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THE HEALTH OF BELFAST.

ON Aug. lst of this year a committee of the Belfast CityCouncil was appointed to inquire into the causes of its highdeath-rate and of its insanitary condition. The members ofthis committee, which took a great deal of evidence, havejust presented their report in the form of an elaborate docu-ment of some fifty pages, which was finally agreed to by amajority at the last meeting and will be considered at a

special assemblage of the city corporation. In the report thecommittee consider the death-rate (262 according to the

Registrar-General and 24’3 according to the city officer ofhealth for 1895) of Belfast to be too high. They point out thatthe death-rate of the city is not, like that of other towns,diminishing, and, what is very serious, they find that in suchdiseases as typhoid fever, typhus fever, scarlet fever, diph-theria, and diarrhoea Belfast has a much higher death-ratethan the average of the thirty-three large English towns, andoccupies a worse position in the death-rate list than anysingle one of these large industrial centres. Confining theirattention to such causes of the high death-rate of Belfastas are more directly under municipal control and to whichmunicipal responsibility directly extends, the committee say,in their opinion, the principal of these are : 1. The absenceof waterclosets in such a large proportion of houses andthe wretched privy and ashpit system in such general use.2. The insanitary sites on which thousands of houses havebeen erected. 3. The numerous courts and lanes that havebeen allowed to exist in the city for many years though con-demned by the sanitary officers as unfit for human habita-tion. 4. The feeble and ineffectual manner in which thePublic Health Acts have been administered. 5. The in-adequate supervision exercised over the construction ofstreets, sewers, and drains. 6. The large number of backpassages that have been allowed to remain undrained, un-paved, and filthy. 7. The number of open sewers, cesspools,and other nuisances that bave been permitted to continue inthe town. After dealing very fully with each of thesecauses the committee submit the following recommendations.

The sanitalry staff.-1. Four additional sub-sanitary officersat least should be appointed immediately. 2. The variousmedical officers of health (dispensary medical officers) shouldbe required by the Public Health Committee to report tothe sanitary authority any nuisances in their district ofwhich they may become cognisant or any influence affecting,or threatening to affect, the public health within such dis-trict. 3. That a much stricter system of supervision beexercised over the work done by sub-sanitary officers.4. That at the first suitable opportunity a properly qualifiedanalyst be attached to the staff of the Public Health Depart-ment.

Notification of infectious diseases. - That the InfectiousDiseases (Notification) Act be immediately adopted, andthat a map or maps be made each year showing in coloursthe precise locality of every case of zymotic disease whichoccurred in Belfast during the year, together with an indexgiving the street number, and that this index and map beopen to public inspection.

Insanitary houses. - That a complete list of all thehouses in Belfast which in the opinion of the medical super-intendent officer of health are unfit for habitation be madeout and that they be either closed or put into propersanitary condition.

Houses without back passages or waterclosets. -That whereany house contains a privy but no back passage the PublicHealth Committee shall order a watercloset to be substi-tuted where practicable ; and if it be found that the sanitaryauthority has not power to require such substitution, powerbe obtained to compel owners, on such terms as the Councilshall deem equitable, to provide waterclosets instead ofprivies, and to provide back passages in all cases where theCouncil shall consider them necessary.

Insanitary siles.--The committee recommend that no

ashpit or midden refuse, or any refuse containing animalor vegetable matter, be deposited by, or with the authority of,any officer or servant of the Council on any land intended orlikely to be used for building purposes, or upon any placewithin the city boundary, unless with the consent of the

Council ; and that no building be erected on any "made" "

ground, or on any ground on which ashpit, midden, or otherrefuse containing animal or vegetable mat’er has been

deposited, until such deposit has been removed or until ajoint certificate has been signed by the surveyor, medicalofficer of health, and the executive sanitary officer that theyhave personally examined the said ground and that suchdeposit is, or has become, innocuous ; and that a map of thecity, open to public inspection, be prepared, showing allthe sites on which ashpit or other refuse has been depositedand upon which dwelling-houses have been erected; andthat this map shall also show the various vacant spaces inthe city which have been used as "tipping" stations andwhich have not been built upon.

Uncompleted streets and back passages.-That these besewered, flagged, or paved at the earliest possible date.Drains and sewers. - The committee recommend that

every house shall have ventilated drains with properly venti-lated intercepting traps, and that in future all sewers be laidin concrete unless the surveyor certify in writing that suchis unnecessary ; further, that all houses with inside water-closets be examined with the smoke-test and water-testbefore being passed by the surveyor as fit for occupation,and that in future the drains of all new houses be tested.That a record, open to public inspection, be kept in thetown hall giving the date when such tests were made and theresults thereof.Ashpits.-That these be furnished with proper doors and

coverings as reauired by Section 44 of the Public Health Act,1878.Plans.-That notice of all plans, with the name of the

bonâ-.fide owner on whose behalf such plans are lodged, shallbe placed on the agenda paper, and shall be consideredbefore any special business of the committee be taken up,and that no plan involving any departure from the by-lawsbe signed until the specific attention of the Council hasbeen directed to it and its sanction obtained. The com-mittee further suggest : 1. That a systematic examinationof houses shall be made with special reference to ventilationand water-supply, and to ensure that cisterns supplyingwater for household purposes are not connected with water-closets and are not open to any means of pollution. 2. Thata systematic visitation be made of the schools of Belfastwith the special object of determining whether there is over-crowding and whether the ventilation and sanitaryarrange-ments are satisfactory. That a report be made to thePublic Health Committee of the laundries that have noventilation except by open windows and of workshopswhere both males and females are employed and no

separate sanitary accommodation is provided. 3. Thatall refuse deposited in pails or boxes be removed dailyby the Public Health Department and that all suchboxes or pails be provided with a cover. 4. That a smallsub-committee be appointed by the Council to examine

thoroughly the efficiency and cost of the most moderndestructors. and to report thereon at an early date with aview to their adoption if deemed desirable. Appendices areattached to the report giving lists of houses with defectivesanitary accommodation, a list of officers in the PublicHealth Department, a list of uncompleted back passages,and the report of the medical officer of health on filled-in

ground at York-road.

POST-SCARLATINAL DIPHTHERIA IN THEFEVER HOSPITALS OF THE METRO-

POLITAN ASYLUMS BOARD.

IaT a previous article we dealt with the report of the

statistical committee of the Asylums Board for 1895, and wepropose here to discuss, by the aid of the matter contained inthe reports of the medical superintendents of the fever

hospitals, the interesting and, from the standpoint of- hos-pital administration, the eminently important subject of

post-scarlatinal diphtheria.We select this subject from the reports partly because

it is one to which considerable attention has been givenand partly because the most important question dealtwith in the volume before us-i.e., that of the antitoxintreatment of diphtheria-has already received attentionin our columns. It may be well in the first instanceto recall in a few words the theses which have been

brought forward to explain the incidence of diphtheria

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upon patients suffering from scarlet fever who have beenisolated in the fever hospitals of the Asylums Board.By some it has been thought that this dreaded sequel toscarlet fever is to be explained by the fact that both scarlet fever and diphtheria are treated in the same hospital, andthe supporters of this view infer that the virus of diphtheriais conveyed in some direct or indirect manner from the diph-theria to the scarlet fever wards. Against this hypothesisit has been urged with no little force that post-scarlatinaldiphtheria was prevalent, although in a minor degree, in thefever hospitals of the Board before diphtheria was admittedinto them, and, further, that the disease manifested itselfin the convalescent hospitals of the Board to which nodiphtheria was admitted. By others " overcrowding "has been offered as an explanation; but although at oneor two of the Board’s hospitals the facts observed fora certain period lent support to this view subsequentexperience has failed to confirm it. Finally, defectivedrainage has been urged as an explanation of post-scarlatinal, as of uncomplicated, diphtheria; but here,again, the evidence is far from convincing. In the reportsof the medical superintendents for 1895 Dr. Goodall sug-gests an explanation, which, although not supported byoverwhelming evidence, has much to commend it, and it hasalso the merit of throwing a new and somewhat consolinglight upon the problem in question. Dr. Goodall recalls thefact that before diphtheria was admitted into the Board’shospitals post-scarlatinal diphtheria had already manifesteditself therein, and he goes on to show that in the year 1888diphtheria, as gauged by the reports of the Registrar-General, as also by other evidence, underwent in themetropolis a marked rise; and collaterally with thatrise there was an increase of post-scarlatinal diphtheriain the hospitals of the Board. Although, he pointsout, this latter fact may be held to lend supportto what we will call the maladministration thesis,it is also capable of receiving an altogether new

interpretation-i.e., that the increase of post-scarlatinaldiphtheria in the scarlet fever wards is but the expressioninside those wards of the general increase of diphtheriawhich in 1888 suddenly commenced to manifest itself in themetropolis as a whole ; and he shows, what is obviously verypertinent to his view, that in the year 1893 the attack-rateof post-scarlatinal diphtheria in the hospitals of the Boardwas 13 per cent.-i.e., not much in excess of the incidenceof diphtheria for the same period on all the children inLondon between the ages of one and ten. Briefly put Dr.Goodall thinks that the increased facilities for the intro-duction of doubtful cases of scarlet fever, some of which mayeither be suffering from diphtheria or have the bacillus ofthat disease in the fauces, is on the whole the best explana-tion at present forthcoming of the prevalence of post-scarlatinal diphtheria in the Board’s hospitals.

Dr. Goodall has, we notice, more fully developed his thesisin the last volume of the Transactions of the EpidemiologicalSociety, which has just been issued, and we commend thepaper to all those who are concerned with the very difficulttask of fever hospital administration. The figures dealt within the Asylums Board report relate solely to the metropolis,and it would be instructive to see them compared with thoserelating to other fever hospitals, such as those of Birmingham,where the rise in diphtheria has not until quite recentlymade itself manifest. There is, however, much in the

report before us which must be regarded as considerablystrengthening Dr. Goodall’s position. For instance, Dr.Birdwood, medical superintendent of the North-EasternHospital, brings forward some very interesting evidence,compiled by Dr. Beggs, one of the assistant medicalofficers of that institution, as to the presence of thebacillus of diphtheria in the throats of patients sufferingfrom scarlet fever. It appears that out of 140 cases ofscarlet fever which were made the subject of bacteriologicalexamination no less than 36 42 yielded the bacillus of diph-theria. Of these cases a little over 25 per cent. either pre-sented clinical evidence of diphtheria or subsequentlydeveloped such evidence, but in a large number of cases thepresence of the bacillus gave rise to no illness whatever al dthe bacilli subsequently disappeared. Here, then, isobviously much to support the view of Dr. Goodall, as itis clear that, if anything approaching the same conditionsas those brought to light at the North-Eastern Hospitalobtained in the days when no bacteriological examinationwas made, this risk of introducing diphtheria into thescarlet fever wards was by no means small. If this view be

a correct one and be only a partial explanation of theprevalence of post-scarlatinal diphtheria, we may hope, withthe progress of bacteriological examination, that a materialreduction in this prevalence will be made. Undoubtedly allour fever hospitals should be fully equipped with bacterio-logical apparatus and with medical officers capable of con-ducting bacteriological examinations. As Dr. Caiger,medical superintendent of the South-Western Hospital,observes, the bacteriological examinations conducted at thelaboratories of the Royal Colleges cannot do away with thedesirability of maintaining a laboratory equipment at each ofthe fever hospitals.

Clearly it is incumbent upon the Asylums Board to developand make use of every methcd of diagnosis and treatmentwhich modern science indicates and to contribute the resultsto medical literature. The year 1895 will stand out in theannals of the Asylums Board as one in which two very im-portant advances were made-the one the treatment of

diphtheria by antitoxin serum and the other the diagnosis ofdiphtheria by bacteriological methods.

VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

’, IN thirty-three of the largest English towns 6860 birthsand 4104 deaths were registered during the week endingOct. 31st. The annual rate of mortality in these towns,which had been 16 3 and 17’6 per 1000 in the two precedingweeks, further rose last week to 19-7. In London the ratewas 20’2 per 1000, while it averaged 19’4 in the thirty-twoprovincial towns. The lowest rates in these towns were 12-3in Portsmouth, 12-8 in Derby, 13 3 in Croydon, and 13-4in Norwich ; the highest rates were 23 5 in Wolver-hampton, 23-7 in Liverpool, 24’7 in Nottingham, and 25-8 inOldham. The 4104 deaths in these towns included 358which were, referred to the principal zymotic diseases,against 351 and 349 in the two preceding weeks ; of these,95 resulted from diphtheria, 66 from;measles, 61 from fever"(principally enteric), 47 from diarrhoea, 46 from scarletfever, 43 from whooping-cough, and not one from small-pox. The lowest death-rates from these zymotic diseaseswere recorded in Portsmouth, Croydon, Blackburn, Norwich,and Preston, and the highest rates in Plymouth, Manchester,Nottingham, and Gateshead. The greatest mortality frommeasles occurred in Bradford, Brighton, Nottingham, Man-chester, Gateshead, and Plymouth ; from scarlet fever in

Derby and Gateshead ; from whooping-cough in Nottingham ;from "fever" " in Bolton ; and from diarrhcea in Derby andWolverhampton. The 95 deaths from diphtheria included64 in London, 7 in Liverpool, 6 in West Ham, and 3in Shefiield. No fatal case of small-pox was registered inany of the thirty-three large towns. There was 2 cases ofsmall-pox under treatment in the Metropolitan Asylum Hos-pitals on Saturday last, Oct. 31st, against 4, 2, and 1at the end of the three preceding weeks ; 1 new

case was admitted during the week. The number ofscarlet fever patients in the Metropolitan Asylum Hos-

pitals and in the London Fever Hospital at the endof the week was ’4160, against 4105. 4073, and 4164on the three preceding Saturdays ; 367 new cases were

admitted during the week, against 424, 372, and 448 inthe three preceding weeks. The deaths referred to diseasesof the respiratory organs in London, which had been 238and 334 in the two preceding weeks, further rose lastweek to 387, but were 4 below the corrected average.The causes of 53, or 1-3 per cent., of the deaths in thethirty-three towns were not certified either by a registeredmedical practitioner or by a coroner. All the causes of deathwere duly certified in Bristol, Oldham, Bradford, Leeds,Newcastle-upon-Tyne, and in twelve other smaller towns ;the largest proportions of uncertified deaths were registeredin West Ham, Birmingham, Liverpool, and Preston.

HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in the eight Scotch towns,which had risen in the five preceding weeks from 14-6to 18 9 per 1000, declined again to 18-6 during the weekending Oct. 31st, and was 1-1 per 1000 below the meanrate during the same period in the thirty-three large Englishtowns. The rates in the eight Scotch towns ranged from13.8 in Aberdeen and 14.0 in Leith to 19.9 in Dundee and