours. Every house is now supposed to have an intercepting ~rap. This trap retains some gallons of sewage in the near neighbourhood of the house. In an ordinary summer night the contents of this trap remain for some eight hours undisturbed, and these contents are putrescible matters, sometimes entering it before decomposition has at all set in, but remaining there long enough for a considerable amount of change to take place. When this trap receives a further quantity of similar wastes it is seldom emptied by such discharge, but is well stirred up, and a portion of its original contents is exchanged for a portion of new material. Sufficient of the old matter is, however, left to start the fermentative process in the new, and even where the change during the

88

Sanitary Progress

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more active part of the day is fairly rapid, the splashings from the liquids adhering to the neighbouring pipes and the viscid matters in the tube itself furnish the necessary ferment for this decomposition. The main sewer is therefore being continually charged from the intercepting traps with stinking putrescent liquids. Not only so, but the material entering this intercepting trap is often already in a putrescent condition. The sink-waste, frequently a pipe 1½ inches in diameter, discharges into a trapped gully capable of holding some gallons of liquid. Even a continuous flow from this 1½-inch pipe would probably take some months to clear out the gully. But the flow is intermittent, and the same process described in the intercepting-trap takes place earlier in the sink gully. A good flush is probably easily capable of nearly emptying the trap of a water-closet. But some careful engineers place a second trap at the bottom of the soil-pipe, and the two-gallon, or even three-gallon, flush from the cistern is quite insufficient to carry the fresh deposit from the closet over both these traps. Under these circumstances, receiving the contents of the sinkwaste and of the soil-pipe and similar delayed wastes from the gully traps of lavatory basins and baths, the contents of the intercepting trap have already begun to putrefy before they reach it. The decomposition already set up is continued in this septic tank, and the liquid flushed into the sewers reaches it even more foul than if the intercepting-trap were its only impediment. Nor is the street gully entirely innocent of aiding this undesirable state of affairs. It generally consists of a small tank, which may contain some six gallons of liquid. Street sweepings, slops of back-to-back houses, enter this catch-pit, much of the solid portions are retained, and putrefactive changes take place in the contents. Such I believe to be the causes which conduce to the offensiveness of the ventilators of our sewers. Our sewers, as already said, instead of carrying the fresh sewage rapidly to the outfall, are conveying an offensive and putrefying liquid at a temperature higher than that of the atmosphere, depositing much of this putrescent material upon their sides when the flush diminishes, and even when temporarily cleansed by a heavy rainfall, leaving surfaces wetted with diluted sewage to dry slowly and contribute to the fouling of the atmosphere of the town. This problem of the ventilation of sewers is one that has not been settled during the last twenty-five years, and it is a question whether it is likely to be settled favourably unless we are willing to diminish the number of the small cesspools which intercept the sewage before it reaches the sewer, and flush out those that remain at short intervals,

~ove:n~r. 19021

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leaving after each flushing some sterilizing agent in their contents. The bacteriological treatment of the sewage at the outfall would make one hesitate in introducing any permanent antiseptic for this purpose, but probably some oxidizing agent, such as a permanganate or a hypochlorite, could be relied upon to sufficiently retard the putrefactive process in the diminished number of traps to allow the sewage to proceed in a comparatively innocuous condition to the outfall, and yet to exert no serious permanent inhibitory influence upon bacterial action in t h e tanks. The oxidizing influence of the disinfectant having been exhausted, even were some of the necessary bacteria killed, it is not beyond the resources of civilization to re-inoculate the putrescent matters with the most suitable bacterium at the septic tank itself. All this, however, again involves work, and consequently expense; but if our towns are to move on in the march of sanitary progress, some such cost will probably have to be faced. I have suggested one of the modes in which a lessening of the offensiveness of sewer gases, as it seems to me, might be accomplished. I do not deny that there are others. It is possible to draw the air rapidly through the sewers, and to l~revent any serious escape into the streets. It is possible to flush the sewers themselves at frequent intervals, and it is possible to accelerate locally the flow of sewage by compressed air and other artificial means. None of these methods, however, has the merit of being inexpensive. I am not one of those who think that the same means should be adopted by every town. Progress lies rather in variety of method and comparison of results, but if we are to get rid of autumn diarrhoea from our large towns, not only the streets and the ashpits, but the sewers themselves, must be more systematically cleansed. Exa~ination of Business Premises.--While a large amount of good work has been and is being done in the way of examining the sanitary condition of the dwelling, offices and shops, it is to be feared, are less attended to. Since the Factory and Workshops Act of 1891 Sanitary Authorities have given considerable and an increasing attention to the sanitation of workshops, factories still remaining under the care of the Home Office. Is it not needful, however, that in the near future all places of employment should come under some sort of health inspection ? Will not the maintenance of our sanitary position during the next twenty.five years depend largely upon the vigour with which we carry out the house-to-house inspection of dwellings and the rigour with which we enforce our powers about overcrowding ? But can we expect the increased progress we all hope for unless we throw

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much of our energies into the inspection of those workplaces in which so much of the time of our citizens is passed ? Some Leqislation l/Fanted.--On the whole, it is not so much new legislation that is wanted as a diligent enforcement by the health authorities of the powers they already possess. Great, however, as these powers undoubtedly are, active workers for sanitary progress are continually being pulled up by disabilities not foreseen when existing statutes became law. The framers of Section 19 of the Public Health Amendment Act of 1890 doubtless believed that a private drain was a private drain, and repairable by the private owner. In this belief they drafted a clause enabling an authority, through its surveyor, to apportion the cost of the repair of any such drain amongst the several ownera The result of this section and of the decisions--varying and apparently contradictory, however, as many of these are--seems to come to this: that if two houses belonging to different owners are connected to the town sewer by a single common drain running through private land, any defect in the common drain must be made good at the cost of the owners in such proportion as the surveyor may determine; but if the two houses belong not to two men but to one, then the common drain, though flowing through private property, is a public sewer vested in the local authority and repairable by them. If this be - - a s I believe it is--the present law in the matter, I think you will agree with me that the law is exactly what Mr. Bumble said it WaS.

The Food and Drugs Acts are full of loop-holes for the escape of the fraudulent trader. The preservation of food and its conveyance from the land where it is plentiful and the inhabitants few to populous places where the consumers are numerous and supplies less abundant are valuable economic advantages. But surely the community has a right to know what it is purchasing. ~Iargarine (so called) may be an exceedingly useful substitute for butter, but the agricultural interest has convinced the Legislature that it must be sold as margarine and not as butter, and has devised stringent regulations--many of them futile--to this end. Meat foods preserved by chemical antiseptics have generally a somewhat lessened food value, even when the antiseptic is not directly poisonous. Borated shrimps potted are clearly different from fresh shrimps similarly prepared. Ought not the borated article to be declared as such by the vendor just as much as the butter substitute ? The consumer who easily suffers from boric acid poisoning can then avoid his foe. Should not some central co-ordinating authority, as has been

Novo,-~r, ~90~

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already hinted, be appointed to watch and regulate the appropriation of water areas? An expert Board, with powers analogous to those of the Charity and Endowed Schools Commissioners, might advise the L ~ s l a t u r e on all Parliamentary schemes, watching on behalf of growing districts that the water-supplies necessary for ~ e m are not carried off by greedier neighbours. But perhaps the most crying need in the way of fresh legislation is for an Act providing for a more frequent census. The change of population which takes place in the several districts making up a large town is often so great that a dead reckoning of ten years leads to most ridiculous estimates of these district death-rates. While the total death-rate of a large city may not be frequently more than 1 or 2 per cent. out, the rates calculated on the only available data for its districts may easily be so--5, 10, even 15 per cent. ~ As a basis for the comparison of our methods of administrative action such disparities are misleading. A five years' enumeration would satisfy most of us. We want data for the m o r e accurate intercensal estimate of our district population, and are content to wait for the decennial census to know how many idiots we have amongst us. Doubtless other matters requiring legislative interference will occur to many of you; I mention only a few as types of these. I lay most stress upon the need of more accurate data for comparing the results of our hygienic activities. Shall we or shall we not obtain this concession ? I believe we shall if we only press for it energetically enough. But to get this and other needful matters we should concentrate the whole energies of all our members in obtaining what we want. Discussion and conference are of the utmost value in determining new methods and deciding on what we should demand; that decided, we can only hope to obtain it b y pressing the necessity of it upon our authorities and cur rulers in season and out of season till it is ours. The organization of a society like ours enables us, when occasion requires, to voice t h e resultant opinion of practically all the medical officers of health in t~e three kingdoms. The power of such an organization should not be lightly used to ventilate fads or exploit personal opinions, but when measures leading to further progress have been fully and carefully decided upon, we should not hesitate to u~e all the powers. of that organization to secure the desired result. * In one area in Leeds the population at the census period in 1901 should --calculated by geometrical proportion from the data of 1881-91--have been 287. At the census in 1901 it turned out to be 6,210. A. rate calculated for this district on the G.P. population would have given a result nearly twenty-twoo t4mes too high.

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Conclusion.--It seems to me, therefore, gentlemen, that there are conditions at work which prevent us from counting too positively upon the diminution of our death-rate during the next twenty-five years at a rapidly accelerated rate. The conditions of greater intelligence and greater determination in this direction will help forward our sanitary progress. Much of the work that has been done during the closing quarter of the last century--work especially in improving house drainage and in removal of slums--will continue to have an increasingly beneficial effect upon the mortality of the next twenty-five years. But against this we must put the tendency to slum-making which is continually going on, the crowding of workers into limited areas, and the natural degrading influences of town life. To meet these over-present dangers, we have a growing tendency and desire on the part of the people to live further from the centre--improvement of communication enabling this to be done--and here and there the removal of industries from our towns into outlying districts, and the construetion of garden cities. I am inclined to look somewhat hopefully to the further use of electricity as a motive power. Not only will it enable the citizen by tube or by tramway to reach more easily the outer circle: it will, I hope, allow, when procurable over large comparatively rural districts, for the erection of small factories in less populous parts. For a small industry, where electric power cables are laid down, it is not now necessary that the manufacturer should erect furnaces, boiler, and a tall chimney. All he needs is a switch. His motors can be placed where in his works they are most needed. The waste of power in running enormous heavy shafting being avoided, he can use as much or as little power as he requires, and need pay only for what he has actually used, not having to run a useless plant for emergencies. The inconvenience of separating work-rooms by open spaces will be greatly lessened when two copper wires condueted underground can carry the necessary power. Factories of this kind, erected where land is cheap, will naturally attract a population around them, and it will be for the local authority to see that the houses built for this population, whether by private enterprise or by the mill-owner, are so arranged that fresh air and light shall be readily admitted to every dwelling. Even in our slums, the necrotic centres of our municipal life, the vigour of the authority must never slacken. It should be made impossible for any landlord to receive rents from overcrowded proper~y. The Public Health Acts give us already sufficient power. It is for us to persuade our masters to exercise it. No department of progress

November, 1902]

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is perhaps more active at present or exciting more attention than ~he housing of the working classes of our towns. It ~s probable that before m a n y years have passed the Local Government Board will have extended to corporations building houses for the working

class the length of time for borrowing money. Is there any reason why, with proper safeguards, cheap money should not also be tent t~o builders for the same purposes ? Is there any reason why some remission of rates--say, for five years, as in France--should not be made by the municipality to owners of property to supply the ~eeessary wants of the poorer classes? It is the industry of our masses that has made it possible for corporations to borrow at cheap rates. Is there any reason why this privilege, which their work has earned, should not in some such way be turned to their advantage ?

GOLD-MINER'S PHTHISIS.--The Johannesburg Chamber of Mines is :anxious to lessen the mortality from this disease among gold miners, and it therefore offers three awards of £500, £250, and ~100 for the best practical suggestions and devices for lessening the amount of dust brought about by rock drilling. Papers must be accompanied by plans, models, or apparatus of the devices suggested, and will be receivable at the offices of the Chamber of Mines, Post-box 809, Johannesburg, up to February 15th, 1903; at the London agents of the Chamber, Messrs. Barsdorf and Co., Wool Exchange, Coleman Street, E.C., up to January 15th, 1903; and at the Paris agents up to the same ~date.

PRIZE EssAYs.--Three prizes, each of the value of ~£10, are offered for essays on subjects connected with tropical diseases. 1. The Sivewright Prize for the best article on " The Nature and Treatment of Diseases, Exclusive of Acute Dysentery, affecting the Lower Part of the Large Intestine in Warm Climates." 2. The Belilios Prize for the best article on "The System of Drainage and Sewerage (Domestic and Municipal)best suited for Tropical Climates." 3. The Lady Macgregor Prize for the best article on " A Critical Examination of the Practical Value of Antityphoid Inoculation." An intending competitor must send in his name, address, and the title of the prize to be competed for, to the Editors, The Journal of Tropical Medicine, 83-89, Great Titchfield Street, London, W., before February 1st, 1903. The papers to be sent to the same by May 1st, 1908. The competition is open to qualified medical practitioners of all denominations and every nationality. The papers may ~Je written in English, French, German, Italian, or Spanish. The names of the prize-winners will be announced in July, 1903, in the public press and in the medical journals. The judges are: Surgeon-General Roe Hooper, C.S.I., President Medical Board, India Office ; Colonel Kenneth MacLeod, LL.D., Professor of Clinical and Military Medicine, Staff ~College, London; and Patrick Manson, C.M.G., F.R.S., LL.D., Medical Adviser, Colonial Office and Crown Agents of Colonies. 7