43/3 LCC I London County Council. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. 1892. 3 (Ordered by the Council to be printed.) JAS. TRUSCOTT & SON, PRINTERS, SUFFOLK LANE, CANNON STREET, E.C. Administrative County of London. REPORT OF THE MEDICAL OFFICER OF HEALTH. 1892. The passing of the Public Health (London) Act, 1891, having placed the London County Council in direct relation with sanitary administration in the administrative county of London, I propose to present to the Council each year a report on the health of London. STATISTICS. Population. The administrative county is conterminous with the registration county, except that the hamlet of Penge having, in 1891, a population of 20,375, is included in the former and not in the latter. The rapid increase of the London population during the present century is evidenced by the fact that between 1801 and 1841 the population doubled itself, and again almost doubled itself between 1841 and 1881. The population ol the registration county in each census year has been as follows— Year. Population. Increase per cent. Year. Population. Increase, per cent. 1801 958,863 - 1851 2,362,236 21.2 1811 1,138,815 20.8 1861 2,803,989 18.2 1821 1,378,947 21.0 1871 3,254,260 16.0 1831 1,654,994 20.0 1881 3,815,544 17.2 1841 1,948,417 17.7 1891 4,211,743 10.3 During the last decade therefore, the increase has been much less than in previous decades of this century. The number of persons living in London is affected by the excess of births over deaths, by immigration, and by emigration. The increase of population in 1851-60 was 441,753, and the excess of births over deaths 253,718. In 1861-70 the increase of population was 450,271, and the excess of births over deaths in this period 331,726. In 1871-80 the figures were respectively 561,284 and 454,475, but in 1881-90 they were 396,199 and 510,384. While, therefore, during the previous decades the population of London was being largely added to by the excess of immigration over emigration, during the last decade the position has been reversed, and London has lost, by the excess of emigration over immigration, more than 114,000 of the population it would have had if there had been no immigration or emigration. The question naturally arises whether this change is due more to diminished immigration, or to increased emigration, and the census of 1891 enables this to be ascertained. The following table shows the number of natives and immigrants in London in the three census years 1871, 1881, and 1891— Number of Natives and Immigrants respectively living in London (Registration) in 1871, 1881 and 1891. Males. Females. Excess of Females. 1871. 1881. 1891. 1871. 1881. 1891. 1871. 1881. 1891. Total Inhabitants 1,523,151 1,797,486 1,990,748 1,731,109 2,018,997 2,220,995 207,958 221,511 230,247 Born in London 975,461 1,147,063 1,323,480 1,080,115 1,254,892 1,435,915 104,654 107,829 112,435 Born out of London 547,690 650,423 667,268 650,994 764,105 785,080 103,304 113,682 117,812 Percentages. Born in London 64.0 63.8 66.5 62.4 62.2 64.7 50.3 48.7 48.8 Born out of London 36.0 36.2 33.5 37.6 37.8 35.3 497 51.3 51.2 Now, the number of London natives in 1881 had increased 16.9 per cent. upon the number in 1871, and in 1891, 14.9 per cent. upon the number in 1881. In 1881, the number of immigrants had increased 18 per cent. upon the number in 1871, and in 1891, only 2 per cent. upon the number in 1881. While, therefore, there has been some falling off in the increase of natives, this has by no means been so marked as the falling off of the increase of immigrants. 2 .» These changes have not been equally shared by the two sexes, for the falling off of the increase of female immigrants has been somewhat less marked than the falling off of the increase of male immigrants, and the falling off of the increase of males born in London has been greater than the falling off of the increase of females born in London. The proportion of males to females is however still increasing, although to a less extent than between 1871 and 1881. Thus, the males constituted 468.0 in every 1,000 of the London population in 1871, 470.9 in 1881, and 472.6 in 1891, or, in other words, for every male there were 1.137 females in 1871, 1.123 in 1881, and 1.116 in 1891. The following conclusions are indicated— 1. That immigration into London has been greatly diminished in the decade 1881-90. 2. That this reduction is greater in the case of males than of females. 3. That emigration has been greater in this decade than immigration. Age and sex distribution.—The age distribution of the London population at the older ages was in 1891 much the same as in former census years, but there was a decrease in the number of children under ten years of age, due no doubt to the decrease in the birth rate referred to on page 8. The following table shows the proportion ot the London population at the several ages in eacn census year since 1851. London—Proportion of population at different ages in 1851, 1861, 1871, 1881, and 1891. (All ages taken as 10,000.) Ageperiod. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85- 1851 1,243 1,031 916 905 1,022 1,812 1,308 882 520 265 84 12 1861 1,292 1,071 943 924 989 1,700 1,307 881 533 264 85 11 1871 1,299 1,075 952 944 988 1,696 1,244 894 535 277 85 11 1881 1,302 1,100 959 967 1,009 1,680 1,234 840 540 272 86 11 1891 1,191 1,078 989 990 1,017 1,704 1,234 875 526 291 93 12 It has already been stated that the relative proportion of males to females in London is increasing. This, however, is not the case at all age periods, for while in every 1,000 males at all ages in London there are fewer males from 20 to 25 years in 1891 than in 1881, there are more females at this age period per 1,000 at all ages in 1891 than in 1881. Again, if the proportion of males at 10-15, 15-20, and 20-25 be examined, it is seen that in 1861, '71, and '81 the males at 20-25 are in larger proportion than the males at 15—20—a result undoubtedly due to migration and almost certainly to immigration. In 1891, however, the proportion of males at 20-25 has fallen below that of males at 15-20. In the case of females, however, the proportions at 15-20 and 20-25 are in each of the four census years in excess of the proportion at 10—15, affording further indication that the migration of females into London has been more sustained than that of males. London—Proportion of population at different ages in 1861, 1871, 1881 and 1891. (All ages taken as 10,000.) Males. Age period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards 1861 1,383 1,142 1,000 917 937 1,640 1,303 874 500 228 68 8 1871 1,385 1,136 1,005 940 945 1,661 1,230 883 505 239 64 7 1881 1,383 1,158 999 955 980 1,653 1,237 822 506 234 66 7 1891 1,252 1,135 1,035 992 975 1,676 1,237 870 496 253 71 8 Females. 1861 1,212 1,009 893 930 1,035 1,754 1,310 887 562 295 99 14 1871 1,222 1,021 904 947 1,027 1,727 1.257 903 563 311 103 15 1881 1,230 1,048 925 976 1,035 1,705 1,232 856 569 305 105 14 1891 1,136 1,028 946 988 1,055 1,728 1,231 880 553 326 113 16 Changes of and density of populations in London sanitary districts.—Administrative London now comprises 41 sanitary districts exclusive of the places mentioned in schedule C of the Metropolis Local Management Act, 1855. While the total population of London has been increasing, the population of certain of the 41 districts has been decreasing, owing mainly to these areas becoming more commercial and less residential in character. Thus a decrease of population since 1881 has occurred in each of the following districts— St. George, Hanover-square Clerkenwell Westminster, St. Margaret and St. John St. Luke St. James, Westminster London—City Marylebone Shoreditch St. Pancras St. George-in-the-East St. Giles Limehouse St. Martin-in-the-Fields St. Saviour, Southwark Strand Bermondsey Holborn CHART I. 3 The districts of Whitechapel and St. Olave, which, in 1881, had shown a decrease of population, showed an increase in 1891. The accompanying chart (I.) shows (a) the districts with decrease of population between 1881 and 1891; (b) the districts in which the increase of population between 1881 and 1891 has been less than the excess of births over deaths in 1881-90; and (c) the districts in which the increase of population between 1881-91 has been greater than the excess of births over deaths in 1881-90. It will be seen that districts in the first group are situated on the north of the Thames, those in the second group are situated on the south as well as the north of the Thames, and practically surround the first group, while districts in the third group form an outer circle. The estimated population of the administrative county of London in the middle of the year 1892 is 4.284.678. living on 75,442 acres, and having an average densitv of 57 persons to an acre. The estimated population and the density of population in the several sanitary districts is shown in the following table. The greatest density of population hitherto attained by any district since 1811 was 241 persons per acre (St. Luke, 1861)— Estimated population middle of 1892. Area in acres. Persons to an acre. Estimated population middle of 1892. Area in acres. Persons to an acre. West— East— Kensington 166,709 2,188 76 Shoreditch 123,695 648 191 Hammersmith 100,471 2,286 44 Bethnal-green 129,400 755 171 Fulham 98,934 1,701 58 Whitechapel 74,859 379 197 Paddington 119,270 1,256 95 St. George-in-the-East 45,627 244 187 Chelsea 97,320 794 123 Limehouse 57,231 465 123 St. George, Hanover-square 77,066 1,117 69 Mile-end Old-town 107,840 677 159 Westminster 55,247 823 67 Poplar 168,072 2,333 72 St. James 24,437 163 150 South— North— St. Saviour, Southwark 26,997 204 132 Marylebone 140,908 1,506 94 St. George, Southwark 59,846 284 211 Hampstead 71,400 2,248 32 Newington 116,838 631 185 Pancras 234,133 2,672 88 St. Olave 12,823 125 103 Islington 323,986 3,109 104 Bermondsey 84,439 627 135 Hackney 235,611 3,937 60 Rotherhithe 39,678 754 53 Lambeth 278,013 3,941 71 Central— Battersea 154,767 2,169 71 St. Giles 39,144 244 160 Wandsworth 165,071 9,285 18 St. Martin-in-the-Fields 14,290 286 50 Camberwell 240,304 4,450 54 Strand 24,413 170 144 Greenwich 169,153 3,425 49 Holborn 32,944 194 170 Lewisham 95,719 6,543 15 Clerkenwell 65,867 380 173 Woolwich 41,404 1,126 37 St. Luke 41,919 237 177 Plumstead 91,894 10,394 9 London, City of 36,939 672 55 The density of population may also be considered in respect of the average number of persons occupying one house. The instructions given to the enumerators of the census of 1891 prescribed that " all the space within the external and party walls of a building was to be considered a separate house by however many families living in distinct tenements or apartments it might be occupied." The census report states that there was some misunderstanding of this instruction, and therefore the figures given are only approximately correct. The following table shows (subject to what has been said) the average number of persons to a house in each sanitary district in 1881 and 1891. 1881. No. of persons per house. 1891. No. of persons per house. 1881. No. of persons per house. 1891. No. of persons per house. West— Central— Kensington 8.1 7.5 St. Giles 11.4 10.6 Hammersmith 6.8 6.9 St. Martin-in-the-Fields 10.2 9.9 Fulham 7.3 7.1 Strand 11.6 11.6 Paddington 8.1 8.1 Holborn 11.1 9.7 Chelsea 7.9 7.8 Clerkenwell 9.7 10.4 St. George, Hanover-square 7.7 6.9 St. Luke 9.7 10.7 Westminster 9.6 9.9 London, City of 7.8 7.1 St. James 9.9 9.6 East— North— Shoreditch 8.3 9.0 Marylebone 9.6 9.2 Bethnal-green 7.6 7.2 Hampstead 7.7 7.1 Whitechapel 9.4 10.2 Pancras 9.5 9.5 St. George-in-the-East 8.1 8.6 Islington 8.3 8.4 Limehouse 7.3 8.1 Hackney 6.7 6.9 Mile-end Old-town 7.5 7.6 Poplar 7.6 7.5 4  1881. No. of persons per house. 1891. No. of persons per house. 1881. No. of persons per house. 1891. No. of persons per house. South— St. Saviour, Southwark 8.2 9.9 Battersea 7.3 7.2 St. George, Southwark 8.3 8.5 Wandsworth 6.4 6.2 Newington 7.7 8.7 Camberwell 6.8 6.9 St. Olave 7.8 6.1 Greenwich 6.6 6.6 Bermondsey 7.8 7.5 Lewisham 6.2 5.8 Rotherhithe 7.4 7.4 Woolwich 7.5 7.7 Lambeth 7.1 7.1 Plumstead 6.3 6.1 The census of 1891 shows the number of persons occupying less than five rooms in the several sanitary districts. Inasmuch as this information enables an estimate to be formed of the character of the several populations, the following table has been prepared from the figures given in the census report. It will be seen that in Lewisham only 1.7 per cent., and in St. George-in-the-East, 22.1 per cent. of the population occupied one room, and that the other districts are ranged between these extremes. As might be expected, the central and eastern districts had a larger proportion of their population living under this condition than the western, northern and southern districts. Considering next the number of persons living in two rooms, it will be seen that Lewisham again bad the smallest proportion of its population, 3.7 per cent., and Clerkenwell the greatest proportion, 32.1 per cent., thus circumstanced. With a view to comparing the London districts, the table also, shows the proportion of the population of each district occupying tenements of one, two, three and four rooms, and in which there were more than two persons toaroom. Employing the term of the census report "overcrowding" to represent such usage, we find that in Lewisham the smallest proportion of the population (0'58 per cent.) lived in overcrowded tenements of one room; and in Whitechapel the greatest proportion of the population (13.45 per cent.); and again in the case of tenements of two rooms, the extremes were to be found in Lewisham (.89 per cent.) and Clerkenwell (18.74 per cent.). The accompanying chart (II.)* shows the condition of the forty-one districts, as to such overcrowding of tenements of one to four rooms, the greatest overcrowding occurring in the districts immediately surrounding the City. Sanitary area. Tenements with, Number of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. Number of one to four roomed tenements with more than two occupants per room. Number of occupiers of such tenements. Percentage of population in such tenements. 1 2 3 4 5 6 7 8 Battersea 1 room 3,351 10.2 6,910 4.6 2.06 984 3,532 2.35 2 rooms 5,267 16.0 18,185 12.1 1.73 1,319 7,646 5.08 3 „ 6,821 20.7 28,605 19.0 1.40 885 6,817 4.53 4 „ 5,479 16.6 28,176 18.7 1.29 352 3,371 2.24 Bermondsey 1 room 3,543 18.6 7,833 9.2 2.21 1,202 4,331 5.11 2 rooms 4,399 23.1 16,085 19.0 1.83 1,261 7,307 8.63 3 „ 3,610 19.0 16,172 19.1 1.49 608 4,686 5.53 4 „ 3,459 18.2 19,308 22.8 1.40 355 3,411 4.03 Bethnal-green 1 room 6,561 23.4 17,211 13.3 2.62 2,927 11,498 8.90 2 rooms 6,694 23.9 27,760 21.5 2.07 2,583 15,955 12.36 3 „ 6,059 21.6 29,828 23.1 1.64 1,447 11,496 8.90 4 „ 4,080 14.6 23,448 18.2 1.44 539 5,260 4.07 Camberwell 1 room 4,650 9.3 9,590 4.1 2.06 1,309 4,839 2.06 2 rooms 6,222 12.5 20,675 8.8 1.66 1,416 8,317 3.53 3 „ 8,338 16.8 34,606 14.7 1.38 1,117 8,708 3.70 4 „ 7,711 15.5 37,492 15.9 1.22 441 4,262 1.81 Chelsea 1 room 4,720 21.0 9,670 10.0 2.05 1,254 4,666 4.85 2 rooms 4,964 22.1 16,920 17.6 1.70 1,256 7,408 7.70 3 „ 3,452 15.4 14,589 15.2 1.41 502 3,989 4.14 4 „ 2,639 11.8 13,106 13.6 1.24 186 1,821 1.89 Clerkenwell 1 room 4,969 30.4 11,668 17.6 2.35 1,823 6,859 10.36 2 rooms 5,156 31.6 21,279 32.1 2.06 2,021 12,407 18.74 3 „ 2,536 15.5 12,589 19.0 1.65 629 5,063 7.65 4 „ 1,115 6.8 6,202 9.4 1.39 139 1,343 2.03 Fulham 1 room 2,245 10.9 4,526 4.9 2.02 634 2,255 2.46 2 rooms 3,200 15.5 10,679 11.7 1.67 728 4,200 4.58 3 „ 5,028 24.4 20,944 22.9 1.39 637 4,919 5.37 4 „ 2,978 14.4 15,095 16.5 1.27 200 1,910 2.08 * (See also page 10.) CHART II. 5 Sanitary area. Tenements with, Number of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenement^. Average occupants per room. Overcrowding. Number of one to four roomed tenements with more than two occupants per room. Number of occupiers of such tenements. Percentage of population in such tenements. 1 2 3 4 5 6 7 8 Greenwich 1 room 3,799 10.7 8,077 4.8 2.13 1,091 4,189 2.53 2 rooms 4,629 13.1 14,666 8.9 1.58 900 5,194 3.14 3 „ 5,211 14.7 21,571 13.0 1.38 684 5,266 3.18 4 „ 6,776 19.1 33,110 20.0 1.22 400 3,841 2.32 Hackney 1 room 4,715 9.8 9,266 4.0 1.97 1,210 4,369 1.90 2 rooms 6,722 14.0 21,936 9.6 1.63 1,451 8,461 3.69 3 „ 8,078 16.8 32,700 14.2 1.35 964 7,477 3.26 4 „ 6,501 13.5 32,564 14.2 1.25 473 4,548 1.98 Hammersmith 1 room 2,354 11.0 4,871 5.0 2.07 677 2,459 2.53 2 rooms 3,433 16.0 11,606 11.9 1.69 826 4,836 4.97 3 „ 3,693 17.2 15,305 15.7 1.38 517 4,011 4.12 4 „ 2,620 12.2 12,998 13.4 1.24 184 1,771 1.82 Hampstead 1 room 1,098 8.3 2,304 3.4 2.10 311 1,167 1.71 2 rooms 1,844 14.0 6,648 9.7 1.80 . 554 3,342 4.88 3 „ 1,585 12.0 6,721 9.8 1.41 247 1,960 2.86 4 „ 866 6.6 4,283 6.3 1.24 62 593 0.87 Holborn 1 room 2,593 32.2 6,770 20.2 2.61 1,125 4,501 13.44 2 rooms 2,526 31.4 9,915 29.6 1.96 906 5,600 16.72 3 „ 1,246 15.5 5,782 17.3 1.55 272 2,197 6.56 4 „ 476 5.9 2,337 7.0 1.23 45 454 1.36 Islington 1 room 12,856 17.7 28,189 8.8 2.19 4,057 15,150 4.75 2 rooms 16,716 23.0 60,639 19.0 1.81 4,755 28,524 8.94 3 „ 11,806 16.3 49,762 15.6 1.40 1,752 13,742 4.31 4 „ 8,015 11.0 41,740 13.1 1.30 743 7,188 2.25 Kensington 1 room 6,398 17.8 13,727 8.3 2.15 1,897 7,235 4.35 2 rooms 6,965 19.4 26,020 15.6 1.87 2,212 13,534 8.14 3 „ 4,115 11.4 18,119 8.9 1.47 725 5,777 3.47 4 „ 2,574 7.2 12,924 7.8 1.26 223 2,169 1.30 Lambeth 1 room 10,837 17.1 22,674 8.2 2.09 3,120 11,545 4.20 2 rooms 11,485 18.1 38,395 14.0 1.67 2,664 15,786 5.74 3 „ 10,023 15.8 41,859 15.2 1.39 1,392 10,757 3.91 4 „ 8,127 12.8 40,796 14.8 1.25 571 5,554 2.02 Lewisham, including Penge 1 room 977 5.2 1,628 1.8 1.67 151 534 0.58 2 rooms 1,262 6.7 3,433 3.7 1.36 144 823 0.89 3 „ 1,722 9.1 6,399 6.9 1.24 137 1,049 1.13 4 „ 2,073 11.0 9,700 10.5 1.17 95 913 0.99 Limehouse 1 room 2,567 20.7 6,321 11.0 2.46 1,010 3,892 6.78 2 rooms 2,845 22.9 10,941 19.1 1.92 934 5,636 9.82 3 „ 2,268 18.3 10,421 18.2 1.53 424 3,302 5.76 4 „ 1,886 15.2 10,336 18.0 1.37 204 1,951 3.40 London, City of 1 room 1,793 22.1 3,858 10.3 2.15 530 2,048 5.46 2 rooms 1,846 22.8 6,585 17.6 1.78 523 3,228 8.61 3 „ 1,224 15.1 4,982 13.3 1.36 170 1,377 3.67 4 „ 696 8.6 3,237 8.6 1.16 54 541 1.44 Mile-end Old Town 1 room 5,122 20.8 11,399 10.0 2.21 1,693 6,323 5.88 2 rooms 5,091 20.6 18,109 16.8 1.78 1,335 7,963 7.40 3 „ 4,675 19.0 20,657 19.2 1.47 784 6,143 5.71 4 „ 3,618 14.7 19,651 18.3 1.36 333 3,238 3.01 Newington 1 room 5,506 20.3 11,893 10.3 2.16 1,654 6,115 5.28 2 rooms 6,355 23.4 22,293 19.3 1.75 1,622 9,476 8.18 3 „ 5,446 20.1 23,811 20.6 1.46 842 6,542 5.65 4 „ 4,218 15.6 22,729 19.6 1.35 377 3,649 3.15 Paddington 1 room 4,785 17.6 9,676 8.2 2.02 1,239 4,636 3.93 2 rooms 5,537 20.4 19,589 16.6 1.77 1,582 9,597 8.14 3 „ 4,858 17.9 19,009 16.1 1.30 531 4,192 3.56 4 „ 2,028 7.5 9,824 8.3 1.21 144 1,395 1.18 6 Sanitary area. Tenements with, Number of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. Number of one to four roomed tenements with more than two occupants per room. N umber of occupiers of such tenements. Percentage of population in such tenements. 1 2 3 4 5 6 7 8 Plumstead 1 room 1,057 5.8 1,934 2 1.83 216 755 0.85 2 rooms 2,134 11.6 6,263 7.1 1.47 296 1,651 1.86 3 „ 2,646 14.4 9,834 11.1 1.24 189 1,439 1.63 4 „ 3,377 18.4 16,605 18.8 1.23 194 1,854 2.09 Poplar 1 room 4,348 12.3 9,373 5.6 2.16 1,334 4,833 2.90 2 rooms 6,311 17.8 21,655 13.0 1.72 1,574 9,072 5.44 3 „ 7,718 21.7 33,938 20.4 1.47 1,221 9,440 5.66 4 „ 7,436 21.0 39,393 23.6 1.32 663 6,391 3.83 Rotlierhitlie 1 room 1,108 13.3 2,421 6.2 2.19 365 1,341 3.42 2 rooms 1,425 17.1 4,969 12.7 1.74 345 2,014 5.13 3 „ 1,469 17.7 6,654 17.0 1.51 276 2,148 5.47 4 „ 1,827 22.0 9,577 24.4 1.31 164 1,561 3.98 St. George, Hanoversquare 1 room 2,998 16.8 5,355 6.8 1.79 567 2,019 2.58 2 rooms 3,860 21.6 12,047 15.4 1.56 724 4,285 5.47 3 „ 2,532 14.2 9,566 12.2 1.26 230 1,762 2.25 4 „ 1,365 7.6 6,041 7.7 1.11 66 633 0.81 St. George-in-the-East 1 room 3,837 37.2 10,127 221 2.64 1,719 6,737 14.71 2 rooms 2,334 22.6 9,720 21.2 2.08 915 5,597 12.22 3 „ 1,863 18.1 9,785 21.4 1.75 537 4,286 9.36 4 „ 1,024 9.9 6,086 13.3 1.49 165 1,623 3.54 St. George-the-Martyr 1 room 4,170 30.1 9,866 16.5 2.37 1,505 5,612 9.10 2 rooms 4,086 29.5 16,123 27.0 1.97 1,407 8,465 14.18 3 „ 2,317 16.7 11,259 18.9 1.62 521 4,094 6.86 4 „ 1,462 10.6 8,468 14.2 1.48 193 1,883 3.15 St. Giles 1 room 3,048 33.6 7,652 19.2 2.51 1,198 4,878 12.26 2 rooms 2,392 26.4 9,127 22.9 1.91 809 5,021 12.62 3 „ 1,155 12.7 5,121 12.9 1.48 203 1,573 3.95 4 rooms 487 5.4 2,351 5.9 1.21 39 386 0.97 St. James, Westminster 1 room 1,323 22.3 2,859 11.4 2.16 383 1,511 6.05 2 rooms 1,721 29.0 5,949 23.8 1.73 459 2,775 11.10 3 „ 862 14.5 3,825 15.3 1.48 175 1,426 5.71 4 „ 327 5.5 1,576 6.3 1.20 24 231 0.92 St. Luke 1 room 3,536 35.9 9,244 21.8 2.61 1,537 6,046 14.25 2 rooms 2,918 29.6 12,693 29.9 2.17 1,287 7,880 18.57 3 „ 1,511 15.3 8,092 19.1 1.79 482 3,893 9.17 4 „ 691 7.0 3,940 9.3 1.38 96 953 2.25 St. Margaret and St. John, Westminster 1 room 3,872 29.1 8,527 15.4 2.20 1,142 4,410 7.94 2 rooms 3,695 27.8 11,178 20.1 1.51 1,021 4,145 7.46 3 „ 1,754 13.2 7,753 14.0 1.47 304 2,381 4.29 4 „ 956 7.2 4,734 8.5 1.24 67 645 1.16 St. Martin-in-theFields 1 room 799 25.6 1,820 12.5 2.28 272 1,039 7.11 2 rooms 751 24.1 2,640 18.1 1.76 204 1,242 8.50 3 „ 426 13.7 1,723 11.8 1.35 58 468 3.20 4 178 5.7 811 5.5 1.14 15 147 1.01 St. Marylebone 1 room 11,296 32.3 25,114 17.6 2.22 3,584 13,741 9.65 2 rooms 8,929 25.6 33,513 23.5 1.88 2,828 17,447 12.25 3 „ 3,932 11.3 17,067 12.0 1.15 670 5,310 3.73 4 „ 1,948 5.6 9,519 6.7 1.22 165 1,634 1.15 St. Olave 1 room 460 17.9 1,054 8.3 2.29 173 625 4.91 2 rooms 794 31.0 3,207 25.2 2.02 293 1,774 13.94 3 „ 482 18.8 2,465 19.4 1.70 121 960 7.55 4 „ 343 13.4 1,923 15.1 1.40 36 343 2.70 St. Pancras 1 room 15,368 26.8 34,318 14.6 2.23 4,959 18,998 811 2 rooms 16,220 28.3 60,613 25.9 1.87 5,065 30,817 1.3.15 3 „ 8,689 15.2 37,723 16.1 1.45 1,439 11,414 4.87 4 „ 4,416 7.7 23,047 9.8 1.30 359 3,501 1.49 Diagrarw I. arriages. 7 Sanitary area. Tenements with, Number of tenements. Percentage of all tenements Total occupants Percentage of populution in each group of tenements. Average occupants per room. Number of one to four roomed tenements with more than two occupants per room. Overcrowding. Number of occupiers of such tenements. Percentage of population in such tenements. 1 2 3 4 5 6 7 8 St. Saviour 1 room 2,091 33.2 4,919 18.1 2.35 753 2,834 10.43 2 rooms 1,690 26.8 6,395 23.5 1.89 611 3,335 12.27 3 „ 949 15.1 4,692 17.3 1.65 220 1,742 6.41 4 „ 587 9.3 3,445 12.7 1.47 92 887 3.26 Shoreditch 1 room 8,373 29.1 20,112 16.2 2.40 3,167 12,037 9.71 2 rooms 7,637 26.5 30,300 24.4 1.98 2,670 16,098 12.98 3 „ 4,959 17.2 24,559 19.8 1.65 1,180 9,315 7.51 4 „ 3,529 12.2 20,258 16.3 1.51 442 4,319 3.48 Strand 1 room 1,854 30.9 4,538 18.1 2.45 709 2,805 11.17 2 rooms 1,556 25.9 6,083 21.2 1.95 541 3,354 13.35 3 „ 983 16.4 4,209 16.8 1.43 157 1,257 5.00 4 „ 309 5.1 1,563 6.2 1.26 37 359 1.43 Wandsworth 1 room 1,868 5.9 3,332 2.1 1.78 352 1,272 0.81 2 rooms 2,749 8.6 8,141 5.2 1.48 445 2,543 1.62 3 „ 3,911 12.3 14,884 9.5 1.27 365 2,769 1.76 4 „ 4,616 14.5 21,752 13.9 1.18 227 2,172 1.38 Whitechapel 1 room 4,575 32.1 13,396 18.2 2.93 2,411 9,891 13.45 2 rooms 4,167 29.2 19,522 26.5 2.34 2,075 13,434 18.26 3 „ 2,173 15.2 12,221 16.6 1.87 750 6,256 8.51 4 „ 1,138 8.0 7,072 9.6 1.55 237 2,411 3.28 Woolwich 1 room 1,341 17.2 2,951 7.2 2.20 422 1,521 3.72 2 rooms 1,434 18.4 4,865 11.9 1.68 339 1,973 4.83 3 „ 1,326 17.0 5,584 13.7 1.40 177 1,370 3.35 4 „ 1,423 18.3 7,280 17.8 1.28 107 1,042 2.55 Marriages. There were 37,175 marriages in the registration county of London in 1892, giving an annual rate of 17.4 per 1,000 living. The marriage rate since 1870 has been as follows— 1871 19.5 1882 18.4 1872 19.9 1883 18.1 1873 19.8 1884 17.9 1874 19.4 1885 17.4 1875 19.6 1886 17.2 1876 19.2 1887 16.9 1877 18.7 1888 16.9 1878 18.5 1889 17.1 1879 18.0 1890 17.6 1880 18.1 1891 17.7 1881 18.1 1892 17.4 The fall in the marriage rate during recent years can be appreciated by reference to the accompanying diagram (I.). The marriage rate of England in the period 1871-80 ranged between 14'4 and 17'6 ; in the period 1881-90, between 14.2 and 15.5; in 1891, the marriage rate was 15'6, and in 1892, 15 4. With the full of the marriage rate there was in 1891, as eompared with previous census years, a relative decrease in the proportion of young married men resident in London, as will be seen in the following table— Married males. Unmarried males. Aged 15 and upwards. Aged 15 to 25. per cent. Aged 15 and upwards. Aged 15 to 25. per cent. 1851 399,098 22,674 5.7 295,446 184,179 62.3 1861 481,386 28,144 5.8 324,689 214,060 65.9 1871 536,788 33,095 5.9 380,763 253,577 66.6 1881 641,808 39,632 6.1 462,550 307,849 66.5 1891 705,865 38,699 5.5 539,151 352,539 66.2 It is, however, noteworthy that the marriages of minors constitute, in successive decennia, an increasing proportion of total marriages. This is shown in the following table— Marriages of minors per cent, of total marriages in London. Men. Women. 1851-60 2.77 11.95 1861-70 3.56 14.56 1871-80 4.71 16.90 1881-90 5.53 18.91 8 Births. There were 131,999 children born in the administrative county of London in the year 1892, giving a birth rate of 30 9 per 1,000 living. The birth rate since 1870 has been as follows— 1871 34.5 1872 35.6 1873 35.3 1874 35.6 1875 35.4 1876 35.9 1877 35.6 1878 35.5 1879 35.5 1880 35.3 1881 34.7 1882 34.5 1883 34.5 1884 34.3 1885 33.4 1886 33.4 1887 32.9 1888 32.1 1889 31.9 1890 30.7 1891 31.9 1892 30.9 The fall in the London birth rate has been shared by that of England, the birth rate in the period 1871-80 having ranged between 342 and 36.3; in the period 1881-90, between 30.2 and 33.9; and having been in 1891, 31.4, and in 1892, 30.4. The number of illegitimate births in London in 1892 was 3.7 per cent. of the total births, and in England 4.2 per cent. The accompanying diagram (II.) shows the excess and defect of the birth rate in relation to the average birth rate of the years 1851-1892. The birth rate in each of the forty-one London sanitary districts in 1892 is shown in the following table— Births. Births per 1,000. West— Kensington 3,708 22.3 Hammersmith 2,914 29.0 Fnlham 3,496 35.4 Paddington 2,936 24.7 Chelsea 2,784 28.7 St. George, Hanover-square 1,519 19.8 Westminster 1,375 25.0 St. James 529 21.7 North— Marylebone 4,344 30.9 Hampstead 1,456 20.4 Pancras 7,140 30.6 Islington 9,556 29.6 Hackney 6,758 28.8 Central— St. Giles 1,129 28.9 St. Martin-in-the-Fields 246 17.3 Strand 576 23.7 Holborn 885 26.9 Clerkenwell 2,174 331 St. Luke 1,904 45.5 London, City of 665 18.0 East— Shoreditch 4,487 36.4 Bethnal Green 4,911 38.1 Whitechapel 3,053 40.9 St. George-in-the-East 1,877 41.2 Limehouse 1,930 33.8 Mile End Old Town 4,013 37.3 Poplar 5,864 35.0 South—- St. Saviour, Southwark 844 31.4 St. George, Southwark 2,119 36.0 Newington 4,094 35.1 St. Olave 463 36.2 Bermondsey 3,177 37.7 Rotherhithe 1,318 33.3 Lambeth 9,226 3.32 Battersea 4,990 3.23 Wandsworth 4,227 25.7 Camberwell 7,480 31.2 Greenwich 5,413 32.1 Lewisham *2,314 24.2 Woolwich 1,236 30.7 Plumstead *2,839 31.0 * The number of births in this table has been obtained by adding the births in each registration subdistrict. Probably a small correction is necessary in the case of Lewisham and Plumstead, as a small portion of Lewisham Sanitary District is included in Plumstead Registration District. Diagram II. Births. Chartm III Deaths. Diagram III. 9 The accompanying chart (III.) shows the districts having in 1885-92 a mean birth-rate of over 36 per 1,000 of population, of 32 to 36, of 25 to 32, and of under 25. Deaths. The London death-rate since the year 1870 has been as follows— 1871 24.6 1877 21.6 1883 20.8 1888 19.3 1872 21.5 1878 231 1884 20.9 1889 18.4 1873 22.4 1879 22.6 1885 20.4 1890 21.4 1874 22.4 1880 21.7 1886 20.6 1891 21.4 1875 23.6 1881 21.3 1887 20.3 1892 20.4 1876 21.9 1882 21.5 The death rate had therefore, with slight exception, been falling from the year 1882 to 1889, but in 1890 and 1891 had been higher than in any year since 1882, and in 1892 higher than in any year since 1886, excepting the years 1890 and 1891. Diagram III. shows the excess or defect of the death rate in each year in relation to the mean death rate for the period 1841-92. In the year 1885 the Registrar-General began to distribute to the several London sanitary districts to which they belong the deaths from all causes and from certain zymotic diseases occurring in London, and in institutions belonging to London but situated beyond the limits of the county, and the death rate for each sanitary district, corrected in this sense can therefore be obtained for each year since 1884. It is, however, a well recognised fact that in comparing death rates of different areas due regard should be paid to differences of age and sex distribution in the populations upon which such death rates are calculated. The age and sex distribution of the populations of London sanitary districts exhibit considerable variations owing to the diverse character of the population comprised within the limits of the county. Thus in the industrial and lower riverside districts, compared with London as a whole, there is generally an excess of males over females at all ages, and a marked excess of persons living in the prime of life and the healthy ages; on the other hand, in the districts which are principally or wholly residential in character, an excess of females at ages 15 and upwards is noticeable owing to the greater demand for domestic servants. Considerable differences are also observable in the proportion of children ur.der 5 years of age in the various districts. For the purpose of comparing the death rates of London districts, correction should be made for these differences in the constitution of the various populations and the "factors for correction" shown in the following table have been calculated for this purpose, and are based on the age and sex distribution of the various districts as enumerated in 1891, and the mean annual death rate for each sex at each age period in England and Wales in 1881-90. The method of calculation is similar to that employed by the Registrar-General in his calculations relating to the 33 large towns of England and Wales, and may be briefly described as follows:— Given (1) Age and sex distribution of population of district A at last census. (2) Death rate for each sex at each age period in England and Wales in the last decennium. To find factor for correcting recorded death rate of A for differences of age and sex distribution between A and England and Wales. Applying (1) to (2) gives standard death rate for A, say x, i.e., a death rate which would be correct on the assumption that the rates of mortality at each age period and for each sex were identical with the mean rates in England and Wales in the last decennium. The difference between x and the death rate for England and Wales, say y, will on the above assumption be entirely due to differences of age and sex distribution in the two populations concerned, and - will therefore represent the factor for correcting the recorded death rate of A. Recorded and Corrected Death Rates per 1,000 persons living in Sanitary Districts of London in 1892. Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Recorded death rate, 1892. Corrected death rate, 1892. Comparative mortality figure, 1892. [London 1,000.] Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Recorded death rate, 1892. Corrected death rate, 1892. Comparative mortality figure, 1892. [London 1000.] England and Wales. 1915 — 190 190 Plumstead 18.51 1.03458 15.2 15.7 727 Poplar 18.49 1.03569 22.4 23.2 1,074 London 17.96 1.06626 20.3 21.6 1,000 Rotlierhithe 18.49 1.03569 21.4 22.2 1,028 Battersea 17.80 1.07584 18.0 19.4 898 St. George, Hanover-square 17.34 1.10438 17.5 19.3 894 Bermondsey 18.10 1.05801 23.0 24.3 1,125 Bethnal-green 18.39 1.04133 23.1 24.1 1,116 St. George-inthe-East 18.43 1.03907 27.7 28.8 1,333 Camberwell 18.10 1.05801 18.8 19.9 921 Chelsea 17.95 1.06685 20.6 22.0 1,019 St. George, South wark 17.35 1.10375 21.9 27.5 1,273 Clerkenwell 17.28 1.10822 24.8 27.5 1,273 Fulham 18.27 1.04817 19.9 20.9 968 St. Giles 17.27 1.10886 23.6 26.2 1,213 Greenwich 18.63 1.02791 19.2 19.7 912 St. James 17.16 1.11597 18.1 20.2 935 Hackney 18.23 1.05047 17.2 18.1 838 St. Luke 17.72 1.08070 26.1 28.2 1,306 Hammersmith 18.05 1.06094 19.6 20.8 963 St. Martin-inthe-Fields 15.74 1.21665 22.9 27.9 1,292 Hampstead 16.63 1.15153 12.3 14.2 657 Holborn 17.62 1.08683 27.3 29.7 1,375 St. Marylebone 17.82 1.07464 21.8 23.4 1,083 Islington 17.90 1.06983 18.8 20.1 931 St. Olave 18.42 1.03963 27.0 28.1 1,301 Kensington 17.38 1.10184 17.6 19.4 898 St. Pancras 17.89 1.07043 22.0 23.5 1,088 Lambeth 18.24 1.04989 19.7 20.7 958 St. Saviour 18.29 1.04702 25.5 26.7 1,236 Lewisham 17.92 1.06864 14.7 15.7 727 Shoreditch 18.45 1 03794 23.0 23.9 1,106 Limehouse 17.59 1.08869 25.5 27.8 1,287 Strand 16.24 1.17919 28.3 33.4 1,546 City of London 16.65 1.15015 22.0 25.3 1,171 Wandsworth 17.93 1.06804 15.7 16.8 778 Mile-end Oldtown 18.58 1.03068 23.1 23.8 1,102 Westminster 16.94 1.13046 23.5 26.6 1,231 Whitecbapel 17.74 1.07948 24.8 26.8 1,241 Newington 18.32 1.04531 24.4 25.5 1,181 Woolwich 16.99 1.12713 20.2 22.8 1,056 Paddington 17.72 1.08070 17.9 19.3 894 2 10 It will be observed by comparing the "factors for correction" that the most marked differences of age and sex distribution occur between Greenwich (factor 1.02791), and St. Martin-in-the-Fields (factor 1.21665). It is interesting to note the constitution of these two populations as regards age and sex. Population at each age period and for each sex per cent. of total population. District. Sex. All ages. 0— 5— 10— 15— 20— 25— 35— 45— 55— 65— d upwards. Greenwich M. 48.31 6.61 6.09 5.68 4.55 4.11 7.53 5.60 4.02 2.35 1.34 .42 F. 51.69 6.61 6.14 5.49 4.90 4.83 8.25 5.98 4.34 2.72 1.74 .69 St. Martin's M. 50.47 3.46 3.15 3.22 5.42 6.80 9.82 7.64 0.77 3.46 1.43 .30 F. 49.53 3.32 3.49 3.78 5.06 7.28 9.98 6.79 5.05 2.89 1.41 .41 From the column showing corrected death rates it will be seen that of the 8 western districts, 2 had, in 1892, a death rate above the London average; of the 5 northern, 2; of the 7 central, all; of the 7 eastern, all; and of the 14 southern, 7 were above this standard. The accompanying chart (IV ) shows the districts which in 1885-92 had a mean death rate of 24 and upwards per 1,000 of population ; those which had a mean death rate of 20-24 ; those which had a mean death rate of 16-20; and those which had a mean death rate of less than 16 per 1,000. Mortality and " overcrowding." The death rates prevailing during the period 1885-92 in the various groups of districts shown on chart II. (page 4) were as follows: groups 1 and 2 have, for convenience, been combined— Proportion of total population living more than two in a room (in tenements of less than five rooms). Death rate "all causes" 1885-92. Districts with under 15 per cent. 17.51 „ 15 to 20 „ 19.51 „ 20 to 25 „ 20.27 „ 25 to 30 ,, 21.76 30 to 35 23.92 „ over 35 „ 25.07 Infant mortality. The number of deaths of children under 1 year of age per 1,000 births is generally regarded as affording a fair test of the healthiness of a district. In London in 1892 the deaths of children of this age were in the proportion of 154 per 1,000 births, and in England 82.4 per 1,000. In the forty-one sanitary districts of London the proportions were as follows — Infant mortality, 1892. Infant mortality, 1892. deaths under year of age. Deaths under 1 year to 1,000 births. Deaths under 1 year of age Deaths under 1 year to 1,000 births. West — East— Kensington 590 159 Shoreditch 740 165 Hammersmith 488 167 Bethnal-green 775 158 Fulham 579 166 Whitechapel 474 155 Paddington 417 142 St. George-in-the-East 344 183 Chelsea 458 165 Limehouse 359 186 St. George, Hanover-square 216 142 Mile-end Old-town 612 153 Westminster 233 169 Poplar 963 164 St. James 68 129 North— South— St. Saviour, Southwark 158 187 Marylebone 574 132 St. George, South wark 375 174 Hampstead 178 122 Newington 704 172 Pancras 1,186 166 St. Olave 85 184 Islington 1,417 148 Bermondsey 516 162 Hackney 901 133 Rotherhithe 198 150 Central— Lambeth 1,250 135 Battersea 814 163 St. Giles 173 153 Wandsworth 620 147 St. Martin-in-the-Fields 36 146 Camberwell 1,157 155 Strand 132 229 Greenwich 801 148 Holborn 187 211 Lewisham 334 144 Clerkenwell 375 172 Woolwich 182 147 St. Luke 270 142 Plumstead 312 110 London, City of 110 165 London 20,361 154 The infant mortality rate of the several sanitary districts during 1885-92 is shown in Chart V. It will be seen that the districts having the heaviest infant mortality correspond closely, but not exactly, with those having the greatest death rate at all ages from all causes. CHART IV. CHART V. Diagram IV. Smallpox 11 Deaths from several classes of disease. The deaths from certain classes of disease registered in the Registration County of London together with the deaths occurring in the several lunatic asylums and hospitals for infectious disease belonging to the county are given by the Registrar General as follows— 1892. Corrected annual average 1882-91. Zymotic diseases 15,667 14,074.3 Parasitic 89 117.9 Dietetic 598 412.2 Constitutional 16,344 16,948.9 Developmental 5,312 5,300.4 Nervous 8,971 9,922.9 Organs of special sense 142 125.9 Circulatory 7,061 6,500.8 Respiratory 19,379 18,986.9 Digestive 4,438 4,783.7 Lymphatic 87 107.7 Urinary 2,168 2,139.2 Generative 554 512.1 Locomotive 331 395.6 Integumentary 334 280.9 Violence (accident) 2,707 2,648.2 ,, (not accident) 523 473.1 Other causes 3,044 3,299.2 Smallpox and Vaccination. Smallpox, which caused 1 death in London in 1889, 3 in 1890, and 8 in 1891, caused 29 deaths in 1892. During each of the seven years 1886-92 the death-rates were below the mean rate of 1851-92. The mortality from this disease in later years can be contrasted with that ol former years by reference to Diagram IV. and to the following figures— Smallpox death-rate per 1,000. 1851-60 0.28 1881-90 0.14 1861-70 0.28 1891 0.00 1871-80 0.46 1892 0.01 During the years immediately antecedent to 1892 a comparatively small number of cases of this disease were notified to the medical officers of health in London. The returns of the Metropolitan Asylums Board supply the following number of cases of smallpox notified in London since the passing of the Infectious Diseases (Notification) Act, 1889— Year. Cases notified. 1890 60 1891 114 1892 425 The recent history of smallpox in London has been as follows:—In the early part of the year 1891 cases of smallpox had occurred among the riverside population. A ship's steward who had been exposed to smallpox in Lisbon suffered from this disease in Limehouse; a grain porter who had been working on board ships in the Surrey Commercial Docks sickened at Greenwich; a dock labourer employed in unloading corn from a vessel on the Thames sickened at Rotherhithe; the child of a man casually employed in the Millwall Docks sickened at Poplar; other cases occurred later in Greenwich and Bermondsey among people engaged in connection with shipping, and a man who had recently come from Swanage sickened in St. Giles. Some of these cases led to the infection of other persons. In the latter part of the year a number of Swiss waiters employed in a house in St. Pancras were attacked, leading to cases of smallpox in that district and in Marylebone. During the year 1891 cases occurred in Limehouse, Greenwich, Rotherhithe, St. Giles, Bermondsey, Bethnal-green, Camberwell, Mile-end, Shoreditch, Kensington, City, Islington, Lambeth, Lewisham, Marylebone, St. Pancras and Wandsworth. In the beginning of the year 1892 four cases of smallpox associated with the outbreak among the Swiss waiters in the latter part of 1891, also occurred. The most notable outbreak in the year occurred in Shoreditch, the particulars of which were supplied me by Dr. Allan, at that time medical officer of health of that district. The first case appears to have been a child living in New Inn-street, whose illness was regarded as chickenpox. This child was away from school on account of this illness during the week ended 7th February. An adult living in the same house suffered from so-called chickenpox on February 20th. A brother of the girl worked in Curtain-road, and although he did not himself suffer he appears to have conveyed infection to others, who in their turn served as sources of infection. In this manner the disease rapidly spread to neighbouring streets, as many as 83 cases occurring in the district during the year, and others resulting from them in the neighbouring districts of St. Luke, Bethnal-green, Hackney, Holborn, Islington, and Whitechapel. The medical officer of health of Kensington reports that four cases of smallpox occurred in one house in that district, the first in the person of a medical man who had been exposed to infection at hospital, and the nature of whose illness was not recognised. Three other members of his family were infected by him. 12 In the year 1892, 425 cases of smallpox were notified, and 299 patients removed from London to the smallpox hospitals of the Metropolitan Asylums Board, of whom 23 were found not to be suffering from this disease. The cases notified were distributed throughout the year as follows— Week of year. Week ending Cases notified. Week of year. Week ending Cases notified. 1 9th January 1 27 9th July 9 2 16th „ 1 28 16th „ 3 3 23rd „ 1 29 23rd „ 4 4 30th „ 2 30 30th „ 2 5 6th February 1 31 6th August 4 6 13th „ 2 32 13th „ 3 7 20th „ 1 33 20th „ 5 8 27th „ 4 34 27th „ 5 9 5th March 4 35 3rd September 2 10 12th „ 9 36 10th „ — 11 19th „ 7 37 17th „ — 12 26th „ 17 38 24th 3 13 2nd April 22 39 1st October — 14 9th „ 12 40 8th „ 2 15 16th „ 13 41 15th „ 3 16 23rd „ 14 42 22nd „ 5 17 30th „ 6 43 29th „ — 18 7th May 17 44 5th November 1 19 14th „ 32 45 12th „ 5 20 21st „ 28 46 19th „ 13 21 28th „ 31 47 26th „ 6 22 4th June 28 48 3rd December 8 23 11th „ 20 49 10th „ 11 24 18th „ 13 50 17th „ 9 25 25 th „ 10 51 24th „ 7 26 2nd July 9 52 31st „ 10 The cases notified in, and the deaths belonging to the several sanitary districts are shown in the following table— Cases notified. Deaths. Cases notified. Deaths. West— Brought forward 170 11 Kensington 3 — East— Hammersmith 2 — Shoreditch 83 4 Fulham 2 — Bethnal-green 36 5 Paddington 3 — Whitechapel 23 — Chelsea 4 1 St. George-in-the-East 4 1 St. George, Hanover-square 1 — Limehouse 7 — Westminster 2 — Mile-end Old-town 10 1 St. James 4 — Poplar 5 — North— South— Marylebone 11 — St. Saviour, Southwark — — Hampstead 1 — St. George, Southwark 2 — Pancras 34 2 Newington — — Islington 42 3 St. Olave — — Hackney 27 1 Bermondsey 2 — Central— Rotherhithe — — Lambeth 24 1 St. Giles 7 — Battersea 4 1 St. Martin-in-the-Fields — — Wandsworth — — Strand 7 — Camberwell 16 1 Holborn 3 — Greenwich 11 1 Clerkenwell 3 — Lewisham 3 — St. Luke 9 4 Woolwich 2 London, City of 5 Plumstead 19 3 Carried forward 170 11 Port of London 4 — 425 29 Dr. Allan, the medical officer of health of Shoreditch, gives in a quarterly report the following information concerning the condition as to vaccination of 90 cases of smallpox in that district—"Dealing first with the unvaccinated class, comprising 16 cases, 8 had the disease in confluent forms and 5 of them died, their ages being 1 year, 15 months, 2 years, 5 years and 31 years respectively; in 1 case the disease was semi-confluent, and in 7 was discrete, but ran the course of ordinary or unmodified smallpox. 67 are recorded to have been vaccinated in infancy, but that statement must not be taken to imply 13 that all the 67 were efficiently vaccinated at that age. In 4 cases no marks of vaccination were to be seen, and of these, 1 had the disease slightly, 2 moderately, and 1 (aged 22) severely, which proved fatal. It is highly probable that these four cases should properly be included under the heading of 'unvaccinated' or 'unsuccessfully vaccinated.' In two others the scar was scarcely perceptible, in one of these the disease was moderate, in the other confluent and fatal; in a number of others the vaccination, as judged from the number and appearance of the scars, appears to have been of low quality, but in all who presented any clear signs of having been vaccinated the disease was less severe, ran a shorter course than ordinary smallpox, and was in no case fatal. Two cases in persons over 40 years of age are stated to have been re-vaccinated, one of these at the age of 10 years, the other in India about 20 years ago. both were mild cases." The report of the Statistical Committee of the Metropolitan Asylums Board for the year 1892. supplies the following figures relating to cases of smallpox admitted during that year into the hospital ships— Total vaccinated cases admitted 218, deaths 3 Cases in which there was "no evidence" as to cicatrices* 40 „ 13 Cases in which vaccination cicatrix was "absent" 62 „ 17 In 1881 the Registrar General began to classify the deaths from smallpox according to whether the deceased was stated to be vaccinated, unvaccinated, or whether there was no statement as to vaccination. The totals of the twelve years 1881-92 are as follows— All ages. 0—1 1—5 5—20 20—40 40-60 60—80 80 and upwards. Vaccinated 1,175 19 28 219 674 201 31 3 Unvaccinated 1,876 299 432 638 394 98 14 1 No statement 1,793 234 219 438 618 226 56 2 The proportion in which the vaccinated and unvaccinated died from smallpox at the different ages will be seen by reference to the following figures, the later age of death of the vaccinated contrasting with the earlier age of death of the unvaccinated. All ages taken as 100. 0—1 1—5 5—20 20—40 40—60 60—80 80 and upwards. Vaccinated ... 100 1.6 2.4 18.6 57.4 17.1 2.6 0.3 Unvaccinated 100 15.9 23.0 34.0 21.0 5.2 0.7 0.1 No statement 100 13.1 12.2 24.4 34.5 12.6 3.1 0.1 This difference of age-incidence, although less marked, is still observable when the numbers relating to "Vaccinated" and "No statement" are combined, as will be seen by reference to the following table— All ages taken as 100. 0—1 1—5 5—20 20—40 40—60 60—80 80 and upwards. Vaccinated and " No statement" 100 8.5 8.3 22.1 43.5 14.4 2.9 0.2 Unvaccinated 100 15.9 23.0 34.0 21.0 5.2 0.7 0.1 The Council receives no returns relating to vaccination, but a few of the medical officers of health publish in their annual reports a tabular statement showing the results obtained during the year. To some others I am indebted for information specially supplied to me by them. The tabular statements contained in the annual reports and the information thus afforded me show that during the year 1892 there was a marked falling off in the number of infants vaccinated, and in some districts the number "unaccounted for including vaccinations postponed" attained large proportions. In Hackney, Limehouse, and Poplar, this number is more than 20 per cent. of the births, in Hackney more than 40 per cent. Among those districts having from 15 to 20 per cent. are Pancras, St. Giles, St. Martin-in-the-Fields, Strand, St. Luke, St. Olave, and Battersea; and from 10 to 15 per cent., Chelsea, Islington, Shoreditch, St. George-in-the-East, St. Saviour, Southwark, St. George-the-Martyr, and Wandsworth. *The report of the Committee points out that "under this heading are included cases stated to have been vaccinated but bearing no visible evidence of the operation, and also cases in which no statement was made, but the nature of the complaint, or other cause, prevented any observation of the marks, if any existed." 14 The only complete returns are published in the reports of the medical officer of the Local Government Board, from which the following table is compiled. The figures given are the last which are available. Table showing the number of children, per cent, of total births remaining "unaccounted for," including cases postponed, when the Vaccination Returns for the undermentioned years were received. Metropolitan Unions. 1879. 1 0. 1881. 1882. 1883. 1884. 1885. 1886. 1887. 1888. 1889. Bethnal-green 8.0 6.3 5.5 7.1 6.1 8.0 8.6 1.11 13.5 16.0 25.1 Camberwell 10.0 7.1 5.2 6.0 6.4 7.0 6.8 8.4 9.4 8.4 12.5 Chelsea 7.1 5.8 51 6.7 5.2 5.1 5.0 5.6 7.2 4.8 6.0 Fulham 7.1 6.0 5.4 4.1 3.8 4.2 4.5 4.5 4.6 5.5 6.0 St. George, Han over-square 9.6 4.8 2.3 4.4 3.1 2.9 4.6 4.3 4.6 4.5 4.0 St. George-in-the-East 7.5 7.0 4.2 4.3 4.7 3.7 4.8 5.3 6.7 7.9 6.5 St. Giles and St. George 12.1 10.2 11.6 9.9 11.4 11.6 11.1 12.2 14.1 17.7 22.5 Greenwich 6.9 6.2 6.6 7.8 10.2 10.4 11.1 11.4 9.6 10.1 11.5 Hackney 6.9 6.1 4.6 6.7 6.2 6.5 9.3 9.3 8.9 12.1 18.5 Hampstead 3.6 3.2 3.1 4.0 5.1 4.2 3.8 4.0 5.0 5.6 5.1 Holborn 7.2 68 6.2 7.6 8.5 9.7 8T 7.7 8.7 10.3 11.3 Islington 9.3 90 8.2 80 8.4 8.0 8.0 7.8 8.1 9.8 9.5 Kensington 4.8 3.5 3.9 5.4 4.6 4.9 5.5 6.5 7.0 6.9 7.5 Lambeth 14.3 12.1 7.6 8.3 8.5 8.6 8.6 9.4 11.1 12.6 13.3 Lewisham 3.0 3.1 3.2 4.1 4.8 4.2 5.2 5.0 6.5 5.9 6.6 City of London 7.0 3.0 2.9 2.9 2.4 3.9 7.4 8.0 8.0 9.0 9.2 Marylebone 7.8 7.5 5.1 6.8 5.5 7.3 5.4 4.6 4.7 4.9 8.1 Mile-end Old-town 7.5 7.2 7.5 8.8 9.8 8.7 8.8 9.7 11.3 14.4 16.6 St. Olave 4.1 5.0 4.1 5.9 10.0 7.3 8.0 9.0 17.7 15.0 15.4 Paddington 7.8 7.6 7.7 9.2 8.8 8.2 8.8 10.1 8.4 11.3 12.7 St Pancras 7.8 7.2 6.3 5.7 4.0 5.2 6.1 6.9 8.7 11.5 13.2 Poplar 4.1 39 4.4 4.0 3.6 3.8 3.0 4.9 5.7 16.9 15.1 St. Saviour 7.0 8.0 5.7 6.7 6.0 8.7 9.1 13.1 18.9 17.1 12.4 Shoreditch 12.8 12.2 10.3 12.0 7.6 6.5 5.6 6.3 5.6 3.7 5.5 Stepney 7.9 9.7 6.2 4.8 2.3 3.7 4.1 5.9 5.3 6.0 8.8 Strand 7.6 9.2 7.2 8.3 7.6 9.3 8.9 8.5 9.7 10.0 16.2 Wandsworth and Clapham 5.5 5.0 5.4 7.1 90 8.2 9.1 9.7 10.6 11.5 12.1 Westminster 5.0 6.0 4.8 5.7 6.1 5.7 6.6 8.5 8.5 4.1 12.8 Whitechapel 2.6 2.3 1.4 1.6 1.6 1.4 1.5 1.8 1.7 2.1 2.8 Woolwich 7.9 64 1.9 1.4 1.5 1.6 18 22 2.2 2.9 3.5 Total 7.8 7.0 5.7 6.6 6.5 6.8 7.0 7.8 9.0 10.3 11.6 Twenty deaths during 1892 attributed to "cowpox and vaccination" were registered in the Registration County of London, the corrected average being 9.9. Measles. Measles caused 3.388 deaths in London in 1892. The death rates from this disease per 1,000 living during 1892 and previous periods have been as follows— 1851-60 0.53 1881-90 0.64 1861-70 0.58 1891 0.43 1871-80 0.51 1892 0.79 Diagram V. shows the excess and defect of the death rate ol measles in relation to the mean death rate 1841-92. The reports of the medical officers of health discuss the neglect to recognise the dangerous character of this disease, and in several instances the notification of measles is recommended. Thus the medical officers of St. Giles, St. George-the-Martyr, Clapham, Streatliam and Wandsworth, express the opinion that notification is desirable with a view to giving increased opportunity for limiting the spread of the disease. The medical officer of the Strand district writes "The question of the desirability of adding measles to the list of notifiable diseases was considered by your board [Board of Works of the Strand District], and your late medical officer gave it as his opinion that 'the suggested addition would be attended by considerable inconvenience to those whose children may happen to be suffering from this disorder, to extra expense on the part of your board, and so far as my experience enables me to form an opinion with very little, if any, real benefit to the community generally.'" The medical officer of Kensington says, "it remains to be proved that any great advantage would accrue from its addition to the list." In May, 1892, the Council received from the clerk of the London School Board a letter, stating that for some time past it had been the practice of the Board to exclude from their schools children coming from houses where measles existed. The Board felt, however, that the information upon which they acted from time to time was very unreliable ; the Board's medical officer had recently been giving his attention to this matter, and the Board was of opinion that measles should be included in the list of notifiable diseases set out in section 55 (8) of the Public Health Act of 1891. The reasons which the Board's medical officer had given for this proposal were as follows— Measles. Diagram V. 15 I. The mortality from measles amongst children being greater than the mortality from all the notifiable infectious diseases put together. II. The want the Board experienced of precise and accurate information of the prevalence of measles in the homes of those attending the schools, and the consequent difficulty of systematically excluding children coming from infected houses. III. The risk of the closure of schools from the alleged prevalence of measles in a district without adequate justification, the medical officer of health having no definite information of the extent of measles in the district. The Public Health and Housing Committee felt that further information as to the usefulness of the notification of measles was desirable before any decision was arrived at, and consequently addressed a letter to the Local Government Board, asking what is the experience of the Board as to the value of compulsory notification of measles in enabling sanitary authorities to obtain control of that disease in urban communities. In reply the Local Government Board stated that the Board were then engaged in an inquiry as to the measures by which the spread of measles can be checked, but that they anticipated that this inquiry would not be completed for some time. They were not then prepared to express a definite opinion on the questions which the Council had addressed to them. Letters were also addressed to the several sanitary authorities in London, asking what had been the action of their medical officers of health in connection with the provision of section 55 (4) of the Act, which provides for the transmission of certificates relating to school children suffering from infectious disease to the head teacher of the schools attended by the patients or by any children who are inmates of the same houses as the patients, and asking what profit had accrued in their districts from the use made of this information by school authorities. The replies supplied evidence that the head teachers had been duly apprised of the existence of such cases as required by the Act. As to the advantages which had accrued some difference of opinion was expressed. The majority of the answers did not go further than the statement that, inasmuch as the exclusion from school of children from infected houses had resulted, the result must be regarded as beneficial. In a few cases it was more definitely stated that advantage had been gained, in others that there was no actual knowledge as to the effects of the new requirement, and in two instances the medical officer of health of the district was unable to state that any benefit had accrued to the district from the use made of this information by school authorities. Enquiry by the Council of the London School Board as to what information had been received from the several districts of the sanitary authorities by the head teachers of the schools of the Board under section 55 (4) of the Act, to what use this information had been put, and what had been the experience of the Board of its value, led to the following report of the Board's medical officer being communicated to the Council. 1. That the medical officers of health, without exception, send, in accordance with the provisions of the aforesaid Act, copies of all notification certificates received by them to the head teachers concerned. 2. That on receipt of such notification certificates the head teachers of the various departments of the schools, have in accordance with the directions of the Board, as contained in their code of regulations and instructions, clause 125, page 107, systematically excluded the children from school who came from the infected houses. 3. That all such notification certificates are subsequently regularly forwarded to him by the head teachers, endorsed by the action taken by the heads of the school departments, and he was thus enabled to keep a correct record of the amount of notifiable infectious sickness in connection with each school under the control of the Board. He was of opinion "that the advantages obtained by the arrangements thus rendered possible by the provisions of the Act above referred to, are of the greatest public benefit, inasmuch as they tend to prevent the spread of infectious disease amongst the most susceptible class of the community, and at the same time reduce to a minimum the necessity of interference with the educational work of the Board." Several of the replies of the sanitary authorities touch directly upon the question whether the compulsory notification of measles was desirable. In the district of St. Margaret and St. John, Westminster, a system of voluntary notification of measles had been instituted by arrangement with the majority of the medical practitioners of the district, and the medical officer of health attached great value to this system ; the sanitary authority had therefore asked the Local Government Board to confirm its order providing that measles should be added to the list of infectious diseases required to be notified in the district. The sanitary authorities of St. Giles and St. Mary, Battersea, had adopted a similar course. The Local Government Board had, however, declined to sanction such addition, stating in their reply to the Vestry of Westminster that "the circumstances are not such as to render it necessary that exceptional arrangements should be made as regards a particular parish in London." A second request by the same local authority led to the reply that pending the completion of enquiries on the subject, they (the Local Government Board) had deferred the consideration of the request. On the other hand in several instances opinions were definitely expressed against the compulsory notification of measles, in some on the ground that such notification would be useless unless accompanied by opportunities being afforded for the isolation of cases of this disease. The accompanying chart (VI.) shows the incidence of measles mortality in the period 1885-92 upon the several sanitary districts of London. The following table shows the number of deaths attributed to this disease and the death-rates from this cause in each district in 1892. 16 Deaths, 1892. Death rate per 10,000, 1892. Death rate per 10,000, 1885-91. Deaths, 1892. Death rate per 10,000, 1892. Death rate per 10,000. 1885-91. West— East— Shoreditch 103 8.4 8.2 Kensington 112 6.7 5.0 Bethnal -green 136 10.5 9.0 Hammersmith 133 13.3 7.1 Whitechapel 65 8.7 7.0 Fulham 128 13.0 St. George-in.theEast 62 13-6 11.0 Paddington 80 6.7 4.0 Chelsea 106 10.9 5.7 Limehouse 72 12.6 10.9 St. George, Hanover. square 49 6.4 3.3 Mile-end Old-town 67 6.2 7.3 Poplar 150 9.0 7.1 Westminster 77 14.0 5.3 St. James 17 70 4.9 South— North— St. Saviour, Southwark 23 8.6 9.6 Marylebone 137 9.8 5.6 St. George, Southwark 69 11.6 8.7 Hampstead 25 3.5 2.4 Pancras 233 10.0 5.8 Newington 182 15.6 6.2 Islington 179 5.5 6.7 St. Olave 16 12.5 7.0 Hackney 102 4.3 5.3 Bermondsey 69 8.2 7.9 Central— Rotherhithe 41 11.1 6.2 Lambeth 187 6.7 5.3 St. Giles 47 121 6.7 Battersea 90 5.8 St. Martin - in - the Fields 9 6.4 4.6 Wandsworth 82 5.0 5.3 Camberwell 191 8.0 5.4 Strand 53 21.8 5.0 Greenwich 106 6.3 6.0 Holborn 30 91 6.9 Lewisham 15 1.6 3.2 Clerkenwell 46 7.0 9.4 Woolwich 19 4.7 5.4 St. Luke 37 8.9 9.5 Plumstead 23 2.5 4.7 London, City of 17 4.6 2.7 London 3,388 7.9 6.2 Scarlet Fever. Scarlet fever caused 1,169 deaths in London in 1892, or about twice the number which occurred in the preceding year. The death rates of this disease per 1,000 living during 1892, and previous periods, have been as follows— 1861.70 1.14 1891 0.14 1871.80 0.60 1892 0.27 1881.90 0.33 The excess and defect of mortality during each of the years 1859 to 1892 in relation to the mean mortality of the whole period will be seen by reference to diagram VI. It will be observed that as compared with former years there has in recent times been a marked decline in the mortality from this disease. The circumstances that influence the prevalence of this disease are not wholly understood, but the opportunity given by the hospitals of the Metropolitan Asylums Board for the isolation of the infectious sick may be reckoned among the factors which have led to this reduction. The larger use of these institutions by those who have learnt to value this means of isolating their sick will be appreciated by reference to diagram VII. This larger use is no doubt in great measure due to the fact that these hospitals have gained the confidence of London residents, to the passing of the Notification of Infectious Diseases Act in 1889, and to the passing of the Public Health (London) Act in 1891. Patients since the passing of the last Act have been admitted into these hospitals free of charge, and although in previous years the costs of maintenance of the sick were only exceptionally recovered from the friends of the patients, it is more than probable that the occasional charge for this purpose in some degree militated against the use of these institutions by poor persons. During the autumn of 1892 the hospitals became full, and the Managers were unable to receive all persons for whom application for admission was made. References to the want of hospital accommodation for cases of scarlet fever appear in the reports of the medical officers of health of St. Martin-in-theFields, St. Luke, St. George-the-Martyr, Wandsworth, Chelsea, Kensington and Marylebone, and the vestry of the last parish themselves made hospital provision for the use of the inhabitants of the district by taking a house in which 55 patients suffering from scarlet fever were treated during September and October. The medical officer of health of Marylebone also states that "a lady received for some little time cases of scarlet fever in a house in that district." The disease is stated to have been generally of a mild character by the medical officers of health of Kensington, Plumstead, Mile-end Old-town and Poplar. The fatality of the cases treated in the hospitals of the Metropolitan Asylums Board was in 1892 slightly in excess of the fatality in 1891; but with this exception less than that of any year since 1873. It is interesting to note that the number of deaths in London per cent. of cases of this disease notified in London during the years since notification of infectious disease has been required, was as follows*— 1890 5.7 1892 4.4 1891 5.2 * It should, however, be borne in mind that the number of cases of infectious disease occurring during the years 1890 and 1891 is probably somewhat understated owing to imperfect notification. Scarlet Fever . Dicugroum VII. 17 There is, therefore, in view of differences in the fatality of scarlet fever, considerable difficulty in estimating the amount of hospital accommodation which may be required for cases of this disease by any knowledge we possess as to the number of deaths which have occurred in past years, but it is obvious that demands for hospital accommodation for cases of scarlet fever may in the future be considerably greater than they were in 1892. During that year as many as 4,067 patients suffering from scarlet fever were at one time (5th November) in the London Fever Hospital and the hospitals of the Metropolitan Asylums Board Of special outbreaks of this disease deserving attention the most important was one occurring in the months of March and April, due to the distribution of infected milk supplied by a large milk vendor in Deptford, who derived his milk from various sources among others from cowsheds at Deptford. This outbreak was first brought to my notice by Mr. Bernays, medical officer of health of Charlton. The circumstances of this outbreak were the subject of enquiry on behalf of the Council by Dr. Hamer, whose report I presented to the Public Health Committee. Dr. Hamer found that scarlet fever due to milk from the Deptford cowsheds had occurred in Charlton, Plumstead, Deptford, Greenwich and Bexley, and Dr. Butterfield the medical officer of health of the West Kent combined sanitary district informed me of cases in Sidcup and Chislehurst also due to this supply. But the chief point of interest which Dr. Hamer's enquiry elicited was the fact that while no evidence of infection of the milk by human agency could be discovered, scarlet fever was prevalent among drinkers of this milk at a time when one of the cows in the Deptford shed, a black and white cow, was observed to have a "cold," was "off her feed," and was yielding milk which was "ropy." A few days later the black and white cow was given a dose of physic, and her milk was not distributed. During the next few days the distribution of the milk of this cow appears to have been intermittent, and again a few days later was with that of four other cows excluded from the business. The five cows which were milked by a particular milkman presented on examination of their udders and teats, certain scabs and excoriations. In no instance were the milkers' hands affected. Dr. Hamer pointed out that the six days on which the black and white cow suffered from a cold, and during which her milk was being supplied, were the six days of maximum infective power of the milk supplied by this vendor in the various localities, and that "after the 1st of April, the day when the treatment of the cow was first commenced, and after which date the milk of this particular cow was on several occasions excluded from the business, the infective property became less marked." It is difficult to estimate how many cases of scarlet fever resulted directly and indirectly from this milk supply, but the medical officer of health of Plumstead (Dr. Davies), speaking of the relative incidence of the disease on children attending four Board schools, says that, "the milk supply which first originated the outbreak (in Plumstead), was located near to these four schools, and doubtless the early victims attended these schools ; then the disease spread from child to child by means of slight undetected cases, and from them to children who attended other schools." A somewhat similar outbreak in Upper Clapton was the subject of investigation and report by Dr. Warry, the acting medical officer of health of Hackney. In this case also a particular milk supply was found to be the cause of numerous cases of scarlet fever and throat illness in the neighbourhood mentioned. With the exception of two churns of milk which were received daily from another source and which enquiry excluded from suspicion, the milk was derived from local cowsheds containing 109 cows. No evidence of the infection of the milk by human agency could be discovered, but the child of one of the milk carriers and several children of one of the cowmen, who themselves received their milk from this source, were among those who suffered from scarlatina and throat illness. An examination of the cows showed that several had cracks and abrasions on their teats, and three others had abnormally high temperature. These three were isolated until their temperature had fallen to the normal, and Dr. Warry was able to point out a lessened incidence of scarlet fever on the drinkers of milk from this vendor "coincident with the isolation of the cows which had abnormal temperatures." The following table shows the number of cases of scarlet fever notified in, and the number of deaths from this disease belonging to the several sanitary districts. The incidence of mortality from the disease on the several districts in the period 1885-22, will be seen by reference to the accompanying chart VII. Cases notified in 1892. Rate per 10,000 in 1892. Deaths in 1892. Death rate per 10,000 in 1892. Death rate 1885-91 per 10,000. West— Kensington 723 43 37 2.2 1.4 Hammersmith 459 46 13 1.3 2.0 Fulham 527 54 29 3.0 Paddington 541 46 21 1.8 1.2 Chelsea 533 55 27 2.8 1.5 St. George, Hanover-square 336 44 11 1.4 1.3 Westminster 295 54 18 3.3 2.1 St. James 69 28 5 2.1 1.8 North— Marylebone 703 50 54 3.8 1.2 Hampstead 322 45 5 0.7 1.0 Pancras 1,292 55 67 2.9 1.6 Islington 1,726 53 53 1.6 1.6 Hackney 1,958 83 66 2.8 2.3 3 18 Cases notified in 1892. Rate per 10,000 in 1892. Deaths in 1892. Death rate per 10.000 in 1892. Death rate 1885.91 per 10,000 Central— St. Giles 175 45 5 1.3 1.6 St. Martin-in-the-Fields 54 38 4 2.8 2.1 Strand 111 46 3 1.2 1.3 Holborn 294 90 13 4.0 2.3 Clerkenwell 379 58 21 3.2 2.8 St. Luke 229 55 9 2.2 3.6 London, City of 284 77 12 3.3 1.4 East— Shoreditch 831 67 36 2.9 3.2 Bethnal-green 932 72 56 4.3 4.3 Whitechapel 539 72 34 4.6 2.3 St. George-in-the-East 289 64 34 7.5 3.5 Limehouse 511 90 28 4.9 4.0 Mile-end Old-town 954 89 39 3.6 3.8 Poplar 1,470 88 64 3.8 2.8 South— St. Saviour, Southwark 120 45 7 2.6 3.3 St. George, Southwark 375 63 17 2.8 4.2 Newington 955 82 45 3.9 3.4 St. Olave 64 50 3 2.4 3.3 Bermondsey 645 77 30 36 3.4 Rotherhithe 167 42 6 1.5 2.9 Lambeth 1,778 64 76 2.7 2.4 Battersea 1,132 73 43 2.8 1.7 Wandsworth 886 54 29 1.8 Camberwell 1,549 65 63 2.6 2.3 Greenwich 1,281 76 37 2.2 1.6 Lewisham 398 42 5 0.5 1.l Woolwich 338 84 11 2.7 0.6 Plnmstead 993 108 33 3.6 0.8 London 27,217 64 1,169 2.7 2.2 The death rates from this disease per 1,000 living during 1892 and previous periods have been as follows— 1861-70 0.18 1891 0.32 1871-80 0.12 1892 0.44 1881-90 0.26 The death rate of 1861-70 is materially affected by the deaths occurring towards the close of the severe epidemic which took place in the latter part of the previous decade, when the disease was not as generally recognised as at the present time. During the next decade a lower mortality prevailed, but in the latter part of that decade the mortality began to increase, and with slight fluctuations has increased until the year under consideration. The mortality from diphtheria in each year of the period 1859-92 in relation to the mean mortality of that period will be seen by reference to diagram VIII., which shows in a similar manner the mortality from croup and diphtheria combined in corresponding years. The rates of mortality from diphtheria in the two decades 1861—70 and 1871.80 corresponded closely with those of England and Wales, but while that of London in 1881-90 was 26 per 1,000 of population, the rate of England and Wales was 16, and in 1891 the London rate was double that of England and Wales. Dr. Longstaff has pointed out that the incidence of diphtheria mortality upon densely inhabited districts in England as compared with sparsely inhabited districts, has become relatively greater in more recent times. I find also that with the more recent increase of diphtheria in London there is a change in the age incidence of mortality from the disease, children at the ages 3 to 10 years suffering more heavily in the decade 1871-80 than before. This change is observable also in the England and Wales figures. Inasmuch as I am at present examining for the Public Health Committee in more detail these circumstances, I refrain from discussing them further for the purposes of this report. It is probable that some of the apparent increase of diphtheria is a question of nomenclature, and the close connection existing between diphtheria and croup will be appreciated by reference to diagram VIII. The medical officer of health of Whitechapel says: "with regard to diphtheria, I have before shown that since that disease appeared more frequently, a corresponding reduction in the cases of croup became evident." The medical officer of St. Luke says that: "I have in previous reports referred to the fact that in proportion as the number of deaths registered from diphtheria increase those from croup decrease." Diphtheria. In 1892, 8,368 cases of diphtheria were notified to the medical officers of health, and 1,859 deaths attributed to this disease were registered. This number is in excess of that of any year since 1859 when deaths from this disease were separately classified by the Registrar-General in the London returns. Digram. VIII. Diphtheria & Croup. CHART VIII. 19 That this change in nomenclature is, however, only partial explanation of the increase of diphtheria is shown by the following figures— London death-rate per 1,000 of croup and diphtheria combined. 1871-80 .30 1891 .42 1881-90 .42 1892 .51 The following outbreak is referred to in the reports of the medical officer of health of St. Luke for 1891 and 1892. Fifteen cases of diphtheria occurred in the Finsbury Barracks in December, 1891, and the beginning of January, 1892. The origin of the outbreak is thus explained a person who had been nursing a case of diphtheria, and who was engaged to nurse one of the soldier's wives in her confinement, called to see if her services were likely to be soon required. She was suffering from sore throat: she took a child upon her lap and kissed it. The child was the first to have the disease, and died in the barracks." Reference is made in the reports of the medical officers of health of Plumstead, Putney (Wandsworth), Clapham (Wandsworth), and Whitechapel, to sewer or drain emanations as a possible cause. In the Plumstead report, ventilation of sewers through gratings in the road is condemned wherever these gratings can act as outlets. In the Putney (Wandsworth) report, the occurrence of three cases of diphtheria in one house is attributed to a leakage of drain air into the larder. The report of the medical officer of health of Clapham (Wandsworth), contains the following statement referring to 56 cases of diphtheria, and 4 of membranous croup. "As regards causation of these cases the drains in the houses where they occurred were carefully tested, and in 24 of these, serious defects, such as very possibly caused the attacks, were found and remedied." The medical officer of health of Whitechapel writes, " there is an almost universally prevailing popular opinion that defective drainage and diphtheria are associated in the relation of cause and effect. It cannot, be too strongly stated that conclusive evidence in support of such opinion, so far as I am aware, cannot be produced. Of course the inhalation of sewer air may reduce the vital energies of a person, and so render him more susceptible to be the victim of diphtheria as well as many other diseases." The medical officer of health of St. Giles referring to Dr. Thome's Milroy lectures, 1891, says, "In regard to the important question of school infection Dr. Thorne is in accord with other observers 'in regarding the aggregation of children at school as the most constant of the conditions under which ordinary diphtheria arises out of the prevalence of indefinite sore throats which so generally precede and accompany its attacks.'" The medical officer of health of Bow (Poplar) refers to an outbreak of diphtheria in that parish occurring in the neighbourhood of the Malmesbury-road Board Schools. He states that, in March, of 25 cases of diphtheria in No. 3 district, 20 were either amongst scholars of these schools or in houses from which these scholars came. The cause of this local prevalence was not evident. The following table shows the incidence of the disease on the several districts of London in 1885-91 and in 1892, and the accompanying chart (VIII.) shows the relative incidence of the disease upon London sanitary districts in 1885-92. *Cases notified in 1892. Cases—Rate per 10,000 in 1892. Deaths in 1892. Death rate per 10,000 in 1892. per 10,000 in 1885-91. West— Kensington 191 11 34 2.0 3.1 Hammersmith 318 32 73 7.3 3.3 Fulham 109 11 31 3.1 Paddington 171 14 28 2.4 3.3 Chelsea 203 21 39 4.0 2.9 St. George, Hanover-square 123 16 26 3.4 3.0 Westminster 141 26 44 8.0 3.3 St. James 28 12 6 2.5 1.2 North— Marylebone 226 16 48 3.4 1.6 Hampstead 132 19 27 3.8 2.0 Pancras 438 19 107 4.6 2.9 Islington 754 23 150 4.6 2.9 Hackney 652 28 131 5.6 3.0 Central— St. Giles 63 16 21 5.4 3.1 St. Martin-in-the-Fields 26 18 12 8.5 1.9 Strand 32 13 8 3.3 2.1 Holborn 62 19 17 5.2 2.8 Clerkenwell 130 20 28 4.3 2.9 St. Luke 45 11 14 3.3 2.8 London, City of 93 25 24 6.6 2.3 East— Shoreditch 215 17 44 3.6 3.3 Bethnal-green 581 45 117 9.1 4.5 Whitechapel 258 35 59 7.9 3.8 St. George-in-the-East 132 29 33 7.3 4.3 Limehouse 93 16 25 4.4 3.7 Mile-end Old-town 258 24 81 7.5 2.8 Poplar 484 29 78 4.7 2.7 *Including 566 cases of membranous croup. 20  *Cases notified in 1892. Cases—Rate per 10,000 in 1892. Deaths in 1892. Death rate per 10,000 in 1892. Rate per 10,000 in 1885-91. South— St. Saviour, Southwark 43 16 6 2.2 3.3 St. George, Southwark 76 13 26 4.4 2.5 Newington 169 15 38 3.3 2.9 St. Olave 17 13 3 2.4 2.5 Bermondsey 96 11 20 2.4 2.1 Rotherhithe 48 12 11 2.8 2.0 Lambeth 538 19 130 4.7 3.5 Battersea 370 24 54 3.5 2.4 Wandsworth 262 16 65 4.0 Camberwell 303 13 78 3.3 2.5 Greenwich 193 11 52 3.1 2.7 Lewisham 144 15 23 2.4 2.1 Woolwich 16 4 4 1.0 1.0 Plumstead 135 15 44 4.8 2.1 London 8,368 20 1,859 4.4 2.9 Including 566 cases of membranous croup. Whooping Cough. The deaths attributed to whooping cough in 1892 numbered 2,491. The death rates from this disease per 1,000 living during 1892 and previous periods have been as follows — 1851-60 0.88 1881-90 0.69 1861-70 0.88 1891 0.68 1871-80 0.81 1892 0.58 The disease was especially prevalent in the eastern districts of London. The number of deaths in 1892 and the death rates in 1885-91 and in 1892 in each district are shown in the following table. Diagram IX. shows the excess and defect of the mortality from this disease in relation to the mean mortality for the period 1841-92, and the accompanying chart (IX.) shows the relative incidence of the disease upon London sanitary districts during the period 1885-92. Deaths, 1892. Death rate per 10,000, 1892. Death rate per 10,000, 1885-91. Deaths, 1892. Death rate per 111.000, 1892. Death rate per 10.000, 1885-91. West— East— Kensington 64 3.8 4.9 Shoreditch 105 8.5 9.5 Hammersmith 54 5.4 6.8 Bethnal-green 128 9.9 9.1 Fulham 65 6.6 Whitechapel 43 5.8 5.1 Paddington 29 2.4, 4.7 St. George-in-the-East 24 53 7.6 Chelsea 39 4.0 7.3 Limehouse 72 12.6 9.8 St. George, Hanover-square 21 2.7 3.6 Mile-end Old-town 110 10.2 8.4 Westminster 20 3.6 6.5 Poplar 178 10.6 7.6 St. James 7 2.9 4.7 South— North— St. Saviour, Southwark 14 5.2 7.2 Marylebone 37 2.6 5.1 St. George, Southwark 44 7.4 9.5 Hampstead 22 3.1 3.4 Newington 93 8.0 7.9 Pancras 155 6.6 6.4 St. Olave 5 3.9 5.5 Islington 161 5.0 6.8 Bermondsey 53 6.3 8.4 Hackney 122 5.2 5.6 Rotherhithe 22 5.6 7.3 Lambeth 135 4.9 6.7 Central— Battersea 101 6.5 6.7 St. Giles ' 11 2.8 5.7 Wandsworth 89 5.4 St. Martin-in-the-Fields 1 0.7 4.5 Camberwell 128 5.3 7.3 Strand 15 6.2 5.4 Greenwich 96 5.7 7.0 Holborn 15 4.6 7.5 Lewisham 69 7.3 4.7 Clerkenwell 45 6.9 7.6 Woolwich 17 4.2 5.8 St. Luke 29 6.9 7.8 Plumstead 38 4.2 5.0 London, City of 15 4.1 3.2 London 2,491 5.8 6.7 Diagram, IX. Whooping Cough. Diagram JC. Typlius Fever. C H A RT IX . 21 The history of typhus during the year 1892 has been as follows—- January—Two cases of typhus occurred in East-street, Plumstead, in a family which had suffered from this disease in the previous year. A girl aged seven died at her home in Tyers-street, Lambeth, the death being certified as typhus ; the source of infection was not discovered. February—A death in Newington was attributed to typhus, but medical opinion differed as to the nature of the malady. March—The death of a casual labourer in Fendall-street, Bermondsey, was certified to be due to typhus. There is some doubt as to the nature of the illness in this case. April—A second death from typhus was registered in Lambeth, and in this case some doubt attaches to the nature of the disease. In the same month a woman was removed to hospital from Hammersmith suffering from this disease. The death of a woman attributed to typhus was registered in Marylebone. The nature of the disease in this case was considered doubtful. A young man suffering from typhus was removed from Boundary-place, Shoreditch. The medical officer of health of Shoreditch thus writes of this case in his report for the quarter ending July 2nd, 1892— "On enquiring at the house occupied by the young man, J.S., I found that three families had been occupying the four rooms, but that the whole of one family was away ill. On tracing them, it appeared that about the middle of March the landlady, Mrs. S., had found her lodger, Mrs. H., who occupied a small back-room upstairs, to be seriously ill and in a state of destitution. On the 18th March, Mrs. H. was removed to the infirmary, and on the 1st April her husband was admitted to the London Hospital. Subsequently, their two children were taken into the infirmary. The young man, J.S., then attempted to cleanse the room, but had to desist on account of the offensive and sickening smell. On the 22nd April, a fortnight after her son's removal, Mrs. S.., the landlady, took ill, and I was notified that she was suffering from enteric fever, but, having seen the case, I was satisfied that it was a typical one of typhus fever, and she was removed to Homerton Hospital, where my diagnosis was confirmed. I am indebted to Dr. Forbes, the medical superintendent of the infirmary, and to Mr. R. J. Williams, house physician to Dr. Fenwick at the London Hospital, for particulars relating to the illnesses of the H. family. The father did not suffer from fever till ten days after admission, when he had a temperature of 103° to 104° Fall, for eleven days, after which it became normal, and it was thought he had an abortive form of enteric fever. Mrs. H. seemed to be suffering from debility and destitution on admission to the infirmary, but not being quite satisfied with the progress of the case, Dr. Forbes procured her admission to Homerton Hospital, and as it was doubtful as to the disease, it was notified as a ' continued fever' (both typhus and enteric fevers, as well as some milder forms of fever being included in this term"). The boys were found on admission to be both suffering from pneumonia; both, but especially the elder, had high temperatures, which subsided suddenly nine days after. All the six persons recovered. While it would be impossible, looking simply at the cases in the H. family, to say that there was any connection with typhus fever in the complaint, yet, when they are regarded in the light of the two typical cases of this disease in the same house and the manner in which it appeared, I am satisfied that the illnesses of the other four persons were manifestations of typhus fever." The illness of a woman in Greenwich was erroneously certified as typhus. Two women were removed to hospital from different houses in Acorn place, Rotherhithe, their illnesses being certified as typhoid. The notes supplied to me at the time by the medical officer of health show that in July a second case, certified as typhoid, was removed from one of these houses, the disease being recognised in the hospital as typhus ; a case of typhus was also removed from the other house, and later in the same month two other cases of typhus were removed from houses already infected, and two cases from a third house in the same street, these three houses supplying seven cases of illness, all of which must be regarded as typhus. One of the earlier cases was a bottle washer in the East India Docks, the other a corn porter. In July a case of tuberculosis was certified in Shoreditch as typhus. Three cases of typhus occurred in one overcrowded and insanitary building in Old-street, Shoreditch. The first case was that of a greengrocer's assistant, whose illness I was informed by the medical officer of health, was not recognised until a second case, that of a shirt and collar ironer, occurred due to infection from the first. A third case, that of a tailor, occurred a month later in this house. The source of infection of the first case is unknown. In August four cases of typhus occurred in Kensington. I extract from the report of the medical officer of health of that district the following statement concerning these cases— " For the first time in many years, there was a limited outbreak of this disease in Kensington, in the month of August. The cases were four in number. The first case, an imported one, came from Brentford, where the sufferer, a married woman, who lived at Acton, had been engaged in fruit picking. Having fallen ill, she sent to her sister, who fetched her to her own home in Tobin-street, and not suspecting the infectious nature of the illness, slept in the same bed with her. The sick woman was visited by her niece, who lived in Walmer-road, and who was the first to become infected. Subsequently, the sister fell ill, and she in turn infected her husband. Meanwhile, the woman from Brentford had gone to her own home at Acton, whilst apparently infective—if it is true, as is alleged, that she infected her husband. But from what disease she was supposed by the Acton authorities to be suffering I do not know, my application for information not having been acknowledged. The three Kensington cases were notified by as many doctors (on August 29th, August 30th, and September 6th respectively) as cases of typhus fever, and as such were removed to the Western hospital. The medical superintendent of the hospital, upon discovering the nature of the illness, immediately communicated with me. I saw the several patients with him, and concurred in his diagnosis. All recovered." September—A case of typhus was removed to hospital from Londesborough-road, Stoke Newington. The patient was a clerk employed in the City, and the source of infection was unknown. October—A case of tuberculosis in Shoreditch was certified to be typhus. A case of enteric fever in Greenwich was certified to be typhus. December—A rag sorter in Church-street, Deptford, was certified to be suffering from typhus and removed to hospital. 22 The cases of typhus which have actually occurred show that much watchfulness will be required to prevent this disease becoming prevalent in London, and certainly an ability to recognise this maladyis imperatively needed. The statements made above suffice to show that typhus may readily occur without recognition, corroborating the report which I presented to the Council in the preceding year, 1891. In that report I had to tell of typhus in Holborn, the nature of the disease not being recognised until several persons had been attacked and death in some instances had resulted, infection being communicated to a second family in the house invaded, and to a house in the Strand where a member of the first family infected worked and where two cases occurred, one ending in death. Five cases had also occurred in one family in Poplar, the nature of the disease not being recognised until one of the later of these cases had been admitted into one of the hospitals of the Metropolitan Asylums Board. Altogether as many as 24 cases of typhus in London became known, in which the disease was not at first recognised, during that year. Enteric Fever. The cases of enteric fever notified in London during the year 189'2 numbered 2,469, and 424 deaths were attributed to this cause, giving a death rate of *1 per 1.000 of population. The decline of enteric fever in London, which has been marked in recent years, has been continued— 1871-80 0.24 1891 0.13 1881-90 0.19 1892 0.10 The only special outbreak to which reference is made in the reports of the medical officers of health is contained in the report for Greenwich. Mr. Hartt thus writes: "Twenty-seven of the cases occurred in a school (where no expense had been spared to render the house everything that could be desired from a sanitary point of view) amongst boys of the age of 13 years, and all were taken ill about the same time in September, 1892. Thirty-three per cent. of the boys escaped the infection. After a long and patient investigation, which necessitated a thorough examination of the whole of the drainage system and water supply (in which I was greatly assisted by your sanitary inspector, Mr. Wilson), it was thought that the source was due to some material which had been taken into the stomach and caused irritation of the alimentary canal. I am happy to state that all the cases recovered." The incidence of mortality from this disease on the London sanitary districts in 1885-92 is shown on the accompanying chart (X.), and the mortality during this period, as well as the number of cases notified in 1892. are shown on the followins table — Diagram XI. shows the deviations from the mean enteric fever death rate for each year of the period 1869-92. Cases notified in 1892. Case—Rate per 10,000 in 1832. Deaths in 1892. Death rate per 10,000 in 1892. Death rate per 10,000 in 1885 91. West— Kensington 58 3 15 .9 1.0 Hammersmith 45 4 4 .4 1.4 Fulham 41 4 1 .1 Paddington 47 4 8 .7 1.3 Chelsea 51 5 6 .6 1.4 St. George, Hanover-square 44 6 8 1.0 1.1 Westminster 24 4 3 .5 1.1 St. James 13 5 1 .4 1.4 North— Marylebone 73 5 15 1.1 1.1 Hampstead 49 7 2 .3 1.0 Pancras ... 118 5 25 1.1 1.5 Islington ... 215 7 40 1.2 1.5 Hackney ... 181 8 23 1.0 1.8 Central— St. Giles 26 7 9 2.3 1.9 St. Martin-in-the-Fields 6 4 - - 1.5 Strand 12 5 4 1.6 2.2 Holborn 24 7 4 1.2 1.6 Clerkenwell 43 7 8 1.2 1.4 St. Luke 14 3 2 .5 1.5 London, City of 28 8 5 1.4 1.1 East— Shoreditch 89 7 13 1.1 1.7 Betlinal-green 102 8 20 1.6 1.7 Whitechapel 42 6 5 .7 1.3 St. George-in-the-East 21 5 9 2.0 1.6 Limehouse 40 7 7 1.2 2.0 Mile-end Old-town 79 7 16 1.5 1.9 Poplar 183 11 26 1.6 1.8 CHART X. Diagram XI. Enteric Fever. Diagram, XII. Diarrhœa. CHART XI. 23  Cases notified in 1892. Case—Rate per 10,000 in 1892. Deaths in 1892. Death rate per 10,000 in 1892. Death rate per 10,000 in 1885-91. South— St. Saviour, Southwark 5 2 1 .4 1.2 St. George, Southwark 28 5 7 1.2 1.0 Newington 58 5 10 .9 1.4 St. Olave 7 5 2 1.6 1.4 Bermondsey 43 5 6 .7 1.4 Rotherhithe 49 12 7 1.8 2.0 Lambeth 119 4 22 .8 1.2 Battersea 70 5 10 .6 1.3 Wandsworth 85 5 13 .8 Camberwell 103 4 22 .9 1.2 Greenwich 116 7 23 1.4 1.6 Lewisham 44 5 4 .4 1.1 Woolwich 17 4 11 2.7 1.1 Plumstead 40 4 7 .8 .7 London 2,469* 6 424 1.0 1.4 *Including 17 cases notified to the Port Sanitary Authority. dlarrhœa. The deaths in London in the year 1892 attributed to diarrhœa numbered 2,548, giving a death rate of 060 per 1,000 persons living. The death rates in previous periods were as follows— 1851-60 1.03 1881-90 0.74 1861-70 1.04 1891 0.57 1871-80 0.94 1892 0.60 Diagram XII. shows the annual fluctuations in mortality from this disease during the period 1841-92. and the mean temperature in the summer quarter of corresponding years. The age distribution of the deaths from this disease registered in London (excluding Penge) in 1892 was as follows— Under 1 year. 1—5 5 and under 20 20 and under 40 40 and under 60 60 and under 80. 80 and upwards. 1,840 409 13 21 54 152 57 The accompanying chart (XI.) shows the incidence of this disease upon the various sanitary districts are London during the period 1885—92. The number of deaths in 1892 and the death rates in 1885-91 and 1892 in the several sanitary. districts are shown in the following table- Deaths 1892. Death rate per 10,000 in 1892. Death rate per ID,000, 1885-91. Deaths, 1892. Death rate per 10,000 in 1892. Death rate per 10,000, 1885-91. West— East— 104 79 Kensington Hammersmith 68 70 41 7.0 5.1 10.5 Shoreditch Bethnal-green 8.4 6.1 10.5 7.7 Fulham 93 9.4 Whitechapel 42 5.6 9.1 Paddington 72 6.1 5.2 St. George-in-the-East 59 13.0 16.9 Chelsea 72 7.4 7.7 Limehouse 37 6.5 10.2 St. George, Hanover-square 20 2.6 4.4 Mile-end Old-town 73 6.8 8.3 6.4 Westminster 22 4.0 6.8 Poplar 109 6.5 St. James 7 2.9 4.7 South— North— St. Saviour, Southwark 14 5.2 9.0 Marylebone 73 5.2 6.4 St. George, Southwark 37 6.2 9.5 Hampstead 15 2.1 2.9 Newington 83 7.1 6.7 Pancras 140 6.0 6.8 St. Olave 11 8.6 9.1 Islington 189 5.8 6.9 Bermondsey 44 5.2 8.4 Hackney 125 5.3 5.9 Rotherhithe 33 8.3 9.5 Lambeth 155 5.6 6.9 Central— Battersea 103 6.7 7.0 St. Giles 22 5.6 6.3 Wandsworth 97 5.9 St. Martin-in-the-Fields 4 2.8 4.8 Camberwell 145 6.1 6.5 Strand 8 3.3 6.6 Greenwich 126 7.4 6.5 Holborn 19 5.8 7.1 Lewisham 41 4.3 4.2 Clerkenwell 41 6.3 10.6 Woolwich 25 6.2 4.8 St. Luke 33 7.9 10.5 Plumstead 33 3.6 4.1 London, City of 5 1.4 3.4 London 2,548 6.0 6.9 24 Cholera. Cholera which had been spreading in south western Russia in the earlier part of the year had by the middle of the year attacked a number of places to the south of the Caucasus, and extending up the Volga, invaded Tzaritzin, Saratov and the province of Samara; numerous cases of a diarrhœal disease appeared also in the suburbs of Paris, causing some 159 deaths in the second quarter of the year. During July Nizni-Novgorod was attacked. In Paris the diarrhoeal disease continued to spread in the suburbs, and in this month the Local Government Board prohibited the importation of rags from France, from ports on the Black Sea and Sea of Azov, and other parts of Turkey, and from the Baltic or North Sea ports. In the first week of August a fatal case of cholera occurred in St. Petersburg, followed shortly by a number of cases and deaths, and the disease, which had already invaded the provinces of the Don, made greater progress in that locality. In the same month cases of cholera in limited number had also been reported in Rotterdam. In Havre a number of cases of " cholerine " were reported, and on the 23rd of the month the authorities of Hamburg announced that cholera was prevailing in that city, the number of cases and deaths to September 10th being stated to be 13,238 and 5,805 respectively, fresh cases occurring each day to the end of October. During November cases of cholera in the west of Europe were reported in Calais, Boulogne, Dunkirk, South Holland and Brussels, and cases of choleraic diarrhoea were reported at L'Orient. During December cases were reported in Paris, Cherbourg, Calais, Epernay, L'Orient, North Holland and Hamburg. On August 25th a circular letter was addressed to sanitary authorities in the metropolis by the Local Government Board, reminding them that in the event of the Board issuing epidemic regulations, such regulations "would impose on the sanitary authorities theduty of making arrangements for the prevention and treatment of cholera, and among those arrangements would be comprised the visitation of poorer houses for the purpose of detecting cholera and diarrhoea, and the provision of medical attendance and nursing, and of medicine and disinfectants." " The arrangements to be made by the sanitary authorities would further include the provision of such additional hospitals and places of refuge as might be necessary for the several parishes and districts, the hospitals being provided for the reception of those cholera patients who could not properly be treated in their own homes, and the places of refuge for the lodgment of those persons not actually sick whom it might be right to keep under observation or to accommodate while their home was either under disinsection or was devoted to a sick person who could not properly be removed." Allusion was made to a letter addressed by the Board on the previous day (August 24th) to the Metropolitan Asylums Managers with reference to the provision of accommodation which could be utilised on the first appearance of cholera in London, but the Board desired " that it should be clearly understood that, although the managers may make a limited provision of hospital accommodation it would devolve under the regulations upon each sanitary authority to provide such hospital accommodation as would, in the event of cholera becoming epidemic in their parish or district, be requisite for the reception of cases where removal to a hospital is required." The providing of places of refuge " would be an undivided function of the sanitary authority." On the following day, August 26th, two memoranda prepared by the Board's medical officer were forwarded by the Board to the sanitary authorities for their guidance, and the suggestion was made that each authority should call upon its medical officer of health for a report as to the action it may be desirable to take, and that a copy of such report should be forwarded without delay to the Board. On August 29th an order was addressed to Port Sanitary Authorities amending the order of the 28tli August, 1890, and requiring that no person should be permitted to land from a cholera infected ship, or from a ship certified by the medical officer of health to have passengers on board in a filthy or otherwise unwholesome condition, unless he satisfy the medical officer of health as to his name, place of destination, and address of such place. The names and addresses of persons permitted to land were to be forthwith transmitted to local medical officers of health by the Port Sanitary Authority, with a view to such persons being kept under observation. The practice of the masters of ships carrying passengers of this class was to charge a fixed sum for the whole time the passengers were on board and to provide them food during this time. The detention of such ships necessarily had a deterring effect on this trade. On August 31st a further order to Port Sanitary Authorities dealing with the question of bilge water was issued, and on September 6th a third order consolidating the previous orders appeared. The steps taken by the Council's Public Health Department are shown in the following report which was subsequently presented to the Council— Public Health Department, 19th September, 1892. I beg to report on the steps which have been taken by the Public Health Department in connection with the outbreak of cholera in Hamburg and other Continental ports. On Wednesday, 24th August, the London newspapers contained the account of the outbreak of cholera in Hamburg. I thereupon called upon the secretary and the medical officer of the Local Government Board, and made inquiry as to the intentions of the Board with respect to the administrative arrangements which would be made in the event of cholera becoming prevalent in London. The secretary informed me that the Local Government Board had no power to impose any duties upon the Council; that, as in 1885, the Metropolitan Asylums Board would be expected to arrange with persons having the control of hospitals, infirmaries, asylums or workhouses for the use of their institutions for the reception of cases of cholera, this accommodation to be for the metropolis generally and irrespective of parochial boundaries; and that the London sanitary authorities would be required to provide any further hospital accommodation needed for the purposes of their respective districts if the disease became prevalent. I pointed out that pending the arrangements which the Metropolitan Asylums Board would make, it was probable that some cases of cholera might be introduced into London, and 25 that it was desirable that every medical officer of health in London should at once learn to which institution any such cases occurring in his district could be removed. The secretary of the Local Government Board thereupon requested the medical officer of that Board to communicate with the London medical officers of health, and letters to these officers were despatched the same day. It being obvious that, apart from the duties of the port sanitary authority, the most pressing need was the organisation of the arrangements of the Metropolitan Asylums Board, and, having been employed by that Board in 1885 when the circumstances were similar, I obtained the leave of the chairman of the Council to offer my service to the managers. This offer was accepted, and I have since been employed in rendering such assistance as I could to the Cholera Committee of the Metropolitan Asylums Board. On the 25th of August three cases of cholera had arrived at Gravesend in the Gemma, a vessel containing poor Jewish immigrants who had embarked at Hamburg. These cases were removed by Dr. Collingridge, the medical officer of the port of London, to the hospital of the port sanitary authority at Gravesend, and subsequently the rest of the passengers of this class on board that vessel were similarly dealt with. The removal of the sick had been effected under the General Cholera Order of the Local Government Board, of the 28th of August, 1890, which also requires the Medical Officer of the Port to record the names and addresses of other persons on board the vessel for the purpose of transmitting this information to the sanitary authorities of the places of destination. The Order gave no authority for similar action in respect to passengers on board vessels not affected with cholera ; but the short time occupied in the journey between Hamburg and London (30 to 40 hours) made it probable that cases of cholera would thus be introduced into the metropolis, and particularly by the poor Jewish immigrants who were arriving in considerable numbers. As matter of fact, I learnt on the 29th August that the Portia, the sister ship to the Gemma, and containing passengers of this class, had already, on the 27th August, been passed by the port authority, no cases of cholera having been known to have occurred on board. It was evidently very necessary that the names and addresses of all such persons arriving in London should be taken, and, after visiting Gravesend and conferring with Dr. Collingridge, I summoned the Council's inspectors, and stationed them (on the 29th August) at the docks where these vessels might be expected, providing them with interpreters, and instructing them to take the names and addresses of all persons arriving from Hamburg. The same night an Order was issued by the Local Government Board extending the powers of port sanitary authorities and enabling them to deal with passengers in a filthy or unwholesome condition arriving from infected ports, and irrespective of the question whether cholera had occurred on board the vessel, and subsequently on learning from Dr. Collingridge that he was prepared to carry out this duty, on the 31st of August I recalled the Council's inspectors. Dr. Hamer, at my request, called upon the principal shipping firms bringing passengers from Hamburg,with a view to learning whether they were willing to take and communicate to the Council the names and addresses in London of all passengers travelling by their boats from infected ports. Dr. Hamer was informed these firms would be willing to do so if asked by the Council. This step has, however, not been necessary, as the Local Government Board, on the 6th September, empowered port sanitary authorities to do what is necessary. I should also add that I obtained the names and addresses of passengers arriving in the Portia, who had been distributed about London, and in each instance I communicated with the medical officer of health of the district in which they had become resident, with a view to these persons being kept under observation. In these proceedings I have had the assistance of Mr. Smith, the Superintendent of the " Poor Jews' Temporary Shelter," 84, Leman-street, Whitechapel, whose knowledge of the movements of Jewish immigrants, and of the vessels in which they arrive, was of the greatest value, and I would desire to acknowledge the aid he has given me. Shirley F. Murphy, Medical Officer of Health. The number of deaths attributed to "cholera" during the year was 87, the numbers in 1889 being 62, in 1890, 84, and in 1891, 71. A case of cholera in Lambeth was regarded by Dr. Verdon, the medical officer of health of that district, as of undoubted Asiatic type. Information of this case was received by him on Monday, October 3rd, from the resident physician of St. Thomas's Hospital. The patient, Dr. Verdon writes in his annual report, "occupied the position of a captain in charge of a river tug plying between Woolwich and Beckton, and his business consisted in loading, unloading and towing from place to place the cargoes of ships. Usually his engagements prevented him from visiting home more frequently than at weekly intervals. On the evening of Friday, two days before his admission into the hospital, he arrived home and complained of feeling unwell. Refusing food, he went to bed ; on Saturday morning he left home for business; on Saturday evening at 9 o'clock he returned. At this time his symptoms were acute, his wife became alarmed, and sought the advice of a local medical practitioner, who visited and prescribed for the patient. The severity of his symptoms increasing, he was removed to St. Thomas's Hospital at 1 o'clock on Sunday morning." The patient died on October 7th. Very complete arrangements were made for the prevention of extension of disease from this case. The bedding, carpets, window blinds, and wearing apparel in the room occupied by the patient at his home were destroyed. Quicklime was spread over the earth and stones in the yard where he had vomited. The house was thoroughly disinfected and cleansed. The other inmates of the house having [4] 26 consented to submit to isolation, arrangements were made for this purpose, and watchmen appointed to ensure that the conditions were observed. No extension of the disease occurred. The tug was disinfected at Gravesend. Two other cases of cholera were admitted from Islington into St. Bartholomew's Hospital, where one patient died. They had arrived at Harwich on the 29th August in the " s.s. Peregrine " from Hamburg, and had travelled to London by rail. The excellent arrangements made by the Port Sanitary Authorities and the efficiency of its administration under Dr. Collingridge, the medical officer of health of the port, excluded from Loudon cases of cholera and persons who had been exposed to cholera infection. Dr. Collingridge's report gives account of 22 vessels which had arrived in the Thames between the 25th August and the 19th October on all of which cases of cholera (one doubtful case) had occurred during the voyage. Of these vessels 14 came from Hamburg, 4 from Antwerp and 1 each from Terneuzen, Narva, Tripoli and Odessa. The action taken by the various authorities with a view to dealing with a possible outbreak of cholera, so far as it can be gathered from the annual reports of the medical officers of health, was as follows — Kensington.—Five thousand copies of a leaflet entitled "Precautions against Cholera," were distributed in the parish. Six assistant sanitary inspectors were appointed for a period of four weeks, with a view to making house to house visitation in the poorer districts, and they made during their period of office 1,500 inspections and served 1,868 " written intimations " of nuisances. St. George, Hanover-square.—The parish was divided into sub-districts, and arrangements were made with medical men for attendance on cases in each sub-district, and with chemists for the supply of medicines. Westminster.—The report states that active measures were taken. Marylebone.—Four additional inspectors were temporarily appointed, arrangements were made with medical men to undertake the treatment of patients should need arise, and with chemists to supply medicines. The endeavour to provide suitable places for " refuges," proved unsuccessful. Hampstead.—Two additional inspectors were appointed for 12 mouths, a circular was printed and distributed. The medical officer of health reported as to the division of the parish into districts, and as to the provision of hospital accommodation and of places of refuge. St. Pancras.—Circulars dealing with cholera precautions and setting forth the addresses of district medical attendants and chemists and of ambulance stations and hospitals for the various districts were prepared and freely circulated. Islington.—The Public Health Committee had under consideration the question of preparations to meet, a possible outbreak of cholera. Hackney.—Two extra sanitary inspectors were temporarily employed. A circular giving rules for the prevention of choleraic or summer diarrhœa was drawn up and distributed. A house suitable for use as a refuge was found and a scheme of medical house to house visitation and treatment was suggested. St.. Giles.— Arrangements were made for utilising a common lodging-house as a hospital; a refuge was provided. Arrangements for medic il visitation, nurses for the sick, the supply of medicines and the removal of the dead were made. A " general sanitary notice " was issued. St. Martin-in-the-Fields.—A special vigilance committee was appointed and inquiry was made as to the hospital accommodation available. Strand.—Arrangements for the burial of the dead were made and the question of providing " houses of refuge " was discussed. Holborn.—The medical officer of health recommended the appointment of a medical visitor to watch new arrivals in the Italian quarter coming from infected ports. He moreover obtained a promise of nursing assistance. Clerkenwell.—Arrangements for medical visitation were made, and in association with the Holborn Board a special inspection was made of the Italian quarter. St. Luke.— It was resolved to appoint three medical visitors and to provide refuges, and a notice was drawn up and circulated. Whitechapel.—A division into sub-districts was made; and preparations were made to use some cottages either as hospitals or as refuges. St. George-in-the-East.—A handbill was distributed, arrangements for medical visitation were considered, and negotiations for the provision of a shelter and a temporary hospital were entered into. Limehouse.—A summary of the precautions deemed desirable by the medical officer of health was prepared and circulated in the district. Mile-end Old-town. — The medical officer of health reported on the subject to the sanitary committee and was authorised to take such steps as might be deemed advisable. Poplar, South.—Reference is made to the rules laid down in 1884 for the guidance of sanitary inspectors and nurses, and to the nursing arrangements made in 1882, which would be applicable in case of emergency. Poplar, North.—The inspectors were instructed to visit certain premises, and the frequent disinfection of gutters, &c., was recommended. St. Saviour.—The London County Council were asked to grant the use of a disused fire station as a hospital, 10,000 handbills were printed and circulated, and the medical officer of health was authorised to make certain arrangements in case of need. St. George-the-Martyr.—The medical officer of health urged upon the vestry the desirability of frequent and periodical inspection of cisterns. St. Olave.—An inspection with a view to ascertaining the mode of water distribution was made, and as result 252 recommendations were addressed calling attention to defects ascertained. Bermondsey.—From the annual report of the vestry it appears that a meeting of medical 27 practitioners in the parish was held on the suggestion of the medical officer of health. Moreover, 100,000 notices were printed and distributed, and the medical officer of health was authorised to provide a tent in the event of additional hospital accommodation being required. Lambeth.—Six additional inspectors were temporarily appointed, and a circular was addressed to vendors of food in the parish. A suitable site for the erection of a temporary hospital if required was indicated. Battersea.—A circular was drawn up and distributed, and the question of hospital provision considered ; the committee also " made arrangements to carry out the necessary preventive measures." Wandsworth.—In the annual report of the Board allusion is made to the Local Government Board circular, and it is stated that " before arrangements could be made for all these purposes the danger came to an end for the year." The medical officer of health of the Streatham sub-district alludes to negotiations instituted to secure sites for temporary hospitals and refuges. Camberwell.—A copy of a memorandum addressed to the Public Health Committee by the medical officer of health is printed as an appendix to the annual report. Woolwich.—" The most active steps were taken to make provision for the proper treatment and nursing of the sick," and for their removal to hospital. Plumstead.—The medical officer of health of Charlton sub-district refers to his fortnightly reports for details of the preparations made. The medical officer of heath of the Plumstead sub-district drew up a handbill which was distributed, and advised that a temporary shelter should be provided. Greenwich (Greenwich Parish).—The medical officer of health embodies in his annual report for 1892 recommendations made to his Board on receipt of a letter from your medical officer, asking whether anything had been done to place this district in a state of preparedness against a possible outbreak of cholera in the summer of 1893. Hammersmith.—The annual report of the vestry states that in consequence of a telegram received the latter end of August from the medical officer of the port of London, stating that five persons had landed from the steamship Gemma and will proceed to Shepherd's-bush, an emergency committee was at once called. The committee gave instructions empowering the officers to deal with the case as they deemed desirable, and also with any case of cholera that might occur in the parish. " The vestry clerk and medical officer of health at once interviewed the persons and made an arrangement with them by which they were kept in quarantine and under strict watch for fourteen days, at the end of which time they were reported to be in good health and were permitted to leave." Shoreditch.— The medical officer of health presented a special report on the precautions to be taken in regard to cholera and the provision for patients. Lewisham.—The medical officer of health refers to the arrangements for receiving information from the port sanitary authority as to persons arriving on board infected ships or from infected ports. Erysipelas. Erysipelas caused 292 deaths in the Registration County of London in 1892. The corrected annual average mortality for the period 1882-91 was 302"8. During the year 6,938 cases of this disease were notified. The cases were thus distributed in the several districts:— Cases. Rate per 10,000. Cases. Rate per 10,000. West— East— Kensington 184 11 Shoreditch 253 21 Hammersmith 120 12 Bethnal-green 336 26 Fulham 107 11 Whitechapel 177 24 Paddington 115 10 St. George-in-the-East 77 17 Chelsea 180 19 Limehouse 100 18 St. George, Hanover-square 58 8 Mile-end Old-town 235 22 Westminster 77 14 Poplar 340 20 St. James 19 8 South— North— St. Saviour, Southwark 37 14 Marylebone 243 17 St. George, Southwark 108 18 Hampstead 54 8 Newington 226 19 Pa*cras 426 18 St. Olave 21 16 Islington 531 16 Bermondsey 170 20 Hackney 353 15 Rotherhithe 73 19 Lambeth 410 15 Central— Battersea 286 19 St. Giles 105 27 Wandsworth 271 17 St. Martin-in-the-Fields 14 10 Camberwell 280 12 Strand 22 9 Greenwich 304 18 Holborn 81 25 †Lewisham 97 13 Clerkenwell 164 25 Woolwich 45 11 St. Luke 103 25 Plumstead 79 9 London, City of 51 14 London 6,933* 16 *Including 1 case notified to the Port Sanitary Authority. †Excluding Penge. Puerperal Fever. Puerperal fever caused 313 deaths in the registration County of London in 1892. The corrected annual average number of deaths for the period 1882-91 was 295.1. During the year 337 cases were notified. 28 The cases were thus distributed in the several districts— Cases. Rate per 10,000. Cases. Rate per 10,000. West— East— Kensington 13 .8 Shoreditch 11 .9 Hammersmith 6 .6 Bethnal-green 14 1.1 Fulham 10 1.0 Whitechapel 11 1.5 Paddington 7 .6 St. George-in-the-East 5 1.1 Chelsea 6 .6 Limehouse 7 1.2 St. George, Hanover-square 2 .3 Mile-end Old-town 13 1.2 Westminster 3 .5 Poplar 12 .7 St. James 1 .4 South— North— St. Saviour, Southwark 2 .7 Marylebone 6 .4 St. George, Southwark 4 .7 Hampstead 8 1.1 Newington 5 .4 Pancras 26 1.1 St. Olave — — Islington 50 1.5 Bermondsey 5 .6 Hackney 16 .7 Rotherhithe 2 .5 Lambeth 17 .6 Central— Battersea 15 1.0 St. Giles 1 .3 Wandsworth 13 .8 St. Martin-in-the-Fields — — Camberwell 15 .6 Strand 1 .4 Greenwich 9 .5 Holborn 3 .9 Lewisham* 3 .4 Clerkenwell 3 .5 Woolwich 3 .7 St. Luke 1 .2 Plumstead 7 .8 London, City of 1 .3 London 337 .8 *Excluding Penge. Influenza, Bronchitis and Pneumonia. The year 1892 was characterised by marked excess of deaths from influenza and pneumonia. The deaths attributed to influenza represent but a proportion of the deaths directly due to this malady. Its effects are especially noticeable in the increased mortality from pneumonia and bronchitis during the weeks of influenza prevalence. But during the year 1892 there has also been increase of deaths from other causes possibly related to influenza; the number of deaths of infants from premature birth was 2,394, the corrected average for the preceding 10 years being 2,083.6, the number of deaths from suicide was 450, the corrected average of the preceding 10 years being 393.8. In 1890, when 652 deaths occurred which were attributed to influenza, four deaths were attributed to the disease in the 1st week, 67 in the 2nd, 127 in the 3rd, when the disease attained its maximum ; in succeeding weeks 105, 75 and 38 deaths from influenza were registered, and the disease gradually subsided, only one or more deaths occurring in almost every other week of the year. In 1891 the deaths rose to 2,336, and occurred chiefly in May and June, the greatest number of deaths (319) being registered in the 20th week (ending May 23rd). In December the number of deaths began again to increase, the number registered in successive weeks in that month being 9, 8, 17, 19 and 37. In 1892, 2,264 deaths attributed to influenza were registered. The number increased in successive weeks until the maximum was attained in the 3rd week (ending January 23rd), when 506 deaths were registered. From this time the number of deaths decreased, but a small number occurred in almost every one of the remaining weeks to the end of the year. The number of deaths from bronchitis was 11,183, and from pneumonia 6,164. The corrected annual average for the preceding ten years being respectively 11,230.0 and 5,171.9. The number of deaths from these diseases has been much influenced by the prevalence of influenza, as will be seen from the. following tables— Mortality in several weeks, 1892. Week of year. Week ending in Influenza. Bronchitis. Pneumonia. Deaths. Corrected average for corresponding week in preceding 10 years. Deaths. Corrected average for corresponding week in preceding 10 years. 1 Jan. 9 95 740 406.9 246 142.9 2 16 271 867 430.0 285 147.7 3 23 506 1,035 382.0 317 142.1 4 30 436 844 342.9 255 125.0 5 Feb. 6 314 492 301.1 215 116.7 6 13 183 368 332.3 140 120.7 7 20 79 259 315.6 137 118.3 8 27 61 291 309.1 116 125.0 9 Mar. 5 34 227 329.4 114 115.5 10 12 30 288 330.7 123 132.7 29 Mortality in six years. Year. Influenza. Bronchitis. Pneumonia. 1887 5 10,326 4,797 1888 3 10,085 4,657 1889 5 8,970 4,061 1890 652 12,448 6,224 1891 2,336 13,136 6,915 1892 2,264 11,183 6,164 In the tables of the Registrar-General the deaths from influenza, bronchitis and pneumonia occurring in public institutions are not distributed to the sanitary districts to which they belong, and the tables in all the reports of the medical officers of health are not prepared on the same basis, hence it is impossible to show accurately the relative mortality from these diseases in each of the several sanitary districts. In January the Council received from the Metropolitan Asylums Board a request that the Council would make an order under section 58 of the Public Health (London) Act necessary to empower the managers to use their ambulances for the purpose of conveying persons suffering from epidemic influenza. The Council accordingly resolved— " That the managers of the Metropolitan Asylum District having applied to the Council to make an order under section 58 of the Public Health (London) Act, 1891, for the purpose of extending the provisions of section 79 (3) of the said Act to the disease of epidemic influenza, the Council do now declare that the case is one of emergency owing to the need for special conveyances for the carriage of patients, and do make an order accordingly; that the order do remain in operation for a period of three months ; that such order be sealed by the Council, and that the solicitor do take the steps prescribed by the Act for giving effect thereto." Under this order nine patients were removed. Phthisis. The deaths from phthisis registered in the administrative county of London in 1892 numbered 8,053. The death rates of this disease in successive periods have been as follows— 1851-60 2.86 1871-80 2.51 1891 2.00 1861-70 2.84 1881-90 2.09 1892 1.88 Cancer. The deaths from cancer registered in the administrative county in the year 1892 numbered 3,180. The death rates of this disease in successive periods have been as follows— 1851-60 .42 1871-80 .55 1891 .77 1861-70 .48 1881-90 .68 1892 .74 The increase in the death rate from cancer is not peculiar to London, but is equally noticeable if the death rates of England be considered. The Registrar-General commenting upon this increase in his report for the year 1889, points out that the increase is more marked among males than females, and that while among children under 15 the rates show a decline, and at the age period 15 to 25 are stationary, they then increase progressively with each successive advance of age. While admitting that some part of the apparent increase is " most certainly attributable to increased accuracy in statement of cause, and to the system introduced some years back into this office of writing for further information in cases where some va<»ue cause, such as tumour, has been given as the cause of death," the Registrar-General adds "it seems scarcely possible to maintain the optimistic view that the whole of the apparent increase can be thus explained; and it must be admitted, as at any rate highly probable, that a real increase is taking place in the frequency of these malignant affections." Meteorology. The tables published in the annual summary of the Registrar-General show that the mean temperature of the air in each quarter of the year was below the average of 121 years except in the spring quarter. The temperature and the fall of rain in each month were as follows— Temperature of the air. Departure from average of 121 years. Bain. Highest by day. Lowest by night. Mean for the month. No. of days it fell. Amount collected. deg. deg. deg. deg. inches. January 51.6 22.3 36.5 — 0.2 11 0.38 February 53.5 18.8 38.8 0.0 19 1.69 March 60.5 22.3 37.3 — 3.8 12 1.09 April 75.3 26.7 46.9 + 0.8 10 1.42 May 85.1 28.7 55.2 + 2.7 11 1.66 June 85.9 37.2 58.1 — 0.1 14 2.27 July 82.4 47.0 59.6 — 2.0 12 1.54 August 84.3 43.8 61.7 + 0.8 16 3.03 September 74.6 37.2 56.3 — 0.2 14 2.01 October 61.9 27.4 45.4 — 4.1 22 3.88 November 60.9 31.2 44.9 - 2.5 18 2.21 December 54.7 17.6 36.7 — 2.3 11 1.13 30 ADMINISTRATION AND LEGISLATION". Dairies, Cowsheds and Milkshops. The Council's inspectors paid 10,085 visits to dairies and milkshops, and 3,460 visits to cowhouses. In three cases prosecutions were instituted and in two cases penalties were imposed amounting to £2 5s. Cases of infectious disease occurred on 69 premises where milk was sold, and the necessary steps were taken for the prevention of the contamination of the milk. The Council as a licensing authority received in 1892 546 applications for renewal of licence for the keeping of cows, and two applications in respect of premises not previously licensed, of the former 535, and of the latter both were granted. On May 10th, 1892, Dr. Corner, medical officer of health for Poplar, informed me that a cowman in that district was suffering from cow-pox. Dr. Hamer made inquiry into the matter, and learnt that a cowkeeper in Poplar had on the 8th April bought two cows which were said to have come from St. Ives ; one of these cows was at the time of purchase affected with sores on the teats. Shortly afterwards 22 more cows were purchased and placed with the two cows from St. Ives. Nearly all these cows became affected with sore teats, but the companion of the St. Ives cow which originally suffered remained free from eruption throughout. On April 29th the man who milked the cow from St. Ives which had sore teats, and three others, noticed swelling of his lips, and a day or two later his arm became similarly affected. On May 3rd this man's wife noticed a pimple on her chin. On May 11th the man was found to present three scabs (on the upper lip, lower lip and forearm); the lesion on the chin of his wife was passing from the vesicular into the pustular stage, at this time it was surrounded by a reddened area of skin, and resembled a vaccine pustule. Both man and wife had been vaccinated in infancy, but not since. The cow originally affected, and six others each had one or more, usually five or six scabs on the teats, and in one instance at the base of the udder close to the origin of the teat. No cases of infectious disease could be traced among the customers of the cowkeeper. A report by Dr. Turner on an outbreak of enteric fever in south-east London in 1891 was presented to the Council in 1892, and Dr. Hamer's report on scarlet fever in the same locality of which account is given on page 17, led the Council to instruct the Public Health and Housing Committee to report: "as to the amendments of the law required to check and prevent the sale of impure or infected milk, whether alone or in the form of ice creams or otherwise." The Public Health and Housing Committee and the Public Control Committee were instructed to report whether any communication could be made to the Board of Agriculture as to including eruptive diseases of the teats and udder of the cow under the Contagious Diseases (Animals) Act. While Dr. Turner's report afforded evidence of the distribution of enteric fever by ice cream there was no proof as to the manner in which the ice cream received its infection. It was possible that the milk used in this ice cream was infected before it arrived on the premises occupied by the ice cream vendor; it had much opportunity for contamination on these premises. The need for the preservation of milk supplies from contamination by special measures was already recognised by the legislature, but the practicability of subjecting to the same conditions all premises in which milk was used for the preparation of other articles of food had to be considered. Certainly the insanitary conditions found to be present on the premises of the vendors of the ice cream in question were such as could and should be dealt with under the general provisions of the Public Health (London) Act. The Committee had already taken this view and had communicated a copy of Dr. Turner's report to the several sanitary authorities and medical officers of health in London. The reference to the two Committees arising from Dr. Hamer's report was duly considered by them. The reference raised questions of much importance. Outbreaks of scarlatina due to milk infection had not infrequently been observed, but the circumstances under which the milk had acquired its infective properties were obscure. Certainly in some instances there was, after careful inquiry, absence of evidence that the milk had been infected by human agency. Investigations of such outbreaks by Mr. W. H. Power had led to the consideration of the possibility of such infection being caused by a cow malady, and in 1887 Sir George Buchanan, then medical officer of the Local Government Board, thus wrote of an outbreak of scarlatina due to milk received from a farm at Hendon. (Aunual report of the medical officer of the Local Government Board for the year 1886.) (1.) The disease in man and in the cow alike is characterised by closely similar anatomical features. (2.) From the diseased tissues and organs of man and cow alike the same micrococcus can be separated, and artificial sub-cultures be made from it. (3.) These sub-cultures, no matter whether established from man or cow, have the property, when inoculated into calves, of producing in them every manifestation of the Hendon disease; except sores on the teats and udders ; no doubt for the reason that the milk apparatus is not yet developed in calves. (4.) But—and this I learn from Dr. Klein's later observations while this report is in preparation— the sub-cultures made from human scarlatina and inoculated into recently calved cows, can produce in those cows, along with other manifestations of the Hendon disease, the characteristic ulcers on the teats; ulcers identical in character with those observed at the Hendon farm. (5.) The sub-cultures, established either from the human or the cow disease, have an identical property of producing in various rodents, a disease similar in its pathological manifestations to the Hendon disease of cows and to scarlatina in the human subject. (6.) Calves fed on sub-cultures established from human scarlatina obtain the Hendon disease. (7.) Children fed on milk from cows suffering under the Hendon disease obtain scarlatina. The above combine, I think, to form a mass of evidence to show that the Hendon disease is a form, occurring in the cow, of the very disease that we call scarlatina when it occurs in the human subject. Later, in 1889, Sir George Buchanan reported that "Dr. Klein succeeded in recognising one particular bacillus which is constantly present in every membrane of diphtheria, and in identifying it from among others that are only occasionally present there," and that Dr. Klein proceeded to inoculate two cows with this bacillus. The results of his experiments are thus summarised in the report for that year of the medical officer of the Local Government Board. 31 Two milch cows in good health inoculated subcutaneously at their shoulders with broth subcultures of diphtheria bacilli derived from a human subject showed a swelling at the place of inoculation, beginning on the third day, increasing in size during the first week, and then becoming smaller. One of these cows, in the course of the second week, and the other in the course of the fourth week, became seriously ill, being until then in seemingly good health and yielding abundant milk; one died on the 15th day, the other was killed on the 25th day. Besides serious changes in the organs, observed post-mortem, the tumours at each spot of inoculation were examined, and material was taken from them for microscopic and pathological study.—The bacilli of diphtheria were found to have multiplied abundantly at the spot of inoculation, and these, transplanted into nutrient media, were able to form there colonies of the bacillus diphtheriæ free from other forms of bacteria. It remains to tell the phenomena of the milk apparatus and of the milk in the two inoculated cows. On the fourth day in one cow, and about the same day in the other, where the cows were to an ordinary observer well and giving plenty of milk, small vesicles made their appearance on the cow's udders, and these rapidly passed into pustules and crusted ulcers. Afterwards similar vesicles running the same course were found on one or more teats of each cow. Dr. Klein gives good reason, first, for believing that these sores were not the result of any accident, nor of the process of milking; and, secondly, for regarding the sores as really being local manifestations of a constitutional disease induced by the diphtheria inoculation—He then examines the lymph of the induced vesicles and pustules; and here "the bacillus diphtheriæ could be demonstrated unmistakeably both in cover-glass specimens and by culture." Next, with matters taken from the udder vesicles and pustules, on the day after the eruption had appeared on one of the inoculated cows, Dr. Klein proceeded to the inoculation of two calves. The calves showed at the spots of inoculation vesicles and pustules similar to those of the cows themselves; the calves fell ill, were killed on the 25th day, and exhibited post-mortem appearances like those found in the cows. Now, as to the milk of the inoculated cows:—On the fifth day, from a healthy teat, carefully guarded against the introduction of accidental matter from the surface, milk was drawn into a sterilized beaker, and a drop (taken with all befitting precautions) was spread on the surface of nutrient gelatine. In three out of four tubes of this gelatine, bacterial colonies formed after the expected interval. There were eight colonies in all. All of these eight, Dr. Klein reports, were "unmistakeably colonies of the bacillus diphtheriæ." There were no other organisms present. Finally, Dr. Klein records an outbreak of his cat-diphtheria, beginning with two cats that had been supplied with milk from one (or both) of the inoculated cows. This incident was not ordained beforehand, and was the consequence of violation of orders; it therefore lacks the precision wanted in an intentional experiment. Further, Professor Brown, the professional officer of the Veterinary Department of the Board of Agriculture, in a special report in 1888 on the eruptive diseases of the teats and udders of cows expressed the opinion that "the slightest sign of udder disease or other disease should be accepted as a sufficient reason for excluding the animal's milk from the common stock" on account of the impurities, which would thus find their way into the milk. Section 34 of the Contagious Diseases (Animals) Act, under which the Dairies, Cowsheds and Milkshops Order, 1885, had been made was repealed so far as that Act was concerned, and had been incorporated in the Public Health (London) Act, of which it became the 23th section. The prohibition therefore contained in the Order that the milk of a diseased cow shall not be sold or used for human food, would, if the Order were reissued under the latter Act, be released from the limitation imposed upon its application by the interpretation of the word "disease" in the Contagious Diseases (Animals) Act. The Joint Committee had before it, however, the consideration that such knowledge as existed of eruptive diseases of the cow was possessed only by the few, and that more general knowledge was required before it would be made a basis of administration. As a first step in this direction the Council was advised to request the Board of Agriculture to cause eruptive diseases of the teats and udder of the cow to be notified, together with tuberculous disease. In the meantime the Committee thought that effort should be made to employ the provisions of the Public Health (London) Act relating to unsound food in any case in which such maladies should be found to exist in any cows. Offensive Trades. During the year 1892, 5,942 visits were paid by the inspectors of the Council's Public Health Department to premises where offensive trades were carried on, and steps were taken to bring premises occupied by slaughterers of cattle into compliance with the by-laws of the Council, which had come into operation during the previous year. In 14 cases prosecution for breaches of the Council's by-laws were instituted, and in 13 cases penalties imposed amounting in the aggregate to £83 1s. The sanction of the Council was given to the establishment anew of the business of a slaughterer of cattle in two instances and of a fellmonger in one instance. In 1892 the Council as a licensing authority received 539 applications for renewal of licences for the carrying on the business of a slaughterer of cattle, and two applications in respect of premises not previously occupied. Licences were granted in 534 cases of renewal, and in the two cases relating to premises not previously licensed. The number of licences granted in 1891 was 651, the reduction in the number of licences granted in 1892 being in the main due to the inability or the unwillingness of slaughterers of cattle bring to their premises into compliance with the Council's by-laws. In the case of knackers' yards 7 existing licences were renewed. During the year I endeavoured to ascertain the average number of animals killed per week during summer and winter in slaughterhouses licensed by the Council. For this purpose inquiry was made of the several licensees by the inspectors, and the following results were obtained— Average number of animals killed weekly. Winter. Summer. Beasts 1,080 886 Sheep and lambs 8,954 11,821 Calves 96 287 Pigs 1,346 692 These figures must of course only be considered as giving an approximation to the number of animals actually killed, but to this extent they may I believe be accepted. Fancy soap manufacture—In the spring of 1892 an enquiry was made into the business of fancy 32 soap making as carried on in London. Tbe Public Health Act, 1891, altered the law relating to the establishment anew of the business of a soap-boiler. Section 19, sub-section 1 (a), prohibits as heretofore the establishment anew of the business of a soap-boiler within the County of London. Sub-section 2 of the same section, however, is new legislation, and provides that the enactment contained in the preceding sub-section shall not render any person liable to a fine for establishing anew with the sanction of the County Council or carrying on the business of a soapboiler, if and as long as that business is a business in which tallow or any animal fat or oil other than olein is not used by admixture with alkali for the production of soap. Factories and Workshops. The passing of the Factory and Workshop Act, 1891, and of the Public Health (London) Act of 1891, rendered the sanitary authorities primarily responsible for enforcing the law enacted to maintain workshops in a sanitary condition. A perusal of the annual reports of medical officers of health for 1892 seems to indicate that only in exceptional instances was any systematic attempt made to carry out the new duties imposed upon sanitary authorities during that year. For the most part references to the subject of workshop inspection occur in the reports in connection with the Outworkers' Order issued by the Secretary of State under section 65 of the Factory and Workshop Act of 1891, and section 27 of the Factory and Workshop Act, 1891. This order, which was gazetted November 4th, 1892, requires the occupier of every factory and workshop, and every contractor employed by any such occupier in any of the following businesses, viz.— (1.) The manufacture of articles of wearing apparel, (2.) The manufacture of electro-plate, (3.) Cabinet and furniture making and upholstery work, (4.) The manufacture of files, to keep lists showing the names of all persons employed. The Local Government Board, in a letter addressed to sanitary authorities dated 19th November, 1892, stated that the authorities should at once take measures to see that the order was made known to those whom it affected, and that the medical officers of health and sanitary inspectors should be instructed from time to time to examine the lists in order to become aware of the places in which outworkers in the trades in question are employed. In 15 of the annual reports allusion is made to this order; in some instances it is stated that steps have been taken to ensure publicity being given to it, in other instances the opinion is expressed that it is impracticable for the sanitary authority to give effect to the order, and that the lists of outworkers should be collected and distributed by some central authority. Mr. Lakeman, the chief inspector of metropolitan workshops for the Home Office, with a view to meeting the difficulty with regard to workers employed in a district not appearing in the outworkers' list prepared in that district, arranged to communicate to each medical officer of health the addresses of those working in his district and appearing in lists prepared in other districts. The following allusions to actual work done during 1892 in the several districts are made in the annual reports. Westminster, St. Margaret and St. John.—In referring to section 38 of the Public Health (London) Act, the medical officer of health writes, "It was found necessary to.call upon the owners in some cases to provide proper watercloset accommodation for the persons in their employ." St. George-the-Martyr, Southwark.—The medical officer of health writes, "During the last seven months of 1892,1 have caused 78 workshops, including laundries and bakehouses, to be registered, and in several instances cleanliness and efficient ventilation to be enforced, overcrowding and other nuisances to be abated, and sufficient and separate watercloset accommodation to be provided for the two sexes." St. James, Westminster.—From the table of work done by sanitary inspectors during the year it appears that in 10 instances nuisances were removed or abated in workshops. Islington.—57 inspections of factories and workshops were made during the year. St. George-in-the-East.—15 workshops were caused to be cleansed and repaired. Limehouse.—112 " factory inspections " were made, and four " factory nuisances abated." Mile-end Old-town.—177 workshops were inspected. Poplar.—A summary is given of notices and improvements carried out at the different manufactories and workshops throughout the district during the year ending 25th March, 1893. Bermondscy.—A list of sanitary works carried out under the Factory and Workshops Act is given. It is not stated how much of this work was carried out in the year 1892. Batter sea.—The medical officer of health writes, "Many inspections were made under the Factory and Workshops Act, which will give the department much work in future. In four cases improved forms of sanitary offices being provided which were previously defective or insufficient." Wandsworth.—" Many inspections of workshops have been made, and workshops have been caused to be cleansed and additional sanitary conveniences have been caused to be provided." Details are given in the reports of the medical officers of health of the several parishes in the district. Greenicich.—In the sub-district of Greenwich 108 factories and workshops were inspected in the year ending 25th March, 1893. In the sub-district of Deptford the inspectors have inspected "many of the workshops and factories in the district." Clerkenwell— Reference is made to the instructions given to sanitary inspectors as to what the vestry regard as sufficieht and suitable accommodation in the way of sanitary conveniences, and as to the minimum air space for each employe in workshops. In the report of the medical officer of health of St. George, Hanover-square, it is recorded that "an additional inspector has been appointed, one of whose duties is to inspect the lists of (such) outworkers, and to ascertain the condition of their dwellings, and especially the presence of cases of infectious disease therein." 33 In several instances the medical officer of health comments upon the impossibility of undertaking workshop inspection with his existing staff. The medical officer of health of Kensington says the work "could not be done effectually without material interference with the current work of inspection of dwelling-houses." The medical officer of health of St. Pancras says, "No inspections of these places have yet been made, nor is there any prospect of their being made by the present staff, whose time is fully occupied with urgent and routine work." The medical officer of health of Hackney says, "Enquiry has revealed the presence of something like 2,000 workshops and dwellings of outworkers which, under this Act and Order, should be inspected to ascertain the presence or otherwise of any insanitary condition. With the present staff it is impossible that this can be attempted." The medical officer of health of Bethnal-green says, "So far no action has been taken by your officers under the above order (Outworkers' Order), for your present staff are so fully occupied that they have not had time to inspect the workshops known to them, it was therefore considered useless to obtain the addresses of fresh ones." The medical officer of health of Whitechapel, referring to the constant changes in domestic workshops, says, "I am at a loss to discover how, even with an increase in your staff, such new duties can be efficiently performed." Fourteen of the annual reports of medical officers of health contain no reference to the subject of workshop inspection. On December 22nd, 1892, I presented to the Public Health Committee a report as to the results of inspections made by Dr. Hamer of workshops in Mile-end Old-town, Whitechapel, St. George-in-theEast, Bethnal-green, and the Strand. The workshops inspected were those comprised in a list furnished * by the honorary secretary of the Sanitary Committee of the Jewish Board of Guardians, which included workshops believed to be faulty in one or another particular. The results obtained in the several districts were as follows— No of workshops inspected. No. overclouded. No. of overcrowded workshops per cent, of total workshops inspected. Mile-end Old-town 44 27 61 Whitechapel 47 22 46 St. George-in-the-East 14 4 28 Bethnal-green 5 2 40 Strand 4 — — The attention of the sanitary authorities concerned was directed to the results of the inspection, and on January 28th a circular was addressed to sanitary authorities asking what arrangements had been made in the several districts for carrying out the provisions of the Public Health (London) Act. 1891, with reference to workshops. The replies received to this communication were summarized in a report of the Public Health Committee to the Council on June 6th—"In most cases it appears that no special arrangements have been made for carrying out an inspection of workshops apart from the ordinary house to house inspection of the district. In three instances, however, an increase of staff is under consideration, in two cases special workshop inspectors have been appointed, and seven authorities appear to have already carried out a systematic inspection of workshops." In the meantime I had presented to the Committee on April 27th a report by Dr. Hamer on workshops in the St. James, Westminster, and Strand districts, in which it was stated that as regards overcrowding these workshops compared favourably with those in the East-end districts; and on May 4th I presented a further report on the East-end workshops previously reported upon, and on June 1st another report on the result of further inspections in Whitechapel and Mile-end Old-town. The last report clearly showed that the action of the Mile-end Old-town vestry was being attended with beneficial results. Bakehouses. The law relating to bakehouses remains practically unchanged, except that whereas antecedent to the passing of the Public Health (London) Act, 1891, the duty of inspecting these premises devolved upon the medical officer of health, no special reference is made to that officer in this Act, the duty of enforcing the statutory provisions relating to bakehouses devolving on the sanitary authorities. Information as to the work done in connection with bakehouses in the several districts is shown in the reports of almost every one of the medical officers of health, and in some instances the number of bakehouses inspected is given, and in others the number of inspections of bakehouses, while in some reports it is not obvious whether the number given relates to one or the other. The number of bakehouses existing in 1892, is shown in reports relating to the following districts— Paddington 108 Strand 30 Kensington 148 Clerkenwell 54 St. George, Hanover-square 56 Shoreditch 104 Hampstead 43 Bethnal-green 123 St. Pancras 202 Poplar 97 Islington 227 St. George, Southwark 63 St. Giles 29 Woolwich 42 These bakehouses were regularly inspected. [ 5 ] 34 In the following districts, the actual number existing is not definitely stated, but the number of bakehouses inspected, or the number of inspections of bakehouses, was as follows— Chelsea ; 68 under inspection. Marylebone; 438 inspections. Hackney; 12 inspected. St. James, Westminster; 151 wbite-washed and repaired. St. Luke ; 37 visited and reported on, 20 served with notices to cleanse and trap drains, &c. St. George-in-the-East; 56 inspected. It was resolved to inspect periodically. Limehouse; 72 bakehouses were inspected twice. Bermondsey ; 82 inspected. Battersea; 215 inspected. Camberwell; 82 inspected. Greenwich ; Greenwich Parish, 86 bakehouses all inspected ; Deptford Parish, 40 cleaned, 9 drain inlets closed, 24 water supplies altered. In Westminster, Holborn, Hammersmith, Mile-end Old-town, Lewisliam, Wandsworth, Plumstead, and St. Martin-in-the-Fields all bakehouses were inspected and notices were served for cleansing or repairs where necessary. In Whitecliapel in one case the use of the bakehouse for sleeping was prohibited. In the reports for St. Saviour, Southwark, Newington, St. Olave, and Lambeth no reference is made to the subject. In St. Pancras the medical officer of health states 85 per cent, of the bakehouses are below the ground level, and, with few exceptions, the floor is over seven feet below the ground level. "The bakehouses are inspected twice a year, and maintained in conformity with the requirements of the Acts, the sections of which were quoted in last year's report, but these requirements do not touch the question of underground construction, and there is extreme difficulty in cleansing and ventilating a cellar such as an underground bakehouse. It would not be in the justice of things to interfere with existing rights, but bakehouses should be registered, for they are constantly changing ownership, and being closed and re-opened. New bakehouses, and bakehouses re-opened after long intervals, should be required to conform to a given standard of construction before being used for the production of bread and other foods." The medical officer of health of Holborn urges the need of waterclosets and urinals appurtenant to bakehouses. The medical officer of health of Shoreditcli says that many of the underground bakehouses require inspecting four or fives times a year, which was impossible with the existing staff. The medical officer of health of St. George-the-Martyr, Southwark, says of the 63 bakehouses in the district, they were " generally, with a few exceptions, in a filthy and unwholesome state, dangerous alike to the health of the journeyman baker who makes the bread, and to the public who eat it." After describing the works required to be executed in bakehouses, he adds, "Legislation forbidding the use of cellar bakehouses, at least of those about to be freshly started in the future, and m'aking the registration to the sanitary authority of all bakehouses compulsory, with medical inspection prior to occupation, is very urgently needed." The medical officer of health of Bethnal-green says of the 102 bakehouses in the district that in 40 per cent, the bread is made in cellars. "In the whole of the parish I only found seven of these places in what I should call a clean and satisfactory condition; the others are either dirty and untidy or some fault was found such as bad ventilation, defective sink traps, closet flushing apparatus out of order, or bad surface drainage of yard, &c." In 10 bakeries he found "the sanitary arrangements so bad, the lighting and ventilation so imperfect, as to render them totally unfit for use," and, in his opinion, incapable of improvement. He accordingly recommended proceedings under section 16 of the Factory and Workshops Act, 1883. In 64 instances the walls, ceilings and passages were in a dirty condition. He adds, "They require frequent inspection and should be visited at least four or five times a year, but your present staff of inspectors are too fully occupied to devote sufficient time to them, and I think that the appointment of a workshop inspector as recommended by the Sanitary Committee should be at once proceeded with." The medical officer of health of Plumstead (Plumstead parish) states his opinion that a certificate of fitness for use of any premises as a bakehouse should be obtained before such premises are thus occupied. Houses let in Lodgings. The Public Health (London) Act, 1891, makes an important alteration in the law relating to houses let in lodgings. Under section 35 of the Sanitary Act, 1866, it was optional for the sanitary authority to make such regulations and to register such houses, and antecedent to doing so it was necessary to obtain an order by one of Her Majesty's principal Secretaries of State (subsequently the Local Government Board), declaring in force in the district the provisions relating to such houses. After the holding of the Royal Commission on the Housing of the Working Classes, the Local Government Board declared these provisions in force in every London district. The Public Health (London) Act, 1891, had now made it obligatory on every London sanitary authority to make and enforce the necessary by-laws. In many districts regulations were in operation before the year 1891. The reports of medical officers of health for the year 1892 show that in Kensington 1,800 houses had been registered and "many wait attention." In Hammersmith the report of the vestry shows regulations were made in 1887, but that no houses have been registered for the reason that "the vestry finds it is enabled to effect all its requirements by the aid of Public Health and other Acts." In St. George, Hanover-square, houses let in lodgings were inspected and regulations enforced. In Westminster by-laws were framed and submitted to the Local Government Board. In Marylebone their were 3,889 inspections of houses which were subject to regulations made under the Sanitary Act. In Hampstead 1,107 houses were subject to regulations made under that Act. In St. Pancras 144 houses were placed on the register, but the medical officer of health states that "the multiplicity of duties falling on your sanitary inspectors has hitherto left no time available for them to be regularly inspected as they should be at least once a year." In Islington 300 houses were on the register and regulations were enforced. In St. Giles 451 houses were on the register. In 361 instances notices were served for breach of regulations, and in 14 instances further proceedings were taken and in some fines imposed. In St, Martin-in-the-Fields the houses registered were regularly inspected. In 35 Clerkenwell 45 notices were served in respect of houses registered. In Shoreditch registered houses were inspected. In St. George-in-the-East 639 inspections were made of registered houses. In St. George-the-Martyr, Soutliwark, regulations were under revision, the insufficiency of the sanitary staff having previously rendered impossible the enforcement of those already in operation. In Bermondsey 16 houses were added to those on the register, the total number registered being 294. In Wandsworth the drafting of by-laws was deferred until model by-laws had been received from the Local Government Board. The report of the Vestry of Camberwell states that regulations had already been made under the Sanitary Act, 1866. In Greenwich 8 houses were registered during the year. In Lewisham the report of the Lewisham District Board shows that registered houses were inspected during the year. Supervision of Common Lodging Houses in London. The subject of supervision of common lodging houses in London was under the consideration of the Council during the year on the report of the Public Health and Housing Committee, which recommended that there should be, (1) an annual registration; (2) that regulations should be made by the Council and enforced by the sanitary authorities instead of the police; (3) that the right of entry possessed by the police should be retained. Underground Rooms. The law relating to the separate occupation as dwellings of underground rooms has been materially altered by the Public Health (London) Act. The conditions under which such rooms were permitted to be occupied had been prescribed by the Metropolis Local Management Act, 1855, and these provisions had remained unaltered until the Act of 1891 came into force. The Act of 1855 made distinction between such rooms occupied separately as dwellings antecedent to the passing of that Act, and those which were first occupied subsequent to 1855. The Act of 1891 attaches more stringent conditions to the separate occupation of underground rooms, and provides that six monthsafter the commencement of the Act these provisions shall apply equally to rooms occupied antecedent to the Act, except that the sanitary authority either by general regulations providing for classes of underground rooms or on the application of the owner of such room in any particular case, may dispense with or modify any of the requirements of the Act which involve the structural alteration of the building, if they are of opinion that they can properly do so having regard to the fitness of the room for human habitation, to the house accommodation in the district, and to the sanitary condition of the inhabitants, andto other circumstances, but any condition which was required before the passing of the Act of 1891 must not be so dispensed with or modified. In the event of the owner of an underground room feeling himself aggrieved by a refusal of dispensation or modification, he may appeal to the Local Government Board. Before 1891 it was the duty of the district surveyors to report to the sanitary authority and to the Council the illegal occupation of underground rooms. These officers have been relieved of this duty by the Act of that year. The report of the medical officers of health of the following districts show the steps taken under the Act. Chelsea—5 rooms were found occupied contrary to Act. St. George, Hanover-square—The separate use of 12 rooms discontinued. Westminster—In the Parish of St. John all underground rooms were measured and registered, and 173 notices served. It was hoped that the following year underground rooms in the Parish of St. Margaret would be dealt with in a similar manner. St. James, Westminster—The separate use of 138 rooms was discontinued. Marylebone—959 separately occupied underground rooms were inspected. Hampstead—The separate occupation of 6 underground rooms was discontinued. St. Pancras ,, ,, 38 „ „ Islington „ „ 6 „ „ Hackney—Penalties were obtained against the owners of two underground rooms. St. Giles— In 26 instances the separate occupation of an underground room was discontinued or alterations effected. St. Martin-in-the-Fields—The separate use of 3 underground rooms was discontinued. Strand ,, ,, 6 ,, ,, Holborn ,, ,, 39 ,, ,, Clerkenwell ,, ,, 45 ,, ,, or alterations effected. St. Luke The separate occupation of 36 underground rooms discontinued. Shoreditch ,, ,, several „ ,, Betlinal-green ,, ,, 4 ,, ,, Whitechapel ,, ,, 6 ,, ,, St. George-in-the-East ,, ,, 58 ,, ,, Limehouse ,, ,, 3 ,, ,, Mile-end Old-town ,, ,, 7 ,, ,, Poplar (north district) ,, ,, 1 ,, ,, St. George, Southwark ,, ,, 15 ,, ,, Lambeth ,, ,, 46 ,, ,, Greenwich ,, ,, 3 ,, ,, The medical officer of health of Wandsworth (Clapham) writes—" Underground rooms are now under the jurisdiction of the Board when occupied separately from any room above ground. The number thus occupied is not great though a great many are used for sleeping and living in, which escape regulation by reason of a single room above ground being used by the same people. It is obviously just as important that the basement rooms should be well ventilated and healthy, if used for sleeping in, when let along with one or more sleeping rooms above ground. I think that an amendment of the law to apply the statutory regulations to them also would be of great value. Another difficulty found in dealing with underground 36 rooms is that at tbe time of inspection there may be no separate occupation of them, whereas in the following week the conditions of tenancy may have changed, as frequently happens, and the rooms become separately occupied. Smoke Nuisance. The Public Health (London) Act, 1891, transferred from the Commissioner of Police to the sanitary authorities the dutv of administering the provisions relating to the abatement of smoke nuisances. The following table shows the number of police officers employed in previous years and the proceedings taken in respect to smoke nuisances. No. of police employed Cost. Cases reported. Cases where proceedings were taken. Convictions. Cafes dismissed or withdrawn. Sergeant. Constable. Part time constable. £ s. d. 1882 1 7 41 3,277 14 8 1,248 168 162 6 1883 1 9 39 3,378 5 4 1,113 126 119 7 1884 1 9 39 3,336 13 4 1,064 145 137 8 1885 1 9 40 3,398 5 4 967 124 120 4 1886 1 9 40 3,530 16 - 940 92 82 8 1887 1 20 29 3,518 13 4 856 86 81 5 1888 1 21 28 3,641 14 8 694 53 49 4 1889 1 24 23 3,594 18 8 769 68 60 8 1890 1 24 23 3,657 6 8 702 53 46 7 The annual reports of the medical officers of health of sixteen districts do not show what steps have been taken to carry out these provisions of the Public Health Act. In the reports relating to the undermentioned districts, statements are made to the following effect. Westminster.—Careful attention was given to the subject of smoke abatement, and several owners of furnaces cautioned. St. James, Westminster.—4 smoke nuisances were abated. St. Pancras.—14 smoke nuisances were abated. Islington.—Regulations relating to smoke nuisances were prepared. Strand.—All cases of nuisance were inquired into and remedied. Holborn.—A register of 45 furnaces prepared and these periodically inspected; 4 were altered so as to make them properly consume smoke; 13 complaints received. Clerkenwell.—26 smoke nuisances were abated. St. Luke.—10 notices were served. Shoreditch.—Persons were frequently cautioned, and 12 smoke nuisances abated. Bethnal-green.—10 smoke nuisances were abated. St. George-in-the-East.—15 smoke nuisances were abated. Limehouse.—25 smoke nuisances were abated. St. George-the-Martyr, Southwark.—10 smoke nuisances were abated. Newington.—Includes the number of smoke nuisances with number of certain other nuisances abated. Bermondsey.—118 notices were served. Lambeth.—The report of the vestry shows that notices were served to abate nuisance. Battersea.—10 smoke nuisances were reported and dealt with. Wandsworth.—Notices were served on some owners. Camberwell.—49 orders were made to abate smoke nuisances. Greenwich.—The report of the district board shows that 13 notices were served. Plumstead.—In Charlton and Lee parishes 1 and 3 notices were served respectively. In Plumstead parish the report states there was less black smoke from the Arsenal, but that there is room for improvement. Housing of the Working Classes. During the year 1892 a number of areas in London were under the consideration of the Public Health and Housing Committee. The following statement shows briefly the action taken in respect of unhealthy areas which were the subject of report by the Committee to the Council. Boundary-street scheme.—The provisional order sanctioning this scheme was received in June, and the Bill confirming the order became law on the 3rd July, 1891. During 1892 the Committee was actively engaged in acquiring the interests in the property, and from time to time as possession of the various premises was obtained I reported in conjunction with the valuer upon their condition. The worst houses were closed at once, in other cases repairs were executed with a view to continuing the tenancies for a time, obviating large displacements and affording opportunity for persons to obtain accommodation elsewhere. In all cases the new residences to which those displaced had recourse were also inspected. A number of schemes under Part II. of the Housing of the Working Classes Act, undertaken jointly by the Council and the district authority, were dealt with during the year; the following areas may be particularly alluded to. Ann-street, Poplar.—The question of dealing with this area had for some time past been before the Committee, the conclusion that action should be taken under Torrens' Acts had been arrived at, and the Poplar Board had been so informed. On the passing of the Housing of the Working Classes Act, 1890, proceedings for closing several of the houses on the area as unfit for human habitation were 37 instituted by the Poplar Board. The magistrate, however, refused to grant closing orders and no material improvement in the condition of the area resulted. Moreover, the Poplar Board declined to take further action, preferring to leave the matter in the hands of the Council. In May, 1892, after conferring with the medical officer of health of the district I reported that in my opinion the defects could only be properly remedied by an improvement scheme. The Committee after carefully considering the question decided to recommend the Council to pass a resolution under section 39, (1) (b) of the Act in respect of the area. This resolution was passed by the Council on December 20th. The area included Bow-court, Edna-place, Prospect-place, Charles-place, Ann's-row, Tavernrow, Tavern-court, and houses in Ann-street and Brunswick-road. It was estimated that about 250 persons would be displaced, and that the net cost of the scheme would be about ,£9,000. An inquiry into the merits of the scheme was held by the inspector appointed by the Local Government Board in 1893, and the scheme was confirmed. Broolce's-market, Holborn.—This area, which is about ¼ acre in extent, was the subject of a representation under Cross' Act made in 1883, but was deemed too small to be treated by a scheme under that Act. The Committee's resolution under section 39 (1) (b) of the Housing of the Working Classes Act with regard to it was passed on October 13th, 1891, a scheme under Part II. of the Act was prepared. The inquiry was held on February 2nd by Mr. C. J. Smith, the Local Government Board inspector, and the scheme was, with some modifications, sanctioned. The Holborn District Board contribute one-half the cost of the scheme (such contribution not exceeding £3,000), in accordance with an order of the Home Secretary. Green-street and Gun-street, Southwark.—In May, 1889, three areas in St. George-the-Martyr, Soutliwark (the Green-street area comprising 28 houses, the Gun-street area comprising 58 housos and the Falcon-court area comprising 33 houses), were represented to the Council by the late Dr. Waterworth under Cross' Acts. The Council thought that the area should be dealt with under Torrens' Acts (now Part H. of the Housing of the Working Classes Act), and the matter was made the subject of an inquiry by an arbitrator (Mr. Cubitt Nicliols) appointed by the Home Secretary. The decision arrived at was that the areas should be dealt with under Part II. of the new Act, the Council contributing one-third of the expense. In 1892, schemes for dealing with the Green-street and Gun-street areas were prepared by the vestry, and on the 8th March the neccessary inquiry was held by an inspector of the Local Government Board and the schemes were, with some modifications, sanctioned. Mill-lane area, Deptford.—This area comprising some 50 houses (including 8 registered lodging houses), with a total population of about 715 persons, was represented 24th March, 1891, by Mr. Roberts, medical officer of health of Deptford, under Part I. of the Housing of the Working Classes Act. The Council was of opinion it should be dealt with under Part II. of the Act, and application was made to the Home Secretary to appoint an arbitrator. Meantime, however, negotiations resulted in agreement between the Council and the Greenwich Board that each should contribute one half of the cost of the scheme, which was estimated at about £39,500 net. The Council parsed a resolution July 12th, 1892, directing a scheme to be prepared, and on July 26th a scheme was submitted under whicli the rehousing of 570 persons was contemplated. This scheme was approved by the Council, and application was made to the Local Government Board for an order sanctioning the scheme. The local inquiry was held in the following year, and the scheme is in course of being carried out. Moira-place and Plumbers-place, Shoreditch.—These areas were represented on April 26th, 1890, by the late Dr. Sutton, medical officer of health for Shoreditch under Cross' Acts. The Council held that the areas should be dealt with under Torrens' Acts. After the passing of the Housing of the Working Classes Act, the Home Secretary decided that the areas should be dealt with under Part II. of that Act, the Council and the vestry each contributing one half the cost. The vestry passed the necessary resolution under section 39 (1) (b) of the Act, and prepared a scheme for rehousing some 400 of the 550 persons of the artizan class who would be displaced, the net cost of acquiring the property being about £51,300. On July 12th the Council approved the scheme, and instructed the Council's officers to attend the local inquiry in support thereof, and to urge the insertion of provisions dealing with certain points. The inquiry was held in 1893, and the scheme confirmed. Norfolk-square, Islington.—The late Dr. Tidy, medical officer of health of Islington, represented this area, comprising45 bouses under Cross'Acts, on 24th June, 188H. The area was considered too small for the application of Cross' Acts, and the vestry after attempting to obtain closing orders for some of the houses, an attempt which proved unsuccessful, prepared a scheme under Part II. of the Housing of the Working Classes Act for dealing with the area. The scheme involved the displacement of 214 persons, of whom 102 were to be rehoused, an open space of 100 feet square being left to form a playground. On October 4th, the Council agreed to contribute one half of the net cobt of the scheme, such contribution not to exceed £4,000. The scheme was confirmed after a local inquiry held in 1893 by the Local Government Board. Queen Catherine-court area, Limehouse.—In January, 1891, the Liruehouse Board directed that a scheme for the improvement of this area under Part II. of the Housing of the Working Classes Act should be prepared. On May 31st, 1892, the Council agreed to contribute one-half of the net cost of a scheme dealing with 29 houses at an estimated cost of £7,400. An inquiry was subsequently held by the Local Government Board, and the scheme was confirmed. London-terrace, St. George-in-thc-East.-- -The Council decided on July 28th, 1891, to contribute one-half of the cost of a scheme under Part II. of the Housing of the Working Classes Act in respect of this area. The inquiry by the Local Government Board, with regard to it was held in June, 1893. I have reported from time to time during the year on a large number of areas, among which I may select for particular mention the following— Bishop's-court and other areas, Clerkenwell. Baltic-court and adjoining courts and alleys in St. Luke's. Greenbank and other areas in St. Olave's. 38 Gun-street-dwellings, St. George-the-Martyr. Great Pearl-street, Whitechapel. Hilliards-court and Whitethorn-place, St. George-in-the-East. Lewin's-buildings, Mile-end Old-town. Mary Ann-buildings, Deptford. Star-road, Fulham. Ship-court and other courts in Westminster. Sexton's-cottages and other blocks of houses, Greenwich. Toulon-street and Thompson's-avenue, Camberwell. Tyrrell-street and adjoining streets, Bethnal-green. Holborn to Strand Improvement.—I made during the summer of 1892 an exhaustive inquiry with regard to the area situated between Holborn and the Strand, and specially reported on three areas in the Strand district (one of them of considerable size and occupied by some 1,700 persons). The Committee subsequently reported to the Council on October 4th, 1892, that these areas appeared to he suitable for being made the subject of schemes under Part I. of the Housing of tbe Working Classes Act. Housing of the Working Classes Act, 1890. In the year 1890 the Council received information that 397 houses had been represented to the sanitary authorities under the Housing of the Working Classes Act as unfit for human habitation. In 1891, 1361 were so represented. In 1892 the number fell to 469, the provisions of the Public Health (London) Act for procuring the closing of insanitary houses being employed in many cases in substitution for those of the former Act. The following table shows the proceedings taken in respect of individual houses during the year 1892 in the several districts exclusive of the City. Tabular statement showing the procedure of district authorities as to houses represented as unfit for human habitation, and concerning which the Council has received copies of representations during the year ended 31st December, 1892. Local authority. Total number of houses concerning which the Council has received information that representations have been made during year ended 51/12/92. Number of houses closed, demolisned or improved by owners without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses lor which closing orders were refused. Number of houses outstanding or concerning which proceedings are in progress. Closed. Demolished. Improved. Total. Subsequently demolished. Subsequently improved. No further action. Total. Battersea — — — — — — — — — — — Berruondsey — — — — — — — — — — — Bethnal-green §73 — 5 5 10 28 16 12 56 — *6 Camberwell — — — — — — — — — — — Chelsea — — — — — — — — — — — Clerkenwell 15 — — 15 15 — — — — — — Fulham 37 — — — — 3 12 6 21 — 16 Greenwich 13 13 — — 13 — — — — — — Hackney — — — — — — — — — — — Hammersmith — — — — — — — — — — — Hampstead 5 — — 2 2 — — 3 3 — — Holborn — — — — — — — — — — — Islington — — — — — — — — — — — Kensington 24 — — — — — — — — — 24 Lambeth — — — — — — — — — — — Lewisham — — — — — — — — — — — Limehouse 18 3 3 7 13 5 — — 5 — — Mile-end Old-town 92 5 3 53 61 — — 11 11 — 20 Newington 8 — — — — — — 5 5 — 3 Paddington — — — — — — — — — — — Plumstead — — — — — — — — — — — Poplar — — — — — — — — — — — Rotherhithe — — — — — — — — — — — St. George, Hanover-square — — — — — — — — — — — St. George-in-the-East 47 3 12 26 41 3 1 2 6 — — St. George-the-Martyr — — — — — — — — — — — St. Giles 26 1 — 1 2 6 7 11 24 — — St. James, Westminster — — — — — — — — — — — St. Luke 1 1 — — 1 — — — — — — St. Martin-in-the-Fields — — — — — — — — — — — St. Marylebone — — — — — — — — — — — St. Olave, Southwark 8 — — — — — — 8 8 — — St. Pancras 2 1 — — 1 — — — — — 1 St. Saviour, Southwark — — — — — — — — — — — Shoreditch 10 — — 10 10 — — — — — — Strand — — — — — — — — — — — Wandsworth 52 5 — 46 51 — — 1 1 — — Westminster 8 1 4 3 8 — — — — — — Whitechapel 2 — — — — — — 2 2 — — Woolwich ‡28 — 4 3 7 — — — — — — Total 469 33 31 171 235 45 36 61 142 — 70 § 1 house subsequently dealt with under the Public Health (London) Act, 1891. ‡ 21 houses subsequently dealt with under the Public Health (London) Act, 1891. * Included in the Boundary-street area improvement scheme 39 The Council during the year 1892 received 694 complaints, in which it was alleged that premises were defective or that there was neglect of sanitary administration. Enquiry was made in respect of each complaint, and whenever necessary the sanitary authorities concerned were communicated with. Inspection was also made to ensure that the subject of complaint was remedied. Mortuaries. Early in the year I communicated with the several medical officers of health, asking for information as to the mortuary accommodation in each district. Enquiry was also made as to whether a post-mortem room was attached to the mortuary, whether a separate room for the bodies of persons dying from infectious complaints was provided, and as to the number of bodies which had been received in the mortuary during each of the preceding three years. Later in the year the information thus obtained was supplemented by inspection of all the mortuaries in London, and it was found that some districts were well provided with proper and adequate mortuary accommodation, but in a large number the provision was inadequate. This subject has been receiving the attention of a joint committee consisting of members of the Public Health and Housing Committee and the Public Control Committee. Disinfection. Under section 23 of the Sanitary Act, 1866, sanitary authorities were empowered to provide the apparatus necessary for disinfection, and under the Infectious Disease (Prevention) Act 1890, they were required to provide, free of charge, temporary shelter or house accommodation with any necessary attendants for the members of any family in which any infectious disease has appeared, who have been compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the local authority. Under the Public Health (London) Act it is obligatory to make provision of both. In 1892 disinfecting apparatus had been provided in the following districts— Districts provided with steam apparatus— St. George, Hanover-square St. Pancras St. Giles Strand Shoreditch Bermondsey Camberwell Greenwich Woolwich Bethnal-green Hampstead St. James Mile-end Old-town Lambeth Plumstead In Hackney a new steam apparatus was ordered. In Whitechapel a new steam apparatus was selected. In St. George-the-Martyr it was decided to have a steam apparatus. The sanitary authorities of St. George-in-the-East and Limehouse decided to combine for the purpose of providing a steam disinfector. In the following districts the sanitary authorities obtain the use of a steam apparatus by arrangement with a contractor— Kensington Paddington Fulham Westminster Islington St. Martin-in-the-Fields Holborn St. Olave Kotherhithe Battersea Wandsworth In the following districts are apparatus for disinfecting with dry heat— Hammersmith Poplar Chelsea St. Saviour, Southwark Marylebone St. George-the-Martyr, Southwark (see Hackney (see above) above) Clerkenwell Newington St. Luke Lewisham Whitechapel (see above) Plumstead (Lee) Limehouse St. George-in-tlie-East(see above), Plumstead, Charlton and Eltham destroy instead of disinfect. Shelters had been provided in the following districts— St. George, Hanover-square St. George-in-the-East Westminster Wandsworth Marylebone Greenwich (Greenwich Parish) Hampstead Woolwich St. Pancras (in course of erection) Plumstead (Charlton Parish) Clerkenwell In several districts the subject of provision of a shelter has been under consideration. Holborn and St. Luke use the shelter of Clerkenwell, each paying £25 per annum. Whitechapel uses, when necessary, a room near the coroner's court. St. Olave has a very imperfect shelter of one room in Vine-street. In Hammersmith and Lambeth arrangement is made on occasions of need. Food and Drugs Act. The Council receives no returns as to proceedings under the Food and Drugs Act, but information as to the number of samples of different articles submitted to the public analysts and the number found adulterated is contained in many of the reports of medical officers of health, and a complete return for the metropolis is contained in the report of the Local Government Board. During the year 1892 7,380 samples were submitted to the public analysts, or 1.7 per 1,000 of the population 40 of the census year 1891, of these samples 16.9 per cent, were found adulterated. The number of samples analysed in the several districts in proportion to population is shown in the following table— No. of sample examined per 1,000 of population (Census, 1891). No. of samples examined per 1,"00 of population (Census,1891). No. of samples examined per 1,000 of population (Census, 1891). Kensington 3.1 St. Giles 4.6 St. Saviour, Southwark. 5.6 Hammersmith 2.3 St. Martin-in-the-Fields. 1.5 St. George, Southwark 1.3 Fulham 1.4 Strand 9.9 Newington 0.4 Paddington 2.3 Holborn 1.2 St. Olave 3.5 Chelsea 1.6 Clerkenwell 2.5 Bermondsey 2.4 St. George, Hanoversquare 4.9 St. Luke 3.4 Rotherhithe 0.2 London, City of 3.1 Lambeth 1.2 Westminster 1.6 Shoreditch 0.8 Battersea 0.6 St. James 2.4 Bethnal Green 0.7 Wandsworth 1.9 Marylebone 3.6 Whitechapel 1.9 Camberwell 0.8 Hampstead 3.1 St. George-in-the-East 3.3 Greenwich 1.2 Pancras 0.8 Limehouse 2.4 Lewisham 0.6 Islington 1.1 Mile End Old Town 1.8 Woolwich 2.5 Hackney 08 Poplar 1.7 Plumstead 2.2 Sanitary Officers. Under the provisions of the Local Government Act, 1888, sanitary authorities were empowered to require payment by the County Council of a moiety of the salary of any medical officer of health of a district appointed or re-appointed after the passing of that Act. The Public Health (London) Act, 1891, provides that this contribution shall be made in the case of every medical officer of health and sanitary inspector elected or re-elected after the passing of the Act. Appointment or re-appointment of the medical officer of health had taken place in the following districts at the end of the year 1892, and the Council is therefore required to pay a moiety of the salaries of such officers— Chelsea, Mile-end Old-town, St. George-in-the-East, Limehouse, St. Giles, St. Olave, St. Saviour (Southwark), St. Luke, Plumstead, St. George-the-Martyr, Islington, Fulham, Woolwich, Battersea, St. Martin-in-the-Fields, the Collegiate Church of St. Peter (Westminster). Statistics. The order of the Local Government Board of the 28th March, 1889, prescribing the duties of medical officers of health, requires the reports of these officers to be made to the end of December in each year. Only those officers are subject to the order who are elected or re-elected after the date of the order. In 1891, however, the Council addressed to sanitary authorities a letter pointing out the desirability of the annual reports of all medical officers of health being made to relate to the same period, and as a result all the statistics in the reports for the year 1892 are for the first time made to the end of that year. With few exceptions each medical officer of health had received returns which enable him to exclude from his statistical tables the deaths of persons occurring in public institutions in his district, but who are not inhabitants of the district, and to include the deaths of persons belonging to the district but which occur in public institutions situated in other parts of London, or in public institutions belonging to London but situated beyond the limits of the county. The reports of the medical officers of health in the majority of cases contain tables recommended by the Society of Medical Officers of Health, but it is not a uniform practice to correct these tables in respect of the deaths occurring as above stated. The tables are not therefore in all cases comparable. There would obviously be much advantage if these corrections were made and if each report contained certain tables identical in each district. Medical officers elected or re-elected subsequent to the order of the Local Government Board are required to supply two tables giving certain particulars, but the reports contain other tabular statements of much value and giving more detailed statistical information than is required by the Board. The general adoption of tables strictly comparable on a uniform system in the several districts would enhance the value of these records. London Water Supply. Dr. E. Frankland, reporting to the President of the Local Government Board on the chemical, physical and bacteriological examinations of the waters supplied by the metropolitan water companies during the year 1892, states that, except in November and December, the weather has been on the whole not unfavourable for the operations of the companies who derive their water from the Thames and Lee, and the quality of their supplies has, except in December, been much more uniformly good, and less subject to violent fluctuations than during the previous year. Dr. Frankland adds that the want of additional storage reservoirs, and in some cases of larger filter areas, is still very emphatically declared both by the chemical and bacteriological examinations, and he proceeds to contrast the quality of the water of the Chelsea Company, which draws its water from the Thames and has 14.2 days' storage, with that of other companies drawing their water from the same source, but having a storage of from 7 to 2.5 days only. But even the storage of the Chelsea Company, he points out, was insufficient in January, February and December, and in like manner the 13.7 days' storage of the East London Company, which draws its supplies from the Lee, was insufficient in January and November and still more so in December. Dr. Frankland, however, states that the samples examined by him were invariably clear and bright, and that even when analysis showed the admission of flood water, the water actually supplied to consumers was always efficiently filtered. 41 The report of the water examiner, Major-General Scott, gives the following table showing the provision made by the several companies drawing their supplies from the Thames and Lee— Capacity of subsidence reservoirs. Filters. Thickness of sand in filters. Monthly rate of Filtration per square foot per hour, 1892. Company. Cubic contents. Number of days' supply. Area. Area per million gallons of average daily supply. Maximum. Minimum. Mean monthly averages. Maximum monthly averages. Gallons, millions. Acres. Acres. Ft. in. Ft. in. Gallons. Gallons. Chelsea 140.0 14.7 6.75 0.71 4 6 3 6 1.75 1.75 East London 615.0 15.1 29.75 0.73 2 0 1 4 1.33 1.33 Grand Junction 64.5 3.5 17.75 0.96 2 0 1 3 1.99 2.25 Lambeth 128.0 6.4 9.50 0.48 3 0 2 6 2.15 2.36 New River 168.1 4.8 16.50 0.48 2 3 1 5 2.08 2.30 Southwark and Vauxhall 66.0 2.5 14.50 0.56 3 0 1 6 1.50 3.50 West Middlesex 117.5 6.7 15.00 0.86 3 3 2 6 1.25 1.33 Major-General Scott adds that some of the companies, in addition to subsiding reservoirs and filters of the ordinary type, have constructed works which enable them to derive a supply of water from the beds of sand and gravel which extend over the Thames valley in the neighbourhood of the intakes, and in some cases to utilise these beds as filters. He refers to the fact that the Grand Junction Company use six acres of filters of a rough character constructed of sand in its natural condition, and used for preliminary filtration, which is succeeded by filtration through washed sand and gravel; and that the East London, the Grand Junction, the Southwark and Vauxhall and the Lambeth Companies collect from the gravel subsoil, water which is pumped through the ordinary filters before filtration. The New River Company possess 13 wells in the chalk, the water of which is mixed with that drawn from the Lee, and the whole is filtered. Experience has increasingly demonstrated the value of bacterial examination of water as a test of efficiency of filtration, and Dr. Frankland's report gives account of the results obtained by such examination of the waters supplied by the several companies. In the first four months of the year the samples were collected at the stand-pipes in London, during the remaining months at the works of the respective companies immediately after the water left the filters, and before it was pumped into the distributing mains. The tubes containing water collected at the works were hermetically sealed and packed in ice. The number of microbe colonies developed from one cubic centimetre of each water examined during the last eight months of the year ranged between: Chelsea, 3 and 16; West Middlesex, 3 and 32; Southwark, filter No. 1, 4 and 148, filter No. 2, 2 and 292, filter No. 3, 10 and 996, gravel water, 6 and 168; Grand Junction, 10 and 236; Lambeth, 4 and 138; New River, 3 and 140; East London, 4 and 134; Kent, 1 and 19. These maxima were, however, exceptional, and the examinations generally showed a number of microbe colonies more nearly approaching the minima. Section 4 of the Metropolis Water Act, 1852, provides that "From and after the thirty-first day of December, 1855, every company shall effectually filter all water supplied by them within the metropolis for domestic use, before the same shall pass into the pipes for distribution, excepting any water which may be pumped from wells into a covered reservoir or aqueduct, without exposure to the atmosphere, and which shall not be afterwards mixed with unfiltered water." It has hitherto been held that this requirement is complied with if the water is free from suspended matter, and necessarily the water supplied has not been judged by any bacterial standard. The need for some authoritative definition of the term " effectually filter " is obvious. Reference to the table extracted from Major General Scott's report shows the great difference in the provision made by the several companies for securing the supply to the consumers of effectually filtered water. The deficiencies of the several companies as regards purification works has been frequently pointed out by the water examiner. In the absence of any statutory definition of efficient filtration, the following statement by Professor Koch is of interest— "(1) The pace of filtration must not exceed 100 mm. in the hour. To make sure of this each separate filter must be provided with a contrivance by which the movement of water in the filter can be restricted to a certain pace, and continually regulated so as to keep that pace. "(2) Each separate filtering basin must, when in use, be bacteriologically investigated once each day. There should therefore be a contrivance enabling samples of water to be taken immediately after they have passed the filter. "(3) Filtered water containing more than 100 germs capable of development in a cubic centimetre should not be allowed to reach the pure water reservoir. The filter should therefore so be constructed that insufficiently purified water can be removed without its mixing with the good filtered water. To these rules I have still to add some observations. In strictness the two last rules would suffice to remove the danger of infection from filtered water so tar as is possible to do so in the case of filtration through sand ; but I think it is questionable whether it is necessary always to insist upon the rule of a daily bacteriological examination of each separate filter. If waterworks by their good construction and their proper and intelligent [6] 42 superintendence give continuously good results tlie strict insistence of bacteriological examination can be restricted to times of danger, i.e., times when the consumption of water is greatest, periods of frost or danger of epidemics. In the meanwhile an examination every three days of the totally filtered water would be sufficient. (Bacteriological examination as it now takes place—when it does take place—i.e., a weekly examination of the totally filtered water, is in all circumstances to be looked upon as insufficient.) In those periods when the bacteriological control is less strict there should be close and strict regulation of the pace of filtration so as to have assurance that the process is properly carried out."* Obviously the efficiency of the filtration effected by the several companies cannot be properly appreciated by information as to average monthly rates of flow, but must be judged by the maximum rates at any one time. Koch's standard would give approximately 49 gallons per superficial foot of filter per 24 hours, or about two gallons per hour. This standard was, as shown by the water examiner's table, exceeded by the Grand Junction, the Lambeth, the New River and the Southwark and Vauxhall Companies. Dr. Frankland strongly recommends double filtration "as affording a second line of defence against the invasion of pathogenic microbes." "Experience," he says, "teaches that even the best arranged filtration plant may at times pass an objectionable number of microbes. A second filtration would, if not invariably, at all events when the filters are recently made or are not working satisfactorily, be very desirable, so as to keep down the number of microbes per cubic centimetre to a very moderate limit. That double filtration is not an impracticable project is proved by the fact that the Grand Junction Company have already begun to carry it out on a very considerable scale. Of course gravel water would not need double filtration." During 1891 and 1892 an investigation has been made by Dr. Alfred Ashby, Mr. G. H. Fosbroke, and Dr. George Turner, on behalf of the Council, of the watersheds of the Thames and Lee with a view to enabling an estimate to be formed of the risks to these rivers and their tributaries, as public water supplies, from pollution of every kind, and as to the probability of the pollution increasing or decreasing. The results of these investigations were submitted to the Royal Commission on Metropolitan Water Supply. Constant supply.—The Metropolis Water Act, 1871, empowers the Metropolitan Board of Works (London County Council) to make application to the several water companies for a constant supply of water in any district in London other than the City. As the result of the action of the Council and of the water companies, the number of houses in London receiving such supply was increased during the year to about 69 per cent, of the houses in London. The London Building Law. The requirements of the London building law as to open space about buildings are included in two Acts. The Metropolitan Building Act, 1855, section 29, provides that every building used or intended to be used as a dwelling house, unless all the rooms can be lighted and ventilated from a street or alley adjoining, shall have in the rear or on the side thereof an open space exclusively belonging thereto of the extent at least of one hundred square feet. The Metropolis Management and Building Acts (Amendment) Act, 1882, section 14, requires every new building intended to be used wholly or in part as a dwelling house, and erected on a site not previously occupied in whole or in part, to have directly attached to it and in the rear of it an open space exclusively belonging to it which varies in proportion to the frontage. If the frontage be 15 feet or less, the open space must be 150 square feet; if exceeding 15 feet, but not exceeding 20 feet, 200 square feet at least; if exceeding 20 feet, and not exceeding 30 feet, 300 square feet at least; and if the frontage exceed 30 feet, the open space must be 300 square feet at least. Thus between two parallel rows of houses backing on each other there must be an interval of some 20 feet or a little more irrespective of the height of the buildings, and this open space subject to the requirement of 100 square feet of open space mentioned above may be covered with buildings to the level of the height of the ceiling of the ground floor storey. Numerous urban authorities in England either by local Act or by by-law made under the Public Health Act, 1875, require open space in proportion to the height of the building, and there is urgent need of this requirement in London. In many instances buildings have been erected which overshadow others, depriving them of the air and light necessary to make them healthy habitations. The only provisions in the London building law for limiting the height of buildings in proportion to the width of the street are contained in section 85 of the Metropolis Local Management Act, 1862. This section prohibits the erection on the side of a new street, of a less width than fifty feet, of any building, except a church or chapel, which shall exceed in height the distance from the external wall in front of such building to the opposite side of such street. The London County Council (General Powers) Act, 1890, prohibits the erection, without the consent of the County Council, of any building, except a church or chapel, of a greater height than ninety feet, exclusive of two storeys in the roof and of ornamental towers, turrets, or other architectural features or decorations. Upon the proper ventilation of and the admission of solar rays into streets the healthiness of a city greatly depends, and the existing law is insufficient for ensuring these conditions. On the 21st of December, if the houses be 40 feet high, to secure one hour of such sunlight on houses situated on a meridional street in the latitude of London, the width of the street would have to be 19'81 feet, for two hours 41'83 feet, for three hours 69'14, and for four hours 107 39. So again if the street * "Water Filtration and Cholera," by Professor R. Koch, of Berlin. Translated from the German by Albert J. A. Ball, Esq., B.A., of the Local Government Board. 43 make an angle with the meridian, the width must be increased to produce the same result, thus— Angle of inclination of street to the meridian. 5° 10° 15° 20° ft ft ft ft, 1 hour 32.84 45.63 58.07 70.07 2 ,, 55.28 68.31 80.82 92.71 3 „ 83.43 97.08 109.99 122.06 4 „ 123.19 138.06 151.87 164.53 At the venial or autumnal equinox, to secure one hour of such sunlight, the meridional street must be 6.65 feet wide, for two hours 13.76 feet, and for three and four hours respectively 21.77 and 31.25 feet. For streets making an angle with the meridian, the following widths are necessary— Angle of inclination of street to the meridian. 5° 10° 15° 20° ft. ft. ft. ft. 1 hour 11.03 15.33 19.51 23.54 2 ,, 18.18 22.46 26.57 30.48 3 ,, 26.26 30.56 34.63 38.43 4 ,, 35.85 40.18 44.20 47.88 The London Building Law, however, as already pointed out, makes no requirement of open space in the rear of houses in proportion to their height, and only limits the height of the house (except to 90 feet) to the width of the street on new streets since 1862. During recent years there has been an increasing tendency to cover land with buildings, and to make insufficient provision for the ventilation and natural lighting of the buildings. Thus it is a frequent practice to replace existing buildings by others containing suites of rooms or "flats," the back rooms of which derive their air and light from enclosed courts or shafts through which air imperfectly circulates, and through which light but inadequately enters the rooms. There is much need for placing under statutory regulation the conditions under which such buildings are erected. Public Health (London) Act, 1891. The Public Health (London) Act, which came into force on the first day of the year 1892, consolidated and extended the public health law in London. The following are the principal amendments— The first section follows closely a similar provision in the Housing of the Working Classes Act, 1890, requiring sanitary authorities to put in force the powers vested in them so as to secure the proper sanitary conditions of all premises within their district. It is made clear that the provisions relating to nuisances apply to those which are dangerous to health, irrespective of the question whether they have actually caused injury. Information of a nuisance may be given to the sanitary authority by any person, and it is made the duty of every officer of a sanitary authority, and of every relieving officer (subject to the regulations of the authority having control over him) to give such information. The sanitary authority may, if they think it desirable, specify the works required for the abatement of a nuisance. When the person causing the nuisance cannot be found and the nuisance does not arise or continue from any act, default or sufferance of the owner or occupier, the sanitary authoritymaydo what is necessary to prevent its recurrence, as well as themselves abate the nuisance as heretofore. The sanitary authority may require the abatement of overcrowding of any house or part of a house, whether it be occupied by the members of more than one family or not. A penalty is provided when the nuisance arose from the wilful act or default of a person, or when any person makes default in complying with any of the requisitions of the notice of a sanitary authority within the time specified. Further in the case of appeal, a person making such appeal is liable to penalty unless he satisfies the court that he had substantial ground for such appeal. When a court making an order is of opinion that the continuance of a nuisance, pending the hearing of an appeal, will be injurious or dangerous to health, and that its abatement will not cause any injury which cannot be compensated by damages, the court may authorise the sanitary authority immediately to abate the nuisance. Under such circumstances, if the appeal is abandoned or dismissed, the sanitary authority may recover the costs incurred in the abatement. The sanitary authorities are required to make by-laws for the prevention of nuisances arising from snow, soot, dust, ashes, rubbish, offal, carrion, fish, or filth or other matter or thing in any street; for preventing nuisances arising from any offensive matter running out of any manufactory, brewery, slaughterhouse, knacker's yard, butchers or fishmonger's shop or dung-hill into any uncovered place; 44 for the prevention of the keeping of animals on any premises in such place or manner as to be a nuisance or injurious or dangerous to health; and as to the paving of yards and open spaces in connection with dwelling houses. The county council is required to make by-laws prescribing the times and conditions of removal of offensive and noxious matter through the streets; as to the closing and filling up of cesspools and privies, the removal and disposal of refuse, and as to the duties of the occupier of any premises in connection with bouse refuse so as to facilitate the removal of it by the scavengers of the sanitary authority. New provisions are made as to the removal of house refuse and the contents of privies, earthclosets and cesspools. It becomes the duty of every sanitary authority to secure the due removal at proper periods of house refuse from premises, and the due cleansing out and emptying at proper periods of ashpits, and of earth-closets, privies and cesspools, and to give sufficient notice of the times appointed for such removal, cleansing out and emptying. The occupier of any premises may recover a penalty from the sanitary authority if the house refuse or the contents of any earth-closet, privy or cesspool are not removed at the ordinary period, and if the authority fails to effect such removal within forty-eight hours after written notice. The removal of house and street refuse by a sanitary authority, when collected or deposited by such authority, is deemed to be a business carried on by that authority within the meaning of the section relating to businesses causing effluvia, and for this purpose the Council may institute proceedings against the sanitary authority as provided in that section. The duty of cleansing footways is made to devolve only on the sanitary authorities. The licensing of knackers' yards is transferred to the Council. The prohibition of the establishment of the business of a soap boiler is not to include the establishment anew with the sanction of the Council of a business in which tallow or any animal fat or oil other than olein is not used by admixture with alkali for the production of soap. The duty of administering the provisions relating to the abatement of smoke nuisances are transferred from the Commissioner of Police to the sanitary authorities. The duty of enforcing the law relating to the consumption of smoke by steamers on the Thames devolves on the port sanitary authority. The provisions relating to workshops and factories are made to accord with those of the Factory and Workshops Act, 1891, the primary duty of administering those relating to the maintenance of workshops in proper sanitary condition devolving on the sanitary authorities. Section 34 of the Contagious Diseases (Animals) Act is repealed, and its provisions embodied in the Public Health (London) A.ct. The interpretation of the word "dairy" is made to include any farm, farmhouse, cowshed, milk-store, milkshop, or other place from which milk is supplied, or in which milk is kept for the purposes of sale. The Council is required to make by-laws with respect to water-closets, earth-closets, privies, ashpits, cesspools, and receptacles for dung, and the proper accessories thereof in connection with buildings, whether constructed before or after the passing of the Act. Every sanitary authority is required to make by-laws with respect to the keeping of water-closets supplied with sufficient water for their effective action. The sanitary authorities are to require sufficient sanitary conveniences in every factory, workshop, and work place, whether erected before or after the passing of the Act. The powers of sanitary authorities in respect to the examination of water-closets are made to extend to ashpits, and are amended so as to require that the works shall comply with their own by-laws and those of the Council. The Act provides for a penalty to be imposed on any person injuring or improperly fouling any sanitary convenience used in common by the occupiers of two or more separate houses or by other persons; and when any such convenience or the approaches thereto, or the walls, floors, seats or fittings thereof are a nuisance or annoyance to any inhabitant of the district for want of proper cleansing, any person having the use thereof in common who is in default, or in the absence of knowledge as to who is in default, each of the persons having such use thereof is liable to penalty. For the purpose of the provision of public lavatories and ashpits and public sanitary conveniences by a sanitary authority, the subsoil of any road, exclusive of the footway adjoining any building or the curtilage of a building, is vested in the sanitary authority. The sanitary authorities are empowered to make regulations with respect to the management of public lavatories and ashpits and public sanitary conveniences, to let the same for any term not exceeding three years, and to charge fees for the use of any public lavatories or water-closets. The power of medical officers of health and sanitary inspectors to seize unsound food is extended to any such article, whether solid or liquid, intended for the food of man, and sold or exposed for sale or deposited in any place for the purpose of sale or of preparation for sale. A justice is also enabled to condemn any article liable to be seized by the officers. Opportunity is given to butchers and others to procure the removal, by the sanitary authority, as trade refuse, of any article in his possession which has become unfit for food. When a person is twice convicted within 12 months of having knowingly and wilfully sold or exposed for sale any unsound food, the magistrate may order that a notice of the facts be affixed to his premises for a period not exceeding 21 days. No newly erected house and no house which is pulled down to or below the ground floor and rebuilt is to be occupied until the sanitary authority have certified that it has a proper and sufficient water supply. A water company cutting off the water supply to any house is required within 24 hours to give notice to the sanitary authority. The sanitary authorities are required to make by-laws for securing the cleanliness and freedom from pollution of tanks, cisterns, and other receptacles used for storing of water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man. The provisions as to notification of cases of infectious disease are extended so as to require the notification of cases occurring in all hospitals other than those belonging to the Metropolitan Asylums Board, except in cases where the illness has been previously notified. The notification certificate is to contain particulars as to the sex and age of the patient, and whether the case occurs in the private practice of 45 the certifying practitioner or in his practice as a medical officer of any public body or institution. When the certificate refers to the inmate of a hospital it must specify the place from which and the date at which the inmate was brought to the hospital. The Metropolitan Asylums Board is required to send weekly to every medical officer of health, as well as to the County Council, returns of the infectious diseases of which they receive certificates. The medical officer of health is required to send a copy of the certificate to the head teacher of any school attended by the patient if a child, or by any child who is an inmate of the same house as the patient. The provision of disinfecting apparatus and carriages for the removal of infected articles by sanitary authorities is obligatory, and sanitary authorities may combine for this purpose. The use of public conveyances for the removal of persons suffering from dangerous infectious disease is prohibited. A person who knows himself to be suffering from a dangerous infectious disease is prohibited from milking any animal, from picking fruit, or from engaging in any occupation connected with food, or carrying on any trade or business in such a manner as to be likely to spread the infectious disease. The power to recover the costs of persons suffering from infectious disease in the hospitals of the Metropolitan Asylums Board is repealed. The same power possessed by sanitary authorities for extending in their own districts the provisions relating to infectious diseases to other diseases than those mentioned in the Act is, for the purposes of extending such diseases over London as a whole, vested in the Council. The provision of mortuaries by sanitary authorities is made obligatory, and the Council is empowered to require the provision by such authorities of buildings for post-mortem examinations. Such building may be provided in connection with a mortuary, and sanitary authorities may combine for the purpose of providing mortuaries and buildings for post-mortem examinations. The Council is required to provide proper accommodation for the holding of inquests, and is empowered to agree with sanitary authorities to maintain places for inquests in connection with mortuaries. The making and enforcing of by-laws for houses let in lodgings is made obligatory on sanitary authorities. The law as to underground rooms is amended, the standard of requirement being increased. The Council is given powers of supersession of any sanitary authority making default with respect to the removal of any nuisance, the institution of any proceedings, or the enforcement of any by-law. The Council may make representation to the Local Government Board if any sanitary authority have made default in executing or enforcing any provisions which it is their duty to execute or enforce of this Act, or of any by-law made under or in pursuance thereof, and the Local Government Board if satisfied after due inquiry that the authority have been guilty of the alleged default and that the complaint cannot be remedied under the other provisions of this Act, shall make an order limiting a time for the performance of the duty of such authority in the matter of such complaint. If such duty is not performed by the time limited in the order, the order may be enforced by writ of Mandamus, or the Local Government Board may (except in the case of the Commissioners of Sewers) appoint the County Council to perform such duty at the cost of the sanitary authority. Every sanitary authority is required to appoint one or more medical officers of health and an adequate number of sanitary inspectors, and the Council is required to pay a moiety of the salaries of such medical officers and inspectors appointed or re-appointed after the passing of the Act. Where the Local Government Board on a representation from the Council, and after local inquiry, are satisfied that any sanitary authority have failed to appoint a sufficient number of sanitary inspectors the Board may order the anthority to appoint such number of additional sanitary inspectors and to allow them such remuneration as the order directs, and the sanitary authority shall comply with the order. Evidence of previous experience during three years in a district of London, or an urban district out of London containing at the last census not less than 20,000 inhabitants, or the possession of a certificate of a body approved by the Local Government Board, is required in the case of every sanitary inspector appointed after the 1st of January, 1895. The sanitary authorities are defined as the Commissioners of Sewers, the vestries and district boards, the Local Board of Woolwich, and in any place mentioned in schedule (c) to the Metropolis Management Act, 1855, the board of guardians for such place or for any parish or poor law union of which it forms part, or if there is no such board of guardians the overseers of the poor of such place, or for the said parish in which it is situate, and the guardians and overseers respectively shall have the same powers for the purposes of this Act as a vestry or district board have under this Act, and their expenses shall be defrayed in the same manner as the expenses of the execution of the Acts relating to the relief of the poor are defrayed in the said place. Shirley F. Murphy, Medical Officer of Health.