These considerations make it very doubtful whether the death-rate of London is of much value, as indicating the amount of disease in the City. Even if we accept it we must not draw any hasty conclusions that the disease-rate bears any definite proportion to the death-rate. There may be much disease with comparatively few deaths, as was the case with the scarlet fever epidemic of last year, and there can be no doubt that the improvement and extension of medical knowledge has very largely diminished the death-rate of those who are sick. Further, an enormous proportion of those who fall ill in London return to the country to die. A fact which must throw considerable doubt on the healthiness (_i.e._, a real vigorous and robust condition, which is the true meaning of health) of the population is the amount of sickness, as evidenced by the ever-increasing work which is thrown upon the hospitals. According to a table which was published last June in _The Hospital_, it appears that in 1887 there were treated in the London hospitals 79,261 in-patients, and 1,180,251 out-patients, or a total of 1,259,512 persons, excluding those who received relief in the hospitals belonging to the Asylums Board (and these were very numerous, owing to the epidemic of scarlet fever), the workhouse infirmaries, the lunatic asylums, and idiot asylums. Thus it appears that in a city whose death-rate was very low more than 25 per cent. of the population had recourse to the hospitals for relief. We must therefore conclude that the death-rate and the disease-rate bear no fixed ratio to each other, especially when we consider that between 2,000 and 3,000 medical men found sufficient work among the population to furnish them with an income. If deaths be few in London, it is clear that second-rate health is by no means exceptional. IMPROVED CONDITION OF MODERN LONDON. Although we have to make many allowances, and take many things into consideration before we can estimate the true value of the London death-rate, it is, of course, undeniable that an enormous improvement in the health of the City has taken place since the beginning of the present century. To what is this due? The chief cause is the increase of knowledge as to the modes in which diseases are spread. Our knowledge of the mode in which small-pox, scarlet fever, cholera, and typhoid are disseminated has led to the establishment of fever hospitals, and to the improvement of the water-supply, and the inspection of dairies. It is not only that the knowledge of doctors has increased, but what is more important, this knowledge has spread to the public, and as “self-preservation is the first law of nature,” the public has assisted in protecting itself. The practice of vaccination, and the dealing with epidemics by the method of isolation, have also materially assisted in diminishing the death-rate.