ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. 1893. (Ordered by the Council to be printed.) Sold by Edward Stanford, 26 and 27, Cockspur Sired, Charing-cruaa, S. W. No. 241—Price 2s. 10-/. [3374 London County Council ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. 1893. (Ordered by the Council to be printed.) JAS. TRUSCOTT AND SON, PRINTERS, SUFFOLK LANE, CANNON STREET, E.C. TABLE OF CONTENTS. Statistics— pagb Population 3 Marriages 3 Births 4 Deaths 6 Life Table, 1881-90 9 Infant mortality 14 Deaths from several classes of disease 14 Principal zymotic diseases 15 Smallpox and vaccination 16 Measles 22 Scarlet fever 24 Diphtheria 27 Whooping cough 31 Typhus fever 33 Enteric fever 34 Diarrhœa 36 Cholera 37 Erysipelas 41 Puerperal fever 42 Influenza, bronchitis and pneumonia 43 Phthisis 43 Cancer 44 Meteorology 44 A dministration— Dairies, cowsheds and milkshops 44 Offensive trades 44 Nuisances 46 Smoke nuisance 46 Regent's and Grand Junction canals 47 Housing of the working classes 49 Houses let in lodgings 52 Common lodging houses 52 Underground rooms 52 Workshops 52 Bakehouses 55 Disinfection and destruction of infected articles 56 Mortuaries 59 Hospital provision for infectious disease 60 Medical officers of health 60 Sanitary inspectors 60 By-laws 61 Special inquiries 61 The destruction of refuse 63 Food 63 Water supply 64 Regulations as to water fittings 66 Legislation 67 Pollution of the Lea 67 Appendices LIST OF DIAGRAMS. to face page Diagram I.—Marriages, 1851-93 4 II.—Births, 1851-93 4 „ III.—Deaths, 1841-93 6 „ IV.—Smallpox, 1841-93 16 Y.—Measles, 1841-93 22 VI.—Scarlet fever, 1859-93 24 „ VII.—Scarlet fever: admissions to and deaths in hospitals of Metropolitan Asylums Board, per cent. of total cases and deaths in London 24 „ VIII.—Scarlet fever, 1892 25 „ IX.—Scarlet fever at various age-periods, 1893 25 „ X.—Diphtheria and croup, 1859-93 28 „ XI.—Diphtheria : admissions to and deaths in hospitals of Metropolitan Asylums Board, per cent. of total cases and deaths in London 28 „ XII.—Diphtheria, 1892 28 „ XIII.—Diphtheria at various age-periods, 1893 28 „ XIV.—Whooping cough, 1841-93 32 „ XV.—Typhus fever, 1869-93 32 „ XVI.—Enteric fever, 1869-93 36 „ XVII.—Diarrhœa in relation to mean temperature (summer quarter), 1841-93 36 Administrative County of London REPORT OF THE MEDICAL OFFICER OF HEALTH 1893. In presenting a report for the year 1898, it is necessary to point out that the time at which an annual report on the health of London can be prepared is dependent on the date at which the reports of the medical officers of health of the several sanitary districts are received by the Council. Some of these reports have been received as early as March, 1894, but others again not till the latter part or close of that year. It may be hoped that the earlier receipt of the reports relating to the latter districts will in future years enable a report for the total area of London to be presented to the Council with less delay. STATISTICS. Population. The population of the Administrative County of London, estimated to the middle of 1893, was 4,327,196, the estimate being in the main based on the assumption that the rate of increase between the censas years 1881 and 1891 has been since maintained. The estimated population of each of the forty-one sanitary districts comprised in the administrative county is shown in the following table— Estimated population. 1893. Estimated population. 1893. Estimated population, 1893. Paddington 120,421 St. Giles 38,641 St. Saviour, Southwark 26,854 Kensington 167,029 St. Martin-in-the-Fields 14,034 St. George, Southwark 59,953 Hammersmith 103,044 Strand 23,788 Newington 117,672 Fulham 104,735 Holborn 32,690 St. Olave, Southwark 12,903 Chelsea 98,182 Clerkenwell 65,589 Bermondsey 84,246 St. George, Hanoversquare 76,043 St. Luke 41,577 Rotherhithe 40,020 City of London 35,870 Lambeth 280,284 Westminster 54,829 Shoreditch 123,440 Battersea 158,105 St. James, Westminster 24,000 Bethnal-green 129,620 Wandsworth 172,143 Marylebone 139,726 Whitechapel 75,178 Camberwell 245,143 Hampstead 73,380 St. George-in-the-East 45,493 Greenwich 171,120 St. Pancras 233,936 Limehouse 57,115 Lewisham 98,258 Islington 327,919 Mile-end Old-town 108,041 Woolwich 41,854 Hackney 240,584 Poplar ... 169,141 Plumstead 94,596 Marriages. There were 37,016 marriages in the Registration County of London giving an annual marriage rate of 172 per 1,000 living, the mean marriage rate of the preceding ten years having been 17.4. The marriage rate since 1870 has been as follows— 1871 19.5 1877 18.7 1888 18.1 1889 17.1 1872 19.9 1878 18.5 1884 17.9 1890 17.6 1873 19.8 1879 18.0 1885 17.4 1891 17.7 1874 19.4 1880 18.1 1886 17.2 1892 17.4 1875 19.6 1881 18.1 1887 16.9 1893 17.2 1876 19.2 1882 18.4 1888 16.9 The accompanying diagram (I.) shows the London marriage rate in each year since 1850 in relation to the mean of the period, 1851-93. In 1893, 4'7 per cent. of the men and 16.8 per cent, of the women married were under 21 years of age. The proportions in preceding periods are shown in the following table ; the proportions in England are also given for the purpose of comparison. Marriages of minors per cent. of total marriages. London. England. Men. Women. Men. Women. 1851-60 2.77 11.95 5.70 17.99 1861-70 3.56 14.56 6.82 20.37 1871-80 4.71 16.90 7.96 22.03 1881-90 5.53 18.91 6.81 20.75 1891 4.86 17.45 5.90 19.01 1892 5.15 17.67 5.87 18.76 While, therefore, in every 100 marriages, both in London and England, there had been antecedent to 1881-90 an increase in the proportion of male and female minors married, in 1881-90 this proportion had in London continued to increase, but in England had decreased. The results of the 4 last three years 1891-3, however, show a decrease in the proportion of marriages of minors in London: thus in this period in London the marriages of male minors constituted 4.92 per cent., and of female minors 17.30 per cent. of the total marriages. Until the year 1885 the reports of the Registrar-General showed the numbers of marriages of minors in each of the registration districts of London. The following table has been prepared with a view to the continuance of this information— Marriages of Minors in London, 1885-92. Registration Divisions and Counties. 1885. 1886. 1887. 1888. 1889. 1890. 1891. 1892. 1893. Men. Women Men. Women. Men. Women. Men. Women. Men. Women. Men. Women. Men. Women. Men. Women. Men. Women. I.—LONDON. Middlesex (part of). Paddington 23 113 31 129 32 125 31 111 34 117 31 116 31 116 32 117 26 96 Kensington 60 203 68 224 67 219 49 200 62 209 58 198 44 194 71 200 60 187 Fulham 50 221 66 207 70 221 79 245 61 231 89 226 73 232 67 267 77 238 Chelsea 31 119 38 123 42 122 39 115 38 122 51 165 33 122 40 135 46 149 St. George, Hanover-square 25 136 30 151 28 158 29 152 22 109 21 136 26 114 25 124 17 117 Westminster 19 73 14 68 15 82 18 77 6 49 15 63 14 73 13 65 15 60 Marylebone 76 237 54 211 49 200 66 199 61 202 64 213 63 213 52 172 49 182 Hampstead 10 30 7 37 9 37 15 30 4 26 7 48 7 40 14 48 11 39 Pancras 93 325 94 329 105 365 94 365 79 326 87 332 97 337 94 356 97 349 Islington 104 397 95 379 92 342 109 406 114 402 91 362 104 407 122 448 88 357 Hackney 58 248 51 223 43 255 38 232 74 261 51 249 60 269 71 275 50 257 St. Giles 15 50 10 54 8 49 9 47 18 58 13 54 9 43 12 48 13 39 Strand 15 65 16 59 14 59 9 44 9 54 17 51 7 49 10 49 23 59 Holborn 66 218 66 207 82 229 63 222 79 227 100 296 79 246 84 274 88 268 London City 37 141 43 171 26 123 17 140 23 140 13 144 11 65 9 87 9 63 Shoreditch 49 231 60 226 56 187 65 213 67 203 69 233 79 261 72 243 85 242 Bethnal-green 415 928 343 824 337 884 240 699 185 650 180 569 190 517 164 430 141 388 Whitechapel 28 89 28 104 26 90 35 129 27 97 25 86 46 124 23 101 22 82 St. George - in - the East 14 51 25 69 18 69 22 66 22 66 25 83 14 57 16 56 15 39 Stepney 30 92 33 81 28 88 18 77 31 92 33 110 31 84 36 102 20 84 Mile-end Old-town 78 301 79 272 77 291 72 268 103 288 93 315 71 332 95 318 93 336 Poplar 54 242 54 244 46 214 45 228 55 213 69 280 70 280 88 268 60 246 Surrey (part of) St. Saviour, Southwark 320 924 331 852 317 890 331 950 315 905 363 946 313 907 339 947 310 898 St. Olave, Southwark 29 114 46 114 40 139 28 116 36 118 35 155 28 130 23 124 35 143 Lambeth 117 390 104 400 90 346 77 320 68 300 76 302 73 291 79 318 75 317 Wandsworth 72 268 77 282 99 299 93 300 97 340 92 352 87 336 99 363 100 371 Camberwell 41 164 45 195 40 194 32 203 53 238 49 237 54 258 49 201 54 226 Kent (part of) Greenwich 56 171 44 175 40 177 42 173 56 176 44 171 54 197 55 176 39 157 Lewisham (excluding Penge) 14 56 18 66 19 67 11 58 13 49 12 70 15 65 17 69 14 64 Woolwich 44 185 43 180 50 169 42 188 40 168 38 171 31 156 45 190 26 164 London 2,043 6.782 2,013 6,656 1,965 6,690 1.818 6,573 1,852 6,436 1,911 6,733 1,814 6,515 1,916 6,571 1,758 6,217 Births. During 1893, 133,417 births were registered in the Administrative County, giving a birth rate of 30.9 per 1,000 living. This birth rate is identical with that of the year 1892. Since 1870 the birth rate in each year has been as follows— 1871 34.5 1877 35.6 1883 34.5 1889 31.9 1872 35.6 1878 35.5 1884 34.3 1890 30.7 1873 35.3 1879 35.5 1885 33.4 1891 31.9 1874 35.6 1880 35.3 1886 33.4 1892 30.9 1875 35.4 1881 34.7 1887 32.9 1893 30.9 1876 35.9 1882 34.5 1888 32.1 The birth rate of England and Wales has in these years fallen in much the same degree, and since the year 1878 has been somewhat less than that of London. Thus in 1891 the birth rate of England and Wales was 31.4, in 1892, 30.5, and in 1893, 30.8. The accompanying diagram (II.) shows the London birth rate in each year in relation to the mean of the period 1851-93. Diagram II. Births. 5 The birth rate in 1893 in each of the London sanitary districts was as follows— Births. Birth rate per 1,000. Births. Birth rate per 1,000. Paddington 3,010 25.1 Bethnal-green 4,756 36.8 Kensington 3,671 22.0 Whitechapel 3,096 41.3 Hammersmith 2,966 28.9 St. George-in-the-East 1,966 43.3 Fulham 3,711 35.5 Limehouse 1,953 34.3 Chelsea 2,854 29.2 Mile-end Old-town 4,146 38.5 St. George, Hanover-square 1,496 19.7 Poplar 5,918 35.1 Westminster 1,358 24.8 St. Saviour, Southwark 780 29.1 St. James 528 22.1 St. George, Southwark 2,169 36.3 Marylebone 4,379 31.4 Newington 4,345 37.0 Hampstead 1,507 20.6 St. Olave 412 32.0 Pancras 7,044 30.2 Bermondsey 3,202 38.1 Islington 9,750 29.8 Rotherhithe 1,379 34.6 Hackney 6,911 28.8 Lambeth 9,222 33.0 St. Giles 1,094 28.4 Battersea 5,225 33.1 St. Martin-in-the-Fields 223 15.9 Wandsworth 4,569 26.6 Strand 594 25.0 Camberwell 7,472 30.6 Holborn 864 26.5 Greenwich 5,377 31.5 Clerkenwell 2,106 32.2 Lewisham 2,471 25.2 St. Luke 1,770 42.7 Woolwich 1,302 31.2 London, City of 627 17.5 Plumstead 2,744 29.1 Shoreditch 4,450 36.2 London 133417 30.9 The number of illegitimate births in London in 1893 constituted 3*7 per cent., and in England and Wales 4.2 per cent. of the total births. In each of the decennia 1871-80 and 1881-90 illegitimate births constituted 3.87 per cent. of the total births in London. For the purpose of more exact comparison between one and another district, the births should, in view of the different age and sex distribution of populations, be considered in relation to the number of women at the child-bearing age. For practical purposes this may be reckoned as including the ages 15-45 years, the number of children born of women above this age being comparatively few. It is desirable also to separate the legitimate and illegitimate births, and to consider the relation of these to the number of women living and not living in wedlock respectively. The data available enable such comparisons to be made for registration districts only, and for this purpose the following table has been prepared— Table showing the number of legitimate births per 1,000 women living in wedlock from 15-45 years of age, and the number of illegitimate births per 1,000 women of this age not living in wedlock. Registration District. Estimated number of females living in wedlock aged 15-45, middle of 1893. Total births 1893 (legitimate). Number of legitimate births per 1,000 females living in wedlock aged 15-45, 1893. Estimated number of females not living in wedlock aged 15-45, middle of 1893. Total births, 1893 (illegitimate). Number of illegitimate births per 1,000 females not living in wedlock aged 15-45, 1893. London 517,570 128.149 248 618-385 4,913 7.9 Paddington 13,068 2,888 221 26,869 126 4.7 Kensington 16,890 3,479 206 42,247 188 4.5 Fulham 26,990 6,370 236 28,175 311 11.0 Chelsea 11,825 2,722 230 14,681 132 9.0 St. George, Hanover-square 13,949 2,723 195 27,254 124 4.5 Westminster 3,887 807 208 6,189 46 7.4 Marylebone 15,557 3,624 233 28,097 746 26.6 Hampstead 7,224 1,465 203 19,474 42 2.2 St. Pancras 29,307 6,727 229 31,127 314 10.1 Islington 40,209 9,487 236 46,242 267 5.8 Hackney 27,731 6,700 241 37,526 210 5.6 St. Giles 4,450 1,021 229 6,481 80 12.3 Strand 2,669 471 176 4,788 21 4.4 Holborn 17,715 4,715 266 16,519 53 3.2 London City 3,080 612 199 6,406 18 2.8 Shoreditch 16,140 4,314 267 13,138 146 11.1 Bethnal-green 16,390 4,680 285 13,586 75 5.5 Whitechapel 9,141 3,039 332 8,303 70 8.4 St. George-in-the-East 6,022 1,906 316 4,335 59 13.6 Stepney 7,073 1,931 273 5,692 24 4.2 Mile-end Old-town 13,722 4,074 297 11,942 82 6.9 Poplar 21,111 5,769 273 15,965 149 9.3 St. Saviour, Southwark 27,102 7,079 261 20,828 210 10.1 St. Olave, Southwark 17,149 4,907 286 13,432 81 6.0 Lambeth 34,369 8,746 254 38,455 477 12.4 Wandsworth 40,033 9,484 237 47,625 322 6.8 Camberwell 29,147 7,249 249 32,165 227 7.1 Greenwich 20,833 5,216 250 20,171 165 8.2 Lewisham 10,497 2,409 229 19,661 75 3.8 Woolwich 14,290 3,535 247 11,002 73 6.6 * Lying-in hospitals are situated in these districts. 6 Deaths. In 1893, 90,364 deaths were registered in the administrative County of London, giving a death rate of 20.9 †per 1,000 of population. Since the year 1870 the London death rate has been as follows— 1871 24.6 1877 21.6 1883 20.8 1889 18.4 1872 21.5 1878 23.1 1884 20.9 1890 21.4 1873 22.4 1879 22.6 1885 20.4 1891 21.0† 1874 22.4 1880 21.7 1886 20.6 1892 20.3† 1875 23.6 1881 21.3 1887 20.3 1893 20.9† 1876 21.9 1882 21.5 1888 19.3 The death rate, therefore, which had with slight exception been falling-from 1882 to 1889, has during subsequent years shown a greater tendency to be maintained. The death rate of each year since 1810, in relation to the mean of the period 1841-93 is shown in the accompanying diagram (III.). The following table enables comparison to be made between the death rates of London and the towns of England having populations of more than 200,000 persons, during the year 1893 and the ten preceding years— Population estimated to the middle of 1893. Death rate per 1,000 living. Population estimated to the middle of 1893. Death rate per 1,000 living. 1883-92. 1893. 1883-92. 1893. London 4306411 20.4 21.3 West Ham 227,405 19.4 18.9 Manchester 515,598 26.5 24.9 Bristol 225,028 19.5 18.9 Liverpool 510,514 26.0 27.3 Bradford 221,611 20.3 21.0 Birmingham 487,891 20.9 22.0 Nottingham 220,551 20.7 18.5 Leeds 382,093 21.9 22.3 Hull 208,709 20.3 21.8 Sheflield 333,922 22.2 22.3 Salford 203,431 24.9 24.1 The London death rate, therefore, in 1893, has been higher than the mean death rate of the preceding ten years. The death rates of six of the other towns have shown an increase in 1893, and of five a decrease. Compared with the following ten foreign cities, London showed in 1893 a lower death rate than the majority, and in the period 1883-92 the lowest death rate, as will be seen by the following table— All Causes. Death rates per 1,000 persons living. 1883-92. 1893. 1883-92. 1893. London 20.4 21.3 St. Petersburg 30.1 30.6 Paris 23.7 21.8 Berlin 23.1 21.0 Brussels 21.9 19.8 Vienna 25.6 24.0 Amsterdam 23.3 18.6 Rome 25.2 22.3 Copenhagen 22.1 20.3 New York 25.8 23.9 Stockholm 21.6 19.2 In 1885 the Registrar-General began to distribute to the sanitary districts to which they belong the deaths from all causes and from certain zymotic diseases occurring in institutions, and death rates corrected in this sense can therefore be obtained for each of the years 1885-93. But for the purposes of a more precise statement it is necessary to have regard to the age and sex distribution of the several populations, and to correct each recorded death rate by the proper factor; the following table is thus obtained. * For the purposes of this table, London includes the Strand Union Workhouse, at Edmonton, the Holborn Union Workhouse, at Mitcham, the City of London Asylum at Stone, and the Metropolitan Asylums and Hospitals situated, outside Registration London; no correction in the death rate is, however, made by the exclusion of deaths of persons not belonging to London occurring in institution* situated within the Registration County. † These death rates are fully corrected for institutions, i.e., by the exclusion of deaths of persons not belonging to but occurring in institutions situated within London, and by the inclusion of deaths of persons belonging to but occurring in institutions situated outside London. Diagram III Deaths. 7 Recorded and Corrected Death Rates* per 1,000 persons living in Sanitary Districts of London in 1893. Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Recorded death rate, 1893. Corrected death rate, 1893. Comparative mortality figure, 1893 [London 1,000. ] England and Wales 19.15 - 19.2 19.2 - London 17.96 1.06626 20.9 22.3 1000 Battersea 17.80 1.07584 18.9 20.3 . 910 Bermondsey 18.10 1.05801 23.9 25.3 1,135 Bethnal-green 18.39 1.04133 25.2 26.2 1,175 Camberwell 18.10 1.05801 19.3 20.4 915 Chelsea 17.95 1.06685 20.0 21.3 955 Clerkenwell 17.28 1.10822 26.7 29.6 1,327 Fulham 18.27 1.04817 19.4 20.3 910 Greenwich 18.63 1.02791 20.6 21.2 951 Hackney 18.23 1.05047 18.9 19.9 892 Hammersmith 18.05 1.06094 18.2 19.3 865 Hampstead 16.63 1.15153 13.0 15.0 673 Holborn 17.62 1.08683 27.2 29.6 1,327 Islington 17.90 1.06983 19.6 21.0 942 Kensington 17.38 1.10184 17.7 19.5 874 Lambeth 18.24 1.04989 20.6 21.6 969 Lewisham 17.92 1.06864 14.7 15.7 704 Limehouse 17.59 1.08869 28.3 30.8 1,381 City of London 16.65 1.15015 23.6 27.1 1,215 Mile-end Old-town 18.58 1.03068 22.6 23.3 1,045 Newington 18.32 1.04531 24.3 25.4 1,139 Paddington 17.72 1.08070 17.8 19.2 861 Plumstead 18.51 1.03458 16.4 17.0 762 Poplar 18.49 1.03569 23.1 23.9 1,072 Rotherhithe 18.49 1.03569 23.2 24.0 1,076 St. George, Hanover-square 17.34 1.10438 16.2 17.9 803 St. George-in-the-East 18.43 1.03907 30.9 32.1 1,439 St. George, Southwark 17.35 1.10375 28.4 31.3 1,404 St. Giles 17.27 1.10886 24.0 26.6 1,193 St. James 17.16 1.11597 19.8 22.1 991 St. Luke 17.72 1.08070 30.9 33.4 1,498 St. Martin-in-the-Fields 15.74 1.21665 21.3 25.9 1,161 St. Marylebone 17.82 1.07464 22.9 24.6 1,103 St. Olave 18.42 1.03963 24.2 25.2 1,130 St. Pancras 17.89 1.07043 22.0 23.5 1,054 St. Saviour 18.29 1.04702 24.2 25.3 1,135 Shoreditch 18.45 1.03794 25.6 26.6 1,193 Strand 16.24 1.17919 30.1 35.5 1,592 Wandsworth 17.93 1.06804 15.2 16.2 726 Westminster 16.94 1.13046 23.6 26.7 1,197 Whitechapel 17.74 1.07948 25.6 27.6 1,238 Woolwich 16.99 1.12713 20.2 22.8 1,022 The "factors for correction" in the above table are calculated upon the age and sex distribution of the population actually resident in the district at the time when the last census was taken. This population did not include persons resident in poor law institutions belonging to the district, but situated beyond its limits. If such persons were included in the population the "factors for correction" would in some instances be slightly modified. Dr. Allan, the medical officer of health of the Strand District, has supplied me with the number of such persons belonging to that district. If these persons be included in the Strand population, it is then found that the standard death-rate is 17.12, the factor for correction 1.11857, the recorded death rate 29.2, and the corrected death-rate 32.7, the comparative mortality figure being 1,466. My last annual report supplied the death rates of the London population from all causes in the year 1892 and preceding years, and the present report gives similar information for the year 1893. But with a view to enable the vital conditions of London to be more clearly appreciated, I have included in this report a life table based on the statistics of the decennium 1881-90. These statistics do not, however, distinguish between the inhabitants of London who have been born within the county and those who, having been born elsewhere, have migrated to London ; the table therefore relates to a population of a mixed character living in London in the decennium 1881-90. This table has been worked on Dr. Farr's short method and affords a sufficient basis for comparison of London vital conditions in different periods. * All death rates in;this report relating to London sanitary districts are fully corrected for institutions (see footnote †, page 6). § For actuarial purposes, such as the calculation of life contingencies and annuities, it is essential that a life table should be constructed to show, out of a given number born, the number surviving at the beginning of each year of age, and the expectation of life at each ages, but for the purpose of comparing the health conditions of different communities or of a single community at different periods, it is sufficient to calculate the life table by a shorter method, such as has here been employed, showing the expectation of life, &c., at birth 8 The tabular matter has been prepared by Mr. G. H. Day, of the Public Health Department, and I am indebted to Mr. A. C. Waters, of the Kegistrar-General's office, for valuable aid in the preparation of the table as a whole. Table A shows the average death rates in London of each sex in groups of ages for the three decennia, 1861-70, 1871-80, 1881-90. In examining these rates the first noticeable point is that in every age group there has been a successive decrease of mortality—in other words, all the rates were lower in 1871-80 than they had been in 1861-70, and were still lower in 1881-90 than they had been in 1871-80. A closer examination of the figures shows that at ages below 15 years the amount of decrease (i.e., the difference between the rates in successive decennia) was less for both sexes in the period 1881-90 as compared with 1871-80 than it had been in 1871-80 as compared with 1861-70; while, excepting for males at ages 65 and upwards, all the age groups over 15 years showed a greater decrease in the second interval than in the first. Again, at ages below 10 the amount of decrease per cent, in 1881-90 as compared with 1871-80, was less than it had been in 1871-80 as compared with 1861-70, while at all other age groups, except males above 65, it was greater (see Table B). The fact that the mortality of children declined less quickly, while that of adults declined more quickly, in the second interval than in the first, requires careful investigation before it will be safe to hazard a conjecture as to its causes and its significance. If the rates of mortality in 1881-90 be directly compared with those in 1861-70, it will be seen that at ages 0-5 the death rates of both males and females have decreased by about one-sixth, at ages 5-10 by more than one-third, from 10-25 by nearly one-third, at 25-35 b^ about one-fifth, at 35-45 by one-eighth and one-ninth respectively, and at ages 45 and upwards by somewhat less than one-twelfth. The regularity of these decreases suggests some definite cause, or more probably a number of causes acting at different ages. The comparatively small decrease per cent, in infant mortality (under 5 years of age) and the comparatively large decrease per cent, in the immediately following 5— year period of life is especially noteworthy. This is a matter for future detailed examination of the causes of death which have been most affected by the decrease. Table A. Death rates in London per 1,000 living at different age-periods in the decennia 1861-70, 1871-80, and 1881-90. Age Period. Males. Females. 1861-70. 1871-80. 1881-90. 1861-70. 1871-80. 1881-90. Under 5 86.91 77.86 73.09 76.32 67.66 63.26 5— 9.37 7.42 5.93 8.85 6.73 5.82 10— 4.24 3.57 2.92 4.07 3.45 2.89 15— 5.82 5.05 4.05 5.10 4.36 3.58 20— 8.23 6.95 5.44 6.22 5.46 4.40 25— 10.86 10.13 8.65 8.80 8.04 6.82 35— 17.14 16.64 14.96 12.84 12.32 11.42 45— 25.68 25.37 23.87 18.52 18.08 17.23 55— 43.85 43.20 41.33 33.45 32.95 30.77 65— 82.83 80.08 77.97 67.23 66.63 63.38 75 and upwards 184.51 176.81 169.36 164.71 159.50 150.26 All ages 26.55 24.38 2210 22.34 2060 18.83 and at ages 5, 10, 15, 20, &c., neglecting the intermediate ages. A life table thus constructed would not be exactly comparable with a life table constructed on the more extended method, but would be perfectly comparable with other life tables constructed on a similar The following table from the supplement to the Thirty-fifth Annual Report of the Registrar-General will serve to give an approximate idea of the amount of error at each age period arising from the use of the short method of calculation as compared with the extended method— Age x Numbers born and surviving at each age lx Expectation of life Ex By English life table. (Extended method.) By short method. Excess by short method. By English life table. (Extended method.) By short method. Excess by short method. 0 511,745 511,745 - 39.91 40.00 .09 5 370,358 370,358 - 49.71 49.82 .11 10 353,031 353,707 676 47.05 47.05 - 15 344,290 344,681 391 43.18 43.21 — .03 25 319,442 317,480 —1,962 36.12 36.49 .37 35 288,850 287,297 —1,553 29.40 29.80 .40 45 253,708 252,703 —1,005 22.76 23.19 .43 55 209,539 210,000 461 16.45 16.89 .44 65 150,754 152,746 1,992 10.82 11.35 .53 75 75,777 78,228 2,451 6.49 7.39 .90 85 16,877 17,835 958 3.73 5.48 1.75 The above table is, of course, not capable of general application, but it may be safely assumed that except at ages 75 and upwards the error in the expectation of life by the use of the "short method" does not exceed the fraction of a year. 9 Table B. (a) Decrease of death rates between the decennia 1861-70, 1871-80 and 1881-90. Age Period. Amount of decrease between 1861-70 and 1871-80. Amount of decrease between 1871-80 and 1881-90. Amount of decrease between 1861-70 and 1881-90. Males. Females. Males. Females. Males. Females. Under 5 9.05 8.66 4.77 4.40 13.82 13.06 5— 1.95 2.12 1.49 .91 3.44 3.03 10— .67 .62 .65 .56 1.32 1.18 15— .77 .74 1.00 .78 1.77 1.52 20— 1.28 .76 1.51 1.06 2.79 1.82 25— .73 .76 1.48 1.22 2.21 1.98 35— .50 .52 1.68 .90 2.18 1.42 45— .31 .44 1.50 .85 1.81 1.29 55— .65 1.20 1.87 1.48 2.52 2.68 65— 2.75 .60 2.11 3.25 4.86 3.85 75 and upwards 7.70 5.21 7.45 9.24 15.15 14.45 (b) Percentage decrease of death rates between the decennia 1861-70, 1871-80 and 1881-90. Age Period. Decrease per cent. between 1861-70 and 1871-80. Decrease per cent. between 1871-80 and 1881-90. Decrease per cent. between 1861-70 and 1881-90. Males. Females. Males. Females. Males. Females. Under 5 10.4 11.3 6.1 6.5 15.9 17.1 5— 20.8 24.0 20.1 13.5 36.7 34.2 10— 15.8 15.2 18.2 16.2 31.1 29.0 15— 13.2 14.5 19.8 17.9 30.4 29.8 20— 15.6 12.2 21.7 19.4 33.9 29.3 25— 6.7 8.6 14.6 15.2 20.3 22.5 35— 2.9 4.0 10.1 7.3 12.7 11.1 45— 1.2 2.4 5.9 4.7 7.0 7.0 55— 1.5 3.6 4.3 4.6 5.7 8.0 65— 3.3 .9 2.6 4.9 5.9 5.7 75 and upwards 4.2 3.2 4.2 5.8 8.2 8.8 In the Registrar General's supplementary report for the decennium 1861-70, a life table for London was published, calculated by Dr. Farr's "short method." In order to show in its clearest form the effect of the decreased mortality on the longevity of the population, a similar table has been constructed for the period 1881-90. As the same method has been used, the results are strictly comparable. The new table is given in two parts (Tables C and D). In Table C the survivors (lx) of 1,000,000 born of each sex are traced through life at each separate year up to 5 years of age, then at quinquennial intervals up to 25, and at decennial intervals up to 85, the mean probability (px) of living one year in each age-period, and the deaths (dx) occurring in each age-period, out of the survivors at the beginning of the period, being shown in separate columns. In Table D the survivors of 509,078 males and 490,922 females born (these being the proportions of the two sexes in a million children born in London in 1881-90) are similarly shown, and to these figures are added the future years of life (Q,,) which will be lived by the lx survivors at each age in the table, and the expectation of life (Ex), or the average future life time at each age. Table C. Life table for London, 1881-90.—Of 1,000,000 of each sex born, the number surviving at several ages, and the deaths in each interval of age; also the mean probability of living a year in each age interval— Age. Males. Females. N umbers born, and purviving at age x. Deaths in interval following age x. Mean probability of living one yearin the interva following age x. Numbers born, and surviving at age x. Deaths in interval following age x. Mean probability of living one year in t he interval following age x. X lx dx Px lx dx Px 0 1,000,000 163,922 .83608 1,000,000 138,281 •86172 1 836,078 62,764 .92493 861,719 60,148 •93020 2 773,314 24,413 .96843 801,571 24,912 •96892 3 748,901 15,316 .97955 776,659 15,611 •97990 4 733,585 10,586 .98557 761,048 10,656 •98600 5 722,999 21,114 .99409 750,392 21,510 •99420 10 701,885 10,187 .99708 728,882 10,471 •99711 15 691,698 13,861 .99596 718,411 12,733 •99643 20 677,837 18,203 .99457 705,678 15,354 •99561 25 659,634 54,644 .99139 690,324 45,531 •99320 35 604,990 84,070 .98515 644,793 69,616 •98864 45 520,920 110,627 .97641 575,177 91,023 •98292 55 410,293 138,906 .95951 484,154 128,230 •96970 65 271,387 146,988 .92496 355,924 167,114 •93857 75 124,399 98,322 .85535 188,810 139,609 •87417 85 26,077 26,077 .74092 49,201 49,201 •76618 [2] 10 Table D. Life table for London, 1881-90.—Of 1,000,000 children born, the numbers of each sex born and surviving at several ages, also the years of life lived after each age in the table, and the expectation of life at each age. Age. Males. Females. Persons. Numbers born, and surviving at each age. Years of life lived at age x and upwards. Expectation of life. Numbers born, and surviving at each. age. Years of life lived at age x and upwards. Expectation of life. Numbers born, and surviving at each age.* Years of life lived at age x and upwards. Expectation of life. X lx Qx Ex lx Qx Ex lx Qx Ex 0 509,078 20,698,543 40.66 490,922 22,046,991 44.91 1,000,000 42,745,534 42.75 1 425,629 20,231,190 47.53 423,037 21,590,012 51.04 848,666 41,821,202 49.28 2 393,677 19,821,537 50.35 393,509 21,181,739- 53.83 787,186 41,003,276 52.09 3 381,249 19,434,074 50.97 381,279 20,794,345 54.54 762,528 40,228,419 52.76 4 373,452 19,056,723 51.03 373,615 20,416,898 54.65 747,067 39,473,621 52.84 5 368,063 18,685,966 50.77 368,384 20,045,898 54.42 736,447 38,731,864 52.59 10 357,314 16,872,523 47.22 357,824 18,230,378 50.95 715,138 35,102,901 49.09 15 352,128 15,098,918 42.38 352,684 16,454,108 46.65 704,812 31,553,026 44.77 20 345,072 13,355,918 38.70 346,433 14,706,315 42.45 691,505 28,062,233 40.58 25 335,805 11,653,725 34.70 338,895 12,992,995 38.34 674,700 24,646,720 36.53 35 307,987 8,434,765 27.39 316,543 9,715,805 30.69 624,530 18,150,570 29.06 45 265,189 5,568,885 21.00 282,'367 6,721,255 23.80 547,556 12,290,140 22.45 55 208,871 3,198,585 15.31 237,682 4,121,010 17.34 446,553 7.319,595 16.39 65 138,157 1,463,445 10.59 174,731 2,058,945 11.78 3] 2,888 3,522,390 11.26 75 63,329 456,015 7.20 92,691 721,835 7.79 156,020 1,177,850 7.55 85 13,275 72,995 5.50 24,154 137,610 5.70 37,429 210,605 5.63 In Table E the life table based on the mortality of 1881-90 is compared with that based on the mortality of 1861-70. It is surprising to find that while in 1861-70, of a million children born, 305,518 deaths occurred in the first 5 years of life, leaving only 694,482 survivors at age 5; in 1881-90 scarcely more deaths occurred in the first 20 years of life, the deaths in the 20 years being only 309,495 per million born, and the survivors at age 20 as many as 691,505. Looked at in a slightly different way the figures show that of 1,000 children born, 61 more reached maturity in the second period than in the first; and that through the whole of the working period of life an excess generally greater than this amount was kept up. At age 65 the earlier table shows 260 survivors, and the later table 313 survivors per 1,000 born. It is true the excess has dropped to 53, but this is a larger proportional excess than at any earlier age, amounting to no less than 20 per cent.; indeed, the proportional excess steadily increases at each successive age period. Table E. Comparison of number of survivors, out of 1,000,000 persons born alive, at twelve ages, according to the rates of mortality prevailing in London in the decennia 1861-70 and 1881-90 respectively— 1. 2. 3. 4. Age. London, 1861-70. London, 1881-90. Excess in 1881-90, as compared with 1861-70. x lx lx 0 1,000,000 1,000,000 5 694,482 736,447 41,965 10 663,560 715,138 51,578 15 649,918 704,812 54,894 20 630,550 691,505 60,955 25 606,482 674,700 68,218 35 549,759 624,530 74,771 45 473,493 547,556 74,063 55 380,348 446,553 66,205 65 259,732 312,888 53,156 75 124,171 156,020 31,849 85 26,289 37,429 11,140 The life table for London in 1861—70 does not show the expectation of life at the various ages; but as these are important for purposes of comparison they have now been computed for ages 5 and upwards (Table F). The materials in the decennial supplement referred to are insufficient to calculate with sufficient accuracy the years of life lived between birth and age 5, according to the life table. 11 Table F. London.—Comparison of expectations of life, at ages from 5 upwards, in 1861-70 and in 1881-90. Age. Males. Females. Ex Percentage increase in 1881-90. Ex Percentage increase in 1881-90. 1861-70. 1881-90. 1861-70. 1881-90. 5 47.49 50.77 6.91 50.87 54.42 6.98 10 44.64 47.22 5.78 48.06 50.95 6.01 15 40.55 42.88 5.75 43.99 46.65 6.05 20 36.67 38.70 5.54 40.32 42.45 5.28 25 33.11 34.70 4.80 36.73 38.34 4.38 35 26.33 27.39 4.03 29.65 30.69 3.51 45 20.32 21.00 3.35 23.03 23.80 3.34 55 14.80 15.31 3.45 16.70 17.34 3.83 65 10.20 10.59 3.82 11.34 11.78 3.88 75 6.91 7.20 4.20 7.43 7.79 4.85 85 5.39 5.50 2.04 5.53 5.70 3.07 Table F shows that the expectation of life of males at age 5 has improved from 47.49 years to 50.77 years, and that of females at the same age from 50.87 years to 54.42 years, a gain of 3.28 years for males and 3.55 years for females, each expectation having improved by about 7 per cent. This means that every 14 children aged 5 in 1881-90 had expectation of as much future lifetime as 15 children of the same age had in 1861-70. At subsequent ages there is in all cases an improvement, though relatively less than at age 5, showing that the greater part of the gain is in the periods of youth and early maturity.* As far as they go the decreased mortality and the consequent improvement in expectation of life are matters for congratulation, but we have not yet compared the mortality and vitality of the inhabitants of London with those of other places. The latest existing life table for the whole of England and Wales relates to the period 1871-80, and we must await the publication of the Registrar General's forthcoming decennial supplement before we can compare the results for London in 1881-90 with those for the whole country in the same period. A comparison of the present London table with that for England and Wales in 1871-80 (Table G) is somewhat favourable to London as regards females, and on the whole unfavourable as regards males ; but it must not be overlooked that the mortality in the whole country was considerably less in 1881-90 than it had been in 1871-80, and it may therefore be expected that the new table for England and Wales will show the expectations of life of both sexes in London to be less than those in the country as a whole. Table G. Comparison of the expectation of life at certain ages, calculated from the rate of mortality prevailing (a) in London during the ten years 1881-1890; and (b) in England and Wales during the ten years 1871-1880. Age. Males. Females. London, 1881-9O. Ex England, 1871-80 Ex London, 1881-90, compared with England, 1871-80. London, 1881-90. Ex England, 1871-80. Ex n, 1881-90, compared with England, 1871-80. 0 40.66 41.35 — 0.69 44.91 44.62 + 0.29 1 47.53 48.05 — 0.52 51.04 50.14 + 0.90 2 50.35 50.14 + 0.21 53.83 52.22 + 1.61 3 50.97 50.86 + 0.11 54.54 52.99 + 1.55 4 51.03 51.01 + 0.02 54.65 53.20 + 1.45 5 50.77 50.87 — 0.10 54.42 53.08 + 1.34 10 47.22 47.60 — 0.38 50.95 49.76 + 1.19 15 42.88 43.41 — 0.53 46.65 45.63 + 1.02 20 38.70 39.40 — 0.70 42.45 41.66 + 0.79 25 34.70 35.68 — 0.98 38.34 37.98 + 0.36 35 27.39 28.64 — 1.25 30.69 30.90 — 0.21 45 21.00 22.07 — 1.07 23.80 24.06 — 0.26 55 15.31 15.95 — 0.64 17.34 17.33 + 0.01 65 10.59 10.55 + 0.04 11.78 11.42 + 0.36 A comparison of the death rates in London and in England and Wales in 1881-90 is favourable to London for males between 10 and 25 years of age and for females between 10 and 35 years of age, and for both sexes over 85 years, but unfavourable at all other ages, as may be seen from Table H. The low mortality of males at ages 10 to 25, and of females at ages 10 to 35 in London is doubtless in great measure attributable to immigration from the rural districts. * In connection with the question of how much of this gain may be due to the introduction into London of healthy lives by immigration of persons born out of London, it is interesting to observe that in 1871 36.0 per cent. of the males and 37.6 of the females in the London population were born out of London, while in 1891 the numbers were respectively 33.5 and 35.3 per cent. 12 Table H. Comparison of mortality at certain age periods in London 1881-90 with mortality in England and Wales 1881-90. Age period. London 1881-90. England and Wales 1881-90. London mortality 1881-90. (England and Wales mortality taken as 1,000.) Males. Females. Males. Females. Males. Females. 0— .07309 .06326 .06159 .05195 1,187 1,218 5— .00593 .00582 .00535 .00527 1,108 1,104 10— .00292 .00289 .00296 .00311 986 929 15— .00405 .00358 .00433 .00442 935 810 20— .00544 .00440 .00573 .00554 949 794 25— .00865 .00682 .00778 .00741 1,112 920 35— .01496 .01142 .01241 .01061 1,205 1,076 45— .02387 .01723 .01936 .01509 1,233 1,142 55— .04133 .03077 .03469 .02845 1,191 1,082 65— .07797 .06338 .07039 .06036 1,108 1,050 75— .15593 .13428 .14664 .13062 1,063 1,028 85— .29763 .26477 .30581 .27082 973 978 Extended life tables, relating to the period 1881-90 have, however, been published by the medical officers of Brighton, Manchester and Glasgow, and these tables form a more satisfactory basis of comparison than the English life table 1871-80, although the reservations as to differences in method (see footnote, § page 7) should here be borne in mind. Table I. Expectation of life (Ex ) at various ages and for each sex in London, Brighton, Manchester and Glasgow, 1881-90. Age. X. Males. E X Females. E X London. Brighton. Manchester. Glasgow. London. Brighton. Manchester. Glasgow. 0 40.66 43.59 34.71 35.18 44.91 49.00 38.44 37.70 5 50.77 52.87 45.59 46.97 54.42 56.92 48.06 48.27 10 47.22 49.12 42.75 44.32 50.95 53.15 45.43 45.44 15 42.88 44.67 38.78 40.51 46.65 49.07 41.50 41.59 20 38.70 40.55 34.62 36.90 42.45 44.76 37.33 38.00 25 34.70 36.51 30.69 33.29 38.34 40.48 33.38 34.60 35 27.39 29.02 23.76 26.06 30.69 32.48 26.30 28.06 45 21.00 22.36 17.80 19.54 23.80 25.07 19.79 21.61 55 15.31 16.48 12.49 13.99 17.34 18.48 13.91 15.60 65 10.59 10.96 8.15 9.38 11.78 12.19 9.11 10.69 Table I shows the expectation of life (Ex) at various ages and for each sex in the towns just mentioned. It is interesting to note that at each age and for each sex the expectation of life in London exceeds that in Manchester and Glasgow, but is less than that of Brighton. From this point of view therefore, London occupies an intermediate position between Brighton, a fashionable health resort, on the one hand, and Manchester and Glasgow, important industrial centres, on the other. In the absence of more recent material for the comparison of the vital conditions of London with those of "healthy districts," comparison may be made between the London life table of 1881—90 and Dr. Farr's Healthy District life table, based on the mortality of certain English districts in the five years 1849-53. the extent to which London conditions of the present time fall short of those of healthy districts some forty years ago can then be seen. In Table J, which gives the survivors at several ages out of a million births, the most noticeable feature is the excessive mortality in London under 5 years of age. Whereas, according to this standard, 1,000,000 males should be reduced in these 5 years by 186,898, and 1,000,000 females by 164,440, in London 1,000,000 males are reduced by 277,001 and 1,000,000 females by 249,608, the excess of mortality in each case being almost exactly 50 per cent. At subsequent ages the London figures are more favourable, but this, it must be presumed, is in great measure due to the constant influx of healthy persons who directly lessen the London death rates, and many of whom return to their homes in the country if their health becomes impaired. From another point of view, the figures show that for males the chance of surviving to age 5 in London is only equal to the chance of surviving to age 25 in the healthy districts, and that for females the chance of surviving to age 5 in London is only equal to the chance of surviving to about 22 in the healthy districts. Table J. Comparison of the number surviving at several ages out of 1,000,000 of each sex born, according to Dr. Farr's Healthy Districts life table 1849-53, and the London life table, 1881-90. Age. X Males. E X Females. E X Healthy Districts, 1849-53. London, 1881-90. Healthy Districts, 1849-53. London, 1881-90. 0 1,000,000 1,000,000 1,000,000 1,000,000 5 814,102 722,999 835,560 750,392 10 785,697 701,885 805,240 728,882 15 771,086 691,698 786,402 718,411 20 750,859 677,837 761,380 705,698 25 723,849 659,634 731,426 690,324 35 666,986 604,990 668,938 644,793 45 606,978 520,920 605,016 575,177 55 532,809 410,293 535,412 484,154 65 419,396 271,387 430,041 355,924 75 238,215 124,399 256,615 188,810 85 64,149 26,077 70,031 49,201 The following table (K) shows the expectations of life derived from the survivorship figures in Table J. Table K. Comparison of expectations of life in London 1881-90 with those in Dr. Farr's Healthy Districts life table. Age. Males. Females. Healthy Districts, 1849-53. E X London, 1881-90. E X London to Healthy Districts taken as 100. Healthy Districts, 1849-53. E X London, 1881-90. E, London to HealthyDistricts taken as 100. 0 48.56 40.66 83.7 49.45 44.91 90.8 5 54.39 50.77 93.3 53.93 54.42 100.9 10 51.28 47.22 92.1 50.88 50.95 100.1 15 47.20 42.88 90.8 47.04 46.65 99.2 20 43.40 38.70 89.2 43.50 42.45 97.6 25 39.93 34.70 86.9 40.18 38.34 95.4 35 32.90 27.39 83.3 33.46 30.69 91.7 45 25.65 21.00 81.9 26.46 23.80 89.9 55 18.49 15.31 82.8 19.24 17.34 90.1 65 12.00 10.59 88.3 12.58 11.78 93.6 75 7.15 7.20 100.7 7.52 7.79 103.6 85 4.01 5.50 137.2 4.19 5.70 136.0 Here the effect of the influx of healthy lives alluded to above is very apparent; and, as might have been anticipated, this influx affects the figures relating to females more than it does the figures relating to males. Among other reasons, it is probable that a larger proportion of females (principally domestic servants) than of males return to their homes when their health breaks down. A reasonable inference is that the figures relating to males are a more trustworthy index of the effect of London life on longevity than those relating to females. But even these figures are unduly raised by immigration of healthy young men, and it is therefore highly probable that the life expectation of persons born, and living their lives, in London is at all ages considerably less than 90 per cent. of the normal expectation. It would be unsafe to draw any conclusions from the figures at ages 75 and 85, since there is always much doubt as to the accuracy of the data at these extreme ages. Infant Mortality. In London in 1893, 21,802 children under 1 year of age died, being in the proportion of 163* deaths per 1,000 births. In 1891 the proportion was 153, and in 1892, 154 deaths per 1,000 births. * See footnote (†), page 6. 13 14 The infant mortality in London compared with that of other English towns having more than 200,000 inhabitants was as follows— Ten years, 1883-92. 1893. Ten years, 1883-92. 1893. London 153 164* West Ham 152 170 Manchester 182 203 Bristol 144 141 Liverpool 185 211 Bradford 166 197 Birmingham 169 198 Nottingham 170 170 Leeds 173 206 Hull 162 206 Sheffield 173 191 Salford 187 210 The infant mortality of London was therefore in 1893 and in the period 1883-92 less than that of any of these towns except Bristol. Bristol again was exceptional in the fact that its infant mortality was in 1893 less than the average of the preceding ten years. The infant mortality of the several London districts in 1893 was as follows— Infant mortality. Deaths under one year of age. Deaths under one year of age to 1,000 births. Deaths under one year of age. Deaths under one year of ago to 1,000 births. Paddington 451 150 Bethnal-green 844 177 Kensington 620 169 Whitechapel 520 168 Hammersmith 474 160 St. George-in-the-East 410 209 Fulham 653 176 Limehouse 401 205 Chelsea 452 158 Mile-end Old-town 619 149 St. George, Hanover-square 199 133 Poplar 1,003 169 Westminster 255 188 St. Saviour, Southwark 120 154 St. James 77 146 St. George, Southwark 447 206 Marylebone 660 151 Newington 763 176 Hampstead 154 102 St. Olave 58 141 Pancras 1,209 172 Bermondsey 537 168 Islington 1,603 164 Rotherhithe 227 165 Hackney 1,049 152 Lambeth 1,371 149 St. Giles 143 131 Battersea 883 169 St. Martin-in-the-Fields 42 188 Wandsworth 647 142 Strand 130 219 Camberwell 1,200 161 Holborn 185 214 Greenwich 887 165 Clerkenwell 425 202 Lewisham 300 121 St. Luke 308 174 Woolwich 208 160 London, City of 83 132 Plumstead 394 144 Shoreditch 791 178 London 21.802 163+ Deaths from several classes of disease. The deaths from the several classes of disease registered in the registration county of London, and occurring in the lunatic asylums and hospitals for infectious disease belonging to the county are given by the Registrar-General in the Annual Summary of Births, Deaths and Causes of Deaths, and the following table has been prepared from the figures contained in the summary. 1893 Corrected annual average 1883-92. Zymotic diseases 16,435 14,258*0 Parasitic 60 112.9 Dietetic 688 438.1 Constitutional 16,726 17,053.5 Developmental 5,731 5,362.7 Nervous 9,352 9,850.1 Organs of special sense 182 131.8 Circulatory 7,099 6,696.5 Respiratory 19,754 19,105.2 Digestive 5,100 4,778.4 Lymphatic 134 108.6 Urinary 2,355 2,185.3 Generative 638 513.5 Locomotive 262 384.9 Integumentary 333 290.3 Violence (accident) 2,918 2,669.0 Violence (other than accident) 507 486.4 Other causes 3,262 3,255.7 * See footnote (*), page 6. †See footnote (†), page 6. 15 The deaths therefore in 1893 show an increase above the average of the preceding ten years in each class of disease except the parasitic, constitutional and the nervous, and in diseases of the locomotive system. Of the zymotic diseases the chief increases are found in the deaths from scarlet fever, influenza, diphtheria, enteric fever, diarrhoeal diseases, erysipelas and puerperal fever, all of which were above the averages of the preceding ten years. Of the dietetic diseases the deaths classified under the headings starvation and want of breast milk, alcoholism and delirium tremens were above the average. Of the constitutional diseases deaths from rheumatic fever, rheumatism of the heart, from gout, rickets and cancer were above the average. Of the congenital diseases deaths from premature birth, atelectasis and congenital malformations were above the average. Of the diseases of the respiratory organs the deaths from croup showed a marked decrease from the average, almost certainly due to transference of deaths from croup to diphtheria; deaths from pneumonia and pleurisy showed an increase related no doubt to the increase of the deaths from influenza. Of the diseases of the digestive system deaths from sore throat, quinsey, enteritis and peritonitis were above the average, the deaths from enteritis being nearly twice the average. Principal Zymotic Diseases. The London death rate per 1,000 living from the principal zymotic diseases was in 1893 lower than that of any of the large towns having a population of more than 200,000 persons, except Birmingham, Bristol and Nottingham, as will be seen from the following table— London 3.08* West Ham 3.39 Manchester 3.72 Bristol 1.65 Liverpool 3.90 Bradford 3.43 Birmingham 3.04 Nottingham 2.62 Leeds 3.47 Hull 4.14 Sheffield 3.52 Salford 4.14 Compared with the following ten foreign cities the London death rate per 1,000 living from the six principal zymotic diseases (smallpox, measles, scarlet fever, diphtheria, whooping cough and fever) was higher in 1893 than those of all but two. In the period 1888-92 six of these cities had a higher rate than London, thus— Six principal zymotic diseases. Six principal zymotic diseases. 1883-92. 1893. 1883-9 1893. London 2.10 2.28* St. Petersburgh 3.37 1.86 Paris 2.16 1.44 Berlin 2.09 1.90 Brussels 1.21 1.30 Vienna 1.69 2.37 Amsterdam 1.71 0.91 Rome 2.37 1.75 Copenhagen 2.14 1.49 New York 2.59 2.21 Stockholm 2.75 2.73 The death rate from the principal zymotic diseases (those mentioned above and diarrhœa) in London and the several sanitary districts of the administrative county in 1893, and the period 1885-92 is shown in the following table— Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10.000 in 1885-92. Deaths in 1893. Death rate per 10000 in 1893. Death rate per 10,000 in 1885-92. West— East— Shoreditch 566 46.0 36.4 Paddington 275 22.9 20.0 Bethnal-green 527 40.8 37.4 Kensington 348 20.9 20.7 Whitechapel 235 31.3 29.7 Hammer smith 246 23.9 32.0 St. George - in - the East 221 48.7 45.9 Fulham 342 32.7 Chelsea 268 27.4 27.2 Limehouse 269 47.2 41.6 St. George, Hanoversquare 118 15.6 17.1 Mile-end Old-town 361 33.5 33.4 Poplar 639 37.9 30.3 Westminster 110 20.1 26.4 St. James 43 18.0 18.8 South— North— St. Saviour, Southwark 82 30.6 32.9 Marylebone 382 27.4 22.0 St. George, Southwark 286 47.8 36.1 Hampstead 97 13.3 13.2 Pancras 761 32.6 26.2 Newing ton 432 36.8 30.8 Islington 930 28.4 26.8 St. Olave 29 22.5 29.7 Hackney 724 30.2 24.5 Bermondsey 275 32.7 31.9 Rotherhithe 136 34.1 31.1 Central— Lambeth 761 27.2 26.5 St. Giles 93 24.1 26.5 Battersea 570 36.2 24.7 St. Martin - in - the Fields 21 15.0 20.3 Wands worth 422 24.6 ) Camberwell 619 25.3 26.5 Strand 68 28.7 24.5 Greenwich 606 35.5 26.3 Holbom 109 33.4 28.7 Lewisham 149 15.2 17.3 Clerkenwell 319 48.8 34.5 Woolwich 101 24.2 19-7 St. Luke 232 55.9 35.6 Plumstead 285 30.2 18.0 London, City of 48 13.4 15.1 London 13.105 30.4† 27.1† *See footnote (*), page 6. * See footnote (†), page 6. 16 Smallpox and Vaccination. Smallpox caused one death in London in 1889, three in 1890, eight in 1891 and 29 in 1892. In 1893 the number of deaths rose to 186. The death rate from smallpox during successive periods has been as follows— Smallpox death rate per 1,000 living. 1851-60 0.28 1891 0.00* 1861-70 0.28 1892 0.01# 1871-80 0.46 1893 0.04* 1881-90 0.14 The death rate in each year since 1840 in relation to the mean of the period 1841-93 is shown in Diagram IV. During successive years since the passing of the Infectious Diseases (Notification) Act, 1889, the number of cases of smallpox notified to the medical officers of health in London has been— Year. Cases notified. 1890 60 1891 114 1892 425 1893 2,815 Notwithstanding the increase of smallpox in London in 1893, London has in this year suffered less from smallpox than the majority of the 12 largest English towns, as will be seen by reference to the following table. It will further be seen that in the majority of these towns the death rate of this disease in 1893 was above the average of the preceding ten years. Death rates per 1,000 living from Smallpox. Ten years, 1883-92. 1893. Ten years, 1883-92. 1893. London 0.07 0.05+ West Ham 0.45 0.24 Manchester 0.02 0.09 Bristol 0.03 0.08 Liverpool 0.04 0.09 Bradford o.oo 0.52 Birmingham 0.05 0.15 Nottingham 0.01 0.02 Leeds 0.01 0.05 Hull 0.03 0.04 Sheffield 0.24 0.02 Salford 0.00 0.11 If the London death rate from smallpox in 1893 be compared with those of the following ten foreign cities, it will be seen that the London rate was exceeded only by those of Paris and St. Petersburg, and in the preceding ten years the London rate was exceeded by those of five of these cities— Smallpox, 1883-92. Smallpox, 1893. Smallpox, 1883-92. Smallpox, 1892. London .07 .05† St. Petersburg .18 .10 Paris .08 .11 Berlin .00 .00 Brussels .26 .04 Vienna .21 .03 Amsterdam .01 .00 Rome .38 .01 Copenhagen .00 .00 New York .02 .05 Stockholm .00 .00 In the year, 2,815 persons were certified to be suffering from smallpox, of whom 2,457 were removed to the hospitals of the Metropolitan Asylums Board. Of the latter, 81 were found on admission not to be suffering from smallpox. See footnote (†), page 6. † See footnote (*), page 6. Diagram IV Smallpox. 17 The cases notified were distributed throughout the year as follows— Cases of Smallpox notified, 1893. Week of year. Week ending Cases notified. Week of year. Week ending Cases notified. 1 7th Januarv 13 27 8th July 74 2 14th „ 21 28 15th „ 72 3 21st „ 19 29 22nd „ 53 4 28th „ 28 30 29th „ 46 5 4th February 31 31 5th August 43 6 11th „ 27 32 12th „ 20 7 18th „ 47 33 19th „ 32 8 25th „ 53 34 26th „ 24 9 4th March 49 35 2nd September 12 10 11th 54 36 9th „ 28 11 18th „ 54 37 16th „ 25 12 25th „ 87 38 23rd „ 17 13 1st April 59 39 30th „ 19 14 8th „ 99 40 7th October 18 15 15th „ 151 41 14th „ 17 16 22nd „ 104 42 2l8t „ 13 17 29th „ 116 43 28th „ 30 18 6th May 166 44 4th November 29 19 13th „ 114 45 11th „ 55 20 20th „ 122 46 18th „ 21 21 27th „ 131 47 25th „ 18 22 3rd June 135 48 2nd December 32 23 10th „ 83 49 9th „ 20 24 17th „ 104 50 16th „ 24 25 24th „ 94 51 23rd „ 21 26 1st July 76 52 30th „ 15 With a view to showing the distribution of small pox at different times of the year in the several districts, the following table has been prepared. The year has been divided into periods of four weeks for this purpose— Cases of Smallpox notified in each of the Sanitary Districts of London, 1893. Sanitary District. Four weeks ended Jan. 28th. Feb. 25th. Mar. 25th. April 22nd. May 20th. June 17th. July 15th. Aug. 12 th. Sept. 9th. Oct. 7th. Nov. 4th. Dec. 2nd. Dec. 30th. West— Paddington — — — 7 10 13 I 5 2 1 3 15 11 Kensington — 5 1 3 11 2 3 3 — 2 18 41 13 Hammersmith — — 3 6 4 1 3 — — Fulham — 1 3 7 10 2 2 — 1 1 2 1 Chelsea 6 — 1 4 7 8 3 — — 1 1 10 2 St. George, Hanover-square 2 — — 4 2 5 3 3 — — 3 1 Westminster 3 2 10 10 11 5 1 1 1 3 St. James — — 1 2 2 21 22 3 1 — — — — North— Marylebone 4 9 17 32 45 35 16 13 1 — 2 4 1 Hampstead — — — 3 7 2 1 — — — — 1 — Pancras 7 1 8 17 26 26 13 8 2 — 2 4 6 Islington 10 10 27 25 17 10 8 3 3 1 8 Hackney 3 7 7 3 8 5 12 6 7 6 1 — — Central— St. Giles 2 5 10 14 18 11 11 1 — 1 St. Martin-in-the-Fields — — 1 3 1 3 2 — — 1 — Strand — 1 3 12 9 3 2 2 Holborn — 1 — 9 7 9 1 2 — 1 Olerkenwell — 2 2 5 1 2 — 2 3 St. Luke — 3 — 1 4 4 3 — — 1 London, City of — 1 4 5 5 9 1 — — — 2 — Carried forward 37 48 98 172 205 176 107 51 21 17 34 79 41 F3] 18 Cases of Smallpox notified in each of the Sanitary Districts of London, 1893—continued. Sanitary District. Four weeks ended Jan. 28th. Feb. 25th. Mar. 25th. April 22nd. May 20th. June 17th. July 15th. Aug. 12th. Sept. 9th. Oct 7th. Nov. 4th. Dec. 2nd. Dec. 30th. Brought forward 37 48 98 172 205 176 107 51 21 17 34 79 41 East— Shoreditch 2 3 2 5 4 2 2 1 2 3 1 1 Bethnal-green 1 2 1 5 7 9 12 15 16 8 2 1 Whitechapel 8 10 24 12 26 11 5 — 1 1 — 1 St. George-in-the-East 5 17 6 6 5 4 4 3 2 1 — — Limehouse — 7 8 15 13 11 13 — — 8 5 — Mile-end Old-town 1 1 6 29 25 15 11 12 3 3 1 2 6 Poplar — 18 26 21 29 18 20 9 13 12 23 24 4 South— St. Saviour, Southwark — — — 1 — 6 1 5 5 St. George, Southwark 2 4 3 8 14 27 6 4 3 8 1 — Newington 3 — 1 3 15 20 14 4 — 1 — 3 St. Olave — 1 5 1 2 1 1 — — — — — — Bermondsey 1 4 6 5 18 10 7 4 — — — — Rotherhithe — 2 2 — 60 8 6 8 3 1 Lambeth 2 3 3 11 9 23 31 10 5 2 3 1 Battersea — 1 3 4 8 30 30 25 4 4 5 1 1 Wandsworth — 1 — — 9 7 6 3 4 1 — 3 — Camberwell 10 22 7 22 21 20 16 8 6 9 2 — Greenwich — 10 26 65 22 25 16 — 1 3 4 11 Lewisham 1 2 2 12 5 3 — — 1 2 — — Woolwich — 1 13 7 6 15 3 2 3 — 6 1 4 Plumstead 3 1 2 9 15 10 3 5 2 3 1 — 6 Port of London 5 — — — — 2 1 — 1 — — 1 — London Total 81 158 244 413 518 453 316 162 96 79 89 126 80 In February, 1893, I reported to the Public Health Committee that in the previous few months there had been an increasing prevalence of smallpox in London, first showing itself in the middle of November, 1892, andattaining to proportions represented by the notification of 106 cases in January, 1893. Inquiry of the medical officers of health had shown that of 104 cases of which particulars were obtained, 45 had been removed to hospital, or were directly traceable to other cases removed to hospital, from casual wards, workhouses, infirmaries, Salvation Army shelters, and common lodging-houses. This report was in April supplemented by another, stating that smallpox was continuing to increase, that the cases notified had been 106 in January, 163 in February, and 272 in March. It had not been possible in the majority of cases to determine the exact source of infection, but 234 were persons without settled lodging or habitation. Of this 234 the source of infection appears to have been traceable in 19 instances to common lodging-houses, in 39 instances to Salvation Arm}" shelters, in 15 instances to casual wards, in 27 instances to infirmaries, and in 13 instances to workhouses. The report of the Statistical Committee of the Metropolitan Asylums Board, for the year 1893, contains a report by Dr. D. L. Long, second medical officer of the River Ambulance Service, from which it is learnt that in the first six months of the year, of the patients received by the Board, infection was traced in 96 cases to Salvation Army shelters, in 16 cases to the Medland Hall, Ratcliffe, in 170 cases to common lodging-houses, in 17 cases to casual wards, and in 10 cases to other free shelters. Details as to the part played by the nomadic class in disseminating smallpox are given by several medical officers of health from whose reports the following is extracted. In Kensington, two cases of smallpox occurred in common lodging-houses in the month of April. In Chelsea, in the beginning of the year, several cases occurred in connection with the Chelsea workhouse and infirmary, the infection being introduced on Christmas eve, 1892, by a tramp who was received into the casual ward. In Fulham, seven cases occurred in the union infirmary, the disease being introduced by a man who came from the casual ward at Epsom. In Westminster, of 42 cases occurring in the first six months of the year, there were 16 at a common lodging-house in Great Peter-street, 14 at a Salvation Army shelter in the Horseferry-road, and 3 among the employees of a licensed victualler carrying on business near this lodging-house. In Hampstead, of 14 cases in 1893, one of the first two was a tramp who was admitted into the casual ward of the workhouse on April 7th. after passing the night on the heath, and who had previously been sleeping in various houses and sheds. Dr. Gwynn, the medical officer of health, reports that it seemed to be clearly established that he had passed one night in the Salvation Army shelter, Blackfriars-road, a centre of infection at that time to which many cases were subsequently traced. In St. Giles, of 64 cases removed to hospital, 27 were removed from the casual ward and common lodging-houses. In St. George-in-the-East, the disease was most prevalent in the early part of the year, and was " confined for most part to the nomadic class." In St. George-the-Martyr, Southwark the epidemic was most prevalent in the early spring, and reached its maximum in May. Dr. Waldo the medical officer of health, reports that there are certain points in its behaviour worthy of notice, such as (a) its origin and spread during November and December, 1892, and the first four months of 1893, 19 by the agency of male vagrants, (b) its subsequent distribution amongst the residential population, particularly in the poorer parts, and (c) the important part played in the spread of the disease by the unregulated Salvation Army and other shelters. In St. Olave, the first case and nearly all the others occurred in a common lodging-house in Tooley-street. In Wandsworth parish, of the first two cases, one occurred in a common lodging-house and the other in a casual ward. In Plumstead the cases of small-pox occurred mostly in localities frequented by tramps. During the months of March, April and May, 8 cases of smallpox occurred in the Council's common lodging-house in Parker-street, St. Giles. The distribution of the cases in point of time led to the conclusion that the first case was the source of infection of the second, the second case of the third, the third of the fourth, fifth, and sixth, and the sixth of the seventh and eighth. The first patient had, with the exception of four or five nights, slept continuously in the house for more than three weeks. In connection with the earlier cases, it was decided to rely on the removal to hospital of the sick person, upon disinfection, and upon giving facilities for the vaccination of the inmates of the house. Later it was resolved to exclude the admission of new comers to the house until a sufficient interval of freedom from smallpox had elapsed. In the early part of the year the Council addressed a letter to the several sanitary authorities referring to the increasing prevalence of smallpox in London, and to the number of cases occurring in casual wards, workhouse infirmaries, Salvation Army shelters and common lodging-houses, and suggesting the desirableness of special facilities being afforded for the vaccination of the employees and lodgers at all such places. The Metropolitan Asylums Board also communicated with these authorities, forwarding a copy of a report by the medical superintendent of the hospital ships in which the incidence of the disease on the nomadic class was pointed out. The Managers urged the adoption of some measures for preventing the further spread of the disease in London, and suggested that "one most effective means to that end would be a systematic medical inspection of casual wards, shelters, common lodging-houses, &c., through the agency of which it would appear there is risk of the disease being widely disseminated." The reportsof some of the medical officersof health show the action taken by their authorities. Thus in Kensington, St. Giles, Limehouse, Bow, and Newington, letters were addressed to the managers and keepers of such places explaining the chief symptoms of the disease, urging them to watch for any appearance of smallpox in their lodgers, and advising them of the course to be taken in the event of any suspected case occurring. The Limehouse District Board recommended the medical inspection of inmates of these places, and were informed by the Salvation Army authorities that they would provide such inspection if the Board were willing to pay the costs, by the Medland Hall authorities that they would take steps to give effect to the suggestions of the Board, and by the police that efficient medical inspection was impossible, and that they had no funds for the purpose. The Vestry of St. George-inthe-East, on receipt of the Council's letter, arranged with the Board of Guardians for a letter to be written to the keepers of common lodging-houses, requesting them to post a printed notice in the several dormitories, to the effect that the public vaccinator attended at the vaccination station on a certain day in each week for the purpose of vaccinating people free of charge, and that any lodgers making application on that day could be vaccinated; and further, the Vestry arranged with the Board of Guardians for the public vaccinator to call at the common lodging-houses in the parish once or twice a week with the necessary lymph for vaccinating any inmate who would be willing to submit to the operation. Of the local prevalences in the year recorded by medical officers of health, the following are the most important— The medical officer of health of Greenwich reports that three cases of smallpox occurred in Blackwall-lane in January. The first case was that of a woman vaccinated in infancy who had a mild and, at the time, unrecognised attack. Her two unvaccinated children were the next sufferers, and one of these children died." Mr. Hartt states that " in a short time 75 cases were reported as occurring in the streets adjoining Blackwall-lane, principally amongst children attending the board school in that locality, many of which could be traced to the Blackwall-lane cases. In one school alone I found 34 children and in another 27 without any visible mark of vaccination. It was found that in the majority of cases the unvaccinated child first contracted the disease, and then brought it home and infected the other members of the family, many of whom had been vaccinated. These latter cases were of a mild type" The medical officer of health of Camberwell states that between December 3rd, 1892, and October, 1893, he received intimation of 150 cases of smallpox. " Of these 115 were removed to hospital and 35 were treated at home. Of those removed to hospital 10 were returned as not suffering from smallpox. In the case of 5 of these 10 no subsequent case of smallpox occurred in the house, and it may be presumed that they were not cases of smallpox. Of the other 5 smallpox recurred in the house in 3 cases, and in the remaining 2, one case was returned after three days owing to its doubtful character, while the other ' was allowed after he had recovered from his illness, for which he was treated at home, to go to the Metropolitan Asylums Board Convalescent Farm.' Of the 35 cases which were not removed, 10 were probably not smallpox. In all but 2 instances wherever an unremoved case of undoubted smallpox existed, other cases followed, mostly in the same house. The occurrence of smallpox in Barset-road led to the discovery of a man who was found to be suffering from smallpox, although he had been at work up to the time of our visiting the house." The medical officer of health of Bow reports " nine cases of smallpox occurred in a house in Windon-street. First case 8 months, unvaccinated, followed by a mother and infant of another family sent to sick asylum. Disease afterwards developed; baby was unvaccinated and died. Other cases were: mother of first case, 36 years, mild, two faint vaccination marks, and two daughters aged 7 and 4 years, both unvaccinated; father of second case, 30 years; brother of second case, 4 vears, unvaccinated ; and sister of second case, 6 years, unvaccinated. Two other children in the house, aged 11 years and 8 years, had been vaccinated and escaped the disease." 20 The medical officer of health of Poplar and Bromley reports, " During the last quarter of the year 1893 a very serious epidemic threatened the poor and densely populated region surrounding Hawgoodstreet. The disease was no doubt spread by the utter carelessness and disregard of the inhabitants, who> visited one another when there was sickness in the house. This visiting did not apply only to Hawgoodstreet and its surroundings, but to other parts of Bromley and Poplar, for in tracing out the origin of the cases it was generally found to be brought about in this manner." The medical officer of health of Mile-end Old-town reports "On April 1st a case occurred at Freeman's-cottages, Old Church-road, and as this patient worked at Bright and May's sweetmeat manufactory in the same locality, I made a careful enquiry from all the employees as to whether there was any case of sickness in their homes, and ascertained that the daughter of the landlady of one of them was not well, but nothing more definite than this. I visited the house and found she was, and had been treated for three weeks by a local doctor for chicken-pox, but there 13 not the slightest doubt that it was a case of small-pox from the first. I traced no less than 16 cases from this source of infection, all of which occurred in Old Church-road and Heath-street, and which in my opinion owe their origin to this mistaken diagnosis." Mr. Taylor and the sanitary inspectors made a house to house inspection in the neighbourhood, and found a young woman suffering from small-pox occupying the same bedroom with two sisters employed in the City. The sufferer was not receiving medical attendance, and her mother at first denied that there was any case of sickness in the house. The patient was removed to hospital and the house disinfected. Referring to 35 cases of small-pox under 12 years of age, Mr. Taylor found 20 were unvaccinated, 10 were vaccinated, and in the case of 5 there was some doubt as to the vaccination. The medical officer of health of Kensington gives account of an outbreak of small-pox in the north-east part of that district, which came to his knowledge in the latter days of October, but " which had been smouldering for a month before the first notification was received." The first case was a child, Maud K., living in the Portobello-road, who fell ill on or about the 22nd of September, but who was not removed to hospital till the 23rd October. The second was her father, who fell ill on or about the 12th October, and who died in his house on the 23rd October. The father was a purveyor of bread and milk, &c., and his business led to many persons calling at his shop during the time he and his daughter were ill. Indeed Dr. Dudfield tells of visits paid to the daughter by her young friends of both sexes, from adjoining houses during her illness, and of her taking part in the business of the shop after 8th October, although her face was covered with scabs. From this centre the disease spread, and Dr. Dudfield gives account of 65 persons attacked in Kensington, this child's illness probably being directly or indirectly responsible for the infection of the remaining 64. Dr. Dudfield thus writes concerning the state as to vaccination of this father and daughter. " The unfortunate man had been an ardent opponent of vaccination; but Mr. Shattock, the Vaccination Officer, informed me that, in March, 1882, he had received a medical certificate of the successful vaccination of Maud, signed by a medical man, now deceased, whose certificates he always viewed with more or less suspicion. The girl's arm, however, exhibited no marks, and her mother subsequently admitted that the vaccination had not " taken." Her father had often boasted that he was unvaccinated : whether he was so appears to be doubtful; but humanly speaking his fatal illness was the result of his child's unprotected state. The remaining children of the family had been successfully vaccinated by the Public Vaccinator, and notwithstanding the intensity of the infection to which for a whole month they had been exposed, one and all escaped.' The late medical officer of health of Paddington gives no details as to the cases in that district, but Dr. Dudfield was able to satisfy himself that Maud K. contracted her illness in the house of her uncle in Barnsdale-road, Paddington. In this house were certain children who appear to have suffered: from small-pox, the first of whom fell ill about the middle of August. The source of infection was not known. Other persons in this house were attacked, among them the relatives of Maud K. The medical officer of health of Chelsea refers to ten cases in November and one in December,, related to the North Kensington outbreak. The following table shows the number of cases of smallpox notified and the deaths attributed to smallpox belonging to the several sanitary districts in 1893, together with the case rate in that year and the death rate in 1893 and in the period 1885-92— Smallpox. Cases, 1893. Case rate per 10,000, 1893. Deaths, 1893. Death rates per 10,000. 1893. 1885—92. Paddington 68 6 4 0.3 0.2 Kensington 102 6 10 0.6 0.2 Hammersmith 17 2 3 0.3 0.2 Fulham 30 3 2 0.2 Chelsea 43 4 1 0.1 0.1 St. George, Hanover-square 23 3 3 0.4 0.2 Westminster 47 9 — — 0.2 St. James 52 22 1 0.4 0.1 Marylebone 179 13 5 0.4 0.3 Hampstead 14 2 2 0.3 0.2 Pancras 120 5 9 0.4 0.4 Islington 122 4 2 0.1 0.5 Hackney 65 3 4 0.2 0.5 St. Giles 73 19 4 1.0 0.6 21  Cases, 1893. Case rate per 10,000. 1893. Deaths, 1893. Death rates per 10,000. 1893. 1885—92. St. Martin-in-the-Fields 11 8 2 1.4 0.3 Strand 32 13 1 0.4 0.2 Holborn 30 9 1 0.3 0.3 Clerkenwell 17 3 — — 0.5 St. Luke 16 4 1 0.2 0.4 London, City of 27 8 3 0.8 0.2 Shoreditch 28 2 3 0.2 0.4 Bethnal-green 79 6 7 0.5 0.3 Whitechapel 99 13 5 0.7 0.3 St. George-in-the-East 53 12 1 0.2 0.5 Limehouse 80 14 8 1.4 0.6 Mile-end Old-town 115 11 8 0.7 0.4 Poplar 217 13 12 0.7 0.7 St. Saviour, Southwark 18 7 — — 0.5 St. George, Southwark 80 13 7 1.2 0.8 Newington 64 5 6 0.5 0.8 St. Olave 11 9 1 0.8 0.1 Bermondsey 55 7 4 0.5 0.8 Rotherhithe 90 23 13 3.3 0.9 Lambeth 103 4 5 0.2 0.4 Battersea 116 7 12 0.8 0.2 Wandsworth 34 2 1 0.1 Camberwell 143 6 11 0.4 0.9 Greenwich 183 11 13 0.8 0.7 Lewisham 28 3 5 0.5 0.2 Woolwich 61 15 4 1.0 0.4 Plumstead 60 6 2 0.2 0.2 Port of London 10 — — — — London 2,815 7 186 0 4† 04† The deaths attributed to cow-pox and vaccination in 1893 numbered 15. The report of the Statistical Committee of the Metropolitan Asylums Board supplies the following figures showing the state as to vaccination of the patients admitted into the institutions of the Board during the year 1893. Cases. Deaths. Vaccination cicatrix or cicatrices— Present 1,624 42 •No evidence 252 44 Absent 500 94 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 13 years 1881-93, are as follows— Smallpox deaths, London. All ages. 0-1 1-5 5-20 20-40 40-60 60-80 80 and upwards. Vaccinated 1,237 22 32 225 706 216 33 3 Unvaccinated 1,955 315 460 654 404 103 18 1 No statement 1,858 239 222 450 646 240 58 3 All ages taken as 100. Vaccinated 100 1.8 2.6 18.2 57.1 17.5 2.7 .2 Unvaccinated 100 16.1 23.5 33.5 20.7 5.3 .9 .1 No statement 100 12.9 11.9 24.2 34.8 12.9 3.1 .2 " Vaccinated " and " No statement " combined. Vaccinated and "No statement " 100 8.4 8.2 21.8 43.7 14.7 2.9 .2 Unvaccinated 100 16.1 23.5 33.5 20.7 5.3 .9 .1 * These cases include cases stated to hare been vaccinated, but bearing no visible evidence of the operation, and also those in which no statement was made, but the nature of the eruption or other cause prevented any observation of the marks, if any existed. † See footnote (†), page 6. 22 The differences between the age-incidence of the deaths of the vaccinated and unvaccinated can therefore be appreciated, a difference which is conspicuous if the cases in the two classes "Vaccinated" and " No statement" are added together and compared with the unvaccinated. In my last report I referred to the large increase, during recent years, in the number of children appearing in the vaccination returns as " not finally accounted for," and to the information which I had received concerning several London districts, which showed that their number had, at any rate in several districts in 1892, still further increased. The returns published by the Local Government Board enable me to show the proportion of children in London " not finally accounted for " per cent, of total births during several years to the year 1891. London Vaccination Returns. Children not finally accounted for (including casea postponed) per cent, of total births. Children not finally accounted for (including cases postponed) per cent, of total births. 1881 5.7 1887 9.0 1882 6.6 1888 7.4 1883 6.8 1889 11.6 1884 6.8 1890 13.9 1885 7.0 1891 16.4 1886 7.8 The following table gives similar information for each of the metropolitan unions for the years 1881-93 inclusive. I am indebted to the clerks of these unions for information relating to the year 1893. Metropolitan Unions. 1881. 1882. 1883. 1884. 1885. 1886. 1887. 1888. 1889. 1890. 1891. 1892. 1893. Bethnal-green 5.5 7.1 61 8.0 8.6 11.1 13.5 16.0 25.1 30.6 38.2. 53.1 54.8 Camberwell 5.2 6.0 6.4 7.0 6.8 8.4 9.4 8.4 12.5 14.0 17.4 15.5 13.2 Chelsea 5.1 6.7 5.2 5.1 5.0 5.6 7.2 4.8 6.0 6.3 16.7 12.1 11.8 Fulham 5.4 4.1 3.8 4.2 4.5 4.5 4.6 5.5 6.0 6.7 5.8 6.5 9.5 St. George, Hanover-square 2.3 4.4 3.1 2.9 4.6 4.3 4.6 4.5 4.0 3.6 3.7 3.4 3.5 St. George-in-the-East 4.2 4.3 4.7 3.7 4.8 5.3 6.7 7.9 6.5 7.9 8.6 9.4 10.8 St. Giles and St. George 11.6 9.9 11.4 11.6 11.1 12.2 14.1 17.7 22.5 17.8 13.6 18.1 19.3 Greenwich 6.6 7.8 10.2 10.4 11.1 11.4 9.6 10.1 11.5 32.3 19.4 9.8 7.1 Hackney 4.6 6.7 6.2 6.5 9.3 9.3 8.9 12.1 18.5 26.0 40.6 49.5 52.8 Hampstead 3.1 4.0 5.1 4.2 3.8 4.0 5.0 5.6 5.1 6.3 7.1 6.9 6.7 Holborn 6.2 7.6 8.5 9.7 8.1 7.7 8.7 10.3 11.3 12.4 12.7 14.2 14.2 Islington 8.2 8.0 8.4 8.0 8.0 7.8 8.1 9.8 9.5 9.2 10.8 12.4 12.8 Kensington 3.9 5.4 4.6 4.9 5.5 6.5 7.0 6.9 7.5 7.6 9.6 10.3 9.2 Lambeth 7.6 8.3 8.5 8.6 8.6 9.4 11.1 12.6 13.3 14.3 16.0 19.6 19.9 Lewisham 3.2 4.1 4.8 4.2 5.2 5.0 6.5 5.9 6.6 6.3 6.2 6.6 6.8 City of London 2.9 2.9 2.4 3.9 7.4 8.0 8.0 9.0 9.2 10.3 8.8 9.3 9.3 Marylebone 5.1 6.8 5.5 7.3 5.4 4.6 4.7 4.9 8.1 7.7 13.4 16.9 24.8 Mile-end Old-town 7.5 8.8 9.8 8.7 8.8 9.7 11.3 14.4 16.6 26.5 49.9 58.8 43.5 St. Olave 4.1 5.9 10.0 7.3 8.0 9.0 17.7 15.0 15.4 14.8 15.3 15.8 16.5 Paddington 7.7 9.2 8.8 8.2 8.8 10.1 8.4 11.3 12.7 11.6 17.7 12.6 10.0 St. Pancras 6.3 5.7 4.0 5.2 6.1 6.9 8.7 11.5 13.2 15.1 15.6 15.7 15.8 Poplar 4.4 4.0 3.6 3.8 3.0 4.9 5.7 16.9 15.1 19.5 19.6 23.6 23.1 St. Saviour 5.7 6.7 6.0 8.7 9.1 13.1 18.9 17.1 12.4 11.6 12.4 12.7 14.9 Shoreditch 10.3 12.0 7.6 6.5 5.6 6.3 5.6 3.7 5.5 9.3 8.8 10.8 16.2 Stepney 6.2 4.8 2.3 3.7 4.1 5.9 5.3 6.5 8.8 12.0 19.0 22.7 26.2 Strand 7.2 8.3 7.6 9.3 8.9 8.5 9.7 10.0 16.2 7.1 12.2 15.4 12.6 Wandsworth and Clapham 5.4 7.1 9.0 8.2 9.1 9.7 10.6 11.5 12.1 12.9 14.7 18.5 12.2 Westminster 4.8 5.7 6.1 5.7 6.6 8.5 8.5 4.1 12.8 13.2 17.0 23.0 Whitechapel 1.4 1.6 1.6 1.4 1.5 1.8 1.7 2.1 2.8 2.7 4.1 4.4 5.3 Woolwich 1.9 1.4 1.5 1.6 1.8 2.2 2.2 2.9 3.5 3.7 3.6 3.7 3.5 Measles. Measles caused 1,659 deaths in London in 1893, or less than half the number of deaths which occurred in 1892 from that cause. The death rates per 1,000 living from this disease in 1893 and previous periods have been as follows— 1851-60 0.53 1861-70 0.58 1871-80 0.51 1881-90 0.64 1891 0.43† 1892 0.79† 1893 0.38† Diagram V. shows the death rate of measles in each year in relation to the mean death rate of the period 1841-93. Compared with the other 11 large towns, London had in 1893 a lower death rate than the majority, whereas in the preceding ten years the mean death rate of London had been in excess of those of the majority. 4 See footnote (†), page 6. • Diagram, V Measles. 23 Death rates from Measles per 1,000 living. Ten years, 1883-92. 1893. Ten years, 1883-92. 1893. London 0.63 0.39* West Ham 0.62 016 Manchester 0.83 0.58 Bristol 0.54 0.11 Liverpool 0.95 0.54 Bradford 0.48 0.31 Birmingham 0.56 0.10 Nottingham 0.48 0.11 Leeds 0.47 0.89 Hull 0.38 0.61 Sheffield 0.52 0.53 Salford 0.88 0.45 The death rate of London from measles has, both in 1893 and the preceding ten years, been greater than that of the majority of the undermentioned foreign cities. Measles. Death rate per 1,000 persons living. 1883-92. 1893. 1883-92. 1893. London .63 .39* St. Petersburg .77 .27 Paris .54 .28 Berlin .29 .20 Brussels .30 .72 Vienna .48 .83 Amsterdam .53 .16 Rome .63 .60 Copenhagen .51 .04 New York .46 .21 Stockholm .59 .00 The reports of the medical officers of health in several instances refer to the neglect of parents among the poorer classes to make effort to limit the spread of this disease. The desirability of requiring the notification of measles is also discussed in these reports. The medical officer of health of Kensington expresses doubt if any great advantage would result from notification unless hospitals were provided for the reception of the sufferers who cannot be properly treated at home. On the other hand, the medical officer of health of St. Giles states that he is still of opinion that the notification of measles would enable measures to be taken for arresting the spread of the disease. The medical officer of health of Wandsworth is of opinion that the spread of measles would be better controlled if all the children in a house infected with measles could be excluded from school, and he urges the notification of measles for this purpose. During the year the medical officer of health of Kensington addressed a letter to the superintendent of visitors of the Chelsea division of the London School Board, pointing out the desirability of an effort being made to exclude from the schools all children coming from houses where the disease exists, and recommending that a circular letter referring to the requirement of the Board that children from infected houses shall not attend school, should be addressed to the parents of school children. He adds that this course was not adopted. The deaths from measles were not uniformly distributed throughout the metropolis, the adjoining districts of Clerkenwell, St. Luke and Shoreditch suffering especially heavily. The death rate in each district in 1893 and in the ten years 1885-92 is shown in the following table— Measles. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Paddington 30 2.5 4.3 Bethnal-green 83 6.4 9.2 Kensington 21 1.3 5.3 Whitechapel 37 4.9 7.2 Hammersmith 4 0.4 8.0 St.George-in-the-East 32 7.1 11.2 Fulham 12 1.1 Limehouse 21 3.7 11.1 Chelsea 23 2.3 6.4 Mile-end Old-town 39 3.6 7.2 St. George, Hanover- 2 0.3 3.7 Poplar 32 1.9 7.4 square St. Saviour, Southwark 6 2.2 9.5 Westminster 5 0.9 6.3 St. James 4 1.7 5.1 St.George, Southwark 35 5.9 9.0 Marylebone 32 2.3 6.1 Newington 34 2.9 7.4 Hampstead 1 0.1 2.6 St. Olave 1 0.8 7.7 Pancras 154 6.6 6.3 Bermondsey 36 4.3 7.9 Islington 129 3.9 6.5 Rotherhithe 10 2.5 6.8 Hackney 57 2.4 5.2 Lambeth 113 4.0 5.5 St. Giles 6 1.6 7.3 Battersea 93 5.9 5.3 St. Martin - in - the Fields 1 0.7 4.8 Wandsworth 36 2.1 Camberwell 83 3.4 5.8 Strand 2 0.8 6.8 Greenwich 103 6.0 6.0 Holborn 18 5.5 7.2 Lewisham 20 2.0 3.0 Clerkenwell 79 12.1 9.1 Woolwich 14 3.4 5.3 St. Luke 58 14.0 9.4 Plumstead 53 5.6 4.4 London, City of 11 3.1 2.9 London 1,659 3.8† 6.4† Shoreditch 129 10.5 8.3 * See footnote (*), page 6. † see footnote (†), page 6, 24 Scarlet Fever. The number of cases of scarlet fever notified in London in the year 1893 was 36,849, and the number of deaths registered was 1,599. The number of cases notified in 1893 was 35 per cent., and the number of deaths registered in 1893, 34 per cent, in excess of the numbers notified and registered respectively in the year 1892. In 1893 the case rate was 8.6, and the death rate 0.37 per 1,000 of population. In this year the fatality (deaths per 100 cases) was 4.34. The rates in 1893 and previous periods were as follows— Period. Death rate per 1,000. Case rate per 1,000. Case mortality per cent. 1861-70 1.14 -* - 1871-80 0.60 -* - 1881-90 0.33 -* - 1891 0.14+ 2.7 5.1 1892 0.27+ 6.4 4.3 1893 0.37+ 8.6 4.3 Diagram VI. shows the death rate from this disease in each year in relation to the mean of the period 1859-93. In the years 1889, 1890 and 1891, the London scarlet fever death rates were less than those of England and Wales, but in 1892 and 1893 were considerably in excess. The scarlet fever death rate of London can be compared with those of other English towns having a population of more than 200,000 persons by reference to the following table— Death rates from Scarlet Fever per 1,000 living. Ten years, 1883-92. 1893. Ten years, 1883-92.  London 0.27 0.37‡ West Ham 0.30 0.35 Manchester 0.47 0.27 Bristol 0.27 0.16 Liverpool 0.52 0.45 Bradford 0.30 0.32 Birmingham 0.26 0.14 Nottingham 0.16 0.37 Leeds 0.64 0.08 Hull 0.22 0.16 Sheffield 0.71 0.27 Salford 0.59 0.20 London therefore in 1893 had a higher death rate than any of the towns except Liverpool and Nottingham, and in this year had a death rate higher than the average of the preceding ten years, West Ham, Bradford and Nottingham being the only others having in 1893 a death rate above the average of the preceding ten years. If the London death rate of scarlet fever be compared with the death rates of the following ten foreign cities, it is seen that in 1893 the London rate was higher than that of all but two of these cities, and in the ten preceding years was higher than those of all but three of these cities, thus— Scarlet fever. Death rate per 1,000, 1883—92. Death rate per 1,000, 1893. Death rate per 1,000, 1883—92 Death rate per 1,000, 1893. London .27 .37‡ St. Petersburg .69 .52 Paris .09 .07 Berlin .24 .34 Brussels .05 .02 Vienna .20 .22 Amsterdam .21 .04 Rome .06 .04 Copenhagen .22 .31 New York .53 .30 Stockholm .78 1.01 The Infectious Diseases (Notification) Act only came into force in 1889. † See footnote (†), page 6. J See footnote (•), page 6 i Diagram VI Scarlet Fever. Diagram VlI Scarlet Fever. Number of death occurring in hospitals of the Metropolitan Asylums Board, per cent of total death in London, 1873-93. Notified Cases. Dia.gram IX Scarlet Fever, 1893. Notified Cases. Diagram VIII Scarlet Fever, 1892. 25 Owing to the increase in the number of cases of scarlet fever in 1893 the hospital accommodation available for this disease in London proved inadequate, and as a result a smaller proportion of the total cases was received into and a smaller proportion of the total deaths occurred in the hospitals of the Metropolitan Asylums Board than in the preceding three years. (See diagram VII.) Sir Edwin Galsworthy states that it has been estimated that had sufficient accommodation existed when the number of scarlet fever patients was at its maximum as many as 6,000 patients, or almost double the actual number, would not improbably have been under treatment in the Board's hospitals at one and the same time. With a view to showing the number of cases in each week in relation to the mean of the year, diagrams VIII. and IX. for the years 1892 and 1893 respectively have been prepared. It will be observed that in the " all age " curves for these years there is a depression in that part of the curve which relates to the month of August, the August depression in the curve for 1893 being much greater than the August depression in the curve for the year 1892. The curve for the year 1893 deserves, therefore, closer examination. If for this purpose the cases of scarlatina notified in that year be divided into three classes, (a) those occurring in children from 0-3 years of age, (b) those occurring in children from 3-13 years of age, and (c) those occurring in persons above 13 years of age, the cases may be considered in relation to school operations, these three groups representing practically (a) those who are too young to attend school, (b) those at the school age period of life, and (c) those who have in great part left school. If curves be constructed with the cases included in these three groups it will be seen that the August depression is much accentuated in the curve relating to children from 3-13 years of age, and that the depression in the curve relating to infants from 0-3 years occurs a little later. This striking diminution of scarlet fever in the month of August, occurring especially among children at the school age period of life, necessarily raises the question whether disease had been spreading in schools and whether the summer holiday has arrested the spread of disease due to this cause. At this season of the year there is, however, another condition which deserves consideration. Coincident with the closing of schools, children in considerable numbers migrate from London, and it may be that the diminution in the number of cases of scarlet fever in August is in some part attributable to this migration. Such inquiry as I have been able to make does not, however, lead me to the conclusion that this circumstance affords sufficient explanation of the reduction of scarlatina during the month of August. School operations must therefore be further considered. I am not able to show for each week the number of children in London who are attending school, but so far as the operations of the schools of the London School Board are concerned the dates at which the schools generally close and re-open can be given. It is probable that the times of the closing and re-opening of many other London schools correspond with the times of the closing and re-opening of the schools of the Board. In 1892 the schools of the London School Board generally closed for the summer holidays on the 21st of July, i.e., towards the end of the 29th week, and re-opened on the 22nd of August, i.e., the beginning of the 34th week. If time is allowed for the period of incubation and a little delay in notification, any effect of school closure on the number of scarlatinal cases notified might be expected to be manifested in the returns for the 31st, 32nd, 33rd, and 34th weeks, and the diagram shows that the August depression corresponds with these weeks. Comparison between the number of cases in three periods of four weeks, (1) the 27th—30th week, (2) the 31st—34th week, and (3) 35th—38th week at several ages gives the following results— Under 3—13 13 years 3 years. years. and above. Increase or decrease per cent, of number of cases in 2nd period in relation to that of 1st +25 —9« +9 Increase per cent, of number of cases in 3rd period in relation to that of 2nd Nil. +52 +15 In the diagram for the year 1893 the August depression is still more marked. In this year the schools generally closed on the 27th July, i.e., nearly the end of the 30th week, and reopened on the 28th of August, i.e., the beginning of the 35th week. Diminution in the number of cases notified might be expected therefore in the 32nd, 33rd, 34th and 35th weeks, and the August depression in the diagram corresponds with these weeks. If comparison be again made between three periods of four weeks, i.e., 28th-31st, 32nd-35th, and 36th-39th, the following results are obtained— Under 3-13 13 years 3 years. years. and above. Decrease per cent, of number of cases in 2nd period in relation to that of 1st —1 -26 -17 Increase per cent, of cases in 3rd period in relation to that of 2nd +9 +65 +26 There appears, therefore, to be a very close relation between the August holidays and the diminution in the amount of scarlatina. The cases notified, and the deaths which occurred in 1893, are sufficiently numerous to be deserving of comment with regard to the question of age distribution. A study of the following table shows that the greater incidence of both disease and death was on males. At the several ages, the greatest incidence of disease was in this year on males and females who were 4 to 5 years of age, the greatest incidence of death was on males of 3 to 4 years and females of 2 to 3 years of age. The fatality (case mortality) of males was greater than that of females. At the several ages the greatest fatality occurred among males under 1 year of age, and among females from 1 to 2 years of age. [4] 26 * Scarlet fever, 1893. Age period. Males. Females. Cases. Deaths. Case mortality per cent. Rate per 100,000 living. Cases. Deaths. Case mortality per cent. Rate per 100,000 living. Cases. Deaths. Cases. Deaths. All ages. 17,704 800 4.5 870 39 19,197 789 4.1 845 35 0— 281 41 14.6 510 74 284 34 12.0 506 61 1— 726 105 14.5 1,470 213 655 108 16.5 1,314 217 2— 1,161 134 11.5 2,247 259 1,135 132 11.6 2,188 254 3— 1,501 131 8.7 2,999 262 1,485 113 7.6 2,899 221 4— 1,610 95 5.9 3,308 195 1,671 111 6.6 3,419 227 5— 6,727 207 3.1 2,912 90 7,467 178 2.4 3,199 76 10— 3,187 37 1.2 1,511 18 3,618 56 1.5 1,683 26 15— 1,353 26 1.9 670 13 1,270 19 1.5 566 8 20— 533 9 1.7 269 5 703 14 2.0 293 6 , 25— 455 13 2.9 133 4 669 13 1.9 170 3 35— 128 — 0.0 51 — 178 5 2.8 64 2 45— 34 1 2.9 19 1 43 3 7.0 22 2 55 and upwards. 8 1 12.5 5 1 19 3 15.8 8 1 The following table shows the number of cases and deaths and the case and death rates of each district in 1893 and in the period 1885-92— Cases. Case rate per 10,000. Deaths, 1893. Death rate per 10,000, 1893. Death rate, 1885-92. Paddington 778 65 33 2.7 1.3 Kensington 943 57 52 3.1 1.5 Hammersmith 665 65 36 3.5 Fulham 706 68 33 3.2 2.0 Chelsea 589 60 32 3.3 1.7 St. George, Hanover-square 591 78 25 3.3 1.4 Westminster 420 77 25 4.6 2.2 St. James 113 47 2 .8 1.8 Marylebone 913 66 68 4.9 1.5 Hampstead 516 71 20 2.7 .9 Pancras 2,589 111 100 2.3 1.7 Islington 2,989 91 94 2.9 1.6 Hackney 2,505 104 74 3.1 2.4 St. Giles 238 62 14 3.6 1.5 St. Martin-in-the-Fields 102 73 2 1.4 2.2 Strand 140 59 19 8.0 1.3 Holborn 311 95 12 3.7 2.5 Clerkenwell 731 112 30 4.6 2.8 St. Luke 361 87 28 6.8 3.4 London, City of 299 84 8 2.2 1.6 Shoreditch 1,008 82 39 3.2 3.1 Bethnal-green 1,488 115 71 5.5 4.3 Whitechapel 811 108 32 4.3 2.5 St. George-in-the-East 485 107 14 3.1 4.0 Limehouse 710 125 35 6.1 4.1 Mile-end Old-town 1,179 109 40 3.7 3.8 Poplar 1,883 112 105 6.2 3.0 St. Saviour, Southwark 210 78 18 6.7 3.2 St. George, Southwark 594 99 42 7.0 4.0 Newington 1,101 94 51 4.3 3.4 St. Olave 117 91 6 4.7 3.2 Bermondsey 570 68 30 3.6 3.4 Rotherhithe 302 76 16 4.0 2.7 Lambeth 2,247 80 69 2.5 2.4 Battersea 1,491 95 40 2.5 1.7 Wandsworth 1,291 75 53 3.1 Camberwell 1,854 76 73 3.0 2.4 Greenwich 1,469 86 71 4.2 1.7 Lewisham 619 63 12 1.2 1.0 Woolwich 258 62 16 3.8 .8 Plumstead 765 81 48 5.1 1.2 Port of London 2 — — — — London 36,953 86 1.588 37† 22† * III the preparation of this table, the question whether the person?, who were attacked and who died, belonged to London is disregarded, the percentages being calculated on the number of cases notified in London, and the number of deaths occurring in London and the institutions belonging to London. Inasmuch as the age of the patient is not in all cases recorded in the notification certificate, it has been necessary to distribute such cases among the various ages proportionately. † See footnote (f), page 6. 27 The more important outbreaks of scarlatina in the year occurred in St. Pancras and Hampstead. The report of the medical officer of health of St. Pancras contains an account of an outbreak of scarlatina in that district and the adjoining district of Hornsey, beginning in the latter part of the month of October among the customers of a milk vendor in Highgate. This milk vendor received his milk from three sources: from his own cows, from Finsbury-park, and from a farm at Hendon. Of the customers supplied solely from his own cows none were attacked, the incidence of the disease being upon the consumers of milk from the other sources. The milk from Finsbury-park and Hendon was distributed in three rounds. The customers on two of these rounds received Hendon milk in the morning and Finsbury-park milk in the afternoon, the customers on the third round received Hendon milk both morning and afternoon. The customers on the first two rounds numbered 191, of whom 8, or 4.2 per cent., were attacked; the customers on the third round numbered 100, of whom 20, or 20 per cent., were attacked. Dr. Sykes ascertained at an early stage that some of the Hendon farm milk had been distributed locally in Hendon by two milk vendors, among whose customers three cases of scarlet fever had occurred, and further, one of the milkmen on the Hendon farm was found on October 21st to be suffering from scarlatina. On proceeding to the farm at Hendon, Dr. Sykes learnt that " the county veterinary inspector had been over to the farm, and had ordered five cows with sore teats and inflammatory symptoms to be isolated, and the milk from these cows to be stopped from sale." Dr. Sykes had early cautioned the Highgate vendor against the supply of milk from the Hendon farm, and orders were subsequently made by the sanitary authority of St. Pancras under section 71 of the Public Health (London) Act, upon the milk vendor in Highgate and the farmer at Hendon, requiring them not to supply within the district of St. Pancras any milk from the dairy and farm referred to, until the withdrawal of such orders by the sanitary authority. A special prevalence of scarlatina in the neighbourhood of Mill-lane, Hampstead, was investigated by the medical officer of health, who reported that the disease " appeared to be greatly disseminated by the agency of the schools in the district." The medical officer of health of Islington comments on the diminution of scarlet fever shortly after the closing of schools for the August holiday, and subsequent increase when the schools re-opened in September. Many of the annual reports of the medical officers of health refer to the insufficiency of accommodation in the hospitals of the Metropolitan Asylums Board. Such references are found in the reports of the medical officers of Kensington, Fulham, Marylebone, Hampstead, Islington, Hackney, St. Pancras, Strand, St. Luke, Shoreditch, and Battersea. The medical officer of health of Fulham expresses the opinion that at times of insufficiency of hospital accommodation the selection of cases for removal to hospital should be in the hands of the medical officer of health of each district. The medical officer of health of Islington addressed a letter to the Metropolitan Asylums Board, recommending the adoption of this course, but the Managers felt themselves unable to accede to this request. In Marylebone, the sanitary authority itself opened a temporary hospital to meet the demands for removal of cases which could not obtain admission into the hospitals of the Metropolitan Asylums Board. This hospital consisted in the first instance of two houses in Marylebone-road, which were placed, free of cost, at the disposal of the vestry by Lord Portman. Three other houses were afterwards added, accommodation being provided for 105 persons. Into this hospital 280 cases of scarlatina and 9 of diphtheria were admitted during the year. Diphtheria The number of cases* of diphtheria notified in London in the year 1893 was 13,712, and the number of deaths belonging to London 3,197. The number of cases notified in 1892 was 8,368, and the number of deaths registered 1,859. The number of cases had therefore increased 64 per cent., and the deaths 72 per cent. In 1893 the death rate per 1,000 of population was '74, and the case rate 3 2. The rates in 1893 and previous periods were as follows— Period. Death rate per 1,000. Case rate per 1,000. Case mortality per cent. 1861-70 0.18 -† — 1871-80 0.12 -† — 1881-90 0.26 -† — 1891 0.31‡ 1.5 22.5 1892 0.44‡ 2.0 22.2 1893 0.74‡ 3.2 23.3 Compared with the diphtheria death rates of other large English towns, having a population of more than 200,000 persons, the London death rate shows a marked excess. It was in fact more than double the death rate of any of these towns, except West Ham. It was ten times as great as the death rate of Nottingham, and six times as great as the death rate of Liverpool. If the mean death rate of London from diphtheria in the ten years 1883-92, be compared with that of the other towns, it is found to be higher than that of any town except Salford. * Cases include membranous croup. † The Infectious Diseases Notification Act only came into force in 1889. ‡ See footnote (†), page 6. 23 The following table gives the death rates of these towns per 1,000 living— Diphtheria—Death rates per 1,000 living. Ten years. 1883-92. 1893. Ten years. 1883-92. 1893. London 0.30 0.76‡ West Ham 0.25 0.42 Manchester 0.20 0.32 Bristol 0.10 0.22 Liverpool 0.16 0.12 Bradford 0.05 0.10 Birmingham 0.12 0.13 Nottingham 0.11 0.07 Leeds 0.08 0.16 Hull 0.08 0.01 Sheffield 0.10 0.18 Salford 0.33 0.29 Notwithstanding the exceptionally high death rate of London from diphtheria in 1893, it will be observed from the following table that the London death rate was below that of certain foreign cities, and in the ten year period 1883-92, below the death rates of the majority— Diphtheria. Death rates per 1,000 1883-92. Death rates per 1,000 1893. Death rates per 1,000 1883-92. Death rates per 1,000 1893. London .30 .76‡ St. Petersburg .61 .26 Paris .78* .52* Berlin 1.11 .92 Brussels .13 .04 Vienna .55† 1.14* Amsterdam .42 .23 Rome .43 .27 Copenhagen .78* .66 New York 1.0 1.05 Stockholm .93 1.40* Judged by the number of deaths attributed to diphtheria, the diphtheria death rate of 1893 is greater than that of any year since the Registrar-General, in his annual reports, began to separate deaths attributed to diphtheria from those attributed to scarlet fever, as will be seen by reference to diagram X. There is reason for thinking that some of this increase is apparent only, and that it is due in part to change in nomenclature, especially by transference to diphtheria of deaths which in former years would have been registered as croup. But even when correction for this transference is made by the addition of croup to diphtheria, it is found that the death rate from the two diseases is in 1893 considerably greater than that of the death rate of these diseases in any year in the period 1859-93. Reference to the table on page 30 shows that although the disease has not been uniformly distributed throughout London, the increase of 1893 has not been limited to any one part of London, but has occurred in almost all the London districts. The circumstances which may have contributed to the present prevalence of diphtheria deserve close examination. It is probable that among the factors concerned is some change in the type of the disease; the records of notification do not, howTever, extend far enough into the past to enable the fatality of later years to be compared with that of the time when the London death rates were at their minimum. The conditions which may cause an alteration in the quality of the contagium are not understood, but there is reason for thinking that epidemic diseases have a more or less regular periodicity with which increased virulence is associated. Among other factors concerned in determining the amount of prevalence of epidemic disease is undoubtedly the opportunity which may exist for the communication of infectious disease from person to person. In my last report I stated that I was examining for the Public Health Committee the statistics relating to diphtheria, and I now append to this report a preliminary memorandum which I presented to the Committee on this subject. (See Appendix I.) In this memorandum, diphtheria death rates in several groups of population, and at several ages in different periods, are compared. The groups of population are—England and Wales, urban, rural, urban excluding London, and London, the word "urban " denoting towns each of which has a population of more than 50,000, the word " rural " denoting the rest of the population of England and Wales. The periods selected for comparison are 1855-00, 1861-70, 1871-80, 1881-90, and 1891-93, the lirst period being determined by the fact that it is the earliest for which it is possible to obtain statistics * Including deaths from crcup. † Including deaths from croup 1891-2. ‡ See footnote (*), page 6. Diagram X. Diphtheria & Croup. Notified Cases. Diagram XII. Diphtheria, 18 92. Notified Cases. Diajram XIII Diptheria, 1893. 29 relating to this disease as distinct from those relating to scarlet fever. The ages selected are—all ages, ages under 3, from 3 to 10 years, and 10 years and upwards. A study of the rates shows that— (1) Antecedent to 1871-80 in groups of population when the diphtheria death rate at all ages was rising, the rate at ages 3-10 years, though generally rising also, rose in less degree than the all-age rate; and when the all-age rate was falling, the rate at ages 3-10 years fell in even greater degree than the all-age rate. (2) That in 1871-80 with a general decline of the diphtheria mortality at all ages in the several groups of population, there occurred in each group at ages 3-10 years a relatively higher diphtheria death rate than before, that is, the diphtheria mortality, at ages 3-10 years did not fall in 1871-80 in anything like the same degree as the diphtheria mortality at all ages. This new departure is most noticeable in London, and least noticeable in the rural groups. The special incidence upon the age 3-10 years in England and Wales and London is maintained in 1881-90 as compared with 1855-60 and 1861-70, but the material is not yet available for determining whether this special incidence is maintained in the other groups. If the London death rates of 1891-3 are compared with those of 1855-60, it is found that in 1891-3 while the all-age death rate had increased 313 per cent., that at the ages 3-10 years had increased 457 per cent., and again if compared with the death rates of 1861-70 it is found that in 1891-3 the all-age death rate had increased 196 per cent., and that at the ages 3-10 years had increased 309 per cent. It is important to determine as accurately as possible the year in the periods 1861-70 and 1871-80 in which the special incidence upon the ages 3-10 years was first manifested, and an examination of the statistics of each year shows that in the year 1871, the year following that in which the Elementary Education Act first came into operation, there was a notable increase of incidence of diphtheria mortality in the age period 3-10 years, which has been maintained ever since, and which has in later years been much accentuated. In view of the change in the age incidence of diphtheria mortality which has been referred to, it is desirable that diagrams illustrating the number of cases notified in each week in the years 1892 and 1893 should be studied as in the case of scarlet fever. Diagrams XII. and XIII. have therefore been prepared for this purpose. It is unnecessary to repeat here the observations on the subject of school influence which have already been made in discussing the decrease of scarlet fever in the month of August. It may however be pointed out that the August depression in the all-age diphtheria curve of 1892 is not obvious, but that of 1893 is distinct, and is especially conspicuous in the curve relating to children y from 3-13 years of age. Comparison of three periods of four weeks, viz., (1) 27th—30th, (2) 31st—34th, and (3) 35th— 38th, gives the following results— Under 3 years 3—13 years. 13 years and above. Increase or decrease per cent, of number of cases in 2nd period in relation to that of the 1st +20 O —O —10 Increase or decrease per cent. of number of cases in 3rd period in relation to that of the 2nd —7 +29 +34 In the year 1893, the schools closed generally on the 27th of July, i.e., near the end of the thirtieth week and re-opened on the 28th of August, i.e., at the beginning of the 35th week. If comparison be made between the three periods, (1) 28th—31st week, (2) 32nd—35th week, and (3) 36th —39th week, the following results are obtained— Under 3 years. 3—13 years. 13 years and above. Increase or decrease per cent, of number of cases in 2nd period in relation to that of the 1st +8 —27 + 1 Increase or decrease per cent, of number of cases in 3rd period in relation to that of the 2nd +6 +81 +33 The following table shows the age distribution of the cases notified and the fatality at the several ages of this disease. It will be seen that the incidence of attacks was greater on females than males and of deaths on males than females; the greatest incidence of disease was in both sexes in 1893 on children three to four years of age, but the greatest incidence of death was on children one to two years of age. The fatality (case mortality) of males was greater than the fatality of females; the highest fatality of the males occurred among those who were under one year of age, and of females among those who were from one to two years of age. A further point of some interest is that while at 'all ages' females suffered more than males from diphtheria, during each of the first four years of life they suffered 30 less heavily, the greater incidence of disease on the female sex at ' all ages' depending solely on the greater incidence at the other ages after four years— Diphtheria, 1893. Age period. Males. Females. Cases. Deaths. Case mortality per cent. Rate per 100,000 living. Cases. Deaths. Case mortality per cent. Rate per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 6,165 1,629 26.4 303 80 7,529 1,642 21.8 332 72 0— 151 101 66.9 274 183 144 83 57.6 256 148 1— 453 298 65.8 917 603 351 236 67.2 704 474 2— 524 279 53.2 1,014 540 508 223 43.9 979 430 3— 608 279 45.9 1,215 558 607 275 45.3 1,185 537 4— 577 222 38.5 1,186 456 600 222 37.0 1,227 454 5— 1,634 342 20.9 707 148 1,922 465 24.2 823 199 10— 684 45 6.6 324 21 884 54 6.1 411 25 15— 459 13 2.8 227 6 665 22 3.3 296 10 20— 343 11 3.2 173 6 575 11 1.9 240 5 25— 468 13 2.8 137 4 762 22 2.9 194 6 35— 169 9 5.3 67 4 297 11 3.7 106 4 45— 63 9 14.3 36 5 142 5 3.5 71 3 55 and upwards 32 8 25.0 19 5 72 13 18.1 31 6 Diagram XI. shows that a smaller proportion of the total cases notified in London were admitted into the hospitals of the Metropolitan Asylums Board in 1893 than in the preceding year, and that a smaller proportion of the deaths occurred in these institutions. The following table shows for each of the London districts (a) the number ot cases and the case rate in 1893, (b) the number of deaths and the death-rate in 1893, (c) the death rate in the period 1885-92. Diphtheria in London, 1893. Cases notified in 1893. Case rate per 10.000 in 1893. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Paddington 289 24 70 5.8 3.2 Kensington 373 22 83 5.0 2.9 Hammersmith 279 27 53 5.2 3.5 Fulham 251 24 64 6.1 Chelsea 236 24 52 5.3 3.0 St. George, Hanover.square 123 16 34 4.5 3.0 Westminster 83 15 14 2.6 3.9 St. James 46 19 14 5.9 1.4 Marylebone 401 29 94 6.7 1.8 Hampstead 166 23 38 5.2 2.3 Pancras 784 34 201 8.6 3.1 Islington 901 28 200 6.1 3.2 Hackney 965 40 206 8.6 3.4 St. Giles 78 20 22 5.7 3.4 St. Martin.in.the.Fields 27 19 8 5.7 2.7 Strand 76 32 22 9.3 2.3 Holborn 98 30 22 6.7 3.1 Clerkenwell 304 46 76 11.6 8.1 St. Luke 155 37 46 11.1 2.9 London, City of 68 19 11 3.1 2.8 Shoreditch 514 42 137 11.1 3.3 Bethnal.green 746 58 136 10.5 5.0 Whitechapel 208 28 61 8.1 4.3 St. George.in.the.East 240 53 62 13.7 4.7 Limehouse 240 42 61 10.7 3.8 Mile.end Old.town 352 33 80 7.4 3.4 Poplar 1,149 68 168 10.0 3.0 St. Saviour, Southwark 89 33 17 6.3 3.2 St. George, Southwark 189 32 45 7.5 2.8 Newington 478 41 93 7.9 2.9 St. Olave 32 25 7 5.4 2.5 Bermondsey 229 27 80 9.5 2.2 Rotherhithe 106 27 31 7.8 2.1 Lambeth 829 30 185 6.6 3.6 Battersea 660 42 167 10.6 2.6 Wandsworth 453 26 113 6.6 Camberwell 515 21 130 5.3 2.6 Greenwich 491 29 147 8.6 2.7 Lewisham 225 23 54 5.5 2.2 Woolwich 27 6 8 1.9 1.0 Plumstead 237 25 85 9.0 2.5 Port of London — — — — — London 13,712 32 3197 7.4† 31† § See footnote (*), page 26. t See footnote (t), page 6. 31 Several references are made to the subject of school influence in the reports of the medical officers of health. The medical officer of health of Fulham writes " no special school influence could be traced in the cases occurring here during the year, as among children attending school there were 99 cases with 23 deaths, and 90 cases with 39 deaths among children not attending school; the incidence of the disease, taking into account the relative number of the two classes being greater on the latter, and in only 5 of the cases occurring among those not attending school was the disease apparently contracted from another child in the same house who had been attending school." The medical officer of health of Hampstead on the other hand writes " personal infection from communication in schools, and from returned cases from hospitals, was found to be one cause of the spread of disease." The medical officer of health of Shoreditch, discussing a special incidence of diphtheria on the Acton ward, states " in several instances no school was attended, but in many cases the disease first attacked a child who was attending school, and who became, apparently, the means of introducing the disease in the family." The medical officer of health of Clapham writes "one fact, however, becomes obvious in looking at the ages of the sufferers. Very nearly all were of school age, very few indeed were under three years of age, and very few over 15. I think therefore that schools are responsible for spreading diphtheria from pupil to pupil to a far greater extent than is generally supposed." The medical officer of health of Putney states that " of the 69 cases notified, no less than 44 occurred in a comparatively small area bounded by the High-street and Charlwood-road to the east and west, and Upper Richmond-road and Lower Richmondroad to the south and north." After discussing the sewer ventilators of this area, and water supply fittings of the houses, he states " as the result of my inquiries, however, in regard to all the cases notified, I was compelled to come to the conclusion that, after making allowance for the injurious results of these sanitary defects the majority of the cases were due to personal infection. I was confident that there were cases of children suffering from mild diphtheria, in regard to whom no precautions were taken, and for whom no medical aid was called in. The infection was either spread from one to another during school hours or while playing together in the streets." In a few instances the opinion is expressed that diphtheria has been caused by exposure to drain or sewer air. Thus the medical officer of health of Plumstead writes " as to the causes of the great prevalence of diphtheria in Plumstead, and the comparative immunity of Woolwich, I can only repeat what I said last year, that I have found nothing but the manhole ventilators to account for it." The medical officer of health of Islington comments on the disappearance of diphtheria from among the children attending the Yerbury-road Board School subsequent to the improvement of the drainage of the school, and states " the Yerbury-road Board School, from the sewer air theory point of view, holds a unique position, for undoubtedly it proves, albeit negatively, that sewer air can and does convey the germs of diphtheria into the interior of our dwellings through defective sanitary appliances." The opinion is expressed by the medical officer of health of St. George-the-Martyr, Southwark, that " amongst the existing causes (of diphtheria) are (a) density of population, (6) close aggregation in schools with insufficient floor space, (c) aggregation in block buildings and on their staircases and court yards, (d) dampness and cold." The medical officer of health of Clapham recommends the exclusion from school of children suffering from any sort of sore throat until the production of a certificate from a medical man that there is no danger of infection. The Public Health (London) Act, 1891, section 55 (4), requires every medical officer of health who receives a certificate under this section to send within twelve hours after such receipt a copy thereof to the head teacher of the school attended by the patient (if a child) or by any child who is an inmate of the same house as the patient. The medical officer of health of St. George-the-Martyr, Southwark, having notified his willingness to supply certificates when premises have been disinfected, found on enquiry at a later period " that about one half only of those who should have called for the certificate of final disinfection came for it." A communication to the London School Board on the subject led to that Board replying on the 16th January, 1894, that the Board had recently decided to insert in the Code of Regulations for the Guardians of Managers and Teachers, the following paragraph—" In the event of the head teacher not receiving this certificate, it becomes his duty to send to the officer of the local authority in order that he may procure it," and it was further stated that " if it should be found that teachers do not get the certificates the School Management Committee of the Board will further consider the matter." The medical officer of health of Lewisham states that " all children are excluded from school who come from a house in which zymotic disease is known to exist. I think that in many cases they are allowed to return before the house is thoroughly free from infection. I have been asked lately by the medical officer of health for the School Board to give certificates in all cases where the disinfection of the house has been completed, certifying that the rest of the children in the house are free from infection, and can therefore return to school. This I have not at present agreed to, as I consider that such certificates should be given by the medical man in attendance, and that it [might throw onus on to sanitary authorities, and possibly in some cases lead to legal proceedings. I think that special provision should be made in the Public Health Act for this matter, as no child should be allowed to resume attendance at school till a medical certificate is given that the other children in the house are free from infection and the house itself has been properly disinfected. The medical officer of health cannot be expected to examine all the children to see whether they are free from infection, and therefore his certificate in regard to disinfection of premises might lead to misunderstanding." The insufficiency of hospital accommodation is mentioned by the medical officer of health of Kensington, and the medical officer of health of the Strand expresses the opinion that opportunity should be given for the bacterial examination of suspected cases of diphtheria. Whooping Cough. The deaths attributed to whooping cough numbered 2327 in 1893, being slightly less than the number of deaths from this disease in the preceding year. 32 The death rates per 1,000 living from this disease in 1893 and previous periods were as follows— 1851-60 0.88 1891 0.68† 1861-70 0.88 1892 0.58† 1871-80 0.81 1893 0.54† 1881-90 0.69 London, however, notwithstanding this progressive decline in the death rate, still had in 1893 and the preceding ten years, a death rate higher than those of the majority of the other large English towns. Death rate from whooping cough per 1,000 living. Ten years, 1883-92. 1893. Ten years, 1883-92. 1893. London 0.65 0.54* West Ham 0.75 0.68 Manchester 0.66 0.47 Bristol 0.49 0.34 Liverpool 0.69 0.55 Bradford 0.45 0.50 Birmingham 0.58 0.66 Nottingham 0.53 0.27 Leeds 0.46 0.44 Hull 0.49 0.38 Sheffield 0.57 0.38 Salford 0.73 0.49 Compared with the following foreign cities, London, both in the period 1883-92 and in 1893' suffered more heavily from whooping cough. Mortality per 1,000 persons living, 1883-92. Mortality per 1,000 persona living, 1893. Mortality per 1,000 persons living, 1883-92. Mortality per 1,000 persons living, 1893. London .65 .54* St. Petersburg .22 .20 Paris .19 .21 Berlin .31 .35 Brussels .22 .21 Vienna .14 .08 Amsterdam .39 .32 Rome .09 .07 Copenhagen .50 .39 New York .30 .29 Stockholm .27 .24 The death rate of each year in relation to the mean rate of the period 1841-1853 is shown in Diagram XIV. As in the case of measles, several of the medical officers of health lay stress upon the neglect of precautions for the prevention of the spread of whooping cough, no effort being made in many instances to isolate infected children or indeed to properlv tend the sufferers. The death rates in each sanitary district in 1893 and in the preceding ten years is shown in the following table— Whooping Cough. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Paddington 60 5.0 4.4 Bethnal-green 60 4.6 9.2 Kensington 65 3.9 4.8 Whitechapel 26 3.5 5.2 Hammersmith 50 4.9 6.7 St.George-in-the-East 23 5.1 7.3 Fulham 82 7.9 Limehouse 64 11.2 10.2 Chelsea 68 6.9 6.9 Mile-end Old-town 44 4.1 8.6 St. George, Hanover- 14 1.8 3.5 Poplar 74 4.4 7.9 square St. Saviour, 20 7.5 6.9 Westminster 15 2.7 6.2 wark St. James 8 3.3 4.5 St. George, 74 12.4 9.2 Marylebone 78 5.6 4.8 wark Hampstead 6 0.8 3.4 Newington 109 9.3 7.9 Pancras 106 4.5 6.5 St. Olave 3 2.3 5.3 Islington 197 6.0 6.5 Bermondsey 46 5.5 8.1 Hackney 165 6.9 5.6 Rotherhithe 33 8.3 7.1 St. Giles 18 4.7 5.3 Lambeth 151 5.4 6.5 St. Martin - in - the - 2 1.4 4.1 Battersea 114 7.2 6.6 Fields Wandsworth 81 4.7 Strand 11 4.6 5.5 Camberwell 109 4.5 7.0 Holborn 16 4.9 7.2 Greenwich 100 5.9 6.9 Clerkenwell 51 7.8 7.5 Lewisham 8 0.8 5.3 St. Luke 40 9.6 7.7 Woolwich 20 4.8 5.5 London, City of 4 1.1 3.3 Plumstead 32 3.4 4.9 Shoreditch 80 6.5 9.4 London 2,327 5.4† 6.6t * See footnote (*), page 6. t See footnote (f), page 6. 33 Typhus Fever. During the year 1893, 22 persons were certified to be suffering from typhus, and 5 deaths from this cause were registered. The death rates from this disease per 1,000 living in 1893 and in previous periods were as follows 1871-80 .05 1892 .003† 1881-90 .008 1893 .003† 1891 .ooo† Inquiry as to the cases notified in London in 1893 gave the following results. In my last report I pointed out the frequency of error in the diagnosis of this disease, and the record of 1893 resembles that of the preceding year in this respect. January.—A case was notified as typhus fever in Marylebone, on removal to hospital the diagnosis was not confirmed. February.—On February 10th a girl aged 7 living in Batter sea sickened, and a day or two later a diagnosis of typhus fever was made, and she was removed to hospital. The case was then found to be one of enteric fever. It appeared that the brother of this girl had been removed to hospital on February 2nd, the case having been notified as one of scarlet fever. The diagnosis of scarlet fever in this latter case was confirmed on admission to hospital. March.—A boy aged 12 living in Fulham was certified to be suffering from typhus, and was removed to hospital on March 6th. The case was there found to be one of enteric fever. A young man aged 19 living in Mile-end was certified to be suffering from typhus on March 19th, and was removed to hospital, when it was found that his disease was not typhus. April.—A man aged 63, who had recently arrived in Paddington from Russia, was certified on April 12th to be suffering from typhus. Patient was ill when he first came (about one week before April 12th) into the district. He was not removed to hospital. On April 30th a case of typhus was notified in Marylebone. The man died, and his death was then certified to have been caused by heart disease. May.—On May 9th a girl living in Bermondsey was certified to be suffering from typhus; the rash was not typically developed, however, and the girl died on the following day. There remained some doubt as to the nature of her illness. On May 20th a boy aged 6 living in Poplar was certified to be suffering from typhus ; there was some difficulty, however, with regard to the diagnosis, and the nature of the malady appears to have remained doubtful. A case was notified on May 27th in Kensington, but subsequently proved to be one of pneumonia and not of typhus. On May 28th a man aged 46 living in Lambeth was certified to be suffering from typhus fever at the house where he had lived for several years; he died after 7 days' illness. He was not removed to hospital. June.—On June 16th a man aged 19 living in Whitechapel was certified to be suffering from typhoid fever. On removal to hospital his illness was found to be typhus fever. The patient had been residing in the house where he was taken ill for three or four years, and no source of infection could be traced. July.—On July 8th a woman living in Limehouse was certified to be suffering from typhus, but the case was subsequently found not to be bne of that disease. On July 26 a girl aged 16, whose place of residence was in St. George, Southwark, was removed to hospital, having been certified to be suffering from typhus fever. The opinion subsequently formed, however, was that her illness was not typhus fever, but that she was suffering from an affection of the pelvic organs. August.—Two children living in Lambeth were certified first to be suffering from diphtheria, and then from typhus fever. They were not removed to hospital. No other cases of typhus existed in the neighbourhood. September.—A child living in Holborn was certified to be suffering from typhus on September 20th. The disease, however, proved to be typhoid, and the sister of the patient developed typhoid fever a few weeks after the commencement of the first child's illness. Two notifications with respect to patients coming from Limehouse were made on September 20th. One of the patients, a girl aged 18, had been certified on September 14th to be suffering from typhoid ; on the 20th she and her brother, aged 10, were certified to be suffering from typhus, and were removed to hospital. The nature of the illness in both cases, however, was ultimately determined to be enteric fever. October.—A girl aged 14 living in Battersea was certified to be suffering from typhus fever on October 10th. She had been resident in the house where she was taken ill about 8 years, and was attending school. The commencement of the illness dated from October 3rd. The patient was removed to hospital. No source of infection could be traced. November.—A man aged 27, a milkseller in Battersea, was certified on November 4th to be suffering from typhus, he was removed to hospital. Dr. Kempster writes: "Enquiry made as to the possible source of infection has failed in this case. Patient had been " in no house where infectious disease had occurred as far as could be ascertained." † See footnote (†), page 6. [5] 34 A certificate was received on November 7th relating to a child aged 7, living in St. George-the-Martyr, Southwark, but the medical man attending the case subsequently cancelled his notification, and returned the case as one of typhoid. The annual report of the medical officer of health of Islington contains reference to a case of typhus occurring in November. The patient was a paperhanger living in the Langdon-road, Islington, who in the first instance was certified to be suffering from enteric fever. He was removed to the Great Northern Hospital, where he died, the death being attributed to typhus. The source of infection was unknown. December.—A case in Shoreditch, notified on December 2nd as typhus, subsequently proved to be one of typhoid fever. It will be seen that after excluding all the cases in which the later development of the malady led to the diagnosis of typhus fever being rejected, there remain ten cases. Three of these cases were admitted to hospitals of the Metropolitan Asylums Board, and the diagnosis of typhus fever was there confirmed, one was removed to the Great Northern Hospital. The remaining six cases were not removed to hospital. Diagram XV. shows the death rate in each year since 1868, in relation to the mean of the whole period 1869-93. Enteric Fever. The cases of enteric fever notified in the County of London during the year 1893 numbered 3,681, and the deaths belonging to London 677, or increases of some 50 per cent. upon the numbers of the preceding year. Diagram XVI. shows the death rate of each year in relation to the mean death rate of the period 1869-93. The rates in 1893 and in previous periods were as follows— Period. Death rate per 1,000. Case rate per 1,000. Case mortality per cent. 1871-80 0.24 * 1881-90 0.19 * _ 1891 0.12† 0.8 15.6 1892 0.10† 0.6 17.2 1893 0.16† 0.9 18.4 London has therefore not only suffered more heavily from enteric fever, but it is noteworthy that in each of the years 1892 and 1893 the cases have been attended by a higher fatality than in the preceding year. The following table shows the case mortality, case rate, and death rate from this disease at various ages during 1893. It will be seen that the incidence of attack and of death was greater on males than on females, but the fatality (case mortality) of females was greater than that of males. § Enteric fever, 1893. Age period. Malta. Females. Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages. 2,040 377 18.5 100 19 1,622 313 19.3 71 14 0— 3 3 100.0 5 5 3 1 33.3 5 2 1— 11 4 36.4 22 8 4 1 25.0 8 2 2— 17 1 5.9 33 2 22 4 18.2 42 8 3— 24 2 8.3 48 4 22 3 13.6 43 6 4— 45 4 8.9 92 8 38 4 10.5 78 8 5— 255 32 12.5 110 14 244 29 11.9 105 12 10— 413 43 10.4 196 20 286 45 15.7 133 21 15— 344 47 13.7 170 23 248 54 21.8 111 24 20— 295 55 18.6 149 28 215 38 17.7 90 16 25— 348 101 29.0 102 30 288 63 21.9 73 16 35— 181 45 24.9 72 18 142 36 25.4 51 13 45— 69 28 40.6 39 16 63 18 28.6 32 9 55 and upwards. 35 12 34.3 21 7 47 17 36.2 21 7 * The Infectious DiseaEes Notification Act only came into force in 1889. † See footnote (†) page 6. § See footnote (*), page 26. 35 The higher incidence in 1893 as compared with that of the preceding year is not due to special prevalence in any one district, but occurred in 34 of the 41 sanitary districts. The following table shows the case rates and death rates per 10,000 in each of the several sanitary districts in 1893, and the death rates per 10,000 in the period 1885-92. Enteric Fever. Cases. Case rate per 10.000. Deaths. Death rates per 10,000. In 1893. In 1885—92. Paddington 67 6 21 1.7 1.3 Kensington 97 6 17 1.0 1.0 Hammersmith 67 7 15 1.5 Fulham 59 6 17 1.6 1.3 Chelsea 76 8 17 1.7 1.3 St. George, Hanover-square 68 9 12 1.6 1.1 Westminster 41 7 7 1.3 1.0 St. James 22 9 6 2.5 1.2 Marylebone 94 7 20 1.4 1.1 Hampstead 35 5 8 1.1 0.9 Pancras 169 7 27 1.2 1.4 Islington 263 8 47 1.4 1.4 Hackney 363 15 53 2.2 1.7 St. Giles 32 8 6 1.6 1.9 St. Martin-in-the-Fields 6 4 1 0.7 1.3 Strand 11 5 1 0.4 2.1 Holborn 41 12 13 4.0 1.5 Clerkenwell 68 10 10 1.5 1.4 St. Luke 32 8 12 2.9 1.4 London City of 27 8 — — 1.1 Shoreditch 117 10 16 1.3 1.6 Bethnal-green 138 11 25 1.9 1.7 Whitechapel 62 8 8 1.1 1.3 St. George-in-the-East 44 10 4 0.9 1.7 Limehouse 115 20 18 3.2 1.9 Mile-end Old-town 146 13 29 2.7 1.9 Poplar 390 23 62 3.7 1.8 St. Saviour, Southwark 21 8 3 1.1 1.1 St. George, Southwark 46 8 13 2.2 1.0 Newington 66 6 13 1.1 1.3 St. Olave 6 5 2 1.6 1.4 Bermondsey 47 6 8 1.0 1.3 Rotherhithe 29 7 8 2.0 2.0 Lambeth 159 6 36 1.3 1.2 Battersea 128 8 22 1.4 1.2 Wandsworth 118 7 18 1.0 Camberwell 141 6 27 1.1 1.2 Greenwich 115 7 28 1.6 1.6 Lewisham 63 6 11 1.1 1.0 Woolwich 28 7 5 1.2 1.3 Plumstead 44 5 11 1.2 0.7 Port of London 20 — — — London 3,681 9 677 16† l.4† In 1892, in view of the risk of invasion of London by cholera, I had made inquiry of the medical officers of health of the several sanitary districts as to any wells in their districts supplying water for domestic use, and as to the fitness of water of such wells for this purpose. The report of the medical officer of health of St. Luke contains an instructive account of the danger attending the use of water from any such well which is exposed to risk of contamination, and emphasizes the importance of critical examination of the circumstances of all local wells. I therefore reproduce this part of Dr. Yarrow's report— Last October, in response to an application of the medical officer of the London County Council, I furnished a list of wells situated in this parish, three of which were found to be supplying water for drinking and domestic purposes. Since furnishing the list, I have narrowly watched the returns of infectious disease, with the view to ascertain if any such could be traced to the use of water obtained from either of the sources indicated, with the result that I am now able to connect an outbreak of enteric fever with the use of polluted water from one of the wells, and to show that the water obtained from a second well is so contaminated with sewage or surface drainage as to render it unfit for the purposes for which it has been used. Well No. 1 is situated in a factory known as 25, Richmond-street, which extends along the rear of 19, 20, 21, 22, 23 and 24 in that street. The ground floor is in the occupation of a firm of zinc workers, who also furnish steam power to the floors above, and which are occupied respectively by the proprietors of decorative glass works, a surgical instrument maker, a hollow razor grinder and a glass embosser on the first floor, an engineer's on the second floor, and a cycle manufacturer and a whalebone polisher on the third floor. About 67 persons are as a rule employed on the premises. The well is described as a tube well about 35 feet deep, and the water, besides being used to supply the boilers to obtain steam power was, at the time of my visit, used also for drinking purposes by all the employees, in fact there was no other source of water on the premises. It further supplied the houses † See footnote (†), page 6. 3 0 Nos. 19, 20 and 26, Richmond-street; 17 persons reside in these houses, making a total of 84 persons who were using the water from the same source. About 20 feet distance from the well there are three water-closets and a large urinal, and about ten feet distant a second water-closet; these are the only sanitary conveniences on the premises. On July 3rd, a case of typhoid fever was notified, occurring in a lad 14 years of age, residing at 15, Wellesley-street; July 29th a man aged 26, also of 15, Wellesley-street, was certified to be suffering from continued fever Inquiries showed that both these patients were employed on the upper floor of the factory, 25, Richmondstreet, also that two other men were absent from work through illness, the nature of which was not then ascertained, as their places of residence were unknown. On August 3rd I obtained a sample of the water from a draw tap on the ground floor, and sent it to Mr. Stokes for analysis. On the 5th he furnished the accompanying certificate— " * * * I am of opinion that the water has become contaminated with surface drainage, and that it is not safe water for drinking purposes. It would be advisable to prohibit such water being used for drinking." Notice was thereupon served on the owners of the premises to discontinue the use of the water for drinking purposes, and the work necessary for obtaining a supply of water from the New River Company's mains was at once proceeded with and completed on August 20th. In the meantime the lad aged 14 (first case notified) died, the cause being certified as typhoid fever. On August 16th, case No. 2 was removed from his home to St. Bartholomew's Hospital, it was then certified as a case of enteric fever, and the patient died August 24th. I have seen the two men whose addresses could not at the time of my visit to the factory be ascertained. One of them was absent from work four weeks, and the other about ten days. The medical man who attended the former informs me that although he was unable to identify the illness with enteric fever, he has no doubt it was in great measure caused by the use of water from a polluted source, in the second of these cases the man was treated at his home for febrile catarrh. On the Wednesday last, September 6th, I received a certificate notifying that a girl 14 years old, residing at 19, Richmondstreet (one of the houses supplied from the well in question) was suffering from enteric fever. Upon enquiry 1 learned that the patient had been ill for four weeks, but the medical men under whose care she had been were unable to satisfy themselves as to the nature of the complaint until after a consultation which took place on the 5th instant. In view of the result of the analysis of the water in the last case I caused samples to be obtained from the two other wells mentioned in the first part of this report, and forwarded the same to Mr. Stokes, and his certificate is as follows— " * * * On consideration of these facts I am of opinion that the water 101a is a moderately good sample of drinking water. In its present state no ill effect could be anticipated from the use of such a supply. There is no evidence of any sewage contamination. Sample 102a is quite unfit for drinking purposes ; it is evidently largely contaminated with sewage or surface drainage, and should certainly not be used at all for drinking purposes or for cleaning out any vessels that may be used to contain food." The sample identified in the certificate as 101a was obtained from No. 2 well, said to be a tube well, depth unknown. It is situated on the premises of a clothworker, &c., 136, Old-street. It is the only source of water supply on the premises, where about 20 persons are employed. All the water, however, from the well passes through a filter before it can be used. Sample 102a, of which such a bad report appears in the certificate, was obtained from well No. 3. This is also said to be a tube well about 25 feet deep. It is situated at 138, Lever-street, in the occupation of a tripe dresser, &c. On my visit to the premises I was informed that the well water was only used for " cooling the various articles after cooking, the water for the latter purpose being obtained from the New River Company, and from which source there was an ample supply on the premises." On receipt of Mr. Stokes' certificate in this case, I also caused a notice to be served on the owners to forthwith discontinue the use of the water from the polluted well for drinking purposes or the preparation of any article of food, and am informed that since the receipt of the notice all dressing, cooking, &c., has been done at other premises belonging to the firm. Nevertheless, seeing the nature of the business, and that they have a supply of pure water, I strongly recommend the vestry to proceed, if necessary, with steps to obtain an order for closing this well, and in accordance with the vestry's resolution the well has since been filled in. Since furnishing the list of wells to the County Council last October, I have learned of the existence of four other wells in the parish, two being situated on premises belonging to Messrs. Le Grand Sutcliffe of Bunhill-row, well sinkers, &c., and two on those of Messrs. Allen and Sons, drug grinders, 7, Cowperetreet. These are all artesian wells, from 175 to 345 feet in depth, and although the water is used by the employees of each firm for drinking purposes, its chief use is that of supplying power for machinery, and having in view the depth of the borings, and the comparatively recent construction in each case, I have not thought it necessary to have the water analysed. Another reference to water as a source of enteric fever is found in the report of the medical officer of health of Plumstead. Dr. Davies states that— In former years it has been possible to trace most of the cases of enteric to infection caught outside the parish, but not so this year. In fact, in the case of all the men employed in the arsenal, I could find no likely source of infection, but the conclusion seems to me irresistible that the source, whatever its nature, was inside the arsenal. Within the last week a case has occurred in which the patient stated that he was in the habit of drinking water used for an engine, and drawn from the arsenal canal. I have also been informed that it is no uncommon practice to drink the water of this canal. As this water is liable to be polluted with the excreta of labourers working in its vicinity, it is very likely to contain the infection of enteric fever. If men are so foolish as to drink this impure water, the arsenal authorities cannot be blamed for the result, provided they supply sufficient sources of pure water. I may add that I have been in communication with the director-general on the subject of enteric fever in arsenal employees ; he instituted an enquiry, and the senior medical officer reported that there were no conditions in the arsenal likely to give rise to enteric. Diarrhcea. The deaths in the administrative county of London attributed to diarrhoea and dysentery in the year 1893 numbered 3,445, being an excess of 35 per cent, over the number of deaths in 1892. The death rates per 1,000 living in 1893 and in preceding periods have been as follows— 1851-60 1.03 1891 0.58* 1861-70 1.04 1892 0.60* 1871-80 0.94 1893 0.80* 1881-90 0.74 The increase in 1893 is no deubt due to the higher temperature of the summer quarter of that year. * See footnote (†), page 6. Diagram XVII. shows the death rate from diarrhoea in each year in relation to the mean of the period 1841-93, and farther shows the mean temperature in the summer quarters of corresponding years. The age distribution of the deaths from this disease registered in London (excluding penge) in 1893 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. 2,567 511 32 25 60 197 54 Compared with the 11 other great towns of England, London both in 1893 and in the preceding ten years 1883-92, had a lower death rate from diarrhoea than any except Bristol, as will be seen from the following table— Death rates from Diarrhoea per 1,000 living. Ten years, 1883-92. 1893. Ten years, 1883-92. 1893. London 0.72 0 80* West Ham 0.79 1.24 Manchester 1.02 1.74 Bristol 0.49 0.63 Liverpool 1.02 1.69 Bradford 0.79 1.46 Birmingham 1.11 1.66 Nottingham 1.03 1.47 Leeds 1.09 1.56 Hull 1.02 2.36 Sheffield 1.08 1.87 Salford 1.41 2.11 The death rate of each sanitary district in 1893 and the mean death rate of the period 1885-93 is shown in the following table— Diarrhcea. Deaths in 1893. Death rate per 10,000 in 1893. Death rate per 10,000 in 1885-92. Deaths in 1893. Death rale per 10,000 in 1893. Death rate per J 0,000 in 1885-92. Paddington 57 4.9 5.3 Whitechapel 66 8.7 8.8 Kensington 100 6.0 4.9 St. George - in - the - 85 18.6 16.4 Hammersmith 83 7.9 10.1 East Fulham 132 12.6 Limehouse 61 10.7 9.7 Chelsea 73 7.6 7.7 Mile-end Old-town 121 11.3 8.0 St. George, Hanover- 26 3.4 4.1 Poplar 185 10.9 6.3 square St. Saviour, 18 6.8 8.4 Westminster 43 7.8 6.5 wark St. James 7 3.0 4.5 St. George, 70 11.6 9.1 Marylebone 84 6.0 6.3 wark Hampstead 22 3.1 2.8 Newington 126 10.8 7.0 Pancras 164 7.0 6.8 St. Olave 9 6.9 9.2 Islington 259 7.9 6.8 Bermondsey 70 8.2 8.0 Hackney 164 6.8 5.6 Rotherhithe 25 6.2 9.3 St. Giles 23 5.9 6.4 Lambeth 197 7.0 6.5 St. Martin - in - the - 5 3.7 4.5 Battersea 122 7.8 6.7 Fields Wandsworth 119 6.9 Strand 12 5.2 6.2 Camberwell 186 7.6 6.4 Holborn 27 8.3 6.9 Greenwich 143 8.3 6.6 Clerkenwell 73 11.2 10.0 Lewisham 38 4.0 4.5 St. Luke 47 11.3 10.2 Woolwich 33 7.9 5.1 London, City of 10 2.8 3.1 Plum stead 54 5.7 4.0 Shoreditch 161 13.1 10.2 London 3,445 8.0† 6.8† Bethnal-green 145 11.4 7.6 Cholera. Before referring to the history of cholera in 1893 it may be well to recall briefly the main features of the epidemic of the preceding year. Judging by published statistics, cholera during 1892 destroyed about 170,000 lives in Europe. Russia, with upwards of 150,000 deaths, suffered to a very much greater extent than any other country, and this estimate would require to be increased by some 70,000 deaths if the adjoining Caucasus were included with European Russia. In Germany rather less than 10,000, and in France less than 5,000 deaths were recorded. Then follow Hungary with some 1,200 fatal cases, Belgium with rather less than 1,000, and Holland with less than 300. A few imported cases were met with in other countries, and in four instances persons who arrived in London itself were * See footnote (*), page 6. †See footnote (†), page 6. 37 33 suspected to be suffering from the malady. The disease appeared to spread in Europe from two centres, reaching Russia from the Caucasus, and travelling across the country from south-east to north-west, and also appearing early in the year in the neighbourhood of Paris, particularly affecting in the first instance a number of communes in the department of the Seine supplied with water taken from the river below the outfall of the main sewer of Paris, and then spreading mainly northwards. Havre was attacked in July, and nearly 500 deaths occurred in that town in the course of a few months. It may be noted too that more than 100 deaths were reported from Lorient. In Germany the chief centre of the disease was Hamburg, in which city more than 8,000 deaths occurred during the year. The Hamburg outbreak assumed special importance in relation to England as the majority of the cases imported into this country were traceable directly or indirectly to that city. At the beginning of 1893, though but few cases of cholera were recorded in Europe, there was evidence of the widespread distribution of the disease. The Hamburg epidemic of 1892 had come to an end in November of that year, but in December there was a small " after epidemic," and cases continued to occur during the early weeks of 1893. Sporadic cases were also reported, in various parts of France, and an outbreak occurred at Grand Port Philippe, a fishing village near Gravelines ; the disease, moreover, had not wholly died out in Russia. At the end of January, 1893, two outbreaks occurred which were subsequently made the subject of report by Professor Koch, the one at a lunatic asylum at Nietleben, and the other, the winter outbreak at Altona. Throughout February and March reports of attacks of cholera were from time to time received from parts of Russia, and there was evidence that the province of Podolia was particularly affected. At the end of March came the news that the French port Lorient, which had suffered in the preceding year, was again attacked, and rumours were current as to the presence of the disease in Marseilles. The number of cases in Russia began to show increase as the weather became warmer, Podolia being still specially involved ; the disease appeared too in the adjoining Austrian territories of Eastern Galicia. In June sporadic cases were reported from several localities in France,, notably from Alais, Nimes, and Montpellier, and from parts of Brittany. In this month cholera was reported to be prevailing in Mecca, and much anxiety was felt lest the pilgrim routes should offer facilities for the spread of infection westwards. It was stated that some 40,000 pilgrims had passed through Suez on their journey east to Mecca, and it was feared that the pilgrims on their return would bring cholera with them. On their way home they would need to pass the quarantine station at El Tor, at which place it was anticipated cases of the disease would ere long be met with. In July reports of cholera continued to be received from Mecca, and it was now stated that a number of cases had occurred at El Tor. The prevalence of the disease appeared to be increasing in Russia and Hungary, and cases were from time to time reported in France. At the end of the month the resources of the quarantine station at El Tor were severely strained, some 18,000 pilgrims being then under detention; the number of actual cases of cholera was not however large. In August the epidemic continued to gain ground. Reports from St. Petersburg showed increase in the number of cases in the Russian provinces; in Galicia the disease was spreading. An outbreak occurred at Naples, and from Holland, Germany and France sporadic cases were reported. These reports continued to be received from the localities previously involved, and it may be noted that an outbreak occurred early in September at Leghorn, and later in the month an asylum at Scutari was attacked. Another outbreak was developed too in Hamburg, some 150 cases being notified in that city during September. The Mecca pilgrimages terminated at the end of September, and it was then ascertained that while some 44,000 pilgrims had passed through Suez on their way east, only 30,388 had returned. During October the general decline in the prevalence of cholera became marked, and in November and December there is little to record. Cases were reported from Teneriffe, however, before the close of the year, the disease still lingered in Russia, and an occasional case was heard of elsewhere. The cholera of 1893 occasioned a much smaller number of deaths than did the epidemic of 1892. In 1893, as in the previous year, the country especially attacked was Russia, the number of deaths, 41,047, falling however far short of that recorded in 1892, viz., 158,589. The Caucasus, which suffered severely in 1892 (upwards of 80,000 deaths), was comparatively free from the disease in the succeeding year, (1,203 deaths) ; in the province of Podolia, however, 7,593 deaths occurred in 1893 as compared with 2,292 in 1892. In Germany the 1893 outbreak was insignificant in comparison with that of 1892, when the returns were swelled by the mortality recorded in Hamburg. In France some 3,000 deaths occurred during 1893. The occurrences of cholera in England and the steps taken in connection with this disease may now be briefly stated. The continued occurrence of sporadic cases of cholera in France determined the issue on June 22nd of a circular letter addressed by the Local Government Board to London sanitary authorities, asking how far the preliminary action taken last year or since decided on by the authorities was to be regarded as enabling them without delay to carry out regulations under Section 82 (1) of the Public Health (London) Act in the event of it being deemed necessary by the Board to issue such regulations. On June 25th a vessel which had had a case of cholera on board arrived in the Tyne from Nantes, and during July two cholera-infected vessels arrived in the Thames. Towards the end of August attention began to be directed to cases of illness occurring in this country, and on material for bacteriological examination being submitted to Dr. Klein, it transpired that Grimsby and Hull were attacked by the disease. On the 1 st September the Local Government Board made an order declaring epidemic regulations to be in force in the urban sanitary districts of Grimsby, Cleethorpe-with-Thrunscoe and the port sanitary district of Grimsby. On September 2nd a case of illness occurred in Westminster, which was stated by Dr. Klein a few days later to be Asiatic cholera. During September and the early part of October cases were reported from a number of localities throughout the country. For the most part these cases were isolated ones. In some instances there appeared reason for supposing infection had been conveyed from Grimsby or Hull; in the majority 39 of instances the source of infection could not be traced. In the case of Grimsby suspicious increase in the number of deaths from diarrhoea had it appeared already been manifested in the early part of August. The total number of notifications of cholera received during the outbreak was 114, and 33 deaths occurred. In Hull the first case was reported on the 24th August, though it is stated in the annual report of the medical officer of health that the first suspicious case of illness was that of a man who sickened on the 16th of August. Between the 6th September and the 20th October there were notified in Hull 17 cases of cholera, 12 proving fatal; 137 cases of choleraic diarrhoea, 4 proving fatal; and 396 cases of diarrhoea, 112 proving fatal. A few cases occurred in Cleethorpes, near Grimsby ; an outbreak in connection with a polluted water supply was noted at Ashbourne, in Derbyshire, 15 cases occurring there, and 9 proving fatal; and cases which proved on bacteriological examination to give positive results occurred at Rotherham, Balby, East Retford, Boston, Morton, Leicester, Cotonhill Asylum, Derby, Liverpool, Manchester, Croydon, Ilkeston, Great Yarmouth, Tividale, Bingley, Keighley, Accrington, North Bierley, Rawmarsh, and one or two other places. During the early part of the year I was in communication with the medical officers of health of London sanitary districts as to the fitness of any local wells in these districts for supply of water for domestic purposes, and as to the state of preparedness of these districts in the event of the appearance of cholera. The question of available hospital accommodation was one which had been specially considered, and in a few instances it was thought that there would be advantage in obtaining permission to use certain plots of vacant land in the Council's possession for the erection of temporary hospitals in case of need. The Council resolved on the recommendation of the Public Health and Housing Committee on the 9th May—" That, subject to the particular sites being approved by the proper committees, the Council do approve of facilities being given in case of necessity for the erection of temporary cholera hospitals on land in its possession." On the occurrence of the case of cholera in Westminster, I was authorised to send to Dr. Klein for bacteriological examination, material from persons suffering from Asiatic cholera, and concerning whose cases this examination was desirable. I accordingly communicated with the London Medical Officers of Health, inviting them to give me notice of suspected cases of this disease, and I was subsequently engaged with Drs. Hamer and Young in making inquiry into all cases which were brought to my knowledge by the medical officers of health, through the returns of notified infectious diseases, or the death returns of the Registrar-General. In all cases of death, whenever practicable, post-mortem examinations were made, and whenever such a course appeared desirable, material was sent to Dr. Klein for bacterial examination. Of the total number of cases investigated, numbering upwards of fifty, there were 16 cases of illness with regard to which suspicion was entertained, in 13 of these cases it was possible to employ bacteriological examination as an aid to diagnosis, and in 4 instances such examinations gave positive results. The first of these cases, the Westminster case above referred to, was that of a cleaner in the House of Commons, who was attacked on September 2nd ; the second patient was an inmate of the Fulham Union Workhouse, who was attacked on September 10th; the third patient lived in Kennington-road, and was attacked on September 11th; and the fourth patient lived in Quinns-square, Waterloo-bridge-road, and was attacked on September 23rd. These four cases were fatal ones, and it is noteworthy that in each instance the patient was more than 50 years of age. Further details concerning the London cases will be found in the report on cholera in London in 1893, which is printed as an appendix to this report. (See Appendix II.) During October reports relative to the occurrence of suspected cases in this country entirely ceased. In London some anxiety was for a few days felt as to the nature of an outbreak of diarrhoeal disease in the Greenwich workhouse. An inmate of this institution was taken ill on October 10th on her way from the workhouse to Royal-street, Lambeth. I made inquiry into the circumstances of her death, and material for bacteriological examination was forwarded to Dr. Klein. It was then ascertained that a number of the workhouse inmates had been suddenly attacked with diarrhoea, and further cases continued for a few days to develop. The disease was however attended by a low rate of mortality, and Dr. Klein's examination gave negative results both in respect of the original case and of subsequent cases, from which material was submitted to him. The report of the medical officer of health of the Port of London contains the following account of ships infected with cholera in the port during 1893— (1.) On the 20th July, the s.s. " Altmore," of Aberdeen, from Malliporum, via Marseilles and Havre arrived at Gravesend, and was cleared by Her Majesty's Customs, and received the certificate of " pratique." On subsequent examination of the vessel by Dr. Williams a man was found who had been suffering from severe diarrhoea-vomiting and cramps. The vessel left Marseilles on the 5th after a stay of two days, during which time the patient had been on shore. The case was so suspicious that the man, although convalescent, was at once removed to the Port Sanitary Hospital, and the vessel and effects disinfected. An examination of the dejecta showed the presence of the comma bacillus. This not only confirmed the presence of Asiatic cholera, but also showed that the patient, though convalescent, was still capable of disseminating infection. This point was clearly demonstrated during the outbreak in Hamburg in 1892, and the practical lesson is that all cholera patients must be isolated for some considerable time, probably not less than ten or twelve days, after complete convalescence—a very serious consideration in dealing with an outbreak of any large extent. (2.) On the 29th July, the s.s. "Bona" which had left Bussorah on the 10th June, reported that a death from cholera had occurred on board on the 19th June. The vessel was disinfected throughout. (3.) On the 2nd August, Mr. Swales, who was acting on behalf of your authority in case of emergency, reported a man sick with suspicious symptoms on board the "Elizabeth McLea,"lying at Sheerness. On examination he was found to be suffering from cholera. He was therefore removed to the Port Sanitary Hospital in the " David Burnett," and the vessel towed round to the isolation moorings off Denton, and there disinfected. She left Cherbourg at 10 a.m. on the 31st J uly, the patient being attacked with the usual symptoms. On bacteriological examination the cholera bacillus was found to be present in his excreta. (4.) On the 26th August, the s.s. " Samuel Tyzack," of Sunderland, from St. Petersburg, arrived at Gravesend, and reported one of the crew suffering from diarrhoea and vomiting. As a precautionary measure he was removed to the Port Sanitary Hospital, and the vessel fumigated. (5.) On the 2nd September, the s.s. "Afghan," of Rochester, from Bussorah, arrived at Gravesend, 40 having had three deaths from cholera on the voyage, the victims being pilgrims from Jeddah. The vessel was simply detained for disinfection. (6.) On the 8th September, a sailmaker on the " City of Athens," of Glasgow, lying at Northfleet (outward bound), was removed to the Port Sanitary Hospital in the "David Burnett" with suspicious symptoms, and the vessel disinfected. (7.) On the 9th September, the engineer of the steam-tug " Eagle," with suspected cholera, was removed to the Port Sanitary Hospital, and the usual precautions taken. Although a marked case clinically, bacteriological examination failed to detect the presence of the comma bacillus. (8.) On the evening of the 14th September, a telegram was received from the medical officer of the London County Council stating that a case of cholera had been admitted into St. Bartholomew's Hospital from the barge " Memory," lying off Castle Baynard-wharf, within the City limits. The barge was at once taken charge of and an inspector placed on board during the night. The barge was loaded with sand, which had been largely contaminated by the liquid excreta of the patient. It was therefore thoroughly saturated with a strong solution of perchloride of mercury, and towed down below the Nore, where it was finally thrown overboard. This was a marked case of cholera, though happily the patient recovered under treatment. (9.) On the 23rd September the s.s. "Amara," of London, from Bussorah, arrived at Gravesend and reported three deaths from cholera on the voyage. She left Bussorah on the 14th August, and the three deaths occurred within the five days following, being buried at sea. The vessel was simply detained for disinfection. (10.) On the same date, the s.s. " Houbrook," of London, from Cronstadt, arrived at Gravesend with a case of cholera on board. The vessel left Cronstadt on the 14th September, the patient being attacked with the usual symptoms on the 17th. He was removed to the Port Sanitary Hospital in the launch " David Burnett," and died a few hours after admission. The comma bacillus was successfully demonstrated. (11.) On the 11th December, the s.s. "Bona" arrived from Bussorah, having had a death from cholera while at Bussorah. No action was deemed necessary. (12.) On the 23rd December, the s.s. " Eton," on arrival at Gravesend, reported having had three cases of illness on the voyage from Sulina, all convalescent on arrival. From the symptoms there seemed little doubt but that they had suffered from an attack of cholera. The vessel was therefore detained for the disinfection of the crew's quarters and all effects therein. In all, therefore, during the six months twelve vessels have been dealt with as infected. Of these, five had actual cases on board at the time and two were suspicious, and therefore treated in the same way. The remaining five had cases during the voyage, and four of these were disinfected as a precautionary measure. The following is an abstract of the references to administrative arrangements in connection with cholera in the annual reports of the medical officers of health— Kensington.—The medical officer of health reports that provision had been made for the establishment of three ambulance stations in the district, at the parish infirmary, the workhouse at Mary-place, and the St. Marylebone infirmary, Notting-hill, at which institutions about 150 or 160 beds could be made available for the sick at a few hours notice. Hammersmith.—The report of the vestry states that certain preliminary arrangements were made. Fulham.—The medical officer of health reports that the Board of Guardians of the Fulham Union had promised to provide beds for 50 patients at the union infirmary, and steps were taken to obtain sites for erection of temporary hospitals and shelters should they have been required. Arrangements were made for four ambulance stations in the district. Chelsea.—Several unoccupied houses in Sydney-street were placed at the disposal of the medical officer of health by the guardians for the reception of persons who might have to be removed, while their homes were undergoing cleansing and disinfection. St. George, Hanover-square.—The medical officer of health reports that " the preparations made by me in 1892 in case of an invasion of cholera were described in my last annual report ; the arrangements made still hold good, and could be set to work at any time." St. Pancras.—The arrangements of the previous year were again adopted, and steps were taken for securing early notice of deaths from diarrhceal diseases. Authority was given by the vestry for compensation to be given for any infected article destroyed, and for the employment of a bacteriologist. Arrangements were also made as to the medical treatment of cases of suspected cholera. Islington.—This district was divided into suitable areas, and a medical practitioner and druggist appointed to each. Posters and handbills, similar to those published in 1892, containing instructions as to the precautions to be adopted, were also issued. Hackney.—A committee of the vestry reported on the subject of hospital provision, ambulance stations, the division of the district into suitable areas for the treatment of the sick, and as to the arrangements which could be made for medical visitation and treatment. The medical officer of health was instructed to make inquiry as to vacant houses in the district which could be utilized as shelters. St. Giles.—The medical officer of health recommended, if there should be necessity, the provision of an hospital on the Shelton-street area, inasmuch as most of the accommodation that the Metropolitan Asylums Board could provide was not within the district. Arrangements were made in such event for the district to be divided into four areas, and for the appointment of medical practitioners, for the supply of drugs and for interments. St. Martin-in-the-Fields.—The arrangements made in the previous year were continued. Three medical practitioners were selected for the treatment of the sick. Strand.—The medical officer of health reports that " the arrangements made by the various authorities in previous years in case of epidemic were re-established in 1893 and improved." Shoreditch.—The Shoreditch Guardians placed at the disposal of the Metropolitan Asylums Board a small block containing ten beds. Provision was made by the vestry for accommodation of persona during the disinfection of their rooms. Poor law medical officers were prepared to keep their surgeries open day and night for the treatment of any one suffering from diarrhoea. Whitechapel.—The preparations were mainly renewal of preparations of previous years. A large open space in possession of the district board was drained so as to be ready upon emergency for the erection thereon of temporary hospitals. 41 St. George-in-the-East.—The measures adopted in 1892 were again revived. Mile-end Old-town.—The medical officer reported that arrangements made in 1892, together with those which could be made at very short notice, would be sufficient. Limehouse.—It was decided to erect a hospital, should occasion require, on the vacant land belonging to the County Council in Cranford-street, Ratcliffe. Poplar.—The medical officers of health reported in July on the result of their enquiries as to sites for temporary hospitals, and as to the use of houses for shelters should there be necessity for such provision, as to the division of the district into suitable areas for visitation by medical men, and as to the arrangements that could be made for the treatment of cholera and diarrhoea. Improvement of apparatus for disinfection is strongly recommended. St. George-the-Martyr.—The medical officer of health referred to his report for the previous year, and to the letter of the Metropolitan Asylums Board, indicating the stations which would be available for ambulances. The lists of institutions in south London into which cases of cholera could be received is also given. Wandsworth District.—The medical officers of health reported on the arrangements which would have become necessary in the event of prevalence of cholera. Thus hospital accommodation, places of refuge, visitation of poorer houses, medical attendances, nurses, &c., disinfection of houses, destruction of infected clothing, and interment of the dead, are referred to. Plans for a temporary hospital in Wandsworth parish were prepared. In Streatham " a site was obtained, hospital tents provided, and other arrangements made." Greenwich.—Greenwich parish.—The medical officer of health made recommendations as to the division of the district into suitable areas for the arrangements for the medical treatment of sick persons, and reported as to the hospital accommodation available. Deptford parish.—The medical officer of health reported that " every arrangement was made in case it [cholera] should appear among us." Woolwich.—The medical officer of health reports "proper steps were taken for dealing with any outbreak of this disease if it had occurred, both in the direction of providing proper medical and nursing treatment and in the provision of litters and hospital accommodation, this latter being again found in the Woolwich infirmary." Plumstead.—The medical officer of health reports—" I was in communication with the County Council and the Asylums Board on the subject, and advised as to preparation for ambulance stations, &c. I also made arrangements to secure the services of trained nurses in case they were needed, and the committee authorised me, in the event of cholera appearing, to take any measures which I might deem necessary before I could consult them." During April, 1893, an international conference was held at Dresden with a view to agreement as to the measures which could be adopted for the prevention of cholera in European countries. The conclusions of the conference were made public at the end of June. It had been arranged that notification of the existence of cholera in a country was to be given to all the governments represented at the conference, but unfortunately it was decided that isolated cases should be ignored, and only a cholera focus (" Foyer ") was to be notified. This understanding rendered the undertaking practically valueless. The conference fixed a maximum of restriction as to land traffic, sea traffic and merchandise, which the contracting governments undertook not to exceed, while certain minimum restrictions were to be enforced by the countries concerned. An important proposal was adopted to the effect that vessels were to be deemed infected only if they had had cholera on board within seven days of arrival, and that they were not to be dealt with as infected ships merely because they had sailed from an infected port. Certain recommendations were made as to modifications, under particular conditions, of the restrictions placed upon the importation of rags.* The conclusions of the conference constituted a distinct advance in the direction of the removal of quarantine restrictions. Erysipelas. The deaths attributed to erysipelas in the Registration County of London in 1893 numbered 292. The corrected annual average of the preceding ten years being 302.8. The number of cases notified and the number of deaths registered in London in each of the last three years were as follows— Cases. Case rate per 1,000 living. Deaths. Death rate per 1,000 living. 1891 4,673 1.1 214 05 1892 6,943 1.6 292 07 1893 9,712 2.2 424 10 During these years, therefore, both cases and deaths have been increasing in number. * The Local Government Board had in 1892 made orders to the effect that no rags from France, or from any port in the Black Sea, or Sea of Azof, or from any other port of Turkey in Asia, and no rags, bedding, or disused or filthy clothing from any foreign port in Europe north of Dunkirk other than ports of Sweden, Norway, or Denmark, should be delivered overside except for the purpose of export or disinfection. On the 7th August, 1893, by a further order, these orders were relaxed so far as they related to rags packed in bales and imported as merchandise; and the above requirements were restricted in their application to dirty bedding or disused or filthy clothing, the terms " bedding " and " clothing " being held to include such articles when torn up, but not to include rags packed in bales or imported as merchandise. This order further provided for the destruction by the sanitary authority or their medical officer of health, at the cost of the person having control over the same, of any bedding or clothing delivered overside or landed for the purpose of disinfection or destruction and not disinfected or destroyed by such person within 48 hours. On the 13th September, 1893, a further order was issued defining the words " rags packed in bales and imported as merchandise," in the order of 7th August, to mean rags compressed by hydraulic force, transported as wholesale marchandise in bales surrounded by iron bands and with marks and numbers showing their origin, and accepted as such by the Commissioners of Her Majesty's Customs. [6] 42 The number of cases and the case rate of each sanitary district in London is shown in the following table— Erysipelas. Cases in 1893. Case rate per 10,000 in 1893. Cases in 1893. Case rate per 10,000 in 1893. Paddington 240 20 Whitechapel 216 29 Kensington 273 16 St. George-in-the-East 112 25 Hammersmith 183 18 Limehouse 186 33 Fulham 156 15 Mile-end Old-town 282 26 Chelsea 206 21 Poplar 566 34 St. George, Hanover-square 82 11 St. Saviour, Southwark 54 20 Westminster 84 15 St. George, Southwark 144 24 St. James 33 14 Newington 284 24 Marylebone 379 27 St. Olave 36 28 Hampstead 78 11 Bermondsey 188 22 Pancras 656 28 Rotherhithe 80 20 Islington 702 21 Lambeth 581 21 Hackney 499 21 Battersea 432 27 St. Giles 98 25 Wandsworth 380 22 St. Martin-in-the-Fields 9 6 Camberwell 436 18 Strand 22 9 Greenwich 357 21 Holborn 95 29 Lewisham 183 19 Clerkenwell 229 35 Woolwich 50 12 St. Luke 168 41 Plumstead 132 14 London, City of 76 21 Port of London 2 — Shoreditch 317 26 London 9.712 22 Bethnal-green 426 33 Puerperal Fever. The deaths attributed to puerperal fever in London in 1893 numbered 352. The corrected annual average of the preceding ten years being 297'9. The number of cases notified and the number of deaths attributed to diphtheria in London in each of the three last years was as follows— Case rate per Death rate per Cases. 1,000 living. Deaths. 1,000 living. 1891 221 •05 222 •05 1892 338 ■08 313 •07 1893 400 •09 352 •08 The number of cases notified and the case rates of each sanitary district in 1893 were as follows— Puerperal fever. Cases in 1893. Case rate per 10,000 in 1893. Cases in 1893. Case rate per 10,000 in 1893. Paddington 18 1.5 Bethnal-green 18 1.4 Kensington 9 0.5 Whitechapel 9 1.2 Hammersmith 18 1.8 St. George-in-the-East 5 1.1 Fulham 18 1.7 Limehouse 6 1.1 Chelsea 5 0.5 Mile-end Old-town 5 0.5 St. George, Hanover-square 3 0.4 Poplar 10 0.6 Westminster 5 0.9 St. Saviour, Southwark 1 0.4 St. James 3 1.3 St. George, Southwark Newington 4 0.7 Marylebone 10 0.1 6 0.5 Hampstead 5 0.7 St. Olave 1 0.8 Pancras 24 1.0 Bermondsey 5 0.6 Islington 40 1.2 Rotherhithe 4 1.0 Hackney 18 0.8 Lambeth 27 1.0 St. Giles 2 0.5 Battersea 19 1.2 St. Martin-in-the-Fields — — Wandsworth 20 1.2 Strand — — Camberwell 23 0.9 Holborn 2 0.6 Greenwich 22 1.3 Clerkenwell 1 0.2 Lewisham 11 1.1 St. Luke 2 0.5 Woolwich 1 0.2 London, City of — — Plumstead 10 1.1 Shoreditch 10 0.8 London 400 0.9 lhe increase observed during these years is therefore also noticeable in the case of puerperal fever. 43 Influenza, Bronchitis and Pneumonia. In 1892 the number of deaths attributed to influenza and to pneumonia was greatly in excess of the average of the preceding ten years. The deaths attributed to bronchitis were below the average. So again in 1893 the number of deaths from the first two diseases was above, and from bronchitis below the average. In 1893, however, the deaths attributed to influenza and bronchitis were fewer, and from pneumonia greater than in 1892. The number of deaths attributed to these diseases in 1892 and 1893, was as follows— Influenza. Bronchitis. Pneumonia. Year. Deaths. Corrected annual average for preceding ten years. Deaths. Corrected annual average for preceding ten years. Deaths. Corrected annual average for preceding ten years. 1892 1893 2,264 1,526 318.7 556.2 11,183 10,413 11,2300 11,260 0 6,164 7,198 5,171.9 5,341.6 Although a few deaths from influenza occurred in each week of the year 1892, the chief prevalence occurred in the first two months of the year. In 1893 there were two periods of maximum prevalence. In March and April the number of deaths though numbering less than 50 in each week were considerably in excess of the numbers registered in the months preceding and following this period. In the latter part of November and in December the disease again attained epidemic prevalence, the increase of deaths from influenza being accompanied by an increase in the deaths attributed to bronchitis and pneumonia. The number of deaths in this period is shown on the following table— Week of year. "Week ending. Influenza deaths. Bronchitis. Pneumonia. Deaths. Corrected average for corresponding week of preceding ten years. Deaths. Corrected average for corresponding week of precediDg ten years. 1893. 44 Nov. 4 8 191 233.8 125 107.1 45 „ 11 20 220 241.5 137 109.7 16 „ 18 22 318 253.5 228 112.2 47 „ 25 36 384 262.8 215 121.8 48 Dec. 2 74 426 259.1 248 115.1 49 „ 9 127 491 268.4 266 113.2 50 „ 16 164 421 281.6 232 112.8 51 „ 23 147 387 305.7 203 121.4 52 „ 30 108 306 404.6 157 136.8 The reports of all the medical officers of health do not afford information as to the number of deaths attributed to influenza in their districts, but the following table gives this number so far as can be learnt from these reports— Estimated population, middle of 1893. Deaths in 1X93. Estimated population, middle of 1893. Deaths in 1893. West— East— Paddington 120,421 75 Shoreditch 123,440 36 Kensington 167,029 93 Bethnal-green 129,620 40 Hammersmith 103,044 17 Whitechapel 75,178 31 Fulham 104,735 39 St. George-in-the-East 45,493 21 Chelsea 98,182 33 South— St. George, Hanover-square 76,043 13 St. George, Southwark 59,953 7 St. James, Westminster 24,000 5 Newington 117,672 33 North— St. Olave 12,903 6 Hampstead 73,380 50 Bermondsey 84,246 16 Pancras 233,936 69 Rotherhithe 40,020 9 Islington 327,919 123 Wandsworth 172,143 64 Hackney 240,584 86 Camberwell 245,143 82 Central— Greenwich 171,120 28 St. Giles 38,641 18 Lewisham 98,258 54 St. Martin-in-the-Fields 14,034 4 Woolwich 41,854 10 Strand 23,788 6 Plumstead 94,596 35 St. Luke 41,577 10 Phthisis. The deaths from phthisis registered in London in 1893 numbered 8,179. The death rates of this disease per 1,000 living in successive periods have been as follows— 1851-60 2.86 1891 2.00* 1861-70 2.84 1892 1.88* 1871-80 2.51 1893 1.90* 1881-90 2.09 * Bee footnote (*), page 6. 44 Cancer. The deaths from cancer registered in London in 1893 numbered 3,412. The death rates of this disease per 1,000 living in successive periods have been as follows— 1851-60 .42 1891 .77* 1861-70 .48 1892 .74* 1871-80 .55 1893 .79* 1881-90 .68 Meteorology. The tables published in the annual summary of the Registrar-General, and prepared by Mr. James Glaisher, F.R.S., from observations at Greenwich, show that the mean temperature of the air in the year 1893 was 51.1 degrees Fahrenheit, or 2.5 degrees above the average of 122 years. The mean temperature of each quarter of the year was also in excess of the corresponding mean of 122 years. The rainfall in the year 1893 amounted to 2013 inches, and was 4.98 inches less than the mean of 78 years. The amount of rainfall in each of the first three quarters of the year 1893 was below the average of the corresponding quarter of 78 years, that of the fourth quarter above the average of 78 years. The temperature and rainfall in each month were as follows— . The temperature and rain ft Month. ill in each month were as follows— Temperature of the Air. Departure from average of 122 years. Rain. Highest by Day. Lowest by Night. Mean for the Month. Number of days it fell. Amount collected. January deg. deg. deg. deg. inches. 52.2 13.9 35.. — 1.2 15 1.45 February 58.8 23.1 41.1 + 23 22 2.72 March 66.3 24.2 46.2 + 5.2 7 0.43 April 80.0 30.2 51.4 + 5.3 3 0.12 May 80.4 380 57.7 + 5.2 9 0.53 June 910 37.3 61.8 + 3.5 8 0.82 July 89.9 47.1 63.1 + lo 18 3.33 August 95.1 43.2 65.5 + 4.6 11 1.25 September 82.8 37.5 57.1 + 0.5 14 1.29 October 66.7 30.2 51.5 + 21 15 4.16 November 60.0 27.4 41.8 — 0.7 16 1.84 December 56.3 20.2 40.6 + 1.6 16 219 ADMINISTRATION. Dairies, Cowsheds and Milkshops. During 1893 the Council's inspectors made 11,034 inspections of dairies and milkshops, and 3,960 inspections of cowsheds. In 9 instances legal proceedings under the Dairies, Cowsheds and Milkshops Order were instituted, and in 7 of these, penalties amounting in the aggregate to £19 were imposed. The number of applications for renewal of existing licenses to cowsheds, dealt with during the year, was 500, of these 483 were granted. Four licenses were granted in the case of new premises for the first time. 217 cases of infectious disease occurring in milkshop premises were dealt with during the year; these included 133 cases of scarlet fever, 46 cases of diphtheria and membranous croup. 21 cases of enteric fever, 10 cases of smallpox, 5 cases of erysipelas and 2 cases of measles. In all cases steps were taken to prevent contamination of the milk. Offensive Trades. During 1893 the Council's inspectors made 4,947 inspections of premises upon which offensive trades (including that of a slaughterer of cattle) were carried on. In 18 instances legal proceedings were instituted, in 15 of these penalties amounting in the aggregate to £56 15s. were inflicted. The number of applications for renewal of existing licenses to slaughterhouse premises dealt with during the year was 528, of these 522 were granted. In the case of knackers' yards, seven existing licenses were renewed. The Council sanctioned during the year the establishment anew of the business of a slaughterer of cattle in four instances, and that of a fellmonger in one instance. An application of Messrs. J. C. and J. Field under sec. 19 (2) of the Public Health (London) Act, 1891, for sanction to the establishment anew of the business of a soap.boiler (such business being 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) was also granted. Messrs. Field undertook to relinquish their existing right to conduct the business of a soapboiler under sec. 19 (1) (a) of the Act at premises in Bermondsey. Two persons were convicted for establishing anew, without the sanction of the Council, the business of a gut-scraper. In March, complaints were received that serious nuisance was caused in Deptford by the distillation of " bone oil," a substance produced in the process of manufacturing animal charcoal. I reported to the Committee and pointed out that " the business of an animal charcoal manufacturer, that * See footnote (*), page 6. 45 is to say, any business in which bones are converted into charcoal, or in which any residual produced in such conversion is dealt with," had been scheduled in 1888 by the Metropolitan Board of Works as an offensive business. The solicitor communicated with the manufacturer, and the business was discontinued. During the year a number of offensive businesses which had been discontinued for a period of nine months or upwards were struck off the Council's register. These businesses included those of a blood-drier, two fat-melters, a fellmonger, a gut-scraper, a manure manufacturer, two soap-boilers, and a tallow-melter. The business of a manure manufacturer carried on at Arch No. 492, London, Brighton and South Coast Railway, Rotherhithe, was discontinued by a magistrate's order in October, 1893. The occupier of these premises had previously been convicted and fined on several occasions for breaches of the by-laws, and in October, 1892, he was warned that if the nuisances were not abated the Council would apply to a court of summary jurisdiction for an order to suspend or prohibit his carrying on the business. In the summer of 1893 further nuisances occurred, and proceedings were again instituted. On this occasion he was fined and warned that should the offence be repeated the magistrate would have no hesitation in making an order depriving him of his business. Further nuisances again occurred, and were proved before the magistrate, and the order was made. The following are the principal nuisances resulting from trade operations referred to in the reports of the medical officers of health— Kensington—(1) From the carriage of fish offal, in this case there was a conviction for the infringement of the Council's by-laws ; (2) from marine stores ; (3) from brick-burning. With respect to marine stores, application had formerly been made to the Metropolitan Board of Works to declare the business of a marine store dealer a noxious trade, but in the opinion of the Board's solicitor this trade could not thus be dealt with, inasmuch as it was not ejusdem generis with those specified in the provisions relating to noxious trades. With respect to brick-burning, the Council had in 1889 asked the sanction of the Local Government Board to make by-laws for regulating this trade. That Board, however, had declined, and had expressed the opinion that section 21 of the Public Health (London) Act would suffice. Proceedings under this section were instituted by the Yestry of Kensington. Hammersmith—From various deposits of dust-bin refuse; from smoke ; from the Albert Mills, Oil Mill-lane; from factories in the neighbourhood of the " Chancellors," Hammersmith; from piggeries; from slaughterhouses; from brick-burning; from tripe-boiling; from bone-boiling in Acton; from gas works. Fulham—From removal of offal and of bones and fat from butcher's premises; proceedings were instituted in connection with the removal of bones and fat, with the result that the defendants agreed to comply with the Council's by-laws pending application to the Council as to the businesses which were subject to such by-laws. St. James, Westminster—From offensive smells and dust, and from discharge of hot water and steam into the vestry's sewer from the electric light station in Mason's-yard. The vestry directed proceedings to be taken. St. Pancras—Effluvia, smoke and heat from fried-fish shop. Order for abatement made by the magistrate. Clerkenwell—" Two offensive trades re-arranged." Shoreditch—From the works of the Gas Light and Coke Company. The officers of the vestry recommended— 1. The provision of funnel-shaped collectors connected with the furnace flues placed above the doors of the retorts to collect the smoke and fumes arising during the drawing and charging of the retorts, and to prevent their dissemination through the retort house. 2. The enlargement and better covering of the shoot at the Whiston-street works to prevent unnecessary contact of the lime with the air. 3. Watering the surface of the dry lime in the lower tiers of the purifiers to prevent dust rising, and covering the unworked surface of the purifier and of the sieves when removed with sacking or tarpaulin, as is done in some works described by Dr. Ballard in his report to the Local Government Board. 4. The passing of air through the purifiers just preceding the removal of the cover, in order to take up as much of the free sulphuretted hydrogen and residual coal gas as possible. The engineer to the Croydon Gas Company was consulted by the vestry. He agreed with the second and third recommendations, but regarded the first as impracticable, and stated that from the account of the precautions taken when a purifier is discharged, he thought it extremely unlikely that any nuisance was caused at either of their (the gas company's) works beyond what is inseparable from the manufacture of gas. A letter was addressed to the gas company, advising them to carry out the recommendations in the report of the engineer. Limehouse—From the smelting of sulphide of antimony, the apparatus allowing the escape of large quantities of sulphuric acid gas; a notice for immediate abatement was complied with. From barges containing fish offal passing along the Limehouse-cut; it was decided that a letter be addressed to the Conservancy Board asking for preference to be given to the passage of such barges, and for proceedings to be taken against the owners if nuisance was caused. Poplar, Bow—From discharging refuse from acetic acid and soda works into sewers ; means were adopted for preventing refuse passing into sewers. From defective smoke hole in connection with fishcuring ; the smoke hole was repaired. From escape of sulphuretted hydrogen from the main shaft of sulphate of ammonia works; the condensing apparatus was increased. From cork-burning; extra precautions were taken to prevent escape of noxious vapours. From burning out castor-oil cans at tin works; the process was discontinued. From escape of noxious vapours from a set of fat-melting pots; the boiling apparatus was repaired. Poplar and Bromley—From fumes from antimony smelting discharged into the atmosphere; the works have been cleansed. From scraping and drying fish-skins; the works were closed. From fumes from drying kilns of colour works discharged into the atmosphere; a condensing apparatus 46 was fitted up. From escape of sulphurous and nitrous gases from the main shaft of chemical works; extra condensing apparatus was fitted. From dust from chaff-cutting escaping into the atmosphere; the works were closed for the present. From vapours from sack-drying escaping into the atmosphere; the works were closed. From vapours and dust from a dust destructor ; a set of cells was fitted. From refuse from naphthaline stills being discharged into the sewer ; the refuse was made to run off into receivers. From escape of offensive vapours from oil-boiling ; the furnace was put into repair. St. George-the-Martyr—From gut-cleaning without the sanction of the Council; the Council required the premises to be closed. From fish-frying ; the nuisance was abated. Rotherhithe—Nuisance from the premises of an oil refiner is referred to. Battersea—From dust and smoke from atmospheric grain elevator; the defects were remedied. Greenwich—From conveyance of offensive matter through the streets ; proceedings were instituted and fines inflicted for infringement of the Council's by-laws. Plumstead—From tripe-boiling without the sanction of the Council; the Council instituted proceedings and a fine was inflicted. Nuisances. During the year 1893, 836 applications were made to the Council for the removal of conditions which it was alleged were dangerous to health. Inquiry was made into the merits of each complaint, and, where necessary, communications were addressed to the sanitary authorities concerned. In January a complaint was received that a pond near Binden-road, Hammersmith, was being filled up with house refuse and sludge. Serious nuisance had been caused in the summer of the previous year by the tipping of refuse into this pond, and the fear of the complainants that the nuisance would recur was ascertained to be a well-grounded one. The Vestry of Hammersmith was communicated with, and the pond was kept under observation. Occasion did not arise for further action on the part of the Council. The Council's attention had been directed from time to time to complaints made by inhabitants of Fulham and Hammersmith relative to an offensive odour which had been attributed to a variety of causes. The Vestry of Hammersmith requested that the Council would direct one of its inspectors to make inquiry into the matter. As the nuisance was of more than local concern, the Committee complied with the vestry's request, and arrangements were made for keeping the locality under special observation. In July I reported that the smell complained of was admitted to be less serious than it was some time before, and not of such frequent occurrence. Certain sources of occasional nuisance were pointed out, and the medical officer of health of Fulham undertook to give the matter further attention. The polluted condition of the Limehouse-cut was the subject of correspondence between the Council and the Lea Conservancy Board during the year. In April I reported on the specific sources of pollution of the cut, and the Public Health Committee urged upon the Conservancy Board the necessity for passing more water down the cut from the upper reaches of the Lea; the engineer to the Lea Conservancy Board reported that it would not be practicable to empty the cut and renew the water, as such a course would probably cause subsidence of the buildings and tow-paths abutting on it. The condition of the cut was still under consideration at the end of the year. In October, 1892, the attention of the Council was directed by the Limehouse District Board to the accumulation of mud and refuse upon the foreshore of Limekiln-creek, and I reported upon the matter and pointed out the need for periodical cleansing. The attention of the port sanitary authority was called to this subject, and in February, 1893, copies of my reports and the correspondence were forwarded to the Local Government Board. Question arose as to the authority upon whom the duty of clearing out the creek devolved, and on May 3rd the port authority obtained a magistrate's order against the Thames Conservancy to abate the nuisance by clearing away the deposit. An appeal against this order was heard on the 13th December, and judgment was given against the port authority. The work of cleansing the creek was not carried out until the following year. In several instances the keeping of swine upon premises unfit for such a purpose was brought to the notice of the sanitary authorities concerned, who were asked to take action under sec. 17 of the Public Health (London) Act. Smoke Nuisance. In my last annual report 1 published a table giving details as to the number of cases of smoke nuisance dealt with by the police, the number of cases in which proceedings before a magistrate were instituted and the number of convictions during each of the years in the period 1882-1890. This table showed that in the year 1890, the year before the Public Health (London) Act came into operation, 702 cases of smoke nuisance were dealt with ; in 53 cases proceedings were taken, and in 46 cases there were convictions. In some of the reports of the medical officers of health the number of cases of smoke nuisance dealt with in 1893 is not stated, but so far as the figures which are supplied show, there were 578 cases which received the attention of the sanitary authorities, proceedings concerning which wpre instituted in 41 f.isps These proceedings were instituted in the following districts— Number of proceedings. Result. Fulham 1 Dismissed. St. Saviour, Southwark 15 Conviction in each case. Bermondsey 17 Conviction ,, Rotherhithe 1 Conviction „ Lambeth 6 Conviction in 5 cases. Wandsworth 1 Not stated. In numerous instances the attention of the sanitary authorities was directed by the Public Control Department of the Council to cases of smoke nuisance, and these authorities took the necessary steps for their abatement. Under the Public Health (London) Act an offence is committed if (a) the furnace is not so constructed as to consume cr burn the smoke, (b) if the furnace is negligently used. In the Fulham 47 case, in which a summons was dismissed, proceedings were taken against the owner of the Fulham Pottery " for so negligently using the furnace as that the smoke arising therefrom is not effectually consumed or burnt." The magistrate, however, held " that although the existence of the nuisance was shown, it was for the vestry to prove that the furnace was so constructed so as to consume or burn the smoke arising therefrom, otherwise there could be no conviction for negligence." Regent's and Grand Junction Canals. During the year 1892 the Vestries of St. Marylebone. St. Pancras, and Paddington appointed a joint committee to consider the condition of the Regent's and Grand Junction Canals in these districts. This Committee caused inspection to be made of the canals, and a report containing the following recommendations was adopted— 1. That the three vestries should each in their respective districts take measures to prevent objectionable solid or liquid substances from fouling the canal, and to prohibit the discharge into the canal of all drainage other than unpolluted surface water. 2. That a sewer be constructed for the Zoological gardens, and that the Crown and the Zoological Society be requested to join with the vestries of St. Marylebone and St. Pancras in defraying the expense. 3. That the canal companies should be required by the vestries to systematically scavenge the surface of the canals and the banks thereof thrice a week on alternate days during June, July and August, and twice a week throughout the rest of the year. 4. That the canal companies should be required to cleanse the bottom of the whole of the canals, including the basins and lay-byes annually. 5. That the canal companies be required to concrete the basins, lay-byes, &c., where mud or other deposits are likely to accumulate. 6. That an overflow should be constructed by the Canal Company at the southern end of Cumberland basin, and that existing sluice valves in the basins should be opened far more often than hitherto. 7. That the County Council be requested to make by-laws pursuant to section 16 of the Public Health (London) Act, 1891. The Public Health Committee of the Council procured copies of the joint report and communicated them to other London sanitary authorities in whose districts the canals are situated, and asked to be informed of the condition of the canals in these districts. In reply the Committee received the following information— Hammersmith.— Letter from the vestry clerk, dated 16th November, stated that the medical officer of health of the district reported that the canal was not in a state of nuisance, and had not heretofore been so found. When rubbish and dead cats and dogs, &c., which have been collected from the surface of the canal, have been found to be burning in heaps on the banks, the company have been called upon by the vestry to remove the offensive matter and to cease to allow such rubbish to be burned. Kensington.—Letter from the vestry clerk, dated 10th December, stated that the canal appeared to be in a satisfactory condition at that time, and not to call for any action on the part of the vestry. Chelsea.—Letter from the vestry clerk, dated 19th November, enclosed copy of reports by the medical officer of health of the district from which it appeared that the principal nuisance was due to the floating carcases of dead animals, but there was also at places a very considerable deposit of thick black mud which is liable to cause offence in warm weather. St. Luke.—Letter from the vestry clerk, dated 21st December, enclosed copy of report of the medical officer of health of the district, dated 13th December, in which it was stated that that portion of the canal known as the basin, and situated within this parish, was in a very unsatisfactory condition from a health point of view, and in which it was recommended that notices to abate nuisances as they arose be served on the owners and occupiers of the several wharves, and where they occurred at frequent intervals, that application be made for recurring orders. The letter of the vestry clerk further stated that the vestry had adopted the course suggested by the medical officer. Shoreditch.—Report of the medical officer of health and surveyor of the district, dated December 8th, in which it was stated that the towing path was in a dirty muddy condition, and that its surface drainage, with horse droppings, urine, &c., flowed into the canal. The water generally was muddy and discoloured. The laden barges passing up and down kept much of the mud in motion; in the basin, lay-byes, and angles formed by the bridges the water was clear, but there were large accumulations of black mud which on being disturbed gave off offensive smelling gases. The report gave a detailed account of the conditions along the banks, and contained recommendations similar to the 1st, 3rd, 4th, and 7th of the conference of the three vestries already referred to and a further recommendation that the canal company should be required to protect the canal and towing path by proper and efficient walls or close palings. The General Purposes and Sanitary Committee of the vestry adopted these recommendations, and also resolved that the canal company be required to macadamize the towing path. Hackney.—Letter from the clerk to the district board, dated February 24th, 1893, forwarded a report of the medical officer of health which contained reference to pollutions of the water from wharves, and from the floating population and barges. The report also referred to the presence of offensive mud varying in depth from a few inches to two feet in the bed of the canal, and to carcases of dead animals floating on the surface. Recommendations similar to numbers 1, 3, 4 and 7 of conference of delegates were submitted to and approved of by the Sanitary Committee on the 5th January, 1893. 48 Beihnal-green.—Letter from vestry clerk, dated November 17th, 1892, stated that the Committee had received no complaints as to the condition of the canal, and that the condition at that time was not unsatisfactory. Limehouse.—Letter from the clerk to the district board stating that in the opinion of the board it was desirable that the Regent's canal should be thoroughly dredged and scavenged periodically, and that the condition of the towing path should be improved. During 1893 Dr. Young inspected the canals on behalf of the Council, and in June, 1893, I presented to the Committee his report, which contained a detailed statement of the several sources of pollution found in the canals in the whole of their course through London. Dr. Young did not at the time of his inspection find the water in the canals offensive, but he found that drainage from some privies and stables from the Zoological-gardens, as well as soakage from dung-heaps, entered the water. He also found that surface washings of the wharves and of the whole length of the towing path, often polluted with horse droppings, together with the refuse and bilge water of barges, contributed to the pollution. In one instance he found pollution from the premises of a paper-stainer, and he further pointed out that among the sources of nuisance were the dead animals which were found floating on the surface, and the effluvia given off by barges carrying house and street refuse and the spent lime and tar of gasworks. He stated that although the water was constantly undergoing some change through the opening of locks for the passage of barges, there was no movement of water comparable to the flow of a river, and as a result the various matters which entered the canal waters either floated on the surface or sank to the bottom, where they rendered the mud offensive. The passage of barges frequently disturbed this mud, and at such times nuisance was likely to be caused, particularly in the basins, in the course of the canal, and at the dead ends such as Cumberland basin, where refuse tended to accumulate. Dr. Young was informed at a wharf in this basin that the water was not scavenged more frequently than once a month, and that during the summer the water became covered with scum which gave rise to nuisance. Dr. Young summarized the conditions which tend to make the canal water foul as follows— 1. The stagnant condition of the water. 2. The collection of mud at the bottom of the canal. 3. The pollution by sewage and other matters, though of small extent. 4. The collection of objectionable and decomposing material on the surface of the water, due to imperfect scavenging. 5. The passage of offensive cargoes along the canal, and especially those from the gasworks. A copy of this report was communicated to the sanitary authorities concerned, and in December, 1893, a conference of these authorities and the Public Health Committee was held at the county hall. Subsequently the following report was presented by the committee to the Council— We have for some time had before us the question of the insanitary condition of the Regent's and Grand Junction canals, referred to us by the Council. Dr. Young, on behalf of the Council, made a careful inspection of those parts of the canals which are in the county of London. The medical officer's report presenting Dr. Young's report on the canals, dated June, 1893, was circulated among the members of the Council and communicated to the safiitary authorities concerned. In December, 1893, a conference was held at the County Hall between the Public Health Sub-Committee and the various sanitary authorities in the county through whose districts these canals run. From the report of the medical officer, it would appear that while a certain small number of pollutions occur from premises on the banks of the canals, the main reasons for the undoubtedly foul condition of the Regent's-canal are— (1.) The collection of mud at the bottom of the canal from insufficient dredging. (2.) The insufficient flow of water producing an almost stagnant condition. (3.) The collection of decomposing material on the surface of the water. (4.) The droppings from barges and the smell of refuse from gasworks while conveyed by barges. The only serious discharge of sewage into the canal was from the Zoological-gardens. The conference was held with a view of ascertaining what steps the various authorities had taken for the improvement of the canals and with what result, and also if possible to arrive at some common decision as to the best course to be adopted. It was stated that the Zoological Society had instructed an engineer to investigate the whole question of the drainage of the gardens, and that his report was awaited. With regard to other causes of pollution, some local authorities had been able to get nuisances abated while others had not. This might have been due to some nuisances being more difficult to localise and to deal with than others, or to the differences in the procedure of the several local authorities. Hackney for instance succeeded in getting mud dredged, while St. Marylebone stated that notices had been served but not complied with. Eventually the delegates all undertook to urge their various authorities to take action with regard to all pollutions of the canals from the banks, it being understood that should this action fail to secure the proper sanitary condition of the water, the Council would take whatever steps it could for the improvement of the flow. The delegates were also informed that should their various authorities fail to take action with regard to the pollution of the canals in their respective districts, it would be our duty to recommend the Council to take proceedings in default under the powers given by section 100 of the Public Health (London) Act, 1891. We have considered the power of the Council with regard to an increased flow of water down the canals. The canal companies have written, stating that the stagnant condition of the water is incidental to all canals which do not canalize rivers, and it is not in their power to pass more water down the canals. We are advised that the statutory obligations of the companies may be considered to apply to navigation rather than to the prevention of pollution. Both companies appear to have power to sell water not required for the purpose of navigation. With regard to the Zoological-gardens, which is Crown property, it is hoped that arrangements will be made for the diversion of its sewage from the canal. The cleansing of the wharves and frontages is the duty of the occupier, the companies being only concerned with the water-way. With regard to dredging the mud along the whole length of the canals the Council has no more power than is given by the Public Health Act when a nuisance exists, and then only in default of a sanitary authority. The only possible other means available is the Rivers Pollution Act, which is applicable to canals. This Act, however, is cumbrous in its action, slow in its operation, longer notices having to be given, and nothing could be done while proceedings under any other Act were pending. If, however, no good results from the efforts of the local authorities it might be worth while to suspend any other action while notices are served under the Rivers Pollution Act. Legislation is evidently wanted to enable the central authority to deal directly with the canal in its course through London. 49 Of course if cither of the two companies come to Parliament for further powers, the occasion should be taken advantage of to endeavour to obtain more stringent provisions for the prevention of nuisance. In the meantime, the initial step lies with the local sanitary authorities. They must require the sufficient cleansing of the surface of the water and the dredging of the canal bed and lay-byes. They must take care that no further pollution takes place from the wharves and frontages on the banks of the canals, and they must enforce the new by-law of the Council with regard to the carriage of foecal or offensive or noxious matter by road or by water through London. On the presentation of this report the Council resolved to take the opinion of counsel, whether it would not be competent for the Attorney-General, if called upon by the Council, to proceed by public indictment against the Grand Junction and Regent's Canal Companies for creating a public nuisance by their neglect of the proper management of their canals and basins within the metropolis. The Committee, later, reported that the case had been submitted to Mr. Poland, Q.C., and that his opinion was— To the effect that he agrees with the Council's solicitor that the canals are "premises" within the meaning of the Public Health (London) Act, 1891. He considers that this is not a case in which the Government would be likely to instruct the Attorney-General to take up the prosecution until after every effort had been made to put a stop to the nuisance under the Public Health (London) Act, 1891. After much consideration he has come to the conclusion that the Council cannot pay the expenses of a prosecution by indictment out of the county fund; and he suggests that at a convenient opportunity the Council should obtain from Parliament the power of spending money for this salutary purpose. So far as the Grand Junction canal is concerned, counsel considers that there is no case against the canal company, having regard to the printed report of the medical officer, which has already been submitted to the Council. It will be remembered that the Council on the 27th February last passed a resolution to the following effect— That the Parliamentary Committee be requested to prepare a bill dealing with the canal property of the Grand Junction and Regent's Canal Companies, with the object of handing over to an administrative board representing the various local governing bodiss interested the entire sanitary control of the canals. We have therefore thought it well to refer counsel's opinion to the Parliamentary Committee for their consideration in connection with that resolution, as it is very doubtful whether, assuming for the moment that the Council had power to spend any money in introducing such a bill, there would be any justification for it, unless it could be shown that the powers of the Public Health Act had been exhausted. We have called the attention of that Committee to the suggestion made by counsel that the Council should apply to Parliament for power to proceed by indictment in the case of this particular nuisance, and possibly this power might be extended generally to any nuisance which the Council found itself unable to adequately deal with under its existing powers. We have at the same time addressed a communication to the sanitary authorities through whose districts the Regent's and Grand Junction canals pass, inquiring what action has been taken since the conference in December last, whether any mud deposits have been removed from the canals, and whether the surface of the water is periodically or regularly scavenged. We have also asked the Yestries of St. Marylebone and St. Pancras what steps have been taken for diverting the drainage of the Zoologicalgardens from the Regent's-canal. We report the course taken for the information of the Council. The Council declined to receive the report of the Committee. The annual reports of the medical officers of health contain the following reference to the canals— Kensington—The medical officer of health reports that after inspection of the canal there did not appear to be any objectionable condition calling for action on the part of the vestry. St. Pancras—The medical officer of health reports that a notice was served on the North Metropolitan Railway and Canal Company to cleanse and scavenge the surface and banks of the canal forthwith and in future three times a week in June, July, and August, and twice in each week in the remaining portion of the year; to cleanse and scavenge the bottom lay-byes and basins of the canal forthwith and in future once in each year; to concrete so much of the canal, including the lay-byes and basins, as are likely to allow mud and other deposits to accumulate ; and to construct an overflow at the southern end of Cumberland-basin so as to change the water in the basin and prevent its stagnation. This notice not having been complied with, the company agreed to a joint inspection of the canal by officers of the company and vestry, for the purpose of verifying the accumulation of mud stated to exist. Many lay-byes and docks being in the occupation of private owners responsible for the maintenance and condition, notices, where necessary, were served upon them. Many h undreds of tons of mud were removed from the waterway, lay-byes, &c. The laying of a sewer to drain the Zoological-gardens was under the consideration of the vestries of St. Pancras and St. Marylebone. Islington—An inspection of the canal showed that " beyond its usual semi-stagnant condition and the collection of a deposit of mud at a lay-bye, together with the discharge of rain-water pipes from a barber's shop, no nuisances were discovered." St. Luke—The medical officer of health states that the report of the Council's medical officer confirms the views he expressed in ] 892. Limehouse—Upon the receipt of the report of the Council's medical officer the board caused notices to be served upon the owners of property on the Regent's-canal to divert the drainage, and on the canal company to remove an accumulation of mud near Brunton's wharf. Housing of the Working Classes. During the year 1893 further progress was made in carrying out improvement schemes with respect to the following areas— (a) Scheme undertaken by the Council under Part 1. of the Housing of the Working Classes Act. Boundary-street.—On July 10th the Public Health and Housing Committee reported that the bulk of the property in the Boundary-street area had passed into the hands of the Council, and a table showing the results of the negotiations and arbitration in respect of the various claims was presented. This return gave £300,000 as the cost, in round figures, of acquiring the property. The valuer's original gross estimate amounted to £371,000. A saving of £71,000 upon the estimated cost had thus been effected in the case of this area—the first to be dealt with under Part I. of the Housing of the Working Classes Act of 1890. 50 In March it was decided to make application to the Home Secretary for an order modifying the method of laying out the area originally sanctioned. The new plan approved by the Council was based on a system of streets radiating from a central open space and provided for rehousing 88 persons in excess of the actual number required by the scheme. The Home Secretary sanctioned the modifications proposed, and subsequently approved a further modification reducing the total number of persons to be rehoused from 5,100 to 4,700, this course being necessitated by the devotion of two-thirds of the Goldsmith's-row site, upon which it had been intended to house 500 persons, to the purposes of an open space. The area had been divided for purposes of reconstruction into five sections; the first of these, that to the north-east, was already cleared in July, and demolition in the second section proceeded during the latter half of the year. Application was made to the Home Secretary to sanction the erection by the Council itself of buildings on the north-eastern section, and the matter was placed in the hands of the Works Committee. The work, referred to in my annual report for 1892, of inspecting premises coming into the Council's possession, and new residences to which persons displaced had recourse, was continued as occasion rendered it necessary in 1893. At the middle of the year 554 houses had been acquired, and 160 houses remained to be acquired ; in 84 instances vacant possession had been obtained, in 325 instances the houses were closed by the Council, and in 145 instances the premises remained occupied. During the latter part of the year possession of some of these houses was obtained and some further closures were effected. (b) Schemes undertaken by the Council with contributions by the district authority under Part II. of the Housing of the Working Glasses Act. Brooke's-market, Holborn.—This scheme was sanctioned in October, 1892. During 1893 the various claims were under consideration, and by the end of the year agreements had been arrived at with nearly all persons interested in the several properties. In June the official arbitrator was appointed. Ann-street, Poplar.—The facts relating to this area are given in my annual report for 1892. The Local Government Board inquiry was held in June, 1893, and the scheme sanctioned in Februarv, 1894. Mill-lane, Deptford.—I gave particulars concerning this area in my annual report of last year. The official inquiry was held in February, 1893, and in July the scheme was sanctioned. Statutory notices were served forthwith on owners of property in the area, and negotiations for the acquirement of the several interests were proceeded with. (c) Schemes undertaken by district authorities with contributions by the Council under Part II. of the Housing of the Working Classes Act. Green-street and Gun-street.—The Vestry of St. George-the-Martyr, Southwark, was engaged during the year in negotiating for the acquirement of the property and in clearing the areas. The desirability of dealing with the Falcon-court area in the same district was considered by the Council and the vestry during the_ year, and the need of extending the area already represented was discussed. Moira-place and Plumber s-place, Shoreditch.—This scheme was referred to in my report of last year. The Local Government Board inquiry was held on February 22nd, 1893. It was subsequently deemed necessary to modify the scheme by abandoning the portion of the new road proposed to be made from Provost-street to Britannia-street. This caused some delay, and the order finally sanctioning the scheme as modified had not been issued at the end of the year. Norfolk-square, Islington.—The inquiry concerning this scheme, referred to in my annual report for 1892, was held in March, 1893, and the scheme was sanctioned in September. The vestry then proceeded to deal with the area. Queen Catherine-court, lAmehouse.—This area was referred to in my annual report for 1892; the official inquiry was held on March 16th, 1893, and the scheme was sanctioned in October. The district board then proceeded to deal with the area. London-temice, St. George-in-the-East.—This area was also referred to in my report of last year. The official inquiry was held on June 22nd, 1893, the order sanctioning the scheme had not been issued at the end of the year. The following areas were under the consideration of the Public Health Committee during 1893— St. Pancras areas.—Representations with regard to three areas, the Somers-town area, the Prospect-terrace and Derry-street area, and the Brantome-place area, were made by the medical officer of health of St. Pancras under Part I. of the Housing of the Working Classes Act; the Council having considered these representations, resolved in May, 1891, that these areas should be dealt with under Part II. of that Act. A local inquiry was ordered, and was commenced in October, 1891, but was adjourned to enable further consideration to be given to the matter. This inquiry was resumed on February 16th, 1893, and continued on February 17th and 27th, and March 1st. On the 27th June, 1893, the Home Secretary's decision was received. A part of the Somers-town area (subsequently known as the Churchway area) was to be dealt with by the Council under PartI. of the Act. Another smaller part was to be dealt with by the vestry under Part II. of the Act, and a third part of the area lying to the east of Chalton-street was to be dealt with by the vestry under Part II. of the Act, the Council contributing one-third of the expense. The " Prospect-terrace and Derry-street area" and the " Brantome-place area " were to be dealt with by the vestry under Part II. of the Act, the Council contributing one-half the expense. The Public Health and Housing Committee reported on October 24th that " in order to give effect to the decision of the Home Secretary the Council's medical officer had taken, in conjunction with the other officers, the necessary steps to prepare a scheme for the reconstruction of that part of the area which the Home Secretary had decided should be improved by the Council alone." This scheme provided for the displacement of 1,266 and for the re-housing of about 650 persons. The 51 estimated cost was £65,000. The Committee recommended that the statutory resolution under section 4 of the Act should be passed with regard to the area, but this recommendation was not adopted by the Council. Star-road, Fulham.—A representation was made with respect to this area under Part I. of the Housing of the Working Classes Act, by_the late medical officer of Health of Fulham, on March 22nd, 1892. The area comprised about l¾ acres and 54 houses, with a population of 310. The Committee viewed the area in May, 1892, and found that repairs were in progress, which there appeared reason to believe would obviate the need for a scheme. The area was kept under observation, and in July, 1893, the Committee was able to report that further action was unnecessary. In accordance with the provisions of section 10 of the Housing of the Working Classes Act, a copy of the official representation was forwarded to the Home Secretary. Salutation-place, Lambeth.— This area was brought to the notice of the Council in 1890. Negotiations were entered into with the Vestry of Lambeth, and subsequently with the Duchy of Cornwall, the holder of the freehold interest; no agreement, however, was arrived at. The Committee then decided to cause a scheme to be prepared for dealing with the area under Part II. of the Housing of the Working Classes Act. Under this scheme it was proposed to deal with 30 houses occupied by 243 persons of the labouring class, and, after clearing the area, to devote the ground to the purposes of an open space, at a net cost of £8,350. The recommendation of the Committee that a resolution under section 39, 1 (6) of the Act should be passed with regard to the area was not, however, adopted by the Council. Bell-lane. Whitechapel.—The acquisition of premises in the Bell-lane area for the widening of Sandy's-row was proceeded with by the Improvements Committee. During the year 1893, the Council received from district authorities copies of representations under the Housing of the Working Classes Act, relating to 391 premises unfit for human habitation. The proceedings of the several authorities are shown in the following table— Housing of the Working Classes Act, 1890. tabular statement showing the procedure 01 district authorities as to houses represented as unfit for human habitation, and concerning which the Council has received copies of representations from the 31st December, 1892, to the 31st December, 1893. Local Authority. Total number of house concerning which the Council has received information that representations have been made from the31/12/92to the 31/12/93. Number of houses closed, demolished or improved by owners without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for 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 — — — — — — — — — — — Bermondsey - - - - - - - - - - Bethnal-green 90 3 29 15 33 16 20 9† 45 - 12 Camberwell — — _ - — - — - - Chelsea - - - - _ - - - _ - - Clerkenwell - - _ — - — — _ - — Fulham 36 7 — 22 29 _ _ 7 7 7 - - Greenwich 7 _ - _ - _ _ - - - 7 Hackney - - - - - - - - - - - Hammersmith - - - — ' - — — - — - — Hampstead 11 - - - - - - 8 8 - 3 Holborn - - - — - - — - - - — Islington - - - - - - - - - - - Kensington 37 - - - - - - 35 35 - 2 Lambeth - - - - - - — - - - Lewisham 25 - - - - - — _ - _ 25 Limehouse 34 8 8 18 34 - - — - - - Mile-end Old-town 67 9 15 34 58 1 - - 1 - 8 Newington - - - - - - - - - - - Paddington - - - - - - - - - - - Plumstead — — — - — — - - - — — Poplar - - - - - - - - - - - Rotherhithe - — — - - - - - - - - St. George, Hanover-square - - - - - - - - - - - St. George-in-the-East 3 - - 3 3 - - - - - - St. George-the-Martyr - - - - - - - - - - - St. Giles 12 - 3 1 4 1 2 5 8 — - St. James, Westminster - - — _ _ — _ - - — _ St. Luke - - - _ — _ - - - - — St. Martin-in-the-Fields - - - — — _ - - - - - St. Marylebone 6 - - - - - - 6 6 - - St. Olave, Southwark 11 - — — — - - 11 11 - — St. Pancras 3 - - - — — - 3 3 — — St. Saviour, Southwark - — ' — — _ _ — - — — — Shoreditch - - — - - _ _ - — — — Strand - - - — - — - - - - Wandsworth 28 2 - 10 12 - - 14 14 - 2 Westminster 7 6 - 1 7 - - - - - - Whitechapel - - - - - - - - - - - Woolwich 14 - 5 2 7 - - 3* 3 - 4 Total 391 35 60 92 187 18 22 101 141 - 63 § Dealt with under the Public Health (London) Act, 1891. † In course of demolition. * A demolition order made in respect to each of these houses. 52 The report of the medical officer of health of Kensington refers to proceedings under this Act in respect of an area in Kensington known as the James-street area, which the vestry had resolved to improve by scheme. The Council expressed the opinion that the scheme was not one to which they should be called on to contribute. The medical officer of health reports that 22 houses in this area were closed under the Act. The need of improvement of the Bell-lane area in Whitechapel is insisted on by the medical officer of health of Whitechapel. Houses let in lodgings. The Public Health (London) Act, 1891, made a material alteration in the law relating to houses let in lodgings. Under the Sanitary Act, 1866, sanitary authorities were empowered to regulate these houses. Under the Act of 1891 the making and enforcement of regulations was made obligatory upon sanitary authorities. Many authorities had made regulations under the Act of 1866, but these regulations were often not enforced, and the powers conferred by the Act of 1866 had therefore been but • little exercised. The passing of the Act of 1891 led some authorities to review the regulations which had already been made, and the year 1893 was in many districts devoted to revising existing and the preparation of new regulations. The annual reports of the medical officers of health supply the following information as to the work of sanitary authorities in connection with this subject. In Kensington 1,800 houses were on the register, and the vestry had new by-laws under consideration. In Hammersmith new by-laws were under consideration. In Fulham new by-laws were made. In St. George, Hanover-square, 73 additional houses were registered. In St. James, Westminster, 34 houses were on the register. In Marylebone 3,488 inspections of registered houses were made. In Hampstead 1,107 houses were on the register. In St. Pancras 164 houses were on the register. In Hackney by-laws had not been made. In St. Giles 478 houses were on the register. In St. Martin-in-the-Fields a special inspector was appointed for the purpose of inspecting houses let in lodgings. In St. George-in-the-East 29 houses were on the register. In Limehouse by-laws were adopted. In St. Saviour's, Southwark, by-laws were adopted and confirmed. In St. George-the-Martyr, Southwark, by-laws were adopted and awaited confirmation. In Bermondsey 312 houses were on the register. In Battersea by-laws were made and confirmed. In Woolwich the revision of the existing by-laws was under consideration. In Plumstead the making of by-laws was under consideration. In several districts in which by-laws were in force, notices were served or proceedings instituted in reference to particular premises. Common lodging-houses. In my last report I stated that the subject of the supervision of common lodging-houses had been under the consideration of the Council during the year, and that, on the recommendation of the Public Health Committee, the Council expressed the opinion that there should be annual registration, that the regulations should be made by the Council, and enforced by the sanitary authorities instead of by the police, and that the right of entry possessed by the police should be retained. Later, a deputation of the Committee conveyed the views of the Council to the Home Secretary, who, in the following year (1893) communicated to the Council his intention to transfer to the Council, by provisional order, the powers of the Commissioner of Police relating to such houses. During the year 1893 a common lodging-house for men, provided by the Council, was opened for the reception of inmates. The house contains provision for 324 persons, and is erected on the Shelton-street area, cleared under the Artizans' and Dwellings Improvement Act, 1875, by the Metropolitan Board of Works. This area, before being cleared, contained a number of lodging-houses used for this purpose. Underground rooms. The reports of medical officers of health show that in many districts underground rooms were found which were illegally occupied, and proceedings were instituted for the discontinuance of such occupation. Thus the number of such rooms dealt with in the following districts were— Paddington, 5; Chelsea, 16; St. George, Hanover-square, 6; St. James, Westminster, 17; St. Pancras, 53 ; Islington, 17; St. Giles, 38; Strand, 33; Holborn, 127; Clerkenwell, 82; St. Luke, 36 ; Bethnal-green, 3 ; Whitechapel, 42 ; St. George-in-the-East, 55 ; Mile-end Old-town, 28 ; Poplar, 3; St. George-the-Martyr, Southwark, 10; Bermondsey, 5; Lambeth, 36; Greenwich, 8. Workshops. In my last report I referred to an inspection made by Dr. Hamer of workshops in Mile-end Old-town, Whitechapel, St. George-in-the-East, Bethnal-green, and the Strand. The number of workshops in the Strand which he had then inspected was very trifling, and in March, 1893, therefore, he made a further inquiry as to workshops in that district, and included in his inspection a number of workshops in St. James, Westminster, the neighbourhood of Soho being selected for the purpose of investigation. Dr. Hamer found that the houses inspected were not originally intended for use as workshops; and that while, as a rule, they were in good repair and clean, and in a few cases the rooms were lofty and well lighted, the workroom was frequently used for sleeping purposes, and the provision of water-closets was inadequate. In respect to overcrowding, although this condition was found to exist on certain premises, the workshops of Soho compared favourably with those of Whitechapel and Mile-end. Even when there had been no infringement of the standard (250 cubic feet per head) usually enforced, Dr. Hamer frequently found the air of the workrooms close and oppressive, and he was led to conclude that " even when the air in the rooms occupied to this extent is renewed three or four times an hour, the amount of carbonic acid pollution must necessarily be considerable, and when no special means of ventilation are provided such frequent removal is impracticable. Under the conditions which were found to obtain in the workshops visited, it is unlikely that the air of the rooms was renewed more often than once or at most twice per hour, and under these circumstances, pollution to a very 53 serious extent is quite compatible with the full allowance of 250 cubic feet of space per head." The appearance of the workers in these West-end workshops was, however, indicative of a higher standard of comfort and of better hygienic surroundings than that of persons employed in workshops in the East-end. There was a more general recognition on the part of the employers of the existence of the statutory provisions relating to woi'kshops, and in many of the rooms an abstract of the Factory and Workshop Act was exhibited as required by section 78 of the Act of 1878. All the rooms had been recently inspected by the Home Office inspector. In April, 1893, Dr. Hamer re-inspected the workshops in Whitechapel, Mile-end Old-town, and St. George-in-the-East, which at the time of his previous inspection in 1892 he had found especially faulty. Speaking generally, steps had in the interval been taken to remedy the conditions which he had found to exist in particular premises, and although the inadequacy of water-closet accommodation did not appear to have been dealt with by the sanitary authorities, overcrowding had been remedied in the majority of cases. The result of Dr. Hamer's second inspection agrees with the statement contained in the report of Mr. Taylor, the medical officer of health of Mile-end Old-town, who, on inspecting, early in 1893, the premises referred to in Dr. Hamer's report of the previous year, found that under ten per cent, were overcrowded. Copies of Dr. Hamer's first report were on the 6th of January communicated by the Council to the sanitary authorities, who were requested to inform the Council of the steps which were being taken to carry out the provisions of the Public Health Act relating to workshops. The replies received showed that only in some districts had any special provision been made for this purpose. In Hampstead, St. George Hanover-square, Newington, and Battersea, additional inspectors had been or would be appointed; in Islington an increase of the staff was under consideration; in Hammersmith, St. James Westminster, Hackney, St. Luke, and Camberwell, the inspection of workshops, it was stated, was made in the course of house-to-house inspection. Other replies were chiefly to the effect that the workshops in the district were being inspected or that the inspectors had been instructed to carry out the provisions of the law. In some districts notices of the out-worker order had been given to the occupiers of workshops. Fuller information as to the steps taken by the sanitary authorities is found in the reports of the medical officers of health, of which an abstract is appended. It will be observed that the duty of dealing with out-workers has been found to be considerable, although this has been rendered easier by the inspector of workshops at the Home Office having arranged to give notice to medical officers of health of the residences of out-workers in their districts. That this difficulty is not insurmountable is evidenced by the excellent work done in Mile-end Old-town. It would obviously increase the facilities for carrying out the law if sanitary authorities communicated to a central authority the addresses of all out-workers not working in their districts, and if the central authority gave the necessary information as to the residence of the out-workers to the sanitary authorities concerned. A useful check, moreover, upon overcrowding of workshops could be exercised if the occupiers were required to exhibit in each workroom a notice indicating the cubic contents of the room. The following references to the administration of the law relating to workshops are found in the reports of the medical officers of health— Kensington—Two women inspectors were appointed for the inspection of workshops in which women were employed; they were supplied with books for the purpose of registration of such premises, these books indicating the details to be recorded, and with other books showing the results of inspection. Dr. Dudfield reported as the result of six months' experience that 1,107 houses had been visited (mostly dressmakers and laundries), 590 workshops inspected, 1,061 workrooms therein inspected. Of these, 56 workshops were found to be overcrowded, 14 insufficiently ventilated, 117 in a dirty condition. In 84 the sanitary arrangements were defective, and 143 notices were served. A recommendation that the women inspectors should be vested with the status of sanitary inspectors was not adopted by the Vestry. Fulham—Increased duties have been placed on the sanitary staff by the above Act (Factory and Workshop Act, 1891), and the circular issued by the Home Secretary relating to out-workers, but with the existing number of inspectors it is not possible to attend to them thoroughly, so that the Act in Fulham is almost a " dead letter." Chelsea—A special report was presented by the medical officer of health on the order under section 27 of the Factory and Workshop Act, 1891. St. George, Hanover-square—An additional inspector was appointed, one of whose duties is to inspect the lists of out-workers, and to ascertain the condition of their dwellings, and especially the presence of cases of infectious disease therein. A register of workshops and workplaces was prepared relating to 455 premises in all, mostly tailors, and dressmakers and milliners. " The number of workshops and workplaces inspected was 86 ; of these the sanitary arrangements of 75 were found defective, the drains of 26 having to be re-constructed. These 86 premises contained 188 workrooms, 42 of which were overcrowded, and 10 in a dirty and unwholesome condition. There were 540 persons found employed in these workrooms, or 182 in excess of the accommodation, taking 250 cubic feet as the minimum amount of cubic space allowed for each person in such places. In all cases where it seemed to be necessary, measures have been taken to diminish the number of persons in workshops so as to prevent overcrowding." St. Pancras—" When a complaint has been made in reference to any factory, workshop or workplace, it has been punctually attended to, and any nuisance, defect or infringement promptly remedied; an attempt to systematically inspect all workplaces in St. Pancras, from premises to premises, upon the principle of house to house inspection, would require, if the inspections were made twice a year, a very large increase in the staff of your inspectors. House to house inspection is of more importance than inspection from workplace to workplace." St. Giles—"A number of factories, &c., which are not subject to the provisions of the Factory 54 and Workshop Act, 1878, were duly visited and inspected, and, where found necessary, orders were made relating to their cleanliness, ventilation, overcrowding, sanitary arrangements and the number of persons employed in or in attendance at such buildings." Strand—" The staff has been strengthened by the appointment of an inspector to carry out the duties imposed by the Factory and Workshop Act, and by the by-laws relating to houses let in lodgings." Holborn—Forms relating to lists of out-workers " have been printed and distributed in the district, and it is the duty of the sanitary inspector to receive the lists of such out-workers, and to ascertain the condition of their dwellings, especially the presence of cases of infectious diseases therein." Shoreditch—" During the year notifications were received from Her Majesty's inspector of factories of insanitary conditions existing in 62 workshops and factories situate in the parish. In 51 of the premises works were effected in compliance with sanitary notices served. Many of the notifications received referred only to dirty conditions of the walls and ceilings, and in a number of cases it was found necessary in addition to order extensive works to be carried out, such as the introduction of additional water-closet accommodation, the improvement of light and ventilation, and the abatement of overcrowding." Bethnal-green—"It was not until December, 1893, that a special officer was appointed to look after the workshops of Bethnal-green. His duties are to systematically inspect and register all workshops in the parish, to measure up and cube all workrooms and fix the number of persons allowed to work therein, to caution occupiers as to overcrowding, insanitary conditions and defective ventilation, and where his cautions are neglected to report the circumstances and take such proceedings in the police-court as may be ordered for the recovery of penalties, &c. Much time and thought were devoted to the work of the new offices and to the preparation of the necessary books, forms and notices. All this has been satisfactorily accomplished." Whitechapel—The sanitary inspectors report "Notwithstanding the large increase in the general work of the district, we have been able to devote some attention to overlooking the workshops under the order issued by the Home Secretary." The tabular statement relating to " sanitary and other work performed by the inspectors," shows that 30 workshops were cleansed, in 30, overcrowding was abated, in 2, additional water-closet accommodation was provided. St. George-in-the-East—Overcrowding of workshops was abated in 22 instances, and 31 workshops were cleansed and repaired. Limehouse—The sanitary inspectors report, "We have been able to give some attention to the inspection of workshops under the order issued by the Home Secretary." The tabular statement of '' sanitary works " shows " factory inspections 20, factory nuisances abated 4." Mile-end Old-town—A detailed statement is given of the proceedings with regard to workshops during the year. These were of a very complete character. A list of over 200 workshops is given, showing the address, position in house, trade, number of persons allowed to work at one time in the workshop on the basis of 250 cubic feet per head, the date of inspection, the condition of the workshop at the time of inspection, and the work carried out under the provisions of the Public Health (London) Act. Referring to out-workers, the medical officer of health, Mr. Taylor, reports— " In the early part ot this year I addressed a circular letter to all employers of labour of this description in our district, drawing their attention to this order, and requesting to be informed of the homes of these outworkers .... In our own area there were 377 different outworkers' homes, all of which were visited, and in almost all cases the workrooms were found to be in a cleanly condition; where sanitary defects were discovered, notices were served and the nuisances remedied. This work of inspection took up a considerable amount of time of the inspectors. One may regard this work as serving a very useful purpose to the community at large, as it ensures their wearing apparel being made in cleanly and properly ventilated workrooms ; and in the event of infectious diseases taking place in these houses, we are enabled to communicate the fact directly to the employers, and so proper precautions can be taken before the clothing is either sent to the shop or sold to the public. During the last year numerous instances of this has occurred, in one case the outworker had some hundreds of coats stored on the same premises where a case of scarlet fever had occurred. I find that we are one of a very few of the authorities that have made any attempt to grapple with this work ; this is to be regretted, as we know that unless it is undertaken all over London there must necessarily be many hundreds of houses in every district that escape observation, as where work is given out by employers outside the area of one's district to employees inside the district, it is impossible for us to become aware of their existence unless all the local authorities carry out the order of the Board in a like manner. It is thought by some that work of this magnitude ought to be carried out by a central body which would co-operate with the local authorities. With this I agree, as unless we have a considerable increase in the staff of inspectors, the order cannot be carried out in its entirety. In our own district, with only one year's experience, I find that it involves a large amount of extra work, and these outworkers' homes will not be able to be visited as frequently as one could wish and at the same time keep up the regular work of our department. I am at the present time having our last year's list revised, as out-workers of the class in our district are constantly moving from one part to another." Poplar—South District—" The out-workers have received the attention of Mr. Raymond (the sanitary inspector) who keeps the out-workers' register. At my suggestion a numbered alphabetical sheet index was made ; every day the addresses on the notifications of infectious diseases are compared with this index, in order to find out whether an out-worker resides in the house where the complaint exists; by adopting this plan, 4 out-workers in Poplar were found in connection with the notifications, and 22 in Bromley. Mr. Raymond made the necessary inquiries and served notices on the occupiers of the 55 factories and workshops, intimating to them the existence of the disease, in order that they should discontinue the supply of work." A tabular statement shows that in 16 cases the water-closet accommodation was insufficient, and was subsequently provided. North District—No water-closet accommodation had been provided in fifteen instances. St. George-the-Martyr, Southwark—121 workshops were entered in the register-book kept for the purpose. " In several instances cleanliness and efficient ventilation have been enforced, overcrowding and other nuisances have been abated, and separate water-closet accommodation has been provided for the two sexes. The medical officer of health points out that four-fifths of the out-workers lived in other metropolitan districts or outside London. For instance, of the out-workers employed by the large firms (engaged in trades mentioned in the order of the Home Secretary), the majority in the tailoring trade live in Whitechapel, and many in the boot business so far afield as Northampton." St. Olave—The medical officer of health, referring to the order relating to out-workers, reports " The list was to be repaired and kept up to date by the occupier of every factory or workshop and every contractor employed by such occupier, and was open to the inspection of the sanitary authority. This Board took every means of making the order known, but the order did not require the lists of outworkers or copies of such lists to be sent to the sanitary authority, and consequently the order was of little practical good in the district. Few of the out-workers living in this district have their factories and workshops situated within it, and consequently it is impossible to follow up these cases. It would have been of great service if the occupier of the factory or workshop were ordered to forward the list of his out-workers to the respective medical officers of health of the various sanitary districts." Bermondsey—The report of the chief sanitary inspector shows that improvements were effected in 76 workshops. Battersea—Sanitary conveniences were required to be provided in 8 instances. Wandsworth.—Glapham—106 workshops were inspected, and were found generally satisfactory ; seven required cleansing and lime-washing, and in two there was insufficient water-closet accommodation ; four new water-closets and two new urinals were provided. Putney—During the year all the workshops have been inspected and found in a satisfactory condition, with the exception of one case of overcrowding, and one case where lime-washing was required. In both of these the defects were remedied. The medical officer of health points out in connection with the out-workers' order that a notice was served on all the occupiers of the factories and workshops referred to requiring them to keep lists of their out-workers. A list of these out-workers was drawn up twice during the year, and notices sent to the sanitary authorities where these workers resided. No lists were received from other parishes. "For all practical purposes, therefore, the order is a dead letter, so far as we are concerned." He recommends that lists should be sent to a central authority at regular periods, with a view to the necessary information being sent to each sanitary authority. Greenwich.—Greenwich Parish—42 premises inspected. Deptford Parish—" The workshops and factories have been inspected, and many sanitary improvements have been carried out." Plumstead—Two clay pipe factories inspected, the ventilation of one found to be unsatisfactory. Bakehouses. The majority of the reports of medical officers of health show the work which has been done in connection with bakehouses in the year 1893. In several instances reference is made to the disadvantages attending the use of bakehouses situated below the ground level. It is a frequent practice in London to use the basement for this purpose, and often the area which abuts on the front of the bakehouse is enclosed and occupied as part of the bakehouse or by the oven with which it is provided. Statements condemnatory of bakehouses so situated are found in the reports relating to Fulham, St. George Hanover-square, St. Pancras, St. Martin-in-the-Fields, Bermondsey, Battersea, and St. George-the-Martyr Southwark, and in the report of the last district, account is given of flooding of certain bakehouses by sewage from the sewers. The medical officer of health of Kensington discusses the subject at length, and refers to previous reports in which he has recommended the regulation of bakehouses by by-laws. The medical officer of health of Fulham recommends the annual licensing and registration of bakehouses and the prohibition of the occupation of those below the ground level. The medical officer of health of St. George, Hanover-square, expresses the opinion that all underground bakehouses should be closed. The medical officer of health of St. George-the-Martyr, Southwark, recommends, inter alia, the licensing and regulation of bakehouses, the prohibition of the use as a bakehouse of a cellar or place almost or altogether below the level of the street, unless it has been occupied before and up to a certain fixed date. The reports relating to some districts contain an expression of opinion that the bakehouses are not unsatisfactory, and in one instance (Putney) that further legislation is not required. The reports of the medical officers of health of the following districts afford information as to the steps taken during the year for the improvement of bakehouses— Paddington—96 bakehouses, regularly inspected. Kensington—316 bakehouses, such action taken in individual cases as was found necessary. Hammersmith—63 bakehouses, inspected quarterly, nine found insanitary, notices served and complied with. Fulham—75 bakehouses, regularly inspected, found to be fairly satisfactory, great improvements having been made in the water supply, drainage, &c.; all but five underground, and this too in the case of those recently opened in new districts. Chelsea—68 bakehouses, under inspection. St. George, Hanover-square—56 on the register, all thoroughly inspected and the necessary improvements carried out by the owners, notices having been served. St. James, Westminster—27 bakehouses, periodically inspected and works of improvement carried out. 56 Marylebone—424 inspections of bakehouses. Hampstead—41 bakehouses, regularly inspected, sanitary conditions fairly good. St. Pancras—207 bakehouses, inspected twice yearly and notices served when necessary. Islington—171 visits to bakehouses. Hackney—17 bakehouses inspected. St. Giles—28 bakehouses, regularly inspected and notices served. St. Martin-in-the-Fields—Bakehouses regularly inspected, found as a rule to be very satisfactory. Strand—28 bakehouses, of which 26 are underground, works of improvement carried out in the case of 20. Holborn—-23 bakehouses, all inspected and the defects found were remedied. Clerkenwell—58 bakehouses, inspected twice in the year and found clean and in good order. St. Luke—37 bakehouses visited, notices served and complied with ; of the total number 21 of the bakehouses are situated in the basement, and for the most part inefficiently ventilated ; the remaining 16 are in the rear of the shops on the same level, being really constructed over the yards. Shoreditch—99 bakehouses inspected, mostly underground, 27 found to be in good sanitary condition, 7 fair, 51 more or less defective, and 11 distinctly bad and most insanitary, satisfactory progress being made in improvement. Bethnal-green—106 under inspection, 44 underground, in the whole of the parish only 13 found in a fairly clean and satisfactory condition, the remainder either dirty or badly ventilated, in 28 the custom of sweeping the refuse under troughs continued notwithstanding strong remonstrances, two bakehouses absolutely unfit for use. St. George-in-the-East—50 bakehouses inspected, some cleansed and repaired. Limehouse—47 bakehouses inspected. Poplar.—Poplar and Bromley—-Inspected twice during the year 86 bakehouses, 47 notices served and complied with, all bakehouses inspected twice yearly. Bow—All bakehouses inspected twice yearly, and 22 notices served and complied with. St. George-the-Martyr, Southwark—66 bakehouses under inspection. Newington—82 bakehouses now being used, of which 15 are of underground construction, various structural alterations have been carried out, and the ventilation improved in several of those underground. Bermondsey—85 bakehouses in the parish, of these 51 are above ground and 34 under, 73 are in use, 12 not used. Rotherhithe—Bakehouses have been inspected, in some of them great improvements have been effected. Battersea—109 bakehouses, 296 inspections of bakehouses, 18 nuisances abated. Since transfer of inspection to local authority, seven bakehouses in the parish have been inspected half-yearly, in a few cases in which defects are found to exist, re-inspection takes place until defects are remedied. Wandsworth.—Clapham—Bakehouses inspected twice during year, lime-whiting required in 15 instances. Putney—Bakehouses inspected twice during year and necessary lime-whiting carried out, all found to be in satisfactory condition. Streatham—Bakehouses duly inspected and necessary lime-whiting and cleansing regularly carried out. Wandsworth—Bakehouses inspected, and their condition as regards cleanliness and general sanitary state found to be satisfactory. Camberwell—308 bakehouse inspections. Greenwich.— Greenwich—96 visits to bakehouses, and those in insanitary state reported to the Board. Beptford—No great fault to be found with bakehouses in Deptford. Lewisham—80 bakehouses regularly inspected. Woolwich—37 bakehouses. " Although for the most part the regulations have been generally observed, there can be no doubt that many of these places are totally unfit for the purpose they are put to, the difficulties, however, in dealing with such are manifest, as it would involve serious interference with trade interests which cannot always be fully justified." Plumstead—37 bakehouses, 32 cleansed, bakehouses inspected in April and October. " They maintain the former standard as to sanitary conditions, but this standard can hardly be a high one until it is made compulsory for them to be certified as fit for their purpose before occupation." Disinfection and Destruction of Infected Articles and Provision of Shelters. The Public Health (London) Act, Section 59, requires sanitary authorities to provide proper premises with all necessary apparatus and attendance for the destruction and for the disinfection, and carriages or vessels for the removal, of articles which have become infected by any dangerous infectious disease; and Section 60 requires sanitary authorities to provide, free of charge, temporary shelter or house accommodation with any necessary attendants for the members of any family in which any dangerous infectious disease has appeared who have been compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the sanitary authority. In April, 1893, I presented a report showing the provision made in the several districts. Referring to disinfection, I pointed out that disinfection by dry heat was a much less satisfactory method than disinfection by steam, that the plan adopted by some authorities of arranging for disinfection to be done by a contractor was not altogether free from objection, and that advantage would result if, in connection with the appliances for disinfection, a laundry were provided where articles which could be boiled could be thus treated and returned in a clean condition to their owners. In only a few districts had special appliances been provided for the destruction of infected articles, and in only thirteen instances had sanitary authorities provided shelters. In discussing the latter, I drew attention to the differences in the character of the provision which had been made, to the need for this provision being adequate for use by night, and to the need of baths in connection with the shelter. The Public 57 Health Committee thereupon reported to the Council, and the following recommendation of the •Committee was adopted by the Council— That the Council do express an opinion for the guidance of sanitary authorities to the following effect— (1.) That dry heat disinfecting apparatus should be replaced by proper and efficient steam apparatus. (2.) That the system of arranging with a contractor for the disinfection of infected articles is not an entirely satisfactory one. (3.) That in view of the difficulty of obtaining suitable sites for the erection of disinfecting apparatus in central districts of London, economy might be effected if sanitary authorities were to combine in the manner provided by Section 59 (2) of the Public Health (London) Act, 1891. (4.) That advantage might be gained if in connection with the machinery for disinfection a laundry were provided where articles which can be boiled could be thus treated and returned in a clean disinfected •condition to their owners. (5.) That in every case separate vehicles should be provided for the conveyance of infected and disinfected articles respectively. (6.) That sanitary authorities who have not yet done so should be urged to provide free of charge, in accordance with Section 60 of the Public Health Act, temporary shelter or house accommodation, with any necessary attendants, for the members of any family who may have been compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the sanitary authority, and also to make such provision well known among the inhabitants of their districts. (7.) That this accommodation should be of a kind which would induce the inhabitants to make use of it. (8.) That a copy of the medical officer's report, together with the Council's views on the subject, be sent to each sanitary authority in London for its consideration. At the time of inquiry for this report the provision made in the several districts was as follows— Districts provided with steam apparatus. 1. St. George, Hanover-square 9. Mile-end Old-town 2. St. James, Westminster 10. Bermondsey 3. Hampstead 11. Camberwell 4. St. Pancras 12. Greenwich (in course of erection) 5. St. Giles 13. Deptford 6. Strand 14. Woolwich 7. Shoreditch 15. Plumstead (parish of Plumstead) 8. Bethnal-green 16. Lambeth Districts provided with dry-heat apparatus. 1. Hammersmith 8. Limehouse 2. Chelsea 9. Poplar 3. St. Marylebone 10. St. Saviour 4. Hackney 11. St. George-the-Martyr 5. Clerkenwell 12. Newington 6. St. Luke 13. Lewisham 7. Whitechapel 14. Plumstead (parish of Lee) The districts which had not made any provision of their own, bid which depended on the services of a contractor. 1. Paddington (steam) 6. St. Martin-in-the-Fields (dry heat and 2. Kensington (dry heat principally steam) used, steam when beds are in a 7. Holborn (steam) foul condition) 8. St. Olave (steam) 3. Fulham (steam) 9. Rotherhithe (steam) 4. Westminster (steam) 10. Battersea (steam) 5. Islington (steam) 11. Wandsworth (steam) In St. George-in-the-East and in the parishes of Charlton and Eltham no apparatus for disinfection was available. The vestry of St. George-in-the-East made an attempt to arrange with another authority for the disinfection of infected articles in its district, but no agreement was arrived at with regard to this matter during 1893. The reports of the medical officers of health show that during the year steam apparatus was provided in Chelsea, Whitechapel, Hackney and St. Olave, the last being placed in the grounds of Guy's Hospital. Both the medical officers of health of Poplar condemn the apparatus in use in that district as inefficient. The following arrangements existed in 1893, for the destruction of infected articles— Kensington—By contract. Hammersmith—Burnt in a heap on the ground at the vestry's wharf after being saturated with paraffin. Fulham—By contractor, who has a cremator erected for the purpose. Chelsea—Burnt at one of the vestry's wharves. No special apparatus. St. George, Hanover-square—Burnt in a destructor erected at a cost of £170. The fumes from the burning material before escaping pass through the furnace of the disinfector. Westminster—No provision. Contractor who disinfects could destroy if necessary. St. James—When occasion requires, bedding is burnt in the large furnaces for the steam boilers at the baths and washhouses. Marylebone—No special appliance. Hampstead—Small articles burnt in open yard, large articles in the destructor. St. Pancras—Destroyed in a furnace capable of burning a dozen beds at one time. Islington—Destroyed in a large furnace belonging to the vestry, who have decided to build a crematorium. [8] 58 St. Giles—Removed in covered vans and burnt in a destructor. St. Martin-in-the-Fields—Sent to contractor who does the disinfection. Strand—A destructor has been in use since 1885. Holborn—Sent to contractor. Clerkenwell—Occasionally burnt in the wharf in Commercial-road. St. Luke—An apparatus has been erected and has been in operation for twelve months. Shoreditch—Burnt in a destructor which is under the same roof as the disinfector. Bethnal-green—Burnt at the stone-yard after being saturated with paraffin. No special apparatus. Whitechapel—Burnt in the destructor. St. George-in-the-East—Formerly burnt at contractor's yard in Limehouse district. On the last occasion bedding was burnt in a yard in the parish. Limehouse—Board has approved plans for the erection of an incinerator. Mile-end Old-town—Burnt in a destructor. Poplar—Burnt in the open air on land adjoining the disinfecting apparatus. No special apparatus. St. Saviour, Southwark—Burnt in an open stove in the yard after being subjected for some hours to temperature of 280° F. in the disinfecting oven. St. George, Southwark—Burnt in the furnace of a Fraser disinfecting oven. Rotherhithe—Mode of destruction left to sanitary inspector to determine. Lambeth —Burnt in a furnace in the stone-yard. Battersea—Burnt in the vestry's destructor. Wandsworth—Clapham possesses a special furnace in the stone-yard. Putney has made no provision, but contractor for disinfection could destroy articles. Camberwell—A destructor is in course of erection. Woolwich—Burnt in the dust destructor. Plumstead—Burnt on the open ground near the river. The following statement shows the shelters which existed in the several districts in 1893— 1. St. George, Hanover-square—The shelter consists of a basement with two rooms and a water-closet in the yard. It is provided with a fireplace, chairs, bedstead, and crockery. There is no special attendant. It has been in existence nine months, and has been used three or four times. It is said that difficulty is experienced in inducing people to use the accommodation. 2. Westminster (St. Margaret and St. John)—Two rooms, with four beds in each, have been provided in the house of the mortuary keeper. These have been in use for three years, and no difficulty is experienced in getting people to go there. Similar provision will be made in connection with the new mortuary and coroner's court which is being built.- 3. Marylebone—The existing accommodation is a room in the basement of the vestry-hall, provided with a fireplace, crockery, chair-bedstead, table and chairs. There is no special attendant. It has been in existence a few months, and has been used three or four times. It is said that difficulty is experienced in inducing people to use it. Much improved accommodation is under the consideration of the vestry. 4. Hampstead—A two-storey two-roomed house has been provided in the stone-yard, Litho*road. The ground floor and upper floor are approached by separate entrances, and each has a watercloset in connection with it. Each room is furnished with a fireplace, a table, chairs and crockery. This shelter is in the care of the man in charge of the stone-yard; it has been in existence three years, and has only been used once. It is stated that difficulty is experienced in inducing people to make use of it. 5. Clerkenwell—A three-storey six-roomed house has been provided. It has one water-closet. The rooms are furnished with fireplaces, chairs and crockery, and in one ground-floor room there are two beds for children to lie on. The caretaker lives next door. This accommodation has been in existence one year, and has been used ten or twelve times. It is said that difficulty is experienced in inducing people to use it. This accommodation is shared by St. Luke, the Charterhouse, Staple and Furnival's Inns. 6. St. Luke—Shares the accommodation provided by the Clerkenwell Vestry. 7. St. George-in-the-East—A two-storey four-roomed house has been provided. The house has a back yard, in which is situated the water-closet. Each room is furnished with a fireplace, chairs and crockery. The gardener of an open space adjoining is the only available attendant. The house is not quite ready, and has never been used. 8. St. Saviour, Southwark—Two rooms have been provided at the top of a house in Nelsonsquare and belonging to one of the sanitary inspectors. They are suitably furnished as bed-rooms, and there are stoves of the ordinary bed-room type for cooking. The sanitary authority provides crockery. These rooms have only been used once, and it is said difficulty is experienced in inducing people to temporarily leave the homes in which they have been dwelling. 9. St. Olave—The only provision is a room in the stone-yard, recognized as altogether inadequate. 10. Wandsworth—Putney—One room has been provided at the vestry's new wharf on the Putney-embankment. The room is now furnished as a kitchen, and bed furniture has not yet been supplied. The house is now occupied by the clerk of the wharf. It has not yet been used as a shelter. Clapliam—One room furnished as a kitchen has been provided in a lean-to building at the vestry's stone-yard. No provision for sleeping has been made. 11. Greenwich—A house has been provided for the whole district. It is not yet fitted up for use. 12. Woolwich—A house has been provided containing five bed-rooms (two furnished), a dining-room, a kitchen, and a bath-room. There are also in the house two rooms occupied by a 59 caretaker. It is stated that people have no great aversion to going there. The house has been much used, the average stay in it being one night, but some persons have been there six nights. 13. Plumstead (Charlton)—One room has been provided in a lean-to building in the parish wharf. It is supplied with chairs and a table and a small gas-stove. No provision has been made for cooking or sleeping. It has only been used once since it was opened a year ago. It is said that people object to going there. The following additional information is given in the reports of the medical officers of health— St. James, Westminster—The report of the vestry states " the house adjacent to the mortuary and stoneyard, and known as 6, Dufour-place, the lease of which, as intimated in the last annual report, the vestry has agreed to take, has been appropriated as a residence for the caretaker of the yard and mortuary and for accommodation for persons temporarily displaced for the disinfection of their homes." St. Pancras—The family shelter at the disinfecting station was in course of erection. Strand—A house has been leased, and will be at all times available. Holborn—" The board came to an arrangement with the Clerkenwell Vestry to use part of their shelter in Northampton-row, and we have invited and urged several poor families to remove temporarily into this convenient shelter, but as yet without success. They prefer to get accommodated by their friends and neighbours. A furnished house in the district might probably attract them, but I fear nothing else will." St. Luke—The report of the Vestry of Clerkenwell states " the St. Luke's Vestry have discontinued their joint tenancy of the shelter provided by this vestry for persons requiring accommodation while their houses are being disinfected." Shoreditch—" An eight-room house, situate at 18, Branch-place, was taken by the vestry at a rental of 18s. per week and furnished with such articles as are likely to be required by any family placed in temporary occupation. A caretaker and his wife were put in charge to look after the premises, air the rooms, bedding, &c., and to make ready for any persons whom it may be necessary to send there whilst their own dwellings are being disinfected. Since August, 18, Branch-place has been used for the accommodation of a family of seven, amongst whom a case of cholera had occurred ; of a second family of seven, amongst whom two cases of smallpox had occurred ; and of a father and two children, the remainder of the family, consisting of the mother and four children, having been removed to the hospital stricken with scarlatina. The whole cost of furnishing the house was just under £10. St. George-in-the-East—Shelter " was used on six different occasions, and was especially useful." Mile-end Old-town—During prevalence of smallpox the sanitary committee gave instructions for a house to be taken as a shelter, and two families immediately lodged in it. " The shelter has been of great service since then, and a number of families have, and are from time to time being lodged temporarily, generally for about twenty-four hours. The attendants are a man in the employ of the vestry with his wife. . . . Those persons who have been obliged to come there have expressed themselves grateful for the privilege." St. Olave—The Board have taken four cottages on leases and have completely furnished one as a shelter, the others being ready in the event of cholera arising in this district." Plumstead—" A house has been taken and furnished as a shelter for families requiring accommodation while their rooms are being disinfected. So far it has been used in only one case." Greenwich—" The house has been partly furnished, and during the year has been inhabited by three families from Greenwich." Camberwell—Up to the end of the year no site was found, but temporary cottages could be used. Wandsworth (Streatham)—The parish has provided "a very comfortable shelter at the new wharf buildings." Mortuaries. The subject of mortuary accommodation in London was during the year under the consideration of a joint committee consisting of members of the Public Health and Public Control Committees. Inquiry was instituted by the Public Health department into the accommodation which had been provided. This accommodation in the following districts was regarded as satisfactory or such as not to necessitate any representations by the Council to the sanitary authority— Kensington , Hampstead Whitechapel Fulham St. Pancras Bermondsey Chelsea Hackney Battersea St. George, Hanover-square St. Giles Camberwell Westminster Clerkenwell Newington Marylebone Bethnal-green Strand A separate chamber for the bodies of persons dying of infectious disease was to be provided in connection with the Fulham mortuary. The accommodation in the following districts was found not to include any separate chamber for the bodies of those who had died of infectious disease— St. Luke St. George-the-Martyr Greenwich Shoreditch Lambeth St. Olave St. George-in-the-East addington In St. George-in-the-East alterations of the mortuary were carried out during the year in order to provide a separate chamber for the bodies of those who had died of infectious disease and to improve the approach to the mortuary. In Paddington the subject of the erection of a new mortuary, or the 60 enlargement of the existing mortuary was under consideration. The existing accommodation at Greenwich consists of a mortuary in each of the parishes of Greenwich, St. Nicholas, Deptford, and St. Paul, Deptford. Each of these contains but one chamber, but the Greenwich mortuary is provided with a post-mortem room. In St. Olave the mortuary contains one small chamber and a post-mortem room. Improvements in the accommodation of the mortuaries in St. James, St. Martin-in-the-Fields and Holborn were, during the year, either made or about to be made. The sanitary authorities of the following districts decided to erect new mortuaries : St. Saviour, Southwark, Rotherhithe, Lewisham, Woolwich, Plumstead, Mile-end Old-town, Limehouse and Wandsworth, in the last of which a new mortuary was erected at Streatham. In this district the parishes of Clapham, Putney, Wandsworth and Tooting are provided with mortuaries. The mortuary in the Hammersmith district, while containing a separate chamber for the bodies of persons who have died from infectious diseases and a post-mortem room, is placed in the stone yard, and is architecturally much out of keeping with the use to which the building is put. With the object of enabling sanitary authorities to have the views of the Council as to the character of the accommodation which should be provided, a plan was prepared showing a coroner's court and mortuary with the proper accessories on a site. Hospital Provision for Infectious Disease. The report of the chairman of the Metropolitan Asylums Board for the twelve months ended March 25th, 1894, shows that the hospital accommodation for fever, at the Manager's disposal in 1892, was decreased during 1893 to the extent of over 1,000 beds (a) by the demolition of certain wooden huts at the Eastern and North-Western Hospitals; (b) by the reduction, under medical advice, of beds at the Eastern, North-Eastern, and Western Hospitals; and (c) by the impossibility of making use (as in previous years) of the Upper Gore Farm Hospital (for convalescent fever cases), in consequence of its being required for smallpox. The decrease was to some extent compensated by the erection of a temporary hospital, containing 400 beds, at Tooting Graveney, but this accommodation was not available until some time after the Managers had been compelled to refuse admission. The chairman states that " by the erection of permanent hospitals on sites lately acquired at Tooting Graveney, Hither-green, and Kidbrooke (Shooter's-hill-road), and by the establishment of one or more convalescent hospitals in the south of the Metropolis, on a site or sites yet to be acquired, there will, at no distant date, exist accommodation for above 5,500 beds in the Fever Hospitals of the Board." The Managers also increased the accommodation at their disposal for smallpox from 1,100 to 1,498 beds. Medical Officers of Health. The Local Government Act, 1888, provides for the payment by the 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. At the end of the year 1892, appointment or re-appointment of medical officers of health had taken place in sixteen districts, and during 1893 nine further appointments were sanctioned by the Local Government Board. There were thus at the end of 1893, twenty-five out of a total of fifty-six medical officers of health a moiety of whose salaries was payable by the Council. The following is a list of the twentyfive districts in which the medical officers of health have been re-appointed or appointed— Battersea. St. George-in-the-East. Chelsea. St. George-the-Martyr, Southwark. Fulham. St. Luke. Islington. St. Martin-in-the-Fields. Mile-end Old-town. St. Giles. Limehouse. St. Olave. Lee—Eltham. St. Saviour, Southwark. Poplar—Boiv. Strand. ,, Bromley and Polar. Woolwich. Plumstead. Places mentioned in Schedule G of the Metropolis Local Management Act— The Close of the Collegiate Church of St. Gray's Inn. Peter. Lincoln's Inn. Furnival's Inn, Staple Inn, and the Liberty Inner Temple. of the Charterhouse. Middle Temple. Sanitary Inspectors. During the year 1893, the Council became liable to pay a moiety of the salaries of 43 sanitary inspectors appointed or re-appointed in the course of that time. In April, 1893, I presented a return showing the number of, and other particulars with regard to sanitary inspectors in the administrative county of London. The total number of such officers (including 5 vacancies and 17 temporary officers), and excluding any reference to arrangements made in places mentioned in Schedule C of the Metropolis Local Management Act, was 188. This number for a population of 4,230,474 persons was equivalent to one inspector to every 22,503 inhabitants. In order to compare the number of inspectors in 1893 with the number employed in 1889 (the date of a former return), it was necessary to omit reference to the City and Whitechapel, as the number of inspectors in those districts did not appear in the return for 1889. Excluding these two districts the number employed in 1889 was 115, as compared with 173 in 1893, the increase being 58. I had to point out, however, 61 that this increase was more apparent than real, inasmuch as before the passing of the Public Health (London) Act, 1891, the police were concerned in the abatement of smoke nuisances, and 48 constables were, before 1891, engaged in this duty, 25 of whom were wholly occupied in connection with it and the remaining 23 partially. Moreover, in the interval between the two returns, a further increase in the work devolving upon sanitary authorities was brought about by the passing of the Infectious Diseases (Notification) Act, the Housing of the Working Classes Act, the Public Health (London) Act, and the Factory and Workshop Act. By-laws. Under the Public Health (London) Act, 1891, the duty devolved upon the Council of making by-laws in respect to the following subjects which were not before subject to by-law. Under section 16 (2). For prescribing the times for the removal or carriage by road or water of any faecal or offensive or noxious matter or liquid in or through London, and providing that the carriage or vessel used therefor, shall be properly constructed and covered so as to prevent the escape of any such matter or liquid, and as to prevent any nuisance arising therefrom. Under section 39 (1). 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 this Act. By-laws were accordingly, after due inquiry, made by the Council, and were confirmed by the Local Government Board on the 28th of June, 1893. (For By-laws, see Appendix III.) Special Inquiries. Rotherhithe.—During the year 1892 the sanitary conditions and administration of the parish of Rotherhithe received the attention of the Public Health Committee on the representation of the Mansion House Council on the Dwellings of the Poor, and I was instructed to report on the subject. Inquiry was accordingly made on behalf of the County Council by Dr. Young, and on the 21st February, 1893, the Council adopted the following report of the Public Health Committee— Insanitary conditions in Rotherhithe. On the 19th of March, 1889, Messrs. D. Cubitt Nichols and Shirley P. Murphy submitted a report showing the result of an inquiry made by them, in pursuance of the instructions of the Secretary of State, as to the immediate sanitary requirements of the parish of St. Mary, Rotherhithe. This report, which was presented to Parliament, stated that it was no exaggeration to say that the results of lax administration abounded in Rotherhithe, and especially in houses occupied by poor persons, and that there was a complete absence of any system which would ensure the remedy of unhealthy conditions on their becoming known to the vestry. In summarising the immediate sanitary requirements of Rotherhithe, the Commissioners stated that in their opinion the work of the sanitary department should be reorganised, that a system of house to house inspection of the district should be instituted, which would necessitate the employment of three inspectors until the condition of the parish was materially improved, that the complaint-book and record of the various steps taken by the vestry or its officers, with the result, should be better kept, and that the provisions of the Sanitary Acts generally should be more fully enforced. On the 29th of April, 1892, the Mansion House Council on the Dwellings of the Poor communicated to the London County Council a list of sanitary defects found in houses during a special inspection of the parish of Rotherhithe by that body, and on the 22nd of November forwarded a second list, showing the conditions then existing. This second list referred to 1,493 defects alleged to be present in 576 houses. On the 19th of December, 1892, the Local Government Board wrote to the County Council, enclosing a copy of correspondence between the Mansion House Council and the Board on this subject. The Board in this correspondence referred to the powers of the County Council under Section 100 of the Public Health (London) Act, 1891. We referred these communications to the medical officer for report, and upon his recommendation Dr. Young was instructed to make a detailed inspection of the houses referred to in the second list forwarded by the Mansion House Council. We informed the Local Government Board, the Mansion House Council and the vestry of this instruction, and the vestry, on the 3rd of January, stated in reply that they had directed their medical officer and sanitary inspector to take immediate steps to remedy any defects in these houses. On the 1st of February Dr. Young reported that he had inspected the houses and found that four houses had been closed. In the case of 10 houses notices had been served by the vestry on the owner for repairs to be executed. In 34 houses repairs of an incomplete character had been effected. As regards 26 houses, some were unlet at the date of visit, or Dr. Young failed to obtain admission. With regard to the remaining 502 houses, we think it desirable to submit to the Council the following extract from Dr. Young's report, from which it will be seen that the complaint of the Mansion House Council was well founded— " In the remaining 502 houses the insanitary conditions described by the Mansion House " Council were found to be still present, and though in a few of these the defects noted may be " regarded as of a trifling character, in nearly all houses additional defects were observed, which " were not included in the list communicated by that body. " The greater number of the defects which were observed were due to neglect of the con" dition of the houses as regards the state of repair and cleanliness. These defects include " leaky roofs, defective or entire absence of guttering and stack-pipes, and defective pointing " of brickwork causing dampness of the walls; broken and rotten floors, in many cases due to the " absence of any means of ventilation of the space beneath, in some instances the floor being laid " on the ground without any intervening air space; dirty and broken walls and ceilings inside, and " a dilapidated condition of walls externally. " Yards and forecourts were found frequently to be insufficiently or badly paved, and though " in nearly all cases a trap was provided for the drain inlet in the yard, many of these were broken, " or defective from the dilapidated condition of the setting. As a consequence of the faulty condi" tion of the paving, the yards were dirty and the ground close to the house often in a damp or " sodden condition. " The water-closets, with few exceptions, were situated in the back yard. A considerable " number were unprovided with a proper water supply, and the pans, which were of the long hopper " form, were found frequently to be foul, and in a few cases cracked and broken. 62 " Some houses were in a very dilapidated and neglected condition throughout. " In addition to the above defects many of the houses inspected were found to be structurally *' faulty, in that the ground floor was below the level of the adjoining street or yard pavement, and " no means were provided for ventilating the space beneath the floor. " A number of houses were found to have dark and unventilated staircases, which lead out of " the ground floor room, or else out of the passage and are situated between the front and back " rooms. " My enquiry has been limited to an inspection of the houses specified in the list supplied by " the Mansion House Council, but the number found to be faulty is so large that it leads to the " conclusion that the sanitary authority have failed to carry out their duties under the Public " Health, London, Act, 1891." We understand that there is but one inspector of nuisances in Rotherhithe, which, according to the preliminary census, had in April, 1891, a population of 39,074. We consider that one inspector is insufficient, and that a representation should be made to the Local Government Board to that effect. Section 1 of the Public Health (London) Act provides that— " It shall be the duty of every sanitary authority to cause to be made from time to time " inspection of their district with a view to ascertain what nuisances exist calling for abatement " under the powers of this Act, and to enforce the provisions of this Act for the purpose of " abating the same, and otherwise to put in force the powers vested in them relating to public " health and local government, so as to secure the proper sanitary condition of all premises within " their district." We have come to the conclusion that the sanitary authority have failed to comply with the requirements of this provision, and that the Council should intervene, as it is authorised to do either under section 100 or section 101 of the Act, which are as follows— Section 100.—" The County Council, on its being proved to their satisfaction that any sanitary " authority have made default in doing their duty under this Act with respect to the removal of " any nuisance, the institution of any proceedings, or the enforcement of any by-law, may institute " any proceeding and do any act which the authority might have instituted or done for that purpose, " and shall be entitled to recover from the sanitary authority in default all such expenses in and " about the said proceeding or act as the County Council incur, and are not recovered from any " other person, and have not been incurred in any unsuccessful proceeding." Section 101 (1).—" Where complaint is made by the County Council to the Local Government " Board that a 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 in pursuance " thereof, the Local Government Board, if satisfied after due enquiry that the authority have been " guilty of the alleged default, and that the complaint cannot be remedied under the other pro" visions 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 " appoint the County Council to perform such duty." We do not consider that it would be satisfactory, in order to remedy the described conditions, that the Council should proceed under section 100, for this section while sufficient for the purpose of default in respect of a particular proceeding or nuisance, does not appear to be a convenient method of dealing with default relating to hundreds of houses. Section 101 on the other hand seems applicable to a case of this kind, and we accordingly recommend— (a.) That complaint be made to the Local Government Board, under section 101 of the Public Health (London) Act, 1891, that the Vestry of Rotherhithe have made default in carrying out the provisions of the Act in their district. (6) That a representation be made to the Local Government Board, under section 107 (2) of the Public Health (London) Act, 1891, that the Vestry of Rotherhithe have failed to appoint a sufficient number of sanitary inspectors. (c) That the vestry and the Mansion House Council be informed of the Council's decision in the matter. Subsequently, on the 21st of March, the Committee presented the following report to the Council— On the 21st February last we reported to the Council upon the insanitary conditions found on a recent inspection of the parish of Rotherhithe, and the Council resolved that complaint should be made to the Local Government Board, under section 101 of the Public Health (London) Act, 1891, that the Vestry of Rotherhithe had made default in carrying out the provisions of the Act in their district. It was also decided to represent to the Local Government Board, under section 107 (2) of the Act, that the vestry had failed to appoint a sufficient number of sanitary inspectors. The vestry were informed of these resolutions, and, on the 24th February, wrote stating that they had decided to take immediate steps to appoint two temporary certificated sanitary inspectors, subject to the approval of the Local Government Board, and that the question of the appointment of an additional permanent inspector had been referred to their Sanitary Committee for consideration and report. We have suggested to the vestry that they should communicate their decision to the Local Government Board, the matter being now in the hands of that Board, and we report the facts for the information of the Council. The Local Government Board, having asked the Council for a detailed statement of the particular cases upon which it relied in support of its complaint under section 101, and the grounds upon which it considered that the complaint in these cases could not be remedied under the provisions of section 100, the Committee on the 25th April presented a further report to the Council as follows— On the 21st of February last we reported to the Council upon the insanitary conditions found on a recent inspection of the parish of Rotherhithe, and the Council resolved that complaint should be made to the Local Government Board, under section 101 of the Public Health (London) Act, 1891, that the Vestry of Rotherhithe had made default in carrying out the provisions of the Act in their district. It was also decided to represent to the Local Government Board, under section 107 (2) of the Act, that the vestry had failed to appoint a sufficient number of sanitary inspectors. A communication in accordance with these resolutions was made to the Local Government Board, and the Board now ask that they may be furnished with a detailed statement of the particular cases upon which the Council relies in support of its complaint under section 101. They also inquire on what grounds the Council considers that the complaint in these cases cannot be remedied under the provisions of section 100 of the Act, which empowers the Council to act in default of a local authority. We have authorised a reply to be forwarded to the Local Government Board, enclosing a copy of 63 Dr. Young's detailed report upon the subject, and we point out that in the opinion of the Council the statutory provision neglected by the vestry is section 1 of the Act, which is as follows— " It shall be the duty of every sanitary authority to cause to be made from time to time inspec" tion of their district, with a view to ascertain what nuisances exist calling for abatement under " the powers of this Act, and to enforce the provisions of this Act for the purpose of abating the " same, and otherwise to put in force the powers vested in them relating to public health and local " government, so as to secure the proper sanitary condition of all premises within their district." We also slate that the Council considers that the conditions found to exist are nuisances within the meaning of section 2, sub-section 1 (a) and (6). In answer to the Board's inquiry as to whether the complaint in these cases cannot be remedied under the provisions of section 100 of the Act, we point out that the default of the vestry relates to so large a number of cases that it does not appear to be contemplated and would not be met by action under section 100, and that what seems to be required is that the vestry should systematically carry out the provisions of section 1. As however, the insanitary condition of the district arises mainly from the deficiency in the sanitary staff we inform the Board that in the opinion of the Council an inquiry under section 107 might render it unnecessary to proceed further in respect of the representation under section 101. We report the course taken for the information of the Council. Later, on the 18th July, the Committee presented the following report, stating that the Local Government Board had instructed its medical inspector, Dr. Theodore Thomson, to hold an inquiry— On the 21st of February last we reported to the Council upon the insanitary conditions found on a recent inspection of the parish of Rotherhithe, and the Council resolved that complaint should be made to the Local Government Board, under section 101 of the Public Health (London) Act, 1891, that the Yestry of Rotherhithe had made default in carrying out the provisions of the Act in their district. It was also decided to represent to the Local Government Board, under section 107 (2) of the Act, that the vestry had failed to appoint a sufficient number of sanitary inspectors. We subsequently informed the Board, in reply to a letter upon the subject, that in the opinion of the Council an inquiry under section 107 might render it unnecessary to proceed further in respect of the representation under section 101. The Board, on the 6th June, forwarded to the Council a copy of a letter from the vestry, stating that they had appointed two temporary assistant sanitary inspectors at a salary of £3 a week each, and intimated that before directing an inquiry with reference to the Council's representation under section 107 of the Act, the Board would be glad to receive any observations which the Council might desire to make on the vestry's letter. We informed the Board in reply that the Council would prefer to reserve any further expression of opinion as to the sufficiency of the sanitary staff until the inquiry asked for by the Council had taken place. We now report for the information of the Council that the Board has instructed its medical inspector, Dr. Theodore Thomson, to hold this inquiry. St. Saviour, Southivark.—During 1893 I was engaged on behalf of the Council in a special inquiry into the sanitary condition and administration of the district of St. Saviour, Southwark, the Mansion House Council on the Dwellings of the Poor, having represented to the Council that the sanitary authority had made default in the performance of its duty. A report was accordingly presented to the Public Health Committee, which is appended. (See Appendix IV.) The conclusions arrived at were thus stated— 1 am satisfied that the representations of the Mansion House Council as to the conditions of houses in the district were substantially accurate, and that these conditions had grown up as a result of the insufficiency of the staff. The sanitary authority had, before my inspection began, endeavoured to remedy the defects, and in this work they had been materially aided by the appointment of the second sanitary inspector in the early part of last year, practically doubling their staff. The work of improvement which has been done deserves recognition on account of its thoroughness. I am, however, of opinion that two inspectors are insufficient, especially in view of the necessity of a systematic inspection of workshops, and in view of the duties which must devolve upon the staff in connection with the regulation of houses let in lodgings. There is need for the sanitary authority to provide a proper mortuary. The present disinfecting oven should be replaced by one in which the disinfection is effected by steam. The Destruction of Refuse. The Public Health (London) Act, section 22 (2), having constituted the Council a sanitary authority for the purposes of the Act with respect to any nuisance arising on premises used by a sanitary authority for the treatment or disposal of any street or house refuse, the Public Health Committee instructed the engineer and myself "to make a thorough inquiry into the whole subject of dust destructors." For this purpose Mr. Santo Crimp and Dr. W. H. Hamer visited Birmingham, Liverpool, Manchester, Oldham, Bradford, and Leeds, and some of the depots in London where destructors are in use, and a report was presented to the Committee. This report was published, and it is not therefore necessary to discuss the subject at length here ; it will suffice to say that the destructors at Oldham and Kidacre-street, Leeds, appeared to be most deserving of commendation, especially for the reason that the outlets for the products of combustion are placed at the end opposite to that at which the material to be burnt is introduced, and consequently those products have to pass over the hottest part of the furnace. The conclusions arrived at were that as regards the best available means of preventing nuisance from destructors, the following points demand special attention. The temperature attained should be sufficiently high; the duration of exposure to a high temperature should be sufficiently long; all the vapour escaping from the refuse should be heated to a sufficient extent, and there should be no possibility of the escape of any undecomposed vapours into the chimney-shaft. Provided the appliance was intelligently and carefully worked, it appeared that the destruction of refuse by fire might be effected with success and without the production of nuisance. Food. The majority of the reports of the medical officers of health contain accounts of articles of food seized by them or the sanitary inspectors on account of its unwholesome condition, and in numerous 6-t instances the persons selling the food were prosecuted and convicted. Thus food seizures were made in Kensington, Fulham, Chelsea, St. Marylebone, St. Pancras, Islington, Hackney, St. Giles, Strand, Holborn, St. Luke, Shoreditch, Whitechapel, St. George-in-tlie-East, Limehouse, Poplar, St. Saviour, Southwark, St. George-the-Martyr, Southwark, St. Olave, Bermondsey, Rotherhithe, Battersea, Wandsworth, Greenwich, Woolwich and Plumstead. The food seized usually consisted of meat, fish, vegetables or fruit. In St. Olave 2,501 tins of meat were seized, and each tin opened, with the result that only 17 were found fit for consumption. In many instances the vendors brought to the sanitary officers the fish which they had purchased in the market and which on subsequent examination was found to be unfit for food. In those cases certificates to this effect were given to them. The report of the medical officer of health of Camberwell contains the history of an outbreak of illness in that district due to the consumption of unwholesome food. This report is of especial interest, inasmuch as it gives account of the infection of a child who had not actually partaken of the suspected article of food, but who, Dr. Bristowe is of opinion, had been infected by its parents, who were themselves sufferers, and with whom it had slept. Dr. Bristowe's report is as follows— In May, 1893, there was an outbreak of illness in the parish, which had all the characteristics of poisoning by some irritant matter. None of the patients had anything in common beyond their symptoms, and the fact that they had all partaken of pork pies bought at one particular place. The total number of persons attacked was forty, including one of your inspectors. The symptoms of the illness were severe diarrhoea, sickness, headache, and weakness, which last seemed out of all proportion to the severity of the other symptoms. In some cases there was an interval of as much as twenty-four hours between partaking of the pies and the onset of the illness; and, in other cases, the patients were attacked early, got better, and then suffered a relapse which was more serious in character than the initial illness. Two of those who were attacked died ; one was a little child who had eaten no pie, but who occupied the same bed as its parents, who had both eaten largely and were suffering severely. It is presumed that the child was infected by the parents' discharges being in some way conveyed into its system. The other case was that of an old lady of seventy-nine. In order to still further elucidate the outbreak, a circular letter was sent to many of the doctors in the parish, asking them if they had had any cases under their care of diarrhoea and sickness accompanied by extreme prostration. In answer to these enquiries we received information which enabled us to discover fresh cases, thus making up the total to forty. At the instance of the Home Office, portions of the pies which were supposed to have been the cause of the fatal termination in the two cases, were examined by Dr. Stevenson of Guy's Hospital, both chemically and bacteriologically. No trace, however, of any poison was found in them. Bacteriologically the result was practically negative. The true cause of the outbreak is consequently difficult to trace. The shop where the pies were bought is, as regards cleanliness and well-being, beyond reproach, and speaking generally, this remark also applies to the establishment in the country (which was visited by Dr. Stevens) where the pies were made, and from whence they were sent to the shop in this parish. There is, nevertheless, no doubt that the poisoning was due to the pies ; and there are grounds for suspecting that it was due to the poisonous influence of some as yet undiscovered living organism which had accidentally infected them. As indicative of the virulence of the poison, it is interesting to note that two persons suffered who had not actually eaten of the pies; one, the child already referred to, who slept with its parents; the other a lady who used, in eating her own dinner, a knife and fork which had also been employed in cutting up a pork pie, of which other members of the family, who were poisoned, partook. A return was in 1894 presented to the House of Commons, " showing in respect of the year ended the 25th day of March, 1893, the number of carcases seized by medical officers of health and inspectors of nuisances in England and Wales under section 116 of the Public Health Act, 1875, and section 47 of the Public Health (London) Act, 1891, and of the number of such carcases condemned by justices under sections 117 and 47 of these Acts, distinguishing as far as practicable the number so condemned in consequence of the animal having suffered from tuberculosis." The return shows that the officers of the district board of Holborn seized 342 carcases, of which 46 were condemned by the justices, and 10 of these carcases were condemned on account of the animal having suffered from tuberculosis. The officers of the Islington Vestry seized 2 carcases, 2 were condemned by the justices, 1 on account of tuberculosis. The officers of the Commissioners of Sewers of the City of London seized 38 carcases, 38 were condemned, 12 on account of tuberculosis. The return also shows that officers of the Vestry of Bethnal-green seized 10 pieces of meat which were condemned and that the meat was believed to be tuberculous, but it was not possible to prove it. The officers of the Holborn District Board also seized a large quantity of tuberculous offal, i.e., lungs, livers, kidneys. Water Supply. In obedience to an instruction of the Water Committee of the Council, I submitted a report on the report of the Royal Commission on Metropolitan Water Supply. This report is reproduced in the appendix (V.) and I propose, therefore, only to refer briefly to the subject here. The opinion of the Royal Commission on the quality of the water supplied to London is thus stated— We are strongly of opinion that the water, as supplied to the consumers in London, is of a very high standard of excellence and of purity, and that it is suitable in quality for all household purposes. We are well aware that a certain prejudice exists against the use of drinking water derived from the Thames and Lea, because these rivers are liable to pollution, however perfect the subsequent purification, either by natural or artificial means, may be; but, having regard to the experience of London during the last 30 years, and to the evidence given to us on the subject, we do not believe that any danger exists of the spread of disease by the use of this water, provided that there is adequate storage, and that the water is efficiently filtered before delivery to the consumers. The favourable opinion expressed in the report of the Royal Commission is admittedly founded on the experience of London during the last 30 years. In the memorandum referred to I have expressed the opinion that the risk to the consumer of water from the Thames and Lea is small, and certainly intermittent, but that risk, such as it is, exists. Although, with the exception of the cholera outbreak of 1866 which is not now nnder consideration, there is no evidence that the water supplied to London 65 during the last 80 years has proved injurious to the consumer, it does not appear to me that this experience, satisfactory as it is so far as it goes, justifies the assumption that there is a complete absence of risk in the use of water from the London rivers. In attempting to estimate the value of this 30 years' experience, it is necessary to have regard to the opportunities which have existed during this period for ascertaining whether injury has resulted, and these opportunities, while perhaps sufficient for the purpose of showing a large or conspicuous injury, would not have sufficed for the demonstration of smaller injury, such as might possibly occur from the use of water from these rivers. Under any circumstances the investigation of the subject is full of difficulty, but the difficulties have been increased by the absence of any sufficient machinery of observation. An increase in the number of cases of enteric fever in London, such as would be likely to result from the supply of imperfectly filtered flood water, might, under such circumstances, readily occur without suspicion attaching to the water supply. For such purpose a system of notification of cases of infectious disease was necessary, and this system has only existed in London during the last few years, and again, an organisation was necessary which would have provided for a proper study of the behaviour of enteric fever in connection with the circumstances of the water supplies, and such organisation did not exist. I think regard must be had for the absence of this very necessary machinery in any conclusion which is based on the experience of the last 30 years. But beyond this it must not be forgotten that circumstances which would now be held to raise question as to the wholesomeness of a water supply, would not in the past have created any suspicion. Indeed, the difficulty of obtaining recognition of the value of such evidence as can be adduced in connection with water-borne disease, even at the present time, cannot be better exemplified than by reference to the unwillingness of the Royal Commission to accept as conclusive the evidence Dr. Barry was able to submit as to enteric fever in the Tees valley, evidence of which the medical officer of the Local Government Board writes—" Seldom, if ever, has the proof of the relation of the use of water so befouled to wholesale occurrence of enteric fever been more obvious and patent."* The favourable opinion entertained by the Royal Commission as to the quality of the water supplied to London is, moreover, dependent on the provision of adequate storage and efficient filtration, and with regard to existing arrangements the Royal Commission reports—" We cannot shut our eyes to the fact that the provision for this purpose differs enormously in the different companies, and in some of them is to our mind quite inadequate." In the report mentioned I have referred to the uncertainty attaching to the action of filter beds; in this connection I may cite the opinion of Professor Koch, of Berlin, who thus writes in 1893—" All that we know of sand filtration therefore compels us to admit that, even under the most favourable circumstances, it cannot afford absolute protection against infection, though, as I have already said, it does afford a protection with which, considering the practical conditions of life, we may rest content."! Dr. Frankland, reporting to the President of the Local Government Board on the chemical, physical, and bacterioscopic examination of the waters supplied by the metropolitan water companies during the year 1893, points out the need of sufficient storage to tide over the largest floods, or of the means of substituting the river water for stored water whenever the chemical quality of the former is better than that of the latter. Thus, he points out, the impounded flood water affected the quality of the supply in March, making it in that month of worse quality, from a chemical point of view, than the raw river water passing the companies' works at the same time. His report is accompanied by diagrams, one of which compares the organic impurity of the raw Thames water at Hampton with that of the average filtered water delivered in London by the five companies drawing from this river, and he states that " except in February and March, the diagram shows that the water delivered by the Thames companies in London was of excellent chemical quality, and it also shows that the lesser flood of October was successfully excluded." Another diagram compares the raw Lea water at Angel-road with the filtered supply of the East London Company as delivered in London, and he states that this diagram shows that even 15 days storage was not sufficient to circumvent the long flood of February. He points out that " in that month the stored water was of inferior chemical quality to that of the Lea passing the intake, and this condition of things was even more marked in the following month of March, when the organic impurity in the stored water was represented by the figures 4"2, whilst that of the raw Lea water passing the company's intake was represented by 2'4 only. During the remaining months of the year this company's water was, as the diagram shows, of excellent chemical quality. The excessive impurity in the raw water in June was completely excluded from the supply, but the flood water of October was not quite so successfully dealt with as was the case with the Thames water in that month." A diagram contrasting the organic elements contained in the unfiltered water of the New River cut with the amount present in the supply of the New River Company shows, Dr. Frankland says, that " except in March, when doubtless owing to recent floods in the Lea the New River Company's supply contained an exceptionally large proportion of organic matter the quality of this company's water was uniformly excellent, and in some cases even better than the average of the deepwell waters." Dr. Frankland's determinations of the microbes in the water of the different companies, for the most part made monthly, showed that this number ranged during the year between the following: minima and maxima— Microbes per cubic centimetre Minimum. Maximum. Chelsea Company's water 0 220 West Middlesex Company's water 5 139 Southwark and Vauxhall Company's water (several filters) 6 1,220 Grand Junction ,, „ ,, 14 392 * Supplement to the twenty-first annual report of the medical officer of the Local Government Board f Zeitschrift fiir Hygiene und Infectionskrankheiten. [9] 66 Microbes per cubic centimetre. Minimum. Maximum. Lambeth Company's water ... 15 366 New River „ 6 37 East London „ „ (several filters) 4 210 Kent „ 0 ... 48 I he report of the water examiner supplies the following information as to the capacity of the subsidence reservoirs and the monthly rate of filtration per square foot of filter per hour in 1893— No. of days' supply. Monthly rate of filtration per square foot per hour. Minimum monthly average. Maximum monthly average. Chelsea 13.5 1.75 1.75 East London 15.0 1.33 1.50 Grand Junction 3.4 1.97 2.56 Lambeth 6.0 2.29 2.64 New River 4.5 2.24 2.43 Southwark and Vauxhall 1.6 1.50 1.50 West Middlesex 6.3 1.27 1.50 Professor Koch has expressed the opinion that the maximum number of microbes should not exceed 100 per cubic centimetre, he regards 2-l gallons of water per square foot per hour as the maximum rate at which the water should be permitted to flow through the filter. Constant water supply.—As the result of the action of the Council and the water companies, the number of houses in London receiving constant water supply was increased during the year to about 79 per cent, of the total houses in London. Quality of water from well in Plumstead.—The medical officer of health of Plumstead refers to an improvement in the quality of water supplied from the Kent Company's well in Park-road, which had previously been deteriorating, as a result, it was thought, of " increasing impregnation of the soil with organic matter." Dr. Davies now reports a considerable reduction in the number of cesspools in the district, but he mentions cesspools still polluting the soil and causing nuisance by overflowing. Regidations as to Water Fittings.—During the year the Local Government Board forwarded to the Council copies of communications which the Board had received from certain of the London sanitary authorities on the subject of the amount of water required for the flushing of water-closets. This subject was considered by the Public Health Committee and reported upon by the officers of the Council. On December 5th the Committee presented to the Council the following report— Capacity of v:ater-closet flushing cisterns. Regulation No. 21 made by the water companies under the Metropolis Water Act, 1871, provides that every water-closet cistern or water-closet service-box, fitti d or fixed after the confirmation of the regulations, in which water supplied by the companies is to be used, shall have an efficient wastepreventing apparatus so constructed as not to be capable of discharging more than two gallons of water at each flush. The Local Government Board has forwarded to the Council a copy of correspondence that has passed between it and certain of the sanitary authorities of London and the water companies respecting a proposal that regulation No. 21 should be altered so as to provide that every water-closet cistern or service-box shall be so constructed as to be capable of discharging three gallons of water at each flush. The Board asks for the Council's observations on the subject. Many of the sanitary authorities consider that a two-gallon flush is inadequate, while the water companies contend that two gallons are sufficient when proper apparatus is provided, and that when the flush is unsatisfactory the reason generally is that the down pipe from the cistern to the pan is of too small a diameter, and the inlet into the pan also too small. This, they assert, destroys the efficiency of the flush. The companies also state that to increase the size of the cisterns as suggested would involve an enormous increase in the quantity of water to be provided, and seriously affect the present undertakings and works of the companies, in addition to causing great expense and inconvenience to occupiers of dwelling houses. We have given careful consideration to the views expressed in the various letters forwarded by the Local Government Board, and have received reports from the Council's officers on the question. We have also made inquiries of six municipalities which control their own water supply, and learn that Edinburgh and Bradford have decided that three gallons should be required, while Leeds allows two and a half gallons in special cases. At Glasgow, Liverpool, Leeds and Dublin, two gallons are used, but the city engineer of Dublin is of opinion that this quantity is too low. We also asked the Sanitary Institute for their views upon the question, and have received from them a detailed report giving the result of a large number of experiments carried out by the institute, and concluding with an expression of opinion that the regulation should be altered so as to provide for the construction of flushing cisterns capable of discharging not less than three nor more than three and a half gallons of water at each flush. We took advantage of an opportunity kindly afforded by the institute of seeing their experiments, and were impressed by the fact that the experiments were conducted under much more favourable conditions than are generally.found in London houses. As we thought it would be very useful to have the opinion of sanitary engineers on the question, we communicated with some of the best known firms. From their replies it appears that all the firms are of opinion that a three-gallon flush is desirable, if not absolutely necessary. It is true that one or two of the firms state that two gallons may flush some of the best types of basins when the water is discharged with sufficient force and the discharge pipes are of sufficient dimensions ; but at the same time they point out that all these favourable conditions are but seldom combined, and that therefore the quantity is too near the margin of efficiency to be an adequate maximum. With regard to the statement of the water companies respecting the effect of imperfect apparatus upon the flush, we rccognise that there is an intimate relation between the conditions indicated by the companies and the amount of water required for flushing, but we must point out that it is impossible to condemn many kinds of apparatus now in use in London, although with only a two-gallon flush they are unsatisfactory. We are, therefore, of opinion that water closet cisterns should be capable of discharging a three-gallon flush, and that regulation No. 21 under the Metropolis Water Act, 1871, should be amended accordingly. We are advised that it would not be within the purview of the regulations of the water companies to prescribe a minimum capacity for flushing cisterns, but that section 39 of the Public Health (London) 67 Act, 1891, enables the Council to make a by-law for this purpose, if it should think fit. We therefore only propose to recommend that the maximum capacity should be increased from two to three gallons, which would at any rate enable the occupier of any premises to have a three-gallon cistern should he so desire. In addition to the above suggested amendment of regulation No. 21 there are a few other amend ments of the regulations which we think should be made, and which we now submit— i. The requirements as to the supply of water to water-closets should apply equally to the supply of water to sinks used for receiving any solid or liquid filth. ii. By-law 3 made by the Council, under section 39 of the Public Health (London) Act, 1891, provides that every person who shall construct a water-closet in connection with a building shall furnish such water-closet with a cistern of adequate capacity for the purpose of flushing, which shall be separate and distinct from any cistern used for drinking purposes. We think it necessary that a regulation shall be made which shall prevent cisterns being brought into use for supplying water for domestic purposes, or for food for beasts, so long as they directly supply any water-closet or sink used for receiving any solid or liquid filth. iii. We also think that in all cases where any premises have a constant water service, there should be a requirement that one or more taps shall be provided for drawing water used for domestic purposes from the rising main. We recommend— That the Local Government Board be informed that, for the reasons given in the foregoing report, the Council is strongly of opinion— (a) That regulation No. 21, under the Metropolis Water Act, 1871, should be amended so as to read as follows— " Every water-closet cistern or water-closet service box hereafter fitted or fixed in " which water supplied by the company is to be used, shall have an efficient waste" preventing apparatus, so constructed as not to be capable of discharging more than " three gallons of water at each flush." (b) That the requirements as to the supply of water to water-closets should apply equally to the supply of water to sinks used for receiving any solid or liquid filth. (c) That a regulation should be made which shall prevent cisterns being brought into use for supplying water for domestic purposes, or for food for beasts, so long as they directly supply any water-closet or sink used for receiving any solid or liquid filth. (<Z) That in all cases where any premises have a constant water service, one or more taps should be provided in connection with the rising main for the supply of water for drinking purposes. Pollution of the Lea. The report of the medical officer of health of Hackney contains reference to the pollutions of the Lea described in the evidence given by Dr. George Turner before the Royal Commission on London Water Supply, and to pollution of the river in Hackney by effluents from sewage farms, and he expresses the opinion that the formation of pools of this water in Hackney-marshes will, unless the water be made freer from pollution, be attended by danger. Legislation. The London County Council (General Powers) Act included a provision making it unlawful without the permission of the Council to erect any building to be used wholly or in part as a dwelling house or to adapt any building to be used wholly or in part as a dwelling house upon land of which the surface is below the level of Trinity high-water mark, and which is so situate as not to admit of being drained by gravitation into an exisiting sewer of the Council. This provision also empowers the Council by regulations (subject to appeal as provided in the Act), (1) to prohibit the erection of dwelling houses or the adaptation of any buildings for use as dwelling houses on such land, or any defined area or areas of such land; (2) to regulate the erection of dwelling houses or the adaptation of buildings for use as dwelling houses on such land or any defined area or areas of such land; (3) to prescribe the level at which the underside of the lowest floor of any permitted building shall be placed on such land or any defined area or areas of such land, and as to the provision to be made and maintained by the owner for securing efficient and proper drainage of the buildings either directly or by means of a local sewer into a main sewer of the Council. A further provision of this Act relating to the prevention of epidemic disease empowered the Local Government Board to assign to the Council any powers and duties under the epidemic regulations made in pursuance of section 134 of the Public Health Act, 1875, which they may deem it desirable should be exercised and performed by the Council. The same section empowered the Local Government Board, if the board are of opinion that any sanitary authority in whose default the Council have power to proceed and act under the Public Health (London) Act, 1891, is making or is likely to make default in the execution of epidemic regulations, to assign by order to the Council for such time as may be specified in the orders such powers and duties of the sanitary authority under the regulations as they may think fit. The expenses thus incurred by the Council are to be recoverable from the sanitary authority in manner provided by sub-section 3 of section 101 of the Public Health (London) Act, 1891. Shirley F. Murphy, Medical Officer of Health. March, 1895. Appendix I. . London County Council Public Health Department, Spring Gardens, S.W. 8th March, 1894. Preliminary Memorandum by the Medical Officer on the increase of Diphtheria in London. (Ordered by the Public Health and Housing Committee to be printed.) Before making any recommendation to the Committee as to the course to be adopted for the purpose of enquiring into the circumstances of the present prevalence of diphtheria in London. I think it well to submit for the Committee's consideration a memorandum on some points in the behaviour of the disease which are indicated by a study of the statistics now available. There is no mention of diphtheria in the statistics of the Registrar General until the year 1855. Before that year deaths registered as due to diphtheria were included with the deaths registered as due to scarlatina. In the London tables the deaths from these two diseases were not separated until 1859, although later tables supply the figures for the period 1855-60. The separate classification of the two diseases in 1859 was probably due to the notable prevalence of diphtheria in that year. Diagrams I. and II. show for England and Wales and for London respectively, for each year since 1859, the excess and defect of diphtheria mortality above and below the mean diphtheria death rate of the whole period. Diphtheria and croup are especially likely to be confused with each other, and therefore while the continuous line gives the mortality registered as due to diphtheria the dotted line indicates the mortality from croup and diphtheria combined. Diagram I. shows that since the excessive mortality of diphtheria which characterised the period 1859-65, the deaths from this disease in England and Wales have been almost altogether below the average. There has been, however, some increase during the later years. When croup and diphtheria are combined the result is much the same, except that the mortality during the later years has been below the mean instead of above it. Diagram II. shows that since the prevalence of diphtheria in 1861-63 the mortality from diphtheria in London has been below the mean until 1883; since that year, however, it has remained above the average, especially in 1892 and in 1893.* When croup and diphtheria are combined much the same result is obtained, except that the excessive prevalence in 1893 as compared with the excess in 1861-3 is less marked. The dotted line (croup and diphtheria) affords, I believe, a much better basis than the continuous line for comparing recent with early diphtheria. I have prepared Table I. in order to show the relative prevalence of the disease in the large towns of England and Wales during a series of years. Table I. Deaths from diphtheria per 1,000 of population. 1872 to '81 1882. 1883. 1881. 1885. 1886. 1887. 1888. 1889. 1890. 1891. 1892. London 0.13 0.22 0.24 0.24 0.22 0.20 0.23 0.30 0.37 0.32 0.32 0.44 Brighton 0.08 0.07 0.04 0.13 0.16 0.18 0.25 0.20 0.10 0.11 0.10 0.20 Portsmouth 0.26 0.82 0.17 0.31 0.31 0.46 0.34 0.12 0.23 0.32 0.14 0.17 Plymouth 0.19 0.12 0.16 0.12 0.13 0.13 0.07 0.14 0.56 0.19 0.07 0.09 Bristol 0.06 0.04 0.09 0.09 0.11 0.14 0.11 0.09 0.07 0.06 0.06 0.14 †Cardiff — 0.25 0.25 0.37 0.40 0.13 0.19 0.08 0.07 0.13 0.13 0.26 Wolverhampton 0.08 0.01 0.05 0.06 0.11 0.18 0.09 0.12 0.09 0.06 0.05 0.05 Birmingham . 0.18 0.14 0.12 0.10 0.11 0.17 0.13 0.09 0.13 0.12 0.08 0.15 Norwich 0.07 0.03 0.06 0.14 0.09 0.13 0.23 0.32 0.17 0.28 0.27 0.16 Leicester. 0.09 0.04 0.05 0.10 0.11 0.03 0.08 0.09 0.07 0.08 0.10 0.07 Nottingham 0.03 0.11 0.17 0.19 0.14 0.05 0.03 0.14 0.05 0.06 0.07 0.10 fDerby — 0.04 0.01 0.01 0.01 0.02 0.07 0.07 0.19 0.19 0.19 0.21 fBirkenhead — 0.03 0.02 0.08 0.14 0.16 0.10 0.07 0.08 0.11 0.11 0.08 Liverpool 0.10 0.09 0.09 0.14 0.23 0.21 0.16 0.11 0.09 0.17 0.12 0.11 fBolton — 0.08 0.06 0.04 0.06 0.06 0.05 0.08 0.29 0.45 0.10 0.11 Manchester 0.08 0.07 0.09 0.06 0.06 0.09 0.20 0.34 0.41 0.39 0.24 0.20 Salford 0.11 0.10 0.12 0.09 0.08 0.06 0.10 0.26 0.72 0.82 0.38 0.26 Oldham 0.10 0.09 0.07 0.04 0.12 0.21 0.41 0.23 0.11 0.04 0.14 0.12 fBlackburn — 0.02 0.00 0.02 0.01 0.00 0.01 0.01 0.04 0.04 0.00 0.01 tPreston... — 0.04 0.14 0.11 0.16 0.08 0.26 0.22 0.30 0.14 0.14 0.14 fHuddersfield — 0.08 0.02 0.05 0.03 0.10 0.42 0.16 0.13 0.05 0.07 0.07 fHalifax — 0.07 0.05 0.03 0.01 0.21 0.08 0.05 0.15 0.16 0.02 0.20 Bradford 0.08 0.03 0.03 0.04 0.08 0.04 0.05 0.02 0.05 0.03 0.08 0.07 Leeds 0.06 0.10 0.13 0.20 0.07 0.08 0.03 0.05 0.05 0.06 0.04 0.08 Sheffield 0.08 0.07 0.07 0.04 0.04 0.03 0.06 0.09 0.16 0.15 0.13 0.24 Hull 0.06 0.08 0.12 0.15 0.04 0.02 0.06 0.05 0.08 0.09 0.07 0.06 Sunderland 0.10 0.15 0.16 0.12 0.10 0.04 0.05 0.11 0.16 0.09 0.08 0.07 Newcastle 0.07 0.03 0.07 0.10 0.16 0.12 0.19 0.21 0.20 0.30 0.22 0.22 *I desire to acknowledge the courtesy of the Registrar General in supplying me, before their publication, with the London statistics relating to diphtheria for the year 1892, and in affording me the opportunity for obtaining the facts as to 1893. f Those Towns for which no death rate is given for the period 1872.81 were not included in the list of great towns for which statistics are given in the annual summaries of the Registrar General until after the census of 1881. [1004—1715 2 I desire at this point to refer to a paper on the Geographical Distribution of Diphtheria in England and Wales, which Dr. Longstaff prepared for the Local Government Board, and which is included in the Supplement in Continuation of the Report of the Medical Officer of that Board for the vear 1887. Dr. Longstaff grouped the registration districts of England and Wales into sparsely, medium, and densely inhabited districts, and obtained in three periods the following death rates from diphtheria per million of population— Sparse. Medium. Dense. 1855.60 248 182 123 1861.70 223 164 163 1871.80 132 125 114 liie tendency ot incidence ot the disease in later times to increase or to be maintained m the densely inhabited districts while it decreased in the sparsely inhabited group, is obvious, and particularly is this contrast notable during the last of these decades. The lessons to be learnt from the figures of the decennium 1881-90 are much needed, and I am permitted by Dr. Longstaff to state that he will continue his study of the subject when the next decennial supplement of the Registrar General is issued, but this volume will not appear until next year. With a view to showing the differences of incidence in successive decennia upon persons at several ages the following Table II. has been prepared. The population of England and Wales has been divided into two groups, the one which I have called "urban " including the population of registration districts of towns having each more than 50,000 inhabitants, the other, which I have called for the sake of comparison " rural," including the rest of the population of England and Wales. The death rates from diphtheria in the three decennia, are given for these populations at each age period. A similar statement is given for England and Wales, for London, and for the "urban " population after deduction of the London population. Table II. Diphtheria death rates per 1,000,000 living at various age-periods. Period. All ages. 0— 1— 2— 3— 4— 5— 10— 15— 20 and upwards England and Wales 1855-60 178 542 743 706 776 723 414 172 68 22 1861-70 184 581 909 803 832 736 393 136 59 26 1871-80 121 287 489 483 580 547 291 88 33 17 1881-90 163 282 685 773 896 848 424 100 36 17 Urban 1855-60 114 459 688 562 579 450 214 70 27 15 1861-70 166 687 1,149 940 836 664 280 66 32 22 1871-80 114 328 595 547 593 566 243 55 20 16 Rural 1855-60 203 574 761 759 847 821 485 207 84 24 1861-70 193 531 801 742 830 768 441 165 72 28 1871-80 125 261 425 445 572 536 317 107 40 18 London 1855-60 126 563 778 652 624 511 232 76 31 18 1861-70 176 755 1,197 1,060 912 715 296 64 35 26 1871-80 122 318 573 628 695 660 289 55 24 17 1881-90 260 534 1,533 1,598 1,750 1,553 601 96 32 20 Urban England (excluding London) 1855-60 102 364 609 481 539 394 199 66 24 10 1861-70 159 633 1,111 845 776 624 268 67 30 19 1871-80 109 334 609 498 533 511 216 55 18 15 For the purpose of appreciating the relative incidence of the disease upon persons living at the several ages in these different populations, it is convenient to eliminate all question of the general prevalence of diphtheria in the three decennia, and therefore Table III. has been prepared in which the death rate from diphtheria at all ages has been taken at 100 and the death rates at each age increased or reduced proportionately. Diagrams III. and IV. illustrate this graphically in the case of England and Wales and of London. In studying these diagrams it must be borne in mind that the lateral dimensions of age periods, whether they include one, five, or ten years are represented as equal instead of being proportionately expanded. DIPHTHERIA. London. 3 Table III. Diphtheria death rates—All ages taken as 100. Period. 0— 1— 2— 3— 4— 5— 10— 15— 20 and upwards England and Wales 1855-60 305 417 397 436 406 233 97 38 12 1861-70 316 494 436 452 400 214 74 32 14 1871-80 237 404 399 479 452 240 73 27 14 1881-90 173 420 474 550 520 260 188 61 22 10 Urban 1855-60 403 604 493 508 395 61 24 13 1861-70 414 692 566 504 400 169 40 19 13 1871-80 288 522 480 520 496 213 48 18 14 Rural 1855-60 283 375 374 417 404 239 102 41 12 1861-70 275 415 384 430 398 228 85 37 15 _1871-80 209 340 356 458 429 254 86 32 14 London 1855-60 447 617 517 495 406 184 60 25 14 1861-70 429 680 602 518 406 168 36 20 15 1871-80 261 470 515 570 541 237 45 20 14 881-90 205 590 615 673 597 231 37 12 8 Urban England (excluding London) 1855-60 357 597 472 528 386 195 65 24 10 1861-70 398 699 531 488 392 169 42 19 12 1871-80 306 559 457 489 469 198 50 17 14 Table III. shows that in England and Wales there has been, relatively to the diphtheria mortality at all ages, a considerably increased incidence of the disease upon the population at ages above 3 and under 10, in the period 1871-80 as compared with that in the period 1861-70. The table also shows that this is true generally for each of the groups of populations, except that in the "urban" (excluding London) there is practically no increase at 3-4.* The increased incidence upon children in this population at the age of 4-5 is, however, strongly marked. It has been possible in the cases of England and Wales and of London to give the figures for a further decade 1881-90. It will be seen that the increase, absolute and relative, of diphtheria mortality, in the former population has been maintained in the period 1881-90 as compared with 1871-80, at each age-period from 3-10 years. In the latter (London) there has been a trifling relative fall at ages 5-10 years, but at ages 3-5 years the increase has been very marked, as in the case of England and Wales. The question whether this change in the age incidence of diphtheria may be due to any alteration in nomenclature deserves to be considered. The following table relating to croup and diphtheria in London has been prepared for this purpose— This table (IV.) shows that when croup and diphtheria are taken together, in the periods 1871-80 and 1881-90 as compared with 1861-70, there has been a relative increase of diphtheria in the ages 3-10 years. Moreover, the trifling relative fall at ages 5-10 years in diphtheria mortality in 1881-90, as compared with 1871-80, is not found to have occurred when croup and diphtheria are taken together. It is indeed interesting to observe how closely the mortality from croup follows that of diphtheria, leading to the conclusion that under the name of "croup" much diphtheria is still registered.† * It is a well recognised fact that the figures given in the census volumes as to persons living at ages under 5 are unreliable and can only be considered as approximations. An examination of the age distribution of the population of " urban " (excluding London) shows that the proportion of children aged 3-4 to those aged 0-5 in the period 1861-70 was 18 96 per cent., and in the period 1871-80 19 36 per cent. Had the former percentage been maintained in the latter period the figures shown in Table III. for " urban " (excluding London) age 3-4 would have been 499 instead of 489. f The relative mortality in any district or groups of districts at various times is best ascertained by combining diphtheria and croup. This is the practice of the Medical Department of the Local Government Board, and the Registrar-General, writing in 1889, says: "It is probable that some part of the increase under diphtheria may be due to diminution under the heading croup, which in accordance with the classification of the College of Physicians, is separated from diphtheria, and placed with the respiratory diseases. But this can only be a partial explanation of the rise which was far greater than the falling off under croup." (Annual Summary of Causes of Death in London, 1889). The deaths registered as being due to diphtheria and to croup do not, however, include the whole of the deaths due to diphtheria. Thus it was the experience of the Medical Department of the Local Government Board in 1889 that deaths, presumably due to diphtheria, had been found after local inquiry to have been attributed to mumps, croup, tracheitis, laryngitis, measles, scarlatina, tonsillitis, ulcerated throat. Inclusion of deaths due to these causes would, however, produce—inasmuch as they are not by any means all diphtheria— a dilution or obscuration of the facts respecting diphtheria mortality. 4 Table IV. (a) LONDON. Death rates per 1,000,000 living. All ages. 0— 1— 2— 3— 4— 5— 10— 1861-70 Diphtheria 176 755 1,197 1,060 912 715 296 64 Croup 264 1,354 2,714 2,221 1,646 1,016 208 7 Diphtheria and croup 430 2,109 3,911 3,281 2,558 1,731 504 71 1871-80 Diphtheria 122 318 573 628 695 660 289 55 Croup 177 771 1,800 1,453 1,178 840 187 4 Diphtheria and croup 299 1,089 2,373 2,081 1,873 1,500 476 59 1881-90 Diphtheria 260 534 1,533 1,598 1,750 1,553 601 96 Croup 159 641 1,575 1,377 1,125 845 197 5 Diphtheria and croup 419 1,175 3,108 2,975 2,875 2,398 798 101 Table IV. (b). Death rate at all ages taken as 100. All ages. 0— 1— 2— 3— 4— 5— 10— 1861-70 Diphtheria 100 429 680 602 518 406 168 36 Croup 100 533 1,069 874 648 400 82 3 Diphtheria and croup 100 490 910 763 595 403 117 17 45 1871-80 Diphtheria 100 261 470 515 570 541 237 Croup 100 436 1,017 821 666 475 106 2 Diphtheria and croup 100 365 794 696 626 502 159 20 1881-90 Diphtheria 100 205 590 615 673 597 231 37 Croup 100 403 991 866 708 531 124 3 Diphtheria and croup 100 280 742 710 686 572 190 24 Table V. (a) gives for each group of population the diphtheria rates for several age periods, so far as they can be shown between 1855-60 and 1861-70, between 1861-70 and 1871-80, and between 1871-80 and 1881-90. The rates of 1855-60 are no doubt less reliable than those of the later periods, for the reason that they relate to a time where the diagnosis of diphtheria was less certain; the rates moreover have been calculated on the assumption that the age distribution of the several populations in the period 1855-60 was the same as that given in the census of 1861, the census of 1851 not giving the proportions of the population at the several ages under 5 years. Table V. (b) gives the decrease or increase per cent, of the diphtheria death rates for the same age periods in the several groups of population. Table V. (a). Showing increase or decrease per cent, in death rates from diphtheria at certain age-periods, between 1855-60 and 1861-70; 1861-70 and 1871-80; 1871-80 and 1881-90 ; and in the case of London, between 1881-90 and 1891-3. Area. Death rate per 1,000,000. 1855-60. Death rate per 1,000,000. 1861-70. Death rate per 1,000,000. 1871-80. Death rate per 1,000,000. 1881-90. Death rate per 1,000,000. 1891-3. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. England and Wales 178 660 516 49 184 757 512 46 121 415 373 30 163 572 557 31 - - - - -Urban 114 564 311 23 166 912 426 29 114 483 347 22 - - - - - - - - Rural 203 695 591 58 193 686 549 54 125 374 388 34 - - - - - - - - Urban (excluding London) 102 480 272 20 159 851 401 27 109 474 310 21 - - - - - - - - London 126 658 337 27 176 990 458 32 122 498 409 23 260 1197 921 31 521 2706 1877 49 5 Table V. (b). Decrease or Increase per cent, in diphtheria death rates between Area. 1855-60 and 1861-70. 1861-70 and 1871-80. 1871-80 and 1881-90. 1881-90 and 1891-3. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. All ages. Under 3 3-10 10 and upwards. England and Wales + 3 + 15 — 1 — 6 —34 —45 —27 —35 + 35 +38 +49 +3 Urban +46 +62 +37 +26 —31 —47 —19 —24 — — — — - - - — Itural — 5 — 1 — 7 — 7 —35 —45 —29 —37 — — — — - - - — Urban (excluding London) +56 + 77 +47 +35 —31 —44 —23 —22 - - - - - - - - London* +40 +50 +36 +19 —31 —50 —11 —28 +113 + 140 +125 +35 + 100 + 126 +104 +58 Tables V. (a) and (6) serve to bring out conspicuously the following facts— 1. That antecedent to 1871-80, in groups of population where the diphtheria death rate at all ages was rising, the rate at ages 3-10 years, though generally rising also, rose in less degree than the all age rate; and that when the all age rate was falling, the rate at ages 3-10 years fell in even greater degree than the all age rate. 2. That in 1871-80, with a general decline of the diphtheria mortality at all ages, in the several groups of population, there occurred in each group at ages 3-10 years a relatively higher diphtheria death rate than before: that is, the diphtheria mortality at ages 3-10 years did not fall in 1871-80 in anything like the same degree as the diphtheria mortality at all ages. This new departure is most notable in London, least notable in the rural groups; and inasmuch as it is suggestive of a fresh factor of diphtheria at ages 3-10 years becoming operative in the decennium 1871-80, there is room for more regret that data for the decennium 1881-90 are not available for all the groups of population that are in question. As regards England and Wales and London, however, in 1881-90 it may be pointed out that as compared with 1855-60 and 1861-70 the special incidence on the age 3-10 years is practically maintained. Inasmuch as the England and Wales and urban populations are made up of other of the five groups under consideration, it is convenient to compare the urban (excluding London), the rural and the London diphtheria rates. It is then seen that the mortality at ages 3-10 years was in 1871-80 maintained in the highest degree in London next in the "urban" (excluding London) population, and least in the "rural," a fact which is suggestive of some new condition coming into existence operating unequally upon this age-period in these different communities, or that such condition had been in 1861-70 already more strongly in operation in the districts inhabited by the rural population, less in operation in the "urban" (excluding London) districts, and least in London; and that its influence in 1871-80 on the two last and especially London prevented these groups of population from sharing in the fall experienced by the "rural" population at 3-10. The well recognised tendency of diphtheria to spread in schools naturally presents itself for examination, and the new departure I have noted needs to be considered in connection with the Elementary Education Act of 1870.t This Act came into operation in 1870, and since that time children have been increasingly aggregated in schools where opportunity for the communication of the disease from one to another necessarily occurs. If increased school attendance has been responsible for the greater incidence of diphtheria on children at school ages, it is to be expected that the increase of diphtheria at these ages would in point of time correspond with this increased attendance. Table VI. relating to London shows a notable increase on the age period 3-10 in the year 1871, which has been maintained more or less ever since, and has in later years been much accentuated. *The following table shows that the change in the age incidence of diphtheria mortality which appears when the figures of London as a whole are given is equally noticeable if the figures of different parts of London are considered. Area. All ages. Under 3. 3-10. 10 and upwards. North districts Diphtheria death rate per 1,000,000,1861-70 199 1,146 548 35 Do. 1871-80 132 489 501 24 Decrease per cent. —34 —57 —9 —32 East districts Diphtheria death rate per 1,000,000,1861-70 143 785 321 22 Do. 1871-80 85 389 237 11 Decrease per cent. —41 —50 —26 —50 South districts Diphtheria death rate per 1,000,000,1861-70 178 950 434 33 Do. 1871-80 137 523 424 27 Decrease per cent. —23 —45 —2 —18 West and central districts Diphtheria death rate per 1,000,000,1861-70 178 1,083 528 35 Do. 1871-80 122 569 456 25 Decrease per cent. —31 —47 —14 —29 † The influence of school attendance was pointed out by Mr. W. H. Power as early as 1876, and its effects have been recognised in a number of investigations made since. Dr. Thorne in his Milroy lectures published in 1891, in discussing the prevalence of diphtheria, refers to the increased opportunity for the dissemination of the disease by schools which has been given by the Elementary Education Act, and I have already in the same year (Presidential address to the Society of Medical Officers of Health; pointed out the change in the age incidence of diphtheria mortality in London since the passing of that Act. 6 Table VI. London. Year. Diphtheria. Diphtheria and Croup. All ages. Death rates per million. Ages 3-10. Death rates per million. Death rate at ages 3-10. (All ages taken as 100.) All ages. Death rates per million. Ages 3-10. Death rates per million. Death rate at ages 3-10. (All ages taken as 100.) 1861 239 597-5 250 552 1,232 223 1862 255 667.1 261 590 1,467 249 1863 275 762.2 277 590 1,573 267 1864 207 545.9 •263 516 1,212 235 1865 144 378.3 262 396 907 229 1866 152 357.6 235 402 872 217 1867 145 360.4 248 385 867 225 1868 158 440.9 279 364 892 245 1869 107 260.1 243 282 656 233 1870 104 286.1 275 286 680 238 1871 105 351.9 335 258 700 271 1872 80 272.8 341 263 761 289 1873 95 304.0 320 308 819 266 1874 122 384.0 314 347 954 275 1875 167 521.3 312 384 1,041 271 1876 109 367.2 337 286 794 278 1877 88 286.8 326 229 639 279 1878 155 546.6 352 320 944 295 1879 155 554.0 357 306 955 312 1880 144 497.5 345 306 950 310 1881 172 635.9 369 345 1,083 314 1882 222 812.2 366 447 1,443 323 1883 244 836.0 342 455 1,430 321 1884 241 822.3 341 427 1,343 315 1885 227 781.7 344 401 1,221 304 1886 212 765.4 361 344 1,090 317 1887 235 810.9 345 389 1,242 319 1888 319 1,168.2 366 442 1,529 346 1889 391 1,396.0 357 501 1,697 339 1890 331 1,163.6 351 456 1,506 330 1891 340 1,250.3 368 420 1,459 347 1892 460 1,629.9 354 510 1,756 344 1893 758 2,743.0 362 Table VII. shows a similar but less marked increase in the case of England and Wales, and it is noteworthy that the incidence on the age period 3-10 before 1871 was greater than it was in London in the corresponding years. Table VII. ENGLAND AND WALES. Year. Diphtheria. Diphtheria and Croup. All ages. Death rates per million. Ages 3—10. Death rates per million. Death rate at ages 3—10. (All ages taken as 100.) All ages. Death rates per million. Ages 3—10. Death rates per million. Death rate at ages 3—10. (All ages taken as l00.) 1861 225 649 288 443 1,132 256 1862 241 675 280 519 1,321 255 1863 315 899 285 653 1,703 261 1864 261 705 270 586 1,468 251 1865 196 552 282 476 1,192 250 1866 140 374 267 382 924 242 1867 120 327 272 322 779 242 1868 137 374 273 342 867 254 1869 117 332 284 319 820 257 1870 120 328 273 311 806 259 1871 111 323 291 291 766 263 1872 93 282 303 251 680 271 1873 108 331 306 291 788 271 1874 150 457 305 361 1,010 280 1875 142 423 298 331 901 272 1876 129 400 310 302 854 283 1877 111 344 310 269 765 284 1878 140 455 325 302 893 296 1879 120 377 314 261 760 291 1880 109 354 325 248 723 292 1881 121 413 341 259 807 312 1882 152 518 341 327 1,033 316 1883 158 536 339 331 1,035 313 1884 186 631 339 363 1,150 317 1885 164 547 334 320 984 308 1886 149 499 335 283 880 311 1887 160 543 339 303 954 315 1888 171 592 346 300 963 321 1889 189 664 351 303 988 326 1890 179 634 354 288 96 335 1891 173 622 360 264 894 338 7 Table VIII. shows the average attendance of children in the London elementary schools for each year since the Act has been in force; and Table IX. the average attendance at public elementary day schools in England and Wales in each year during the period 1861-80. It is matter for regret that I am unable to show the average attendance of London children at voluntary schools before 1871, for it needs to be stated that while the Act was passed in 1870 visitors whose services were necessary for enforcing school attendance were not appointed until 1872. Such information, however, as I have been able to obtain leads to the belief that there was activity in provision of increased accommodation in London voluntary schools in the beginning of the decennium 1871-80. Table VIII. Table showing the average number of children in attendance at all efficient schools in the Metropolis for the past quarter for 1871-1873 inclusive ; for the past half-year for 1874 to 1886 inclusive ; for the past nine months for 1887 ; and for the past twelve months 1888 to 1893. Dec., 1871. Dec., 1872. Dec., 1873. Dec., 1874. Dec., 1875. Dec., 1876. Dec.. 1877. Dec., 1878. Dec., 1879. Dec., 1880. Dec., 1881. Dec., 1882. A verage attendance— Board schools 895 19,421 40,481 70,853 91,646 114,380 146,155 165,900 185,518 200,694 220,068 238,205 Non-Board schools 1173,406 165,482 195,662 199,613 196,851 199,605 190,163 184,607 182,728 181,649 177,438 174,723 Total 174,301 184,903 236,143 270,466 288,497 313,985 336,318 350,507 368,246 382,343 397,506 412,928 Dec., 1883. Dec., 1884. Dec., 1885. June, 1886. March, 1887. March, 1888. March, 1889. March, 1890. March, 1891. March, 1892. March, 1893. Average attendance— Board schools 266,013 278,224 298,317 303,715 319,443 328,578 342,321 345,746 347,857 362,585 379,445 Non-Board schools 173,845 169,011 167,242 163,477 165,099 162,349 164,770 164,434 162,525 165,0.50 174,035 Total 439,858 447,235 465,559 467,192 484,-542 490,927 507,091 510,180 510,382 527,635 553,480 Table IX. Average attendance of children at public elementary day schools in England and Wales for the years 1861-80. Year. Average attendance. Increase or decrease per cent, over previous year. Year. Average attendance. Increase or decrease per cent, over previous year. 1861 753,444 1871 1,231,434 + 6.9 1862 780,690 + 3-6 1872 1,336,158 + 8.5 1863 799,156 + 2.4 1873 1,482,480 + 11.0 1864 796,661 — 0.3 1874 1,678,759 + 13.2 1865 848,044 + 6.4 1875 1,837.180 + 9.4 1866 863,420 + 1.8 1876 1,984,573 + 8.0 1867 911,681 + 5.6 1877 2,150,683 + 8.4 1868 978,521 + 7.3 1878 2,405,197 + 11.8 1869 1,062,999 + 8.6 1879 2,594,995 + 7.9 1870 1,152,389 + 8-4 1880 2,7-50,916 + 6-0 A further point consistent with school influence deserves passing comment. It has been pointed out by Dr. Downes that the mortality of females from diphtheria is greater than that of males. Thus in England and Wales in 1861-70 the male death rate at all ages was to the female death rate as 100 to 108. This difference is more marked at the school age period of life than at all ages. The statistics of more recent years show that these differences are diminishing, and this might be due to any circumstance such, for instance, as school life, tending to subject the two sexes to more equal conditions. England and Wales. Males 3-15. Females 3-15. Males. All ages. Females. All ages. 1861-70 100 129 100 108 1871-80 100 124 100 107 1881-90 100 119 100 106 It is impossible to draw conclusions from these figures only as to how much of the prevailing diphtheria may result from the condition which has thus relatively raised the rate of mortality at the school age period of life, but it is obvious that disease contracted by children of school age has opportunity for communicating itself to younger and older persons just as disease contracted by 8 infants and older persons may lead to the infection of children at the school age period of life. The following Tables X. (a) and X. (b) afford, however, reason for thinking that this condition is in active operation at the present time in London, and I think the first step to be taken in investigating the present prevalence is to endeavour to determine the extent to which schools are contributing to diphtheria dissemination, especially those in which infants and younger children are taught. Table X (a). LONDON. DIPHTHERIA. Death rate per 1,000,000. Death rate at each age period (all ages taken as 100). All ages. Under 3. 3-10 10 and upwards. Under 3. 3-10 10 and upwards. 1855-60 126 658 337 27 522 267 21 1861-70 176 990 458 32 562 260 18 1871-80 122 498 409 23 408 335 19 1881-90 260 1,197 921 31 460 354 12 1891-3 521 2,706 1,877 49 519 360 9 Increase per cent, in death rates between 1855-60 and 1891-3. 1861-70 and 1891-3. All ages. Under 3. 3-10 10 and upwards. All ages. Under 3. 3-10 10 and upwards. 313 311 457 81 196 173 309 53 Table X (b). DIPHTHERIA AND CROUP. Death rate per 1,000,000. Death rate at each age period (all ages taken as 100). All ages. Under 3. 3-10. 10 and upwards. Under 3. 3-10. 10 and upwards. 1855-60 320 2,100 823 28 656 257 9 1861-70 430 3,044 1,018 34 708 237 8 1871-80 299 1,812 852 23 606 285 8 1881-90 419 2,374 1,358 32 567 324 8 1891-2* 465 2,586 1,608 38 556 346 8 Increase or decrease per cent, in death rates between 1855-60 and 1891-2* 1861-70 and 1891-2* All ages. Under 3. 3-10. 10 and upwards. All ages. Under 3. 3-10. 10 and upwards. + 45 + 23 + 95 + 36 + 8 — 15 + 58 + 12 * The figures relating to croup at the age periods shown in this table are not yet available for the year 1893. The death rate at all ages from diphtheria and cioup combined in the period 1891-3 was, however, 581 per million, as compared with 465 in the period 1891-2. The rate (581) of 1891-3 is an increase over the rate of 1855-60 of^82 per cent., and over the rate of 1861-70 of 35 per cent. Shirley F. Murphy, Medical Officer of Health. Appendix II. London County Council. cholera in london during 1893. Report of the Medical Officer of Health on the subject of Cholera in London during 1893, together with Dr. Klein's report on bacteriological examinations made in connection therewith. (Printed by order of the Public Health Committee, 22nd January, 1894.) Public Health Department, Spring Gardens, 3.W., 18th January, 1894. In reporting to the Committee on September 28th as to the steps taken in connection with cholera during the recess, I stated that inquiry had been made into all instances which came to my knowledge of persons in London suffering from disease suspected to be Asiatic cholera, and in a few cases in which it appeared desirable that there should be bacteriological examination, material from such cases was sent to Dr. Klein. I addressed a letter on September 8th to the medical officers of health of the London sanitary districts, informing them that I was authorised to send material to Dr. Klein in cases where bacteriological examination was desirable, and inviting them to give me notice of suspected cases of cholera. I received immediate personal information of several such cases, and in addition to the inquiries thereupon undertaken, a systematic investigation was instituted also into the history and symptoms of persons notified as suffering from cholera or choleraic diarrhoea, as well as into the cases of death registered during the latter part of August, September, and the early part of October, and attributed to cholera or choleraic diarrhoea. In the large majority of cases investigated the symptoms were those of ordinary summer diarrhoea of a severe type; in a few instances the existence of marked collapse associated with vomiting and diarrhoea, and with one or more of the following symptoms—cramps in the limbs, blueness and shrivelled appearance of extremities, altered voice, rice-water evacuations—suggested the desirability of bacteriological enquiry as an aid to diagnosis. In cases of death of patients exhibiting symptoms of this kind a post-mortem examination was also made, and a portion of the lower part of the small intestine with its contents was submitted to Dr. Klein for report. In other instances stools presenting the rice-water character obtained from patients who subsequently recovered, were submitted to Dr. Klein for examination. In one or two instances no material for bacteriological examination was obtainable, but the clinical symptoms that had been manifested in some of these cases were quite as suggestive as those which occurred in the cases from which material was obtained and gent to Dr. Klein. In all instances careful inquiry was made as to a source of infection. In no case was it possible to trace any connection between the suspicious cases occurring in London and other suspected cases whether occurring in London or elsewhere; and further in no single instance was there any evidence of spread of the disease from any of the cases brought under notice. A history was given by two patients of their having eaten fish which had come from Grimsby; by several patients of having eaten fried fish and shell fish; and by one patient of having eaten shrimps. In all these cases other persons had partaken of the particular food specified without ill effect. The following cases are selected from the total investigated, upwards of fifty in number. Cases which proved on enquiry to afford no reasonable suspicion of the illness having been Asiatic cholera have been eliminated. Of the remainder, 16 in number, material from 13 was sent to Dr. Klein; from two by the Medical Officer of the Local Government Board, from 11 by myself. In four of these cases Dr. Klein's examination gave positive results. The 16 persons of whose illness account is here given include persons at various periods of life, but all the four persons, in whose cases positive results were obtained as the result of bacteriological examination, were over fifty years of age. All the 16 cases except one belonged to the poorer classes of the community. I present Dr. Klein's report on the subject of bacteriological examination of cholera, as well as an abstract of notes of the clinical history of the 16 cases, and of the post-mortem appearances of the cases which proved fatal. These notes are, in the majority of instances, an abstract of information obtained by Dr. Hamer from medical officers of health, from the medical attendants or from the friends of the patients, and are supplemented, when possible, by our own observations. I have to acknowledge the aid thus afforded me by Dr. John Norton (Westminster), Dr, Millson (Newington), Dr. Verdon (Lambeth), Dr. Waldo (St. George-the-Martyr), and Dr. Warry (^Hackney). Case 1. M. B. (female), set. 50, Marsham-street, Westminster. A cleaner in the House of Commons. Had been nowhere save between her home and the House of Commons, and to shops to make necessary purchases. Had latterly been prone to suffer from diarrhoea, but had been quite free from it for some five weeks before her fatal illness. She ate fried fish for supper on an evening towards the end of the week ending September 2nd. On September 3rd and 4th the patient and her daughters ate rabbit and pickled pork, and the daughters suffered from slight diarrhoea and abdominal pains on September 4th, but had quite recovered on September 5th. On this day, while at the House of Commons, patient was seized with diarrhoea and returned home; vomiting and cramps set in and the stools were of the rice-water character. In the evening she was much collapsed; she died on the evening of September 6th. No. 141—Price 2d. Sotd by E. Stanford, 26 and 27, Coclcspur-street, Charing-craes, S.W. 4316 2 Dr. Scott, of Westminster, stated that a post-mortem examination showed the intestines to be injected, the lower part of the ileum being quite pink. A portion of the ileum was taken to Dr. Klein by Dr. Sweeting, medical inspector of the Local Government Board, who was present at the post-mortem examination. Dr. Klein subsequently stated that the case was one of undoubted Asiatic cholera. "The symptoms of the disease and the pathological condition of the intestine, the microscopic characters of the rice-water stool and of the intestinal contents, and the cultivation tests, were in every respect most typical of Asiatic cholera." Case 2. H. T. (male), set. 25, printer. Chapel-street, Clerkenwell. On the evening of September 7th he drank a pint of beer, and ate some fish, an egg and a sandwich for supper. On the 8th September, at 8 a.m. diarrhoea set in. The diarrhoea continued, and at 10 a.m. cramps in the limbs began, and, on admission to St. Bartholomew's Hospital, he was cold and blue. Temperature 96.2 in the axilla, 100'4 in the rectum. There was suppression of urine. On the 9th he passed a motion, which was sent to Dr. Klein for examination. Patient's condition improved, and he soon became convalescent. No other case of similar illness occurred in the house. Report by Dr. Klein. "The evacuations were of a rice-water character; in a slightly turbid watery fluid were suspended numerous greyish-white flakes. Examined under the microscope, these flakes consisted chiefly of leucocytes, but not of epithelial cells like the flakes of typical cholera. In microscopic specimens crowds of bacteria (bacillus coli) were seen, some also that looked like commas. Cultivations proved entirely negative qua comma bacilli." Case 3. A. B. (female), set. 54. Patient had been an inmate of the Fulham Union Workhouse for a long time, and was engaged up to September the 9th in washing the dirty clothes of workhouse inmates. September 10th, at 1.80 p.m., patient had" an attack of convulsions," followed by vomiting, diarrhoea, and cramps. At 3 p.m. she was blue and collapsed; the vomiting and cramps continued, and at 9 p.m. diarrhoea again set in, the motions being of a rice-water character. She died at 5 a.m. on the 11th September. The assistant medical officer of the infirmary stated that a post-mortem examination made the same evening showed there was acute inflammation of the upper part of the small intestine, with some patches of extravasated blood. The intestinal contents were grumous and blood-stained. Dr. Klein reporting on the specimen submitted to him stated that "although the microscopic characters of the intestinal contents were not so typical as in the Westminster case (case 1), the cultivations were positive, and in every respect characteristic of Asiatic cholera." Case 4. J. E. (male), set. 61, master sculptor, Kennington-road. Patient was at Ramsgate with his three daughters from September 2nd to 4th. He then came home, and only went out to go to his office a short distance away. While at Ramsgate he ate some shrimp paste. On September the 5th he suffered from colic and began to feel "out of sorts." On the 9th he slept badly; on the 10th he was rather better; on the morning of the 11th he suffered from vomiting and purging with cramps, became rapidly worse, and at 11 a.m. was almost pulseless, blue and cold. In the evening at 7 p.m. he was transfused and seemed a little better for a time, but died between 5 and 6 next morning. One of his daughters was said to have had slight diarrhoea on the 6th. A post-mortem examination showed some injection of the coats of the small intestine, particularly of the ileum. There were old adhesions binding together coils of intestine. The contents of the bowel were like watery mucus. Report by Dr. Klein—"In microscopic specimens there were seen numerous epithelial flakes containing amongst numerous straight bacilli some distinctly comma and S-shaped ones. Cultivations were made in peptone salt, and yielded in 18 hours a crop of comma bacilli which, in sub-cultures in the various media, proved identical with the choleraic comma bacilli. Distinct cholera-red reaction." Case 5. W. N. (male), set. 19, lighterman, Park-street, Poplar. Patient was quite well when he left home for Purfleet one week previous to his attack of illness. He worked with three other men on a barge, the " Memory," and they were engaged at Purfleet on the 12th September loading up with sand. They started for London at 10 p.m. on the same night, and patient had a bun and some beer at Erith. He subsequently complained of being thirsty, and was cautioned not to drink river water, but could not recollect whether he had done so. About 11 a.m. on the 13th September pain in the belly commenced, and was succeeded by vomiting and severe diarrhoea, with cramps in the limbs. He was admitted into St. Bartholomew's Hospital during the afternoon, and on admission at 5 p.m. was semi-comatose, cold and dusky. About 9 p.m. his condition was rather more hopeful; his voice was husky, but he was quite conscious, and the diarrhoea had ceased ; there was, however, still occasional vomiting. On the 14th reaction had set in, the face being flushed, the temperature just below normal (97.8). No action of the bowels had occurred for 24 hours, and no urine had been passed during that period. The patient gradually improved. There was no action of the bowels for a period of some days, and no bacteriological examination could in consequence be made. His barge mates remained in good health. Case 6. S.B. (female), set. 53, Tabard-street, Newington. Patient was housekeeper at a mission-house in the above street. She rarely went outside the house; on September the 8th, however, she went with a friend to Greenwich, and there bought some o O shrimps. She only ate a few, as the taste was disagreeable. Dr. Millson, the medical officer of health of the district, who gave me notes of this case, states that she had eaten tomatoes, and had partaken freely of pears with the peel on, prior to her illness. Patient suffered from slight diarrhoea "on and off" from September 7th. At 2 a.m. on the 14th September purging and abdominal pain set in, and collapse soon supervened. In the evening her condition improved. On the 15th she was distinctly better, but there was still profuse diarrhoea. The improvement was maintained on the 16th. On the 17th, however, she was not so well. On the 18th the severe diarrhoea returned, collapse became extreme, and the patient died at midnight. There was no other case of similar illness in the house. A post-mortem examination by Dr. Millson, at which Dr. Hamer and I were present, showed the small intestine to be injected ; there were extensive adhesions (old) of the lungs to the chest wall. A piece of ileum was sent to Dr. Klein. Report by Dr. Klein—"The intestine was much congested and contained solid gelatinous stringy masses. Microscopic examination showed numerous epithelial flakes, and in them crowds of bacillus coli, but no definite commas. Cultivations proved altogether negative qua commas." Case 7. E. C. E. (male), set. 5, Gee-street, St. Luke's. On September the 15th diarrhoea and vomiting commenced. The stools resembled rice-water. Patient rapidly sank into a condition of extreme collapse, and on admission to hospital at midnight appeared to be in extremis. The purging and vomiting however ceased, and on the 16th his condition steadily improved, and he made a good recovery. Report by Dr. Klein—"The stools contained numerous flakes, but they were not of the epithelial character. Amongst crowds of various bacilli, there were few that looked like commas. Cultivations proved negative qua commas." Case 8. J. E. F. (male), set. 11, 20 Block, Little Sutton-street, Clerkenwell. Patient ate on 16th September some fried fish, which his friends say came from Grimsby. (His brother also ate some of the fish, and he vomited shortly afterwards.) On the 17th September, patient vomited and was purged. He was taken to St. Bartholomew's Hospital, and was then in a collapsed condition; there were no cramps in the limbs. The stools were like rice-water. The next day patient was much better, and he made a good recovery. Dr. Klein examined two of the evacuations passed by this patient. Report by Dr. Klein—"The stools contained in a slightly turbid fluid numerous whitish grey flakes, which on examination were seen to be made up of leucocytes, not of epithelial cells. No definite commas in them. Cultivations proved negative. Rice-water stools of same case was obtained on the following day, September 19th. The microscopic examination of the flakes and the cultivation again yielded negative results." Case 9. S. F. (male), set. 6, 22 Block, Little Sutton-street, Clerkenwell. On September the 18th he ate some fried fish obtained from the same shop as the fish eaten by J. E. F., case 8. On the 19th he ate an ice, and a few minutes afterwards was attacked with vomiting and diarrhoea. He was admitted the same evening into hospital, and there passed two motions, not of a rice-water character. The vomiting was frequent, and streaks of blood were seen in the material brought up. There was suppression of urine for 28 hours, and considerable collapse. The patient made a good recovery. No bacteriological examination was made in this case. Case 10. T. S. (male), set. 26, builder, Ottaway-road, Hackney. On September the 16th he ate a bloater for breakfast, and he subsequently ate some whelks. On September the 17th he ate pickled pork, which his wife and child shared, both remaining well. At 1 a.m. on the 18th, vomiting and diarrhoea with cramps in the limbs set in. The stools looked like rice-water. On the afternoon of the same day he was admitted into St. Bartholomew's Hospital in a state of collapse. The diarrhoea had then ceased, and from this time his condition improved, and he made a good recovery. One of the rice-water-like evacuations was obtained on September 18th by Dr. Warry, Acting Medical Officer of Health of Hackney, and submitted to Dr. Klein on September 22nd. Report by Dr. Klein—"Numerous whitish grey flakes were present, which under the microscope did not show the epithelial character. There were present crowds of straight bacilli. Cultivations proved entirely negative qua commas." Case 11. A. B. (male), set. 15, printer, Thesiger-road, Penge. On the 20th September, patient began to suffer from diarrhoea and abdominal pain. After the commencement of symptoms he ate a bloater, but does not recollect eating shell fish or fish of any kind prior to his attack. The indisposition passed off for a time, but returned on the morning of tha Sllst, when he was attacked with abdominal pain, vomiting and headache. At 10 a.m. he was admitted into hospital, and was then much collapsed, suffering from vomiting and diarrhoea, but his voice was unaltered. There were no cramps in the limbs throughout the illness. The stools were not typically rice-water. He made a good recovery. There was no other case of similar illness in the house. Report of Dr. Klein—"Microscopical examination showed numerous flakes, but they were not cf the epithelial character, and they contained crowds of bacillus coli. No definite comma bacilli could be detected in the stool. Cultivations proved negative." Case 12. R. N. (male), £Bt. 60, glass cutter, Artizans'-dwellings, Quinn's-square, Waterloo-bridge-road. Patient came with his family to the block of buildings named above about four weeks before his illness began. No strangers subsequently were entered as tenants in the block save a family which 4 came in after the commencement of patient's illness. Patient's work took him to various districts Id the county of London, sometimes outside the boundary; nothing definite could, however, be ascertained concerning his movements during the few days preceding his illness. It was certain, however, that he had not slept away from home. On September 22nd he ate some liver and bacon. On the 23rd diarrhoea commenced. The next day he felt better, but the diarrhoea returned in the evening. On the 25th he went to work, but was compelled to return Lome on account of severe diarrhoea, accompanied by vomiting. On the 26th the motions was blood-stained; voice not characteristic of cholera; he became collapsed, and died at 10 p.m. Throughout his illness there was abdominal pain, but no complaint was made by patient of cramps in his limbs. There was no other case of similar illness in neighbouring tenements. Post mortem the intestines were found injected throughout their whole length, there was a little fluid in the peritoneal cavity. There were submucous hemorrhages in the lower ileum and the large intestine. This extravasation was very extensive in the head of the caecum. A portion of the lower ileum was taken to Dr. Klein. Report by Dr. Klein—"The mucous membrane was deeply congested, the Payer's patches and solitary follicles prominent and deeply congested; the contents of the ileum a brownish fluid. On microscopical examination numerous epithelial flakes could be distinguished. Crowds of different bacteria present, among them a fair number of commas and S-shaped forms. Peptone salt cultures yielded crops of commas giving markedly the cholera-red reaction. The peculiar character of these commas was this: that while in gelatine plate cultivations the colonies were of the general character of the choleraic commas except that the liquefaction proceeded very slowly, in gelatine stab cultures they did not produce liquefaction. In agar and other media they did not differ from the typical cholera commas." Case 13. A. K (male), set. 53, vagrant, lodging-house, Campbell-road, Islington. Patient had stayed on and off at the above address for some weeks. On the 19th September he went to Wood-green, returning to Islington at night; a day or two later he went to St. Mary Cray, and slept at a lodging-house there, the address of which he could not give. He had while at St. Mary Cray eaten some damsons and boiled pork, but had not had any shell fish. On the 23rd he returned from St. Mary Cray to Islington, and at 8 p.m. on that day was seized with abdominal pain, vomiting, diarrhoea, and cramps in the limbs. At 11 p.m., on admission to the infirmary, he was much collapsed, and was suffering from severe vomiting and diarrhoea; the stools were described by the nurse as "like ricewater an hour or two later he began to improve, and quickly rallied, and on the following day was quite convalescent. There was no other case of similar illness in the Islington lodging-house. No bacteriological examination was made in this case, as the stools had not been preserved. Case 14. H. C. (female) set. 74. An inmate of the Greenwich Union Workhouse, who was taken ill on her way from the workhouse to Royal-street, Lambeth. Patient left the workhouse on October the 10th to spend the day at the above address. She had been suffering early on the morning of the 10th from mild diarrhoea; later, severe purging and vomiting coming on, she was unable to return to Greenwich. Her symptoms became more severe when she arrived at the house of her niece at Royal-street, Lambeth. She was cold, collapsed, but not actually blue, her voice was not altered, and she had no definite cramps; she died on the morning of the llth October. A post-mortem examination was made, and the small intestine was found somewhat injected throughout, and containing a grumous liquid which was very faintly bile tinged. A piece of the ileum was taken to Dr. Klein. Report by Dr. Klein—"On microscopic examination, crowds of bacilli were found, some short, others long cylinders, and some filamentous, also some few forms that looked not unlike commas. Cultivations proved entirely negative qua commas." A number of cases of diarrhoeal disease having developed among inmates of the Greenwich Union Workhouse, an enquiry was instituted into the outbreak by the Local Government Board. The report on the result of this inquiry is not yet published. It is sufficient, as far as case 14 is concerned, to say that the disease was not found to be cholera. Case 15. A. L. (female) set. 43, Great Peter-street, Westminster. Wife of an employe at the gasworks. She had not been away from home for a week before her illness. On the 12th and 13th October patient suffered from cramps in the legs, and on the 15th diarrhoea commenced. On the 16th she vomited for the first time, and her condition became rapidly worse, and she died at 11 a.m. The details which could be obtained concerning patient's previous history were very meagre. No medical man attended her during her illness. The practitioner who saw the body shortly after death made a post-mortem examination, and found the small intestine reddened with injection. He formed the opinion that the death was from natural causes, and might be due to cholera. A coroner's jury expressed the hope that a bacteriological examination would be made. A piece of the ileum was sent to Dr. Klein. Report by Dr. Klein—"Dr. Hamer brought to me a piece of ileum. This was much congested, and contained brownish blood-stained fluid. No definite commas amongst crowds of bacteria. Cultivations entirely negative qua comma bacilli." Case 16. E. 0. (female), set. 14. Bookfolder, Merlin's-place, Clerkenwell. October 20th, pain in abdomen and shivering came on, followed by frequent vomiting. On 21st the vomiting continued, and was accompanied by diarrhoea. Motions light-coloured. On the 22nd delirious, still vomiting. On 23rd patient was admitted into St. Bartholomew's Hospital. Patient was then much collapsed with cold extremities. Died same night. 5 A post-mortem examination was made, and there was found to be intense purulent peritonitis. There was no lesion visible to the naked eye to account for this. A portion of the ileum and peritoneal fluid was given to Dr. Klein. Report by Dr. Klein—"In the peritoneal turbid fluid and in the solid masses of lymph, numerous cocci—in clumps and as diplo-cocci—could be distinguished. The whole of the intestine was congested, and in its cavity solid lumps of lymph containing the same masses of cocci. No common bacilli could be found. Cultivations proved negative qua comma bacilli." Shirley F. Murphy, Medical Officer of Health. Dr. Klein's Report. St. Bartholomew's Hospital, November 29th, 1893. The Medical Officer of the London County Council. Sir, I beg herewith to report on the result of the microscopic and bacteriological examination of the cases of supposed cholera that occurred during September and October last, within your district. Before giving these results, it is necessary to state a few points concerning the pathological, microscopic and bacteriological characters of the intestine in cases of Asiatic cholera. Almost all pathologists and bacteriologists concur with Koch on the following points: (a) the comma bacillus which Koch discovered in the stools and intestinal contents of cases of Asiatic cholera, represents a well-defined species, which possesses certain characteristic morphological and cultural features; (b) this species does not occur in any acute intestinal disease except in Asiatic cholera, it certainly does not occur in sporadic cholera or cholera nostras, as far as our present knowledge goes; (c) the comma bacillus of Finkler—to some extent morphologically and culturally resembling Koch's comma bacillus—does not occur in cholera nostras or in Asiatic cholera. Now, the generally recognized morphological and cultural characters of Koch's comma bacillus, which for brevity's sake I will call the cholera vibrio, are for practical purposes sufficient to make a diagnosis; but since last year's Hamburg epidemic, Dr. Dunbar has added to these one further test (practically described already by Dunham), which I consider of very great importance. This further test is the characteristic rose-coloured tint called the cholera-red assumed by the peptone-salt cultures of the cholera vibrio on adding to them a drop or two of pure sulphuric acid. This red reaction is distinct and definite, and may be demonstrated as early as six to ten hours after setting up the peptone culture of the cholera vibrio. The history of this test is as follows—It has been known for some years by the researches of Bujwid that mineral acids added to a broth culture of cholera vibrio produce this cholera-red; but it has been shown that also in broth cultures of other species of comma bacilli, the same red colour is produced by the same methods, and Salkowski has taught us that the red colour is due to the presence of nitrites and indol. Dunham has further shown that, in order to obtain the cholera-red reaction, the presence of peptone in the broth is of importance, and he used for obtaining rapid growth and distinct red reaction 1 per cent, of peptone and \ per cent. salt. Dunbar showed the important practical fact that this culture-medium of Dunham is of great importance for a rapid detection and isolation of the cholera vibrio—so much so, that in as little space of time as six or eight hours (though better still at longer intervals), a considerable crop of the cholera vibrios may be obtained, even if at the outset (that is, at the time of inoculation of the peptone fluid) only few vibrios are introduced. Although other intestinal bacteria show growth in that peptone solution—proteus vulgaris, bacillus coli, vibrio of Finkler—yet the cholera vibrio grows in the peptone incomparably faster, moreover the cholera-red reaction is not obtained with these microbes even when abundant; as a matter of fact, I have had experience of several cases in which though the microscopic examination of the contents of the ileum failed to give positive indication of the presence of the cholera vibrio, yet the peptone cultures made from such contents—teeming as they were with crowds of cocci, bacillus coli and spore-bearing bacilli—yielded after 6, 8 or 10 hours incubation at 37° C. almost a pure crop of the cholera vibrio. I need hardly point out the very great importance of this method in arriving at a rapid conclusion. True, when initially the cholera vibrios are present in the intestinal contents in large numbers (I have had to examine cases where they were present to the almost complete exclusion of other bacteria) pure, cultures of the cholera vibro in broth, on Agar, on gelatine, in peptone, are obtainable with comparative facility; but when one is dealing with cases such as I have mentioned above (and most of the cases to be reported here were of this character) every other method, except the peptone culture, failed to give positive evidence as to the presence of the cholera vibrio. The indications that guided me in forming the diagnosis of cholera are briefly these— 1.—The condition of the stool, or the condition of the intestine, submitted for examination. In true cholera the intestine is more or less injected in its mucosa and serosa; its cavity contains fluid material, either like rice-water as in the typical cases, or of a light to dark brown fluid character (like pea soup) sometimes blood tinged; the epithelium of the mucous membrane is altogether detached in larger or smaller flakes, or is only loosely adhering and easily detached. The presence of actual epithelial flakes in the cavity of the intestine forms an important point. I have had submitted to me stools from certain cases, e.g., case 2, which were, to the naked eye inspection, not distinguishable from typical rice-water stools of cases of Asiatic cholera; numerous flakes of the so-called "mucus-flakes" were present, but these were not true epithelial flakes. As microscopic and cultural observations showed, no comma bacilli could be discovered in them, and the patients that had voided those stools rapidly recovered. My experience of Asiatic cholera coincides with that of all other observers on this point, viz., that if in the (epithelial) "mucus-flakes" of the rice-water stools or of the contents of the ileum, Koch's comma bacilli (as far as size, shape, motility and arrangement) occur in great numbers— (in some typical cases they occurred in almost pure culture)—the diagnosis Asiatic cholera is quite 6 justified.* There is no other acute intestinal disease of man known in which such a condition occurs. The rice-water stool of the woman Bailey for instance, case 1, and of several others which I have examined, had the character just stated; so that in these cases the microscopic examination alone enabled me to make the diagnosis of true cholera; the cultivation in peptone; the cholera-red reaction in these cultures, after 6, 8 or 10 hours; the cultivations in gelatine plates, in Agar plates, and in stab and streak cultures in gelatine and in Agar, fully confirmed the correctness of the provisional conclusion. 2,—The peptone culture of the stool or of the intestinal contents in all cases yielded positive results if at the outset cholera vibrios were present. I stated in a former paragraph that there were cases in which from the microscopic examinations alone no preliminary conclusion could be arrived at, since amongst the crowds of bacteria present, only here and there an organism was found which in size and shape (comma shaped) resembled Koch's vibrio; but Dunham's peptone-salt solution inoculated with the material, yielded positive evidence, inasmuch as already after 6-12 hours copious crops of the cholera vibrios were obtained, which in sub-cultures (gelatine, Agar, potato, milk and peptone) proved themselves the undoubted cholera vibrios. Such, amongst others I have examined, were cases 8,4 and 12. 3.—In addition to the above tests we have the characters of the growth obtained by cultivation in the ordinary media, to which I need not further refer. These then were the lines on which I have hitherto based my preliminary reports as to the result of the examination of intestines or stools submitted to me. Knowing that Koch's comma bacillus (judging by morphological and cultural and chemical characters) does not occur in any except true cholera cases, I have felt justified when they were shown to be present in the stool or in the intestinal contents, in definitely pronouncing those cases as Asiatic cholera. Whether cases in which they (the particular comma bacilli) cannot be demonstrated by the above tests are or are not cases of true Asiatic cholera, cannot, in the present state of our knowledge, be satisfactorily answered. It is on record that experienced observers, who have devoted special attention to this very point, have had before them cases which, clinically and pathologically, presented the characters of Asiatic cholera— cases which occurred in localities, and at times when true cholera was rife (in Hamburg, in Russia, in France, and elsewhere)—but in which no Koch's comma bacilli could be demonstrated. In conclusion, I wish to state that the comma bacilli which I have isolated from the numerous cases of cholera that occurred in England during September and October last do not belong to one single species, or, to speak more correctly, they rather represent varieties of a species; though, in a general way, their morphological and cultural characters are the same, there nevertheless exist between them certain definite and permanent differences in their mode of growth in the different media, and the amount of cholera-red produced by them in the peptone cultures. The results of the bacterioscopic examination of the eleven cases submitted to me have been referred to in the preceding report. I append the annexed tabular statement, in which each case is indicated by the reference number which it bears in that report. Microscopic characters. General character in cultivation. Cholera-red re-action. Stab-culture in gelatine. Formation of pellicle in gelatine after liquefaction had set in. Potato oulture. Milk culture. †Case 1 Typical Positive Distinct Quick liquefaction Slight pellicle No growth after 14 days Fluid after 14 days Case 2 Not typical Negative — — — — — †Case 3 99 Positive Distinct Fairly quick liquefaction Good pellicle No growth after 14 days Fluid after 14 days Case 4 ,, ,, Distinct Quick liquefaction Slight pellicle Colourless growth Coagulation after 6 days Case 5 ,, Negative — — — — — Case 7 ,, if — — — — — Case 8 „ ff — — — — — Case 10 ,, ft — — — — — Case 11 — — — — . — Case 12 ,, Positive Distinct Not liquefying in stabculture No pellicle Colourless growth Remains fluid Case 14 ,, Negative — — — — — Case 15 ,, ,, — — — — — Case 16 ,, ,, — — — — — Yours faithfully, (Signed) E. Klein. *Numerous statements have appeared in the lay and medical press from which a conclusion has been drawn that I have changed my opinions on this point. To show that such conclusion is contrary to fact, I may be allowed to recall what I stated in my articles on cholera, that appeared in the "Practitioner" in 1886-1887, which have been reprinted in book form. ("The Bacteria in Asiatic Cholera," Macmillan.)—On page 114 of this work, I say—"One thing, however, may be said with certainty, namely, that as far as our limited knowledge at present goes, in no intestinal disorder in man (except Asiatic cholera) have comma bacilli behaving in artificial cultures like those of Asiatic cholera been yet found in the intestinal examinations."And on page 115—" Hence I agree with the proposition that if in any case of diarrhcea the choleraic comma bacilli can be shown both by the microscope and by culture experiments to exist, then the suspicion that it may be a case of Asiatic cholera is quite justified." f These two cases were examined by Dr. Klein for the Medical department of the Local Government Board. Appendix III. LondonCounty Council. By-laws made by the London County Council under the Public Health (London) Act, 1891. By-laws under Section 16 (2). For prescribing the times for the removal or carriage by road or water of any fecal, or offensive or noxious matter or liquid in or through London, and providing that the carriage or vessel used therefor shall be properly constructed and covered so as to prevent the escape of any such matter or liquid, and as to prevent any nuisance arising therefrom. Pascal and offensive matter. 1. Every person who shall remove or carry byroad or water in or through London any faecal or offensive or noxious matter or liquid, whether such matter or liquid shall be in course of removal or carriage from within or without or through London, shall not remove or carry such matter or liquid in or through London except between the hours of 4 o'clock and 10 o'clock in the forenoon during the months of March, April, May, June, July, August, September, and October, and except between the hours of 6 o'clock in the forenoon and 12 o'clock at noon during the months of November, December, January, and February. Such person shall use a suitable carriage or vessel properly constructed and furnished with a sufficient covering so as to prevent the escape of any such matter or liquid therefrom, and so as to prevent any nuisance arising therefrom. Provided that this by-law shall not apply to the carriage of horse dung manure. As to the closing and filling up of cesspools and privies. Closing and filling up of cesspools and privies. 2. Any person who shall by any works or by any structural alteration of any premises render the further use of a cesspool or privy unnecessary, and the owner of any premises on which shall be situated a disused cesspool or privy, or a cesspool or privy which has become unnecessary, shall completely empty such cesspool or privy of all faecal or offensive matter which it may contain, and shall completely remove so much of the floor, walls, and roof of such privy or cesspool as can safely be removed, and all pipes and drains leading thereto or therefrom, or connected therewith, and any earth or other material contaminated by such faecal or offensive matter. He shall completely close and fill up the cesspool with good concrete or with suitable dry clean earth, dry clean brick rubbish, or other dry clean material, and where the walls of such cesspool shall not have been completely removed, he shall cover the surface of the space so filled up with earth, rubbish, or material, with a layer of good concrete six inches thick. 3. Every person who shall propose to close or fill up any cesspool or privy shall, before commencing any works for such purpose, give to the Sanitary Authority for the district not less than forty-eight hours notice in writing, exclusive of Sunday, Good Friday, Christmas day, or any bank holiday, specifying the hour at which he will commence the closing and filling up of such cesspool or privy, and during the progress of any such work shall afford any officer of the Sanitary Authority free access to the premises for the purpose nf insnectinc the same. 2075—4325 No. 104.—Price 3d. Sold by Edward Stanford, 26 and 27, Cocksfur-atreet, Charing-cross, S.W. 2 As to the removal and disposal of refuse, and as to the duties of the occupier of any premises in connection with house refuse so as to facilitate the removal of it by the scavengers of the Sanitary Authority. Removal and disposal of refuse. 4. The occupier of any premises who shall remove or cause to be removed any refuse produced upon his premises shall not, in the process of removal, deposit such refuse, or cause or allow such refuse to be deposited upon any footway, pavement, or carriageway. Provided that this by-law shall not be deemed to prohibit the occupier of any premises from depositing upon the kerbstone or upon the outer edge of the footpath immediately in front of his house, between such hours of the day as the Sanitary Authority shall fix and notify by public announcement in their district, a proper receptacle containing house refuse, other than night soil or filth, to be removed by the Sanitary Authority in accordance with any by-law in that behalf. 5. Every person who shall convey any house, trade or street refuse across or along any footway, pavement or carriageway shall use a suitable receptacle, cart, carriage, or other means of conveyance properly constructed so as to prevent the escape of the contents thereof, and in the case of offensive refuse so covered as to prevent any nuisance therefrom, and shall adopt such other precautions as may be necessary to prevent any such refuse from being slopped or spilled, or from falling in the process of removal upon such footway, pavement or carriageway. If in the process of such removal any such refuse be slopped or spilled, or fall upon such footway, pavement or carriageway, such person shall forthwith remove such refuse from the place whereon the same may have been slopped or spilled, or may have fallen, and shall immediately thereafter thoroughly sweep or otherwise thoroughly cleanse such place. Daily removal of house refuse. b. Where a bamtary Authority arrange lor the daily removal of house refuse in their district or in any part thereof, the occupier of any premises in such district or part thereof on which any house refuse may from time to time accumulate shall, at such hour of the day as the Sanitary Authority shall fix and notify by public announcement in their district, deposit on the kerbstone or on the outer edge of the footpath immediately in front of the house or in a conveniently accessible position on the premises, as the Sanitary Authority may prescribe by written notice served upon the occupier, a movable receptacle, in which shall be placed, for the purposes of removal by or on behalf of the Sanitary Authority, the house refuse which has accumulated on such premises since the preceding collection by such authority. The Sanitary Authority shall collect such refuse, or cause the same to be collected, betjveen such hours of the day as they have fixed and notified by public announcement in their district. Weekly removal of house refuse. Offensive refuse. 7. The Sanitary Authority shall cause to be removed not less frequently than once in every week the house refuse produced on all premises within their district. 8. Where, for the purposes of subsequent removal, any cargo, load, or collection of offensive refuse has been temporarily brought to or deposited in any place within a sanitary district, the owner (whether a Sanitary Authority or any other person) or consignee of such cargo, load, or collection of refuse, or any person who may have undertaken to deliver the same, or who is in charge of the same, shall not without a reasonable excuse permit or allow or cause such refuse to remain in such place for a longer period than twenty-four hours. Provided (a) that this by-law shall not apply in cases where the place of temporary deposit is distant at least one hundred yards from any street, and is distant at least three hundred yards from any building or premises used wholly or partly for human habitation, or as a school, or as a place of public worship or of public resort or public assembly, or from any building or premises in or on which any person may be employed in any manufacture, trade, or business, or from any public park or other open space dedicated or used for the purposes of recreation, or from any reservoir or stream used for the purposes of domestic water supply; (b) that this by-law shall not prohibit the deposit, within the prescribed distances, of road slop unmixed with stable manure for any period not exceeding one week, which may be necessary for the separation of water therefrom. 9. Where a Sanitary Authority or some person on their behalf shall remove any offensive refuse from any street or premises within their district, such Sanitary Authority or such person shall properly destroy by fire or otherwise dispose of such refuse in such manner as to prevent nuisance. Provided always that this by-law shall not be deemed to require or permit any Sanitary Authority or person to dispose of or destroy by fire any night-soil, swine's-dung or cow-dung. 10. A Sanitary Authority or any person on their behalf who shall remove any offensive refuse from any street or premises within their district shall not deposit such refuse, otherwise than in the course of removal, at a less distance than three hundred yards from any two or more buildings used wholly or partly for human habitation or from any building used as a school, or as a place of public resort or public assembly, or in which any person may be employed in any manufacture, trade or business, or from any public park or other open space dedicated or used for the purpose of recreation, or from any reservoir or stream used for the purposes of domestic water supply. Provided always that this by-law shall not be deemed to prohibit such deposit of 3 such refuse for a period of twenty-four hours, when such refuse is deposited for the purpose of being destroyed by fire, in accordance with any by-law in that behalf. 11. For the purposes of the foregoing by-laws the expression "offensive refuse" means any refuse, whether "house refuse," "trade refuse," or "street refuse," in such a condition as to be or to be liable to become offensive. Penalties. Penalties. 12. Every person who shall offend against any of the foregoing by-laws shall be liable for every such offence to a penalty of five pounds, and in the case of a continuing offence to a further penalty of forty shillings for each day after written notice of the offence from the Sanitary Authority. Provided nevertheless that the Court before whom any complaint may be made, or any proceedings may be taken in respect of any such offence, may, if the Court think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this by-law. The seal of the London County Council was hereunto affixed on the 22nd day of June, 1893. . L.s De la Hooke, Clerk of the Council. Allowed by the Loeal Government Board this twenty-eighth day of June, 1893. Henry H. Fowler, President. Hugh Owen, Secretary. London County Council. x By-laws made by the London County Council under the Public Health (London) Act, 1891. By-laws under Section 39 (1). With respect to waterclosets, earthclosets, privies, ashpits, cesspools, and receptacles for dung, and the proper accessories thereof in connection with buildings, whether constructed before or after the passing of this Act. Waterclosets and earthclosets. 1. Every person who shall hereafter construct a watercloset or earthcloset in connection with a building, shall construct such watercloset or earthcloset in such a position that, in the case of a watercloset, one of its sides at the least shall be an external wall, and in the case of an earthcloset two of its sides at the least shall be external walls, which external wall or walls shall abut immediately upon the street, or upon a yard or garden or open space of not less than one hundred square feet of superficial area, measured horizontally at a point below the level of the floor of such closet. He shall not construct any such watercloset so that it is approached directly from any room used for the purpose of human habitation, or used for the manufacture, preparation, or storage of food for man, or used as a factory, workshop, or workplace, nor shall he construct any earthcloset so that it can be entered otherwise than from the external air. He shall construct such watercloset so that on any side on which it would abut on a room intended for human habitation, or used for the manufacture, preparation, or storage of food for man, or used as a factory, workshop, or workplace, it shall be enclosed by a solid wall or partition of brick or other materials, extending the entire height from the floor to the ceiling. He shall provide any such watercloset that is approached from the external air with a floor of hard smooth impervious material, having a fall to the dojr of such watercloset of half an inch to the foot. He shall provide such watercloset with proper doors and fastenings. Provided always that this by-law shall not apply to any watercloset constructed below the surface of the ground and approached directly from an area or other open space available for purposes of ventilation, measuring at least forty superficial feet in extent, and having a distance across of not less than five feet, and not covered in otherwise than by a grating or railing. 2. Every person who shall construct a watercloset in connection with a building, whether the situation of such watercloset be or be not within or partly within such building, and every person who shall construct an earthcloset in connection with a building, shall construct in one of the walls of such watercloset or earthcloset which shall abut upon the public way, yard, garden, or open space, as provided by the preceding by-law, a window of such dimensions that an area of not less than two square feet, which may be the whole or part of such window, shall open directly into the external air. He shall, in addition to such window, cause such watercloset or earthcloset to be provided with adequate means of constant ventilation by at least one air-brick built in an external wall of such watercloset or earthcloset, or by an air-shaft, or by some other effectual method or appliance. Waterclosets. 8. Every person who shall construct a watercloset in connection with a building, shall furnish such watercloset with a cistern of adequate capacity for the purpose of flashing, which shall be separate and distinct from any cistern used for drinking purposes, and shall be so constructed, fitted, and placed as to admit of the supply of water for use in such watercloset so that there shall not be any direct connection between any service pipe upon the premises and any part of the apparatus of such watercloset other than such flushing cistern. Provided always that the foregoing requirement shall be deemed to be complied with in any case where the apparatus of a watercloset is connected for the purpose of flushing with a cistern of adequate capacity, which is used solely for flushing waterclosets or urinals. He shall construct or fix the pipe and union connecting such flushing cistern with the pan, basin, or other receptacle with which such watercloset may be provided, so that such pipe and union shall not in any part have an internal diameter of less than one inch and a quarter. 6 He shall furnish such watercloset with a suitable apparatus for the effectual application of water to any pan, basin, or other receptacle with which such apparatus may be connected and used, and for the effectual flushing and cleansing of such pan, basin, or other receptacle, and for the prompt and effectual removal therefrom and from the trap connected therewith of any solid or liquid filth which may from time to time be deposited therein. He shall furnish such watercloset with a pan, basin, or other suitable receptacle of non-absorbent material, and of such shape, of such capacity, and of such mode of construction as to receive and contain a sufficient quantity of water, and to allow all filth which may from time to time be deposited in such pan, basin, or receptacle, to fall free of the sides thereof and directly into the water received and contained in such pan, basin, or receptacle. He shall not construct or fix under such pan, basin, or receptacle, any "container " or other similar fitting. He shall construct or fix immediately beneath or in connection with such pan, basin, or other suitable receptacle, an efficient siphon trap, so constructed that it shall at all times maintain a sufficient water seal between such pan, basin, or other suitable receptacle and any drain or soil pipe in connection therewith. He shall not construct or fix in or in connection with the watercloset apparatus any D trap or other similar trap. If he shall construct any watercloset or shall fix or fit any trap to any existing watercloset or in connection with a soil pipe, which is itself in connection with any other watercloset, he shall cause the trap of every such watercloset to be ventilated into the open air at a point as high as the top of the soil pipe, or into the soil pipe at a point above the highest watercloset connected with such soil pipe, and so that such ventilating pipe shall have in all parts an internal diameter of not less than two inches, and shall be connected with the arm of the soil pipe at a point not less than three and not more than twelve inches from the highest part of the trap and on that side of the water seal which is nearest to the soil pipe. Soil pipes. 4. Any person who shall provide a soil pipe in connection with a building to be hereafter erected, shall cause such soil pipe to be situated outside such building, and any person who shall provide or construct or refit a soil pipe in connection with an existing building, shall, whenever practicable, cause such soil pipe to be situated outside such building, and in all cases where such soil pipe shall be situated within any building, shall construct such soil pipe in drawn lead, or of heavy cast iron jointed with molten lead and Drotterlv caulked. He shall construct such soil pipe so that its weight in proportion to its length and internal diameter, shall be as follows— Diameter. Lead. Iron. Weight per 10 feet length. Not less than Weight per 6 feet length. Not less than 3½ inches 65 lbs. 48 lbs. 4 „ 74 ,, 64 „ 5 .. 92 „ 69 „ 6 „ 110 „ 84 „ Every person who shall provide a soil pipe outside or inside a building shall cause such soil pipe to have an internal diameter of not less than three and a half inches, and to be continued upwards without diminution of its diameter, and (except where unavoidable) without any bend or angle being formed in such soil pipe, to such a height and i.i such a position as to afford by means of the open end of such soil pipe a safe outlet for foul air, and so that such open end shall in all cases be above the highest part of the roof of the building to which the soil pipe is attached, and where practicable, be not less than three feet above any window within twenty feet measured in a straight line from the open end of such soil pipe. He shall furnish the open end of such soil pipe with a wireguard covering, the openings in the meshes of which shall be equal to not less than the area of the open end of the soil pipe. In all such cases where he shall connect a lead trap or pipe with an iron soil pipe or drain he shall insert between such trap or pipe and such soil pipe or drain a brass thimble, and he shall connect such lead trap or pipe with such thimble by means of a wiped or over-cast joint, and he shall connect such thimble with the iron soil pipe or drain by means of a joint made with molten lead, properly caulked. In all such cases where he shall connect a stoneware trap or pipe with a lead soil pipe, he shall insert between such stoneware trap or pipe and such soil pipe a brass socket or other similar appliance, end he shall connect such stoneware trap or pipe by inserting it into such socket, making the joint with Portland cement, and he shall connect such socket with the lead soil pipe, by means of a wiped or overcast joint. In all cases where he shall connect a stoneware trap or pipe with an iron soil pipe or drain, he shall insert such stoneware trap or pipe into a socket on such iron soil pipe or drain, making the joint with Portland cement. 7 He shall so construct such soil pipe that it shall not be directly connected with the waste of any bath, rain-water pipe, or of any sink other than that which is provided for the reception of urine or other excremental filth, and he shall construct such soil pipe so that there shall not be any trap in such soil pipe or between the soil pipe and any drain with which it is connected. Waterclosebs. 5. A person who shall newly fit or fix any apparatus in connection with any existing watercloset, shall as regards such apparatus and its connection with any soil pipe or drain, comply with such of the requirements of the foregoing by-laws as would be applicable to the apparatus so fitted or fixed if the watercloset were being newly constructed. Earthclosets. 6. Every person who shall construct an earthcloset in connection with a building shall furnish such earthcloset with a reservoir or receptacle, of suitable construction and of adequate capacity, for dry earth, and he shall construct and fix such reservoir or receptacle in such a manner and in such a position as to admit of ready access to such reservoir or receptacle for the purpose of depositing therein the necessary supply of dry earth. He shall construct or fix in connection with such reservoir or receptacle suitable means or apparatus for the frequent and effectual application of a sufficient quantity of dry earth to any filth which may from time to time be deposited in any receptacle for filth constructed, fitted, or used, in or in connection with such earthcloset. He shall construct such earthcloset so that the contents of such reservoir or receptacle may not at any time be exposed to any rainfall or to the drainage of any waste water or liquid refuse from any premises. 7. Every person who shall construct an earthcloset in connection with a building 6hall construct such earthcloset for use in combination with a movable receptacle for filth. He shall construct such earthcloset so as to admit of a movable receptacle for filth, of a capacity not exceeding two cubic feet, being placed and fitted beneath the seat in such a manner and in such a position as may effectually prevent the deposit upon the floor or sides of the space beneath such seat, or elsewhere than in such receptacle, of any filth which may from time to time fall or be cast through the aperture in such seat. He shall construct such receptacle for filth in such a manner and in such a position as to admit of the frequent and effectual application of a sufficient quantity of dry earth to any filth which may be from time to time deposited in such receptacle for filth, and in such a manner and in such a position as to admit of ready access for the purpose of removing the contents thereof. He shall also construct such earthcloset so that the contents of such receptacle for filth may not at any time be exposed to any rainfall or to the drainage of any waste water or liquid refuse from any premises. Privies. 8. Every person who shall construct a privy in connection with a building shall construct such privy at a distance of twenty feet at the least from a dwelling-house, or public building, or any building in which any person may be or may be intended to be employed in any manufacture, trade, ir business. 9. A person who shall construct a privy in connection with a building shall not construct such privy within the distance of one hundred feet from any well, spring, or stream of water used, or likely to be used, by man for drinking or domestic purposes, or for manufacturing drinks for the use of man, or otherwise in such a position as to render any such water liable to pollution. 10. Every person who shall construct a privy in connection with a building shall construct such privy in such a manner and in such a position as to afford ready means of access to such privy, for the purpose of cleansing such privy and of removing filth therefrom, and in such a manner and in such a position as to admit of all filth being removed from such privy, and from the premises to which such privy may belong, without being carried through any dwelling-house, or public building, or any building in which any person may be or may be intended to be employed in any manufacture, trade or business. 11. Every person who shall construct a privy in connection with a building, shall provide such privy with a sufficient opening for ventilation as near to the top as practicable and communicating directly with the external air. He shall cause the floor of such privy to be flagged or paved with hard tiles or other non-absorbent material, and he shall construct such floor so that it shall be in every part thereof at a height of not less than six inches above the level of the surface of the ground adjoining such privy, and so that such floor shall have a fall or inclination towards the door of such privy of half an inch to the foot. 12. Every person who shall construct a privy in connection with a building shall construct such privy for use in combination with a movable receptacle for filth, and shall construct over the whole area of the space immediately beneath the seat of such privy a floor of flagging or asphalte or some suitable composite material, at a height of not less than three inches above the level of the surface of the ground adjoining such privy; and he shall cause the whole extent of each side of such space between the floor and the seat, other than any part that may be occupied by any door 8 or other opening therein, to be constructed of flagging, slate, or good brickwork, at least nine inches thick, and rendered in good cement or asphalted. He shall construct the seat of such privy, the aperture in such seat, and the space beneath such seat, of such dimensions as to admit of a movable receptacle for filth of a capacity not exceeding two cubic feet being placed and fitted beneath such seat in such a manner and in such a position as may effectually prevent the deposit, upon the floor or sides of the space beneath such seat or elsewhere than in such receptacle, of any filth which may from time to time fall or be cast through the aperture in such seat. He shall construct such privy so that for the purpose of cleansing the space beneath the seat, or of removing therefrom or placing or fitting therein an appropriate receptacle for filth, there shall be a door or other opening in the back or one of the sides thereof capable of being opened from the outside of the privy, or in any case where such a mode of construction may be impracticable, so that for the purposes aforesaid the whole of the seat of the privy or a sufficient part thereof may be readily moved or adjusted. 13. A person who shall construct a privy in connection with a building shall not cause or suffer any part of the space under the seat of such privy, or any part of any receptacle for filth in or in connection with such privy, to communicate with any drain. Waterclosets, earthclosets and privies. Earthclosets and privies. 14. Every person who shall intend to construct any watercloset, earthcloset, or privy, or to fit or fix in or in connection with any watercloset, earthcloset, or privy any apparatus or any trap or soil pipe, shall, before executing any such works, give notice in writing to the clerk of the Sanitary Authority. 15. Every owner of an earthcloset or privy existing at the date of the confirmation of these by-laws shall, before the expiration of six months from and after such date of confirmation, cause the same to be reconstructed in such manner that its position, structure and apparatus shall comply with such of the requirements of the foregoing bylaws as are applicable to earthclosets or privies newly constructed. Ashpits. 16. When any person shall provide an ashpit in connection with a building, he shall cause the same to consist of one or more movable receptacles sufficient to contain the house refuse which may accumulate during any period not exceeding one week. Each of such receptacles shall be constructed of metal and shall be provided with one or more suitable handles and cover. The capacity of each of such receptacles shall not exceed two cubic feet. Provided that the requirement as to the size of each of such receptacles shall not apply to any person who shall construct such receptacle or receptacles in connection with any premises to which there is attached as part of the conditions of tenancy the right to dispose of house refuse in an ashpit used in common by the occupiers of several tenancies, but in no case shall such ashpit be of greater capacity than is required to enable it to contain the refuse which may accumulate during any period not exceeding one week. 17. The occupier of any premises who shall use any ashpit shall, if such ashpit consist of a movable receptacle, cause such receptacle to be kept in a covered place, or to be properly covered, so that it shall not be exposed to rainfall, and if such ashpit consist of a fixed receptacle, he shall cause the same to be kept properly covered. 18. Where the Sanitary Authority have arranged for the daily removal of house refuse in their district, or in any part thereof, the owner of any premises in such district or part thereof shall provide an ashpit which shall consist of one or more movable receptacles, sufficient to contain the house refuse which may accumulate during any period not exceeding three days, which the Sanitary Authority may determine, and of which the Sanitary Authority shall give notice by public announcement in their district. Each of such receptacles shall be constructed of metal, and provided with one or more suitable handles and cover. The capacity of each of such receptacles shall not exceed two cubic feet. Provided always that this by-law shall not apply to the owner of any premises until the expiration of three months after the Sanitary Authority have publicly notified their intention to adopt a system of daily collection of house refuse in that part of their district which comprises such premises. 19. Where any receptacle shall have been provided as an ashpit for any premises in pursuance of any by-law in that behalf, no person shall deposit the house refuse which may accumulate on such premises in any ashpit that does not comply with the requirements of these by-laws. Cesspools. 20. Every person who shall construct a cesspool in connection with a building, shall construct such cesspool at a distance of one hundred feet at the least from a dwellinghouse, or public building, or any building in which any person may be, or may be intended to be, employed in any manufacture, trade, or business. 21. A person who shall construct a cesspool in connection with a building, shall not construct such cesspool within the distance of one hundred feet from any well, spring, or stream of water. 9 22. Every person who shall construct a cesspool in connection with a building, shall construct such cesspool in such a manner and in such a position as to afford ready means of access to such cesspool, for the purpose of cleansing such cesspool, and of removing the contents thereof, and in such a manner and in such a position as to admit of the contents of such cesspool being removed therefrom, and from the premises to which such cesspool may belong, without being carried through any dwelling-house, or public building, or any building in which any person may be, or may be intended to be, employed in any manufacture, trade, or business. He shall not in any case construct such cesspool so that it shall have, by drain or otherwise, any means of communication with any sewer or any overflow outlet. 23. Every person who shall construct a cesspool in connection with a building, shall construct such cesspool of good brickwork bedded and grouted in cement, properly rendered inside with cement, and with a backing of at least nine inches of well-puddled clay around and beneath such brickwork, and so that such cesspool shall be perfectly watertight. He shall also cause such cesspool to be arched or otherwise properly covered over, and to be provided with adequate means of ventilation. Receptacles for dung. 24. A person shall not use as a receptacle for dung any receptacle so constructed or placed that one of its sides shall be formed by the wall of any room used for human habitation, or under a dwelling-house, factory, workshop, or workplace, and he shall not use any receptacle in such a situation that it would be likely to cause a nuisance or become injurious or dangerous to health. 25. Every owner of any existing receptacle for dung shall, before the expiration of six months from the date of the confirmation of these by-laws, and every person who shall construct a receptacle for dung, shall cause such receptacle to be so constructed that its capacity shall not be greater than two cubic yards, and so that the bottom or floor thereof shall not, in any case, be lower than the surface of the ground adjoining such receptacle. He shall so construct such receptacle that a sufficient part of one of its sides shall be readily removable for the purpose of facilitating cleansing. He shall also cause such receptacle to be constructed in such a manner and of such materials, and to be maintained at all times in such a condition as to prevent any escape of the contents thereof, or any soakage therefrom into the ground or into the wall of any building. He shall cause such receptacle to be so constructed that no rain or water can enter therein, and so that it shall be freely ventilated into the external air. Provided that a person who shall construct a receptacle for dung, the whole of the contents of which are removed not less frequently than every forty-eight hours, shall not be required to construct such receptacle so that its capacity shall not be greater than two cubic yards. And provided that a person who shall construct a receptacle for dung, which shall contain only dung of horses, asses or mules with stable litter, and the whole of the contents of which are removed not less frequently than every forty-eight hours, may, instead of all other requirements of this by-law, construct a metal cage, and shall beneath such metal cage adequately pave the ground at a level not lower than the surrounding ground, and in such a manner and to such an extent as will prevent any soakage into the ground; and if such cage be placed near to or against any building he shall adequately cement the wall of such building in such a manner and to such an extent as will prevent any soakage from the dung within or upon such receptacle into the wall of such building. Cleansing of water- closets, earthclosets, privies, and receptacles for dung. 26. The occupier of any premises shall cause every watercloset belonging to such premises to be thoroughly cleansed from time to time as often as may be necessary for the purpose of keeping such watercloset in a cleanly condition. The occupier of any premises shall once at least in every week cause every earthcloset, privy, and receptacle for dung belonging to such premises to be emptied and thoroughly cleansed. The occupier of any premises shall once at least in every three months cause every cesspool belonging to such premises to be emptied and thoroughly cleansed. Provided that where two or more lodgers in a lodging-house are entitled to the use in common of any watercloset, earthcloset, privy, cesspool, or receptacle for dung, the landlord shall cause such watercloset, earthcloset, privy, cesspool, or receptacle for dung to be cleansed and emptied as aforesaid. The landlord, or owner of any lodging house, shall provide and maintain in connection with such house, watercloset earthcloset or privy accommodation in the proportion of not less than one watercloset, earthcloset, or privy, for every twelve persons. For the purposes of this by-law, " a lodging-house " means a house or part of a house which is let in lodgings or occupied by members of more than one family. " Landlord" in relation to a house or part of a house which is let in lodgings, or occupied by members of more than one family, means the person (whatever may be the nature or extent of his interest) by whom or on whose behalf such house or part of a house is let in lodgings or for occupation by members of more than one family, or who for the time being receives or is entitled to receive the profits arising from 10 such letting. " Lodger " in relation to a house or part of a house which is let in lodgings or occupied by members of more than one family, means a person to whom any room or rooms in such house or part of a house may have been let as a lodging or for his use or occupation. Nothing in this by-law shall extend to any common lodging-house. Maintenance of closets, &c. 27. The owner of any premises shall maintain in proper condition of repair every watercloset, earthcloset, privy, ashpit, cesspool, and receptacle for dung, and the proper accessories thereof belonging to such premises. Penalties. Penalties. 28. Every person who shall offend against any of the foregoing by-laws shall be liable for every such offence to a penalty of Five pounds, and in the case of a continuing offence to a further penalty of Forty shillings for each day after written notice of the offence from the Sanitary Authority. Provided nevertheless that the Court before whom any complaint may be made or any proceedings may be taken in respect of any such offence may, if the Court think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this by-law. The seal of the London County Council was hereunto affixed on the 22nd day of June, 1893. H. De la Hooke, Clerk of the Council. Allowed by the Local Government Board this twenty-eighth day of June, 1893. Henry H. Fowler, President. Hugh Owen, Secretary. Appendix IV. London County Council. Public Health Department, Spring Gardens, S.W , 23rd December, 1893. Report of the Medical Officer on the Sanitary Condition and Administration of the District of St. Saviour, Southwark. (Printed by order of the Public Health and Housing Committee.) The Mansion House Council on the Dwellings of the Poor having asked the Local Government Board to cause an enquiry to be made into the sanitary condition of the parishes of St. Saviour and Christchurch, Southwark, the Local Government Board suggested that the Mansion House Council should submit to the London County Council the particulars of cases in which they considered the St. Saviour's District Board had made default. The Mansion House Council thereupon on the 30th of March, 1892, communicated to the London County Council the particulars of certain cases in which in the opinion of the Mansion House Council the District Board had made default and asked the London County Council to exercise the powers vested in it by sections 100 and 101 of the Public Health (London) Act, 1891, and I was instructed to report on the sanitary condition and administration of the district. Speaking first of the actual matters of complaint, the Mansion House Council had communicated to the District Board two lists of premises which were regarded as faulty in one or another particular. These lists were accompanied by the following summaries of defects— Summary of First list. Number of houses inspected 224 Unpaved or badly paved yards 74 Untrapped or defective yard gulleys 9 Untrapped or defective sink gulleys 5 No water supply to waterclosets 10 Defective apparatus to waterclosets 32 No dustbins 49 Defective dustbins 47 Water closets supplied from drinking-water cisterns 25 Watercloset pans foul and broken 16 Dilapidations—broken floors, damp walls, defective roofs, &c. 94 Defective or uncovered cisterns 8 Defective water fittings 7 Defective gutters 11 Defective stackpipes 22 Structural defects 21 Total defects 430 Summary of Second list. Number of houses inspected 337 Unpaved or badly paved yards 74 Undrained areas 37 Untrapped or defective yard gulleys 5 Untrapped or defective sink gulleys 5 No water supply to waterclosets 7 Defective apparatus to waterclosets 46 Waterclosets supplied from drinking-water cisterns 6 Watercloset pans foul and broken 33 Waterclosets placed in cellars and under stairs, dark and unventilated 37 No dustbins 34 Defective dustbins 31 Defective or uncovered cisterns 1 Defective water fittings 28 Defective gutters 9 Defective stackpipes 4 Structural defects, e.g., floors below level of streets, houses built back to back, no through ventilation 109 Dilapidations, e.g., broken floors, damp walls and defective roofs 130 Illegally occupied basements 3 Total defects 599 Of the 561 houses to which the attention of the District Board had been directed, I inspected 226 with the following results, and subsequently inspected the district generally. In more than one-half of the houses on the lists of the Mansion House Council the defects had been remedied at the time of my inspection, and in the remaining houses notices had in almost every case been served, and in many instances the houses had been closed or works were in progress. [9596—1717 2 The sanitary district of St. Saviour, Southwark, consists of the two parishes, Christchurch an St. Saviour, and is situated on the southern bank of the Thames. The soil, as shown by borings for wells, is a superficial deposit of made ground, brick earth, and gravel or sand overlaying the London clay, and having a thickness in one locality of 27½ feet, and in another of 34 feet. The total area of the district is 255 acres, of which 51 are tidal or foreshore The parishes of St. Saviour and Christchurch are now sub-districts of the registration district of St. Saviour, Southwark, which includes with these sub-districts the sanitary districts of St. Georgethe-Martyr and Newington. The number of persons per acre in the district of St. Saviour, in the neighbouring districts and in London in the middle of the year 1891. was as follows— St. Saviour 134 St. George-the-Martyr 210 St. Olave 184 Bermondsey 135 Lambeth 70 London... 56 The sanitary district of St. Saviour, Southwark, has at any rate for some years contained a large proportion of persons engaged in industrial occupations. The census report for the year 1861, (the last report which gives the occupations of this particular population), shows that of 9,754 males over 20 years of age, the industrial class in that year constituted 64.6 per cent., the proportion in London as a whole being 54.4 per cent. More recent account of the population is given in Mr. Charles Booth's work, "Labour and Life of the People," published in 1891, from the appendix to which, the following statement relating to four areas is taken. The first three of these areas are situated wholly in the sanitary district of St. Saviour, Southwark, the last is, in about equal proportions, in the two sanitary districts of St. Saviour and St. George-the-Martyr. (a) E. Southwark Bridge-road N. River Thames W. Gravel-lane S. Union-street Many poor, rough, water-side labourers in a network of old alleys near the river. Better streets contain many small tradesmen and skilled mechanics, whose lodgers are generally poorer. People in blocks of Peabody models earn sufficient to live decently. (b) E. Gravel-lane N. River Thames W. Blackfriars-road S. Little Charlotte-street Mostly business premises, &c., north of Southwark-street, majority of the inhabitants belong to a respectable, though poor, working class, with some exceptions in fairly regular work. Remainder are fairly comfortable class of artisans, small shopkeepers, clerks, printers, &c. (c) E. Blackfriars-road N. River Thames W. Broadwall S. Great Charlotte-street Very mixed block, some good houses and busy business premises in main thoroughfares, and small old houses in courts out of them. Many mechanics and labourers, some very poor and casual, working at waterside, &c., with a number of printers and tradesmen. A very large proportion of the people, labourers, hawkers, charwomen, sweeps, &c., are living in great poverty, with many bad characters among them. The principal streets contain many shopkeepers and artisans who generally let upper floors to poor people. (d) E. Southwark-Bridge-road N. Union-street, Charlotte-street W. Blackfriars-road S. Friar-street Classification of the Inhabitants. [##]In Poverty. In Comfort. Grand Total. A B C & D Total Per cent. E & F G & H Total Per cent. a 139 1,344 2,750 4,233 59.2 2,861 59 2,920 40.8 7,153 b 106 482 1,834 2,422 65.7 1,230 32 1,262 34.3 3,684 c 14 222 1,950 2,186 45.5 2,360 262 2,622 54.5 4,808 d 788 3,060 2,482 6,330 77.2 1,434 444 1,878 228 8,208 London 30.7 69.2 The classes into which the population of each of these blocks and districts is divided are as follows: A. The lowest class—occasional labourers, loafers, and semi-criminals. B. The very poor—casual labourers, hand-to-mouth existence, chronic want. C & D. The poor—including alike those whose earnings are small, because of irregularity of employment, and those whose work, though regular, is ill-paid. E & F. The regularly employed and fairly paid working class of all grades. G & H. Lower and upper middle class and all above this level. 3 Compared therefore with the population of London as a whole, the population of St. Saviour, Southwark, is poor. The following table shows that, while the population had increased in each successive census year, from 1831 to 1861, it has since the latter year diminished, so that the population in 1891 is actually smaller than in 1831. Sanitary District of St. Saviour. Census Year. Population. No. of inhabited houses. Person to each house. 1831 31,711 4,543 70 1841 32,975 4,659 71 1851 35,731 4,600 7.7 1861 36,170 4,471 8.1 1871 30,250 3,726 8.1 1881 28,662 3,465 8.2 1891 27,177 3,624 7.5 It will be observed that while the population slightly increased in the decade 1841-51, the number of inhabited houses decreased, and this decrease is attributed in the census report for the year 1851, to the removal of many families to the suburbs, especially after the severe visitation of cholera in 1849. House property, the report states, had consequently depreciated, and private houses formerly occupied by single families were in many instances let out in rooms to the poorer classes. This no doubt more than compensated for the removal of families to the suburbs. Again, the census report of 1861 comments on the fact that since 1851 in St. Saviour, many houses had been pulled down to the ground, cleared for the purpose of forming the new street from High-street, Borough, to Stamford-street. And again, in 1871, the census report of that year states that the decrease in the parishes of Christchurch and St. Saviour, Southwark, is attributed to the demolition of houses for the construction of the London, Chatham and Dover Railway and the Charing-cross extension of the South Eastern Railway, for the formation of the new Southwark-street, and the erection of business premises. In the last decade there has been a slight increase in the number of houses owing to building on part of the land which had been cleared, but the total effect of these changes has been that the district of St. Saviour has practically had its population reduced almost to that which it possessed in the year 1811, when the population numbered 26,399. Another point which deserves notice is that while the number of persons to each inhabited house had increased in almost each census year from 1831 to 1881, it was diminished in 1891, this circumstance probably finding explanation in the fact that a larger proportion of the inhabited houses are now used for trade purposes. The number of empty houses in each census year was as follows— 1831 326 1841 182 1851 244 1861 204 1871 148 1881 208 1891 431 The census of 1891 gives a table as to the occupation in the London sanitary districts of tenements of less than four rooms, and from this it is learnt that 42.7 per cent. of the population of St. Saviour occupy one and two room tenements, the average number of persons per room in this class of tenement being 2.12. The following table shows the proportion of the population living in tenements of one and two rooms, and the average number of persons in each of these rooms in St. Saviour and neighbouring districts. District. Proportion of population living in 1 and 2 rooms. Average number of persons per room. St. Saviour 42.7 per cent. 2.12 St. George-the-Martyr 43.5 ,, 2.11 St. Olave 33-5 „ 2.08 Bermondsey 28.2 ,, 1.94 Lambeth 22.2 „ 1.81 The population of St. Saviour differs in a marked degree from that of London as a whole in the relative proportion of males to females, thus, in 1891 these proportions were as follows— St. Saviour. London. Males 53.1 per cent. 47.3 per cent. Females 46.9 52.7 showing a marked preponderance of males in St. Saviour, Southwark. This may be in part explained by the existence of the Christchurch workhouse, which is licensed by the Local Government Board for 475 inmates, and which, I am informed by Dr. Herron, the Medical Officer of Health of the district, provides accommodation for four married couples, but is otherwise entirely occupied by males. Again, the Lost Boys' Home in Southwark-street, and which has accommodation for 120 boys, contributes to the excess of males in the district. It will, however, be seen from the following table that this excess is not limited to any particular age periods, but is present in each age-period except that of from 0-5 years. 4 Proportion of Population of each Sex at certain age-periods. 1891. All Ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards St. Saviour, Southwark— Males, Per cent. of total population 53.10 5.83 5.49 5.15 5.55 5.36 8.60 7.03 4.68 3.03 1.86 0.49 0.04 Females, Per cent. of total population 46.90 6.07 5.16 4.75 4.63 4.33 7.15 6.05 4.35 2.52 1.46 0.37 0.04 London— Males, Per cent. of total population 47.27 5.92 5.36 4.90 4.69 4.61 7.92 5.85 4.11 2.35 1.20 0.33 0.04 Females, Per cent. of total population 52.73 5.99 5.42 4.99 5.21 5.56 9.11 6.49 4.64 2.92 1.72 0.60 0.09 The following figures, however, show that the preponderence of males in the district was not manifested by any census before 1871 and that since 1861 the number of females in the district has decreased in a greater degree than the number of males. Year. Population. Per cent. of total population. 1861 36,170 17,683 males 48.9 18,487 females 51.1 1871 30,250 15,175 males 50.2 15,075 females 49.8 1881 28,662 14,706 males 51.3 13,956 females 48.7 1891 27,177 14,432 males 53.1 1 12,745 females 46.9 In part explanation of this fact it should be noted that the district is largely occupied by a population not employing domestic servants. As long ago as 1861, 9.6 per cent. of the females in the district were employed as domestic servants, whereas in London as a whole the proportion was 13.5 per cent. Since that year, as already stated, the females have decreased in larger proportion than the males; this decrease, no doubt, being in part attributable to the increasing tendency of that portion of the population generally employing domestic servants to migrate from the central districts of the metropolis to the suburbs. While the proportion of males to females of the St. Saviour population differs from that of London, the age distribution of the two populations is very similar, as will be seen from the following table: In every 100 of Population. 1891 0-5 5.10 10.20 20.65 65 and upwards. St. Saviour 11.9 10.6 20.1 53.1 4.3 London 11.9 10.8 19.8 53.5 4.0 It may be concluded therefore from the evidence which is available that the population of the sanitary district of St. Saviour contains a considerable excess of persons in the industrial class, an excess of males over females, and this population has an age-distribution which does not differ from that of London as a whole. Births.—The mean birth-rate of St. Saviour and London, during each of the three last decennial periods, was as follows— St. Saviour. London. 1861-70 34.1 35.4 1871-80 36.2 35.4 1881-90 34.2 33.1 It will be seen that the fall which has taken place in the London birth-rate during the last period of ten years, has been shared by the district of St. Saviour. Deaths.—The statistics published by the Registrar General enable the death-rates of London sanitary districts, corrected for deaths in institutions, to be known only since the year 1885. Since that year deaths occurring in public institutions belonging to London have been distributed to their proper districts. The following figures are thus obtainable : Mortality. St. Saviour. London. 1885-91. 1892. 1885-91. 1892. All causes (per 1,000) 26.3 25.5 19.9 20.3 Principal zymotic diseases (per 100,000) 341.0 246.0 270.0 280.0 Smallpox ,, 6.0 — 5.0 0.7 Measles „ 96.0 86.0 62.0 79.0 Scarlet fever „ 33.0 26.0 22.0 27.0 Diphtheria „ 33.0 22.0 29.0 44.0 Whooping cough „ 72.0 52.0 67.0 58.0 Typhus „ — 3.7 0.4 0.3 Enteric fever „ 12.0 4.0 14.0 10.0 Simple and ill-defined fever ,, 0.5 — 1.2 0.5 Diarrhoea „ 90.0 52.0 69.0 60.0 5 The following figures will serve for the purpose of comparing the rates of mortality of St. Saviour district, with those of neighbouring districts— District. Mortality per 1,000, all causes. Mortality from principal zymotic diseases, per 100,000. 1885-91. 1892. 1885-91. 1892. St. Saviour 26.3 25.5 341 246 St. George-the-Martyr 25.9 24.9 365 338 St. Olave 23.0 27.1 295 314 Bermondsey 22.4 23.0 327 265 Lambeth 19.8 19.8 267 255 The following table shows the number of deaths under one year of age to every 1,000 registered births in the district of St. Saviour, in the neighbouring districts, and in London, for each of the eight years 1885 to 1892 inclusive— District. 1885 1886 1887 1888 1889 1890 1891 1892 St. Saviour 156 170 199 203 167 185 201 187 St George-the-Martyr 166 187 190 172 175 209 184 174 St. Olave 190 188 270 149 159 145 188 184 Bermondsey 135 153 170 154 146 152 167 162 Lambeth 137 152 154 133 142 152 152 135 London 148 159 158 146 141 162 154 154 The general and zymotic rates of mortality or the district of bt. Saviour are therefore greater than those of London, and they compare unfavourably with those of all the surrounding districts with the exception of St. George-the-Martyr. The district of St. Saviour has, at the present time, a rateable value of £348,189. The Borough Market makes a return of about £7,000 a year, which has hitherto been applied to the reduction of the rate for the maintenance of the poor in the parish of St. Saviour; about a year ago, however, Parliamentary powers were obtained to borrow a sum of £100,000 for the purpose of extending and improving the market, and the £7,000 a year therefore will henceforth he applied to the paying off of that debt. The houses in the district of St. Saviour are mostly brick structures of two and three storeys in height. They are for the most part situated in fairly wide streets, having regard to their height, and have with certain exceptions through ventilation and yard space in their rear. In numerous instances the ground floor is one or more feet below the level of the adjoining pavement, a condition which it is stated is due to the raising of the road at a time subsequent to the erection of the house. The district has been altered by the construction of main thoroughfares and the development of railways, and dwelling houses, particularly in localities near the river, have been replaced by large warehouses. A number of courts and alleys have thus disappeared, but others remain, and some of these are open to greater objection on health grounds than houses situated in streets. St. Margaret's-court is approached by an archway beneath a house in High-street, Borough, and is continued into Redcross-street. The width of the court varies from nine to thirty feet, the greater part of it being about fourteen feet wide. On either side of the court is a row of houses three storeys in height. The houses were, when inspected, generally in a fair state of repair, but the majority have no through ventilation or back yards, and the waterclosets are situated in the basement; other houses in this court have a scullery on the ground floor, ventilated by an opening in the rear, and in these cases the watercloset is situated in the scullery. In four instances houses in this court had been closed. Queens Arm' s-court is approached by an archway beneath a house in Upper Ground-street. The width of the court is fifteen and a half feet, and the houses are three storeys in height. The court consists of a double row of houses, twelve in all. The yard space of these houses is limited, those on the west side of the court having yards three feet nine inches deep, and those on the east side five feet deep. Other groups of cottages two storeys in height are still to be found in the district. Between the north of Sumner-street and the river is a considerable area occupied by more than one hundred houses of this class and irregularly placed. In this area are— William's-court, approached by an archway five feet wide under a house in Sumner-street; the passage-way between the houses is nine feet wide, and the height of the houses is about twenty feet. They have yard space at their rear of a little more than a hundred square feet in area. Pitt's-place, a cul-de-sac, consists of a double row of similar houses, the width of this court being about eighteen and a half feet. On the south side, the houses have about eighty square feet of yard space; on the north side, nearly one hundred and fifty square feet. Ladd's-court, a cul-de-sac, is a continuation of Pitt's-place; the width of the courts about fourteen feet, and the houses are from two to three storeys high. On the south side the back yards vary from fifty to one hundred and twenty square feet, and on the north side they are about seventy square feet in area. Noah's Ark-all«y.—The passage-way is at the widest part about seven and a half feet in width ; there is a single row of houses two and three storeys in height, fronted by workshops ; the houses have back yards of nearly one hundred and fifty square feet in area. White Hind-alley consists of a single row of cottages, two and three storeys in height, situated on a passage-way from five and a half to eleven feet wide, and fronted by a high wall. The yard space at the rear of these cottages varies from fifty-six to over ninety square feet in area. Moss-alley.—Tne houses are two and three storeys in height, fronting a passage-way from eight to sixteen feet wide; the back yards on the east side are about eighty square feet in area, on the west side about seventy square feet. 6 Taylor'8-yard, comprises a few houses two storeys in height, situated on a passage-way fourteen feot in width. The houses in this area are old, but in the majority of instances fairly maintained, and appear to be occupied by a respectable class of people. The rents vary from 5s. 6d. per week for three rooms to 8s. 6d. for four. Nearly all the houses in Pitt's-place and the houses in the west side of Williams-court have been recently acquired by an electric lighting company for the extension of their premises. In some few instances the level of the site of a court is below that of neighbouring streets, thus impeding the ventilation of the court and tending to promote dampness. Brunswick-place and Hatfield-place are thus situated, lying between two almost parallel streets, Hatfield-street and Brunswick street. The houses in Brunswick-place are two storeys in height, with one room on each floor, and with no back yatd nor through ventilation, while the houses in Hatfield-place have two rooms on each of two floors, and have small back yards. The sites of these houses are from three to six feet below the level of the sites of the neighbouring houses in Brunswick and Hatfield streets. The houses in all these localities require re-arrangement. It may be expected that the extension of neighbouring commercial premises will suffice for the removal of the courts and alleys between Sumner-street and the river, and it may perhaps be found that the proximity of the premises in St. Margaret's-court to the important thoroughfare of High-street, Borough, will lead to reconstruction, otherwise the improvement of this court by scheme will become necessary. In the case of Queen's Arms-court there appears no reason why its improvement by scheme should be delayed. A number of blocks of artizans' dwellings have been erected in the district providing more than eleven hundred tenements, mostly of two or three rooms. Single rooms are let at two and sixpence to five shillings per week; tenements of two rooms from four to seven shillings; tenements of three rooms from five shillings and threepence to nine shillings per week. I was informed that allowing for the somewhat frequent removal of persons of the class living in these buildings, the tenements were nearly always occupied. At the beginning of the inspection for the purposes of this report, it was found that in one set of buildings, six storeys in height, the light and ventilation in some of the rooms was seriously obstructed, owing to the buildings being erected round two enclosed courts having respectively areas measuring 8 by 11 and 9½ by 23 feet. At the instance of the sanitary authority, the buildings were improved by the demolition of one part. In another set of dwellings, six storeys in height, the light was obstructed by a warehouse from 4½ to 6 feet distant, and about as high as the block of dwellings itself. In some instances the relative positions of door and window in the rooms gave less opportunity for the ventilation of these rooms than was desirable. Common lodging-homes.—An inspection of common lodging-houses and shelters, of which a list was obtained from the sanitary authority, showed that accommodation for over eight hundred persons had been provided in the district, some two hundred beds being charged for at the rate of 4d. per night, the large majority of the remainder at 6d. per night, and about a hundred at other prices, ranging from 5d. to Is. per night. Houses let in lodgings.—The District Board has for many years possessed by-laws for houses let in lodgings, but these are not enforced. I am informed that no houses were ever registered under these by-laws. The Board has since the passing of the Public Health (London) Act, adopted a fresh code which awaits the confirmation of the Local Government Board. Dr. Herron estimates that the number of houses which will require to be registered is about 750. Overcrowding.—Dr. Herron has informed me that he has found very little overcrowding of dwellings. Inspections are, however, limited to the day, and later visits are only made exceptionally when complaints of overcrowding have been received. It is the practice of the sanitary authority to require, in the case of rooms occupied by day and by night, 500 cubic feet of air space for each adult, and 250 for each child. In the case of rooms occupied by night, only 300 cubic feet of air space is required for each adult, and 150 for each child. Sewers.—During my inquiry I was informed that the Council's main sewer in Union Street was defective. I made, therefore, the following inspection :— I traversed the sewer in Union Street from Southwark Bridge Road to High Street, Borough, and up High Street towards London Bridge; this length of the sewer had recently been underpinned, and was in good order. Entering it again by a side entrance in Princess Street, the sewer was traversed as far as the corner of Gravel Lane; there was a good deal of deposit in the western two-thirds of this length ; provision has, I am told, already been made for improving the gradient. In that part of the District Board's sewer, from Princess Street to Union Street, there was a very large amount of deposit. In view of the condition of the sewer, it was deemed unsafe to traverse it with a light in a southerly direction. Entering the Stamford Street sewer near Blackfriars Road, this sewer was traversed for a short length and found to be clean. Entering the sewer in Broadwall, and going southerly into Hatfield Street, this sewer was found in similar condition. I was told by the Board's surveyor that tidal inlets are largely used for flushing the District Board's sewer, and that as a result the removal of deposit was less necessary than would otherwise be the case. Bakehouses.—Of the bakehouses, a list of which was obtained from the sanitary authority, 16 were inspected. The majority of these were situated in the basement. In particular instances there was some want of cleanliness. With regard to ventilation, this was less easily effected in bakehouses situated in the basement, and in some cases the height from floor to ceiling was so limited as to render efficient ventilation, without draught, a difficulty. In one instance an open dustbin and an unenclosed watercloset were found in the bakehouse. Slaughterhouses and Cowsheds.—There are no licensed slaughterhouses and but one licensed cowshed in the district. Workshops.—The sanitary authority had no list of workshops, but I subsequently learnt from the office of H.M. superintending inspector of workshops, that the total number within the St. Saviour's boundary on the books of that department, was 285. At the time of my own inspection there had been no inspection by the sanitary authority of the workshops in the district. I have, however, 7 been since supplied with a list of " sanitary works," relating mainly to drains and waterclosets in connection with workshops, and which have been carried out under the supervision of the authority during the past year. Hitherto, however, there has been no special inspection of workshops. Mortuary.—The mortuary which has been provided consists of a railway arch, this one arch serving for the bodies of persons who have died from infectious as well as non-infectious maladies, and for post-mortem examinations when such are required. The mortuary is altogether unsuited for the purpose, and it is not matter for surprise that its use is practically limited to receiving the bodies of those found drowned in the Thames. Disinfection.— For the purposes of disinfection, the sanitary authority has provided an oven which is situated in a railway arch adjoining that used as a mortuary. The oven is heated by gas, and is an apparatus far less efficient than those in which steam is used. Articles requiring disinfection are removed by means of a truck. When bedding is unlit for further use, it is burnt and replaced, but this event is of rare occurrence. No charge is made for disinfection. Houses are disinfected by the burning of sulphur in the rooms, stripping paper from walls, and lime-whiting ceilings, the wall-stripping and lime-whiting being carried out at the owner's expense. Scavenging.—At the time of the commencement of my inspection the sanitary authority contracted for the removal of the house and street refuse of the district, and the cleansing of the roads, but employed its own servants to cleanse the footways and the Borough market. The refuse which was removed by the contractor was taken to Bankside, aud shot into barges on the Thames. The refuse collected by the sanitary authority was removed to a wharf in Lambeth occupied by the Strand Board of Works. Now none of the work is done by a contractor, but the authority employs its own servants. The house refuse is removed systematically from houses, the scavenger calling at each house on his round, and not waiting to be summoned when his cry is heard. Shelter for the accommodation of persons during the disinfection of their rooms.—In accordance with the requirements of section 60 (4) of the Public Health (London) Act the sanitary authority has provided two rooms at the top of a house in Nelson-square, occupied by one of the sanitary inspectors, in which poor persons can be accommodated during the disinfection of their own rooms. This shelter is provided with three beds, and other furniture by the sanitary authority. Sanitary administration.—For the sanitary administration of the district, the District Board has appointed a medical officer of health and two sanitary inspectors and has also in its service a man who is employed in disinfection and in the testing of drains of houses. The second inspector was not appointed until February, 1892. There is no clerk attached to the sanitary department, the inspectors preparing their own notices and keeping the records. The inspectors report to the [medical officer of health who, since March 1st, 1892, has had general supervision of the work of the sanitary department. A book is kept at the office to which the hall-porter has access, and in which inhabitants can enter their complaints; it is however found by experience that this book is not used, but complaints are often made verbally or sent by letter. In another book is entered the particulars of every house inspected, a page being devoted to each house. There was at the time of my enquiry no ledger kept containing a list of premises, the subject of proceedings, and by which could be seen the nature of the proceedings and the results. This however has since been provided. The sanitary inspectors visit houses on complaint, but this inspection is not limited to houses concerning which representation is made to the sanitary authority. I am informed it is the practice of the inspectors, when their attention is directed to any particular house, to inspect other houses in the same street, and further, when a complaint is received respecting any house, inquiry is not limited to the subject of the complaint, but the house is examined throughout with a view to the discovery of any other defects that may exist. The requirements of the sanitary inspectors are comprehensive. The ventilation of house drains is insisted on, and all new drains are subjected to the water test before being regarded as satisfactory. A return which I presented to the Council's Public Health Committee in April of the present year, showed that while in the district of St. Saviour there was one sanitary inspector to 13,581 inhabitants, it was found necessary in St. Giles to employ one to every 7,956, and in as many as eight London districts the strength of the sanitary staff' was in excess of that of St. Saviour. Until February of last year there has been but one sanitary inspector, and the arrears of work in the district must therefore have been considerable. That much progress has been made is beyond doubt, but in view of the character of the district, which I have endeavoured to describe in the earlier pages of this report, I do not regard two inspectors as sufficient to maintain it in proper sanitary condition. The systematic inspection of workshops still remains untouched, and the work which will devolve upon the sanitary authority in connection with the registration of houses let in lodgings will make further important demands upon the efforts of the staff. In conclusion I may state that— (1) I am satisfied that the representations of the Mansion House Council as to the conditions of houses in the district were substantially accurate, and that these conditions had grown up as a result of the insufficiency of the staff. The sanitary authority had, before my inspection began, endeavoured to remedy the defects, and in this work they had been materially aided by the appointment of the second sanitary inspector in the early part of last year, practically doubling their staff. The work of improvement which has been done deserves recognition on account of its thoroughness. I am, however, of opinion that two inspectors are insufficient, especially in view of the necessity of a systematic inspection of workshops, and in view of the duties which must devolve upon the staff in connection with the regulation of houses let in lodgings. (2) There is need for the sanitary authority to provide a proper mortuary. (3) The present disinfecting oven should be replaced by one in which the disinfection is effected by steam. Shirley F. Murphy, Medical Officer of Health. . Appendix V. London County Council. Report of the Medical Officer on the Report of the Royal Commission on Metropolitan Water Supply, 1892-3, (Printed by order of the Water Committee, 18th January, 1894.) The instruction to the Royal Commission on the Water Supply of the Metropolis was to enquire whether the present sources of supply of the metropolitan water companies were adequate in quantity and quality. The instruction of the Committee to myself is to discuss the report of the Royal Commission, and in doing so I propose to limit my observations to that portion of the report which relates to the quality of the present sources of supply, a subject upon which the Commission received a large amount of valuable though occasionally conflicting evidence. I may say at the outset that I fully recognise that the report and conclusions of the Commission are entitled to the greatest respect, but in discussing some of the points which are dwelt upon in that report, I desire to emphasize certain aspects of the case which I think may properly be submitted for the consideration of the Committee. The Royal Commission had before it evidence submitted by the medical men, who, acting under the instructions of the County Council, had inspected the Thames and Lea, and their tributaries. This evidence showed that the rivers from which the water companies draw their supplies receive from the towns situated on their banks, at varying distances above the intakes, sewage effluents which, after treatment of the sewage, either by filtration through land, or by chemical processes, enter the rivers. In addition to these, numerous pollutions from smaller populations discharging into cesspools and ditches reach, untreated, the streams at times of heavy rainfall. Such sewage must, not infrequently, contain the excremental matter of persons suffering from typhoid fever, and may not improbably in the future contain from time to time the excreta of persons suffering from cholera. The virus of both these diseases has been found by past experience to have been disseminated by water, and to have produced fatal results in persons drinking such water. Nevertheless, the Commission reports, "we are strongly of opinion that the water as supplied to the consumer in London is of a very high standard of excellence and purity, and that it is suitable in quality for all household purposes. We are well aware that a certain prejudice exists against the use of drinking water derived from the Thames and Lea, because these rivers are liable to pollutions, however perfect the subsequent purification by natural or artificial means may be ; but, having regard to the experience of London during the last thirty years, and to the evidence given to us on the subject, we do not believe that any danger exists of the spread of disease by the use of this water, provided that there is adequate storage and that the water is efficiently filtered before delivery to the consumers " The report of the Commission is in the main devoted to a discussion of the risks to the water consumer from the two diseases I have mentioned, and for practical purposes it is not necessary at the present time to go beyond them. Not only are these diseases known to be water-borne, but experience has shown that a very small amount of the excremental matter of persons suffering from them is capable under favourable circumstances of infecting vast volumes of water, thereby causing disastrous results to persons who consume water thus polluted. There are very strong grounds for thinking that these maladies are caused by micro-organisms contained in the excreta, and there is much reason for believing that certain micro-organisms, which have been identified and studied, are the essential elements which cause these diseases. It is shown in the report of the Royal Commission that the following circumstances contribute to the safety of the London consumer— The apparent inability of the organisms of cholera and enteric fever to live for long periods outside the animal body in which they have been developed. The fact that they multiply by fission and not by the formation of spores, which are peculiarly resistant to hostile influences. The dilution to which the polluting matter reaching the rivers is subject, and especially at times of flood, by the large amount of fluid with which it is admixed. The action of light, of low temperature and of vegetable organisms to which the organisms in the polluting matter are exposed in the river, and which are known to be prejudicial to their existence. The fact that floods occur preferentially in the winter when the temperature is low. The length of flow of the rivers, between the points at which they receive the pollutions and those at which the water is taken for public consumption. This gives opportunity for subsidence, and for light and for river organisms to act deleteriously upon such disease-producing organisms as may be present in the water. The treatment by the water companies of this water by subsidence and filtration, both of which contribute materially to free the water supplied to the consumer from organisms of all kinds. Evidence was received by the Commission which tended to show the large powers possessed by running waters of freeing themselves from pollution. It would serve no useful purpose to discuss this evidence in any detail ; the fact may be accepted that these powers exist, and are operating in the Thames and Lea to an extent which contributes in no small degree to the safety of the London water consumer. There are, however, a few points to which brief reference must be made. 2 The Commission obviously does not consider it necessary that these natural processes should in themselves be sufficient to render a water supply fit for domestic purposes, but is satisfied if such agencies and the operations of the water companies combined, suffice to insure that wholesome water is supplied to the consumers. As evidence that this is the view of the Commission, I may cite the following statement in their report, which follows a reference to the well-known cases of the distribution of cholera in 1854 by water from a well in Broad-street, Golden-square, and of enteric fever in 1879 by water from a well in Caterham. " The question, however, is not whether such dissemination is possible under any circumstances, but whether water, however slightly contaminated, can be freed from such contamination by proper precautions, such as adequate storage and filtration, or whether, as contended, it must be regarded as for ever unsuitable for drinking purposes." Now it is probable that the completeness of the future operations of the water companies may depend upon the necessity which can be shown for efficient filtration, using the word efficient in the sense which is indicated by recent observations. It is therefore a matter of great importance that the natural processes of purification should not be held to be more deserving of reliance than they actually are. I have therefore studied the statements in the Commission's report which bear upon this subject, with the result that I am led to think that some of the reasons given for assuming that the London population is not exposed to risk, are less deserving of acceptance than appears at first sight. Dilution of polluting matter. The Royal Commission has evidently been impressed by the dilution to which any excremental matter must be subjected which enters its waters. Thus the Commission, after taking the smallest annual flow in the Thames over Teddington weir in any one of the eleven years 1881-91, and the largest estimated number of cases of enteric fever in any one of those years (1,001), shows that this would give 294 million gallons to one case, " an amount which perhaps may be more readily apprehended if described as a mass five miles in length, one hundred yards in width and six feet in depth. A similar calculation made for the Lea gives for each typhoid case a body of water three miles in length, one hundred yards in width, and six feet in depth." I confess that this argument appears to me to be open to objection. The risks to London water supplies are less from the average number of cases of enteric fever in the water area in a year than from the occurrence of a number of cases at any one time in a community which discharges its sewage into the rivers. Thus, typhoid fever is not usually distributed equally throughout the year, but is especially prevalent in certain mouths, and if this circumstance only were considered, the volumes of Thames and Lea water given in the above paragraph would for these periods have to be differently stated. In estimating risk of this kind, regard must be had for the possibility of some exceptional outbreak, due perhaps to milk, and giving rise to hundreds of cases of this malady in the towns situated a limited number of miles above the intakes, and discharging their sewage into the rivers. No doubt the treatment of this sewage before its discharge is, under ordinary circumstances, a safeguard of much value, but there has been experience of a town having to discharge its sewage untreated into a river, owing to a temporary failure in its machinery for treatment, and this at a time when the town was suffering from an epidemic of enteric fever. For the safety of Londoners, the natural processes of purification and the operations of the water companies must uninterruptedly be equal to the demand which would be made upon them in such an event. Again, referring to the outbreak of enteric fever in Caterham in 1879, the Commission states— " It appears from returns made by the Chairman of the Caterham Water Company that the total amount of water pumped from the well in the 14 days, during which it was being continually polluted, was 1,861,000 gallons. But if the volume of water brought down by the Thames to the intake be taken into account, and also the fact that at least 98 per cent. ef tho microbes in water are removed by filtration, it will be found on calculation that in order to produce an equal amount of pollution in the water supplied to the London consumers to that of the Caterham well, nearly half-amillion cases of typhoid fever must occur in a fortnight in the Thames valley above the intake, the discharges from all these cases passing into the river as directly and in as great a proportion as did the discharges of the workmen into the Caterham well, and no part of these discharges being arrested or destroyed on their way down to the Hampton intakes or during the sojourn in the subsidence tanks. But the entire population of the valley above Hampton consists—men, women, and children—of only about one million persons." In estimating the value of this argument in connection with London water supply the following circumstances must be remembered. There is no accurate knowledge of the amount of water which a single case of enteric fever can render virulent, and certainly no safe deduction of this kind can be made from the occurrence at Caterham. The man who infected the water in the Caterham well suffered from a comparatively mild attack of enteric fever, i.e., he was only confined to his bed for two days, and it is quite likely that the evacuations of mild cases of the disease are less virulent than those of severe cases. He was only employed in this well during certain hours of work, and it may therefore be assumed that but a portion of his daily excreta were evacuated during these working hours. At other times he had no opportunity of polluting the water. It must also be remembered that he insisted that when in the well he used the bucket, and that his evacuations were sent to the surface. It may therefore be that the contamination of the water, which was pumped was effected by mere splashings from the bucket. But whatever quantity of his excreta entered the well, it is impossible to assume that it rendered virulent as much water as it was capable of rendering virulent, for the multiplication of the bacillus in water must be accepted; all we know is that the water company pumped 1,861,000 gallons in a fortnight, and it is quite possible that if the company had pumoed a much larger volume of water, this larger amount would have been found to be infective. For all we know, less than part of this man's daily excreta may have polluted the well water; the excreta may have contained matter the virulence of which was only 1/10 of that of the 3 evacuations of cases sufficiently severe to lead to the patient remaining in bed daring a much longer period than two days; and had the company pumped five times as much water, this might have been found to be infective. If so, the occurrence of 100 cases of typhoid fever of average severity in a town above the intakes, a very possible event at any moment, might be thought of, instead of the half-amillion cases mentioned in the report of the Commission. I follow the Commission in leaving out of consideration (for the purposes of this particular part of the discussion) all questions of the opportunities for the destruction of the typhoid bacillus in the river. I do not of course propose to assume that the pollution of a well is parallel to the pollution of a running stream, but inasmuch as I understand the Commission to suggest that we should draw deductions as to the safety of Londoners from the comparisons it has itself made between the amount of water polluted in the Caterham well and the London rivers, I think it well that this point should be discussed. Viability of typhoid bacillus, The Commission in referring to the length of time the typhoid bacillus retains its vitality after leaving the human body, says, " it appears to be the belief of bacteriologists that such dejecta begin to lose their virulence after a very few days, and the longest period for which the typhoid bacillus has as yet been found to retain its vitality when in fecal matter, does not exceed 15 days." Even the shorter period would, however, in point of time, give ample opportunity for typhoid dejecta in the sewage of several of the larger towns on the banks of the Thames to reach the intakes of the water companies while still virulent. It is very difficult to determine by experiment to what extent typhoid bacilli can be carried from such sources as low down the river as the intakes of the water companies. The most important experiments which were made with a view to obtaining information on this subject, were conducted by Professor Hay Lankester, and are thus referred to in the report of the Royal Commission. " It is certainly true that no pathogenic bacteria have yet been detected in the water of these rivers; but to this it is answered with much force, that the samples used in the ordinary method of examination by plate culture are so excessively minute that it cannot be inferred, from such want of detection in the sample, that the bacteria are really absent from the bulk. This objection is, however, met, at any rate to a considerable extent, by the experiments carried out by Professor Ray Lankester. In some of these a considerable volume of raw river water was passed through a Pasteur-Chamberland filter, which, while it allows the water to percolate, holds back all the bacteria ; while in others the substance for examination was obtained by taking some of the gelatinous layer of living microbes that had accumulated on the surface of a filter of one of the London water companies. The material obtained by these several processes from a relatively large bulk of water was then subjected to the most delicate of modern tests for the detection of typhoid bacilli, namely, that known as the method of Parietti, and in no case was this bacillus found to be present. Experiments such as these, though they cannot be said to demonstrate the total absence of pathogenic bacteria from the river water before it enters the filter beds, yet add largely to the probability of their being present, if at all, only in very small numbers." I do not gather that Professor Lankester is, without further experience, disposed to regard the testing of the deposit on the filter beds as altogether reliable, for although in his statement he says, " We have the bacteria and solid particles filtered off at Ditton from many millions of gallons of water, and in this concentrated material Parietti's method would surely reveal the typhoid bacillus if present." he later adds, " No doubt it would be interesting and important to make continuous examination for it in this deposit once a week during a series of years." And again still later in giving evidence when asked, " Would it be fair to represent that material for bacteriological purposes as the concentrated, say, essence of the raw material, the worst essence that you could get of the raw material ? " he replied, " I should say so, with this qualification of course, that some destructive changes may have already been set up in the deposit, and on that account I obtained the deposit at as early a period as possible ; that is to say, from a comparatively newly started filter bed." The matter collected on the Chamberland filter, Professor Lankester thinks free from this objection. It must not, of course, be assumed that the quantity of concentrated " material" from the filter bed, which must have been actually examined by Professor Lankester, contained the organisms of the many million gallons of water which passed through the whole of the filter bed : the amount of material examined must be thought of as being related to a quantity of water, a fraction of the total amount filtered, having the same proportion to this total amount that the area occupied by the concentrated material examined by Professor Lankester bore to the total area of the filter bed. These experiments of Professor Lankester do not do more than show that the typhoid bacillus was not present in certain quantities of Thames water, of which we do not learn the exact amount, and I do not myself attach any great importance to them. Considering the varying conditions of a river and the varying amount of of typhoid fever present in towns above the intakes, it is quite possible that the typhoid bacillus might be present at one time and not at another. Indeed, Professor Lankester (apparently employing a different method) himself failed to find the bacillus in the sewage of Oxford. It is true that his investigation was made at a time when typhoid fever was not known to exist in the town, but the excreta of typhoid patients must often at other times have gained access to the sewer, and even during the time of his investigation unrecognised cases of typhoid are not unlikely to have been present in a population of the size of that of Oxford. His tests of Thames water moreover were made at a period of the year when the number of cases of this disease is in England usually below the average. Number of organisms required to produce disease. I need not refer to the evidence as to the necessity for a certain number of pathogenic organisms being required to produce disease, for the reason that there is no knowledge of how few of the typhoid 4 bacilli may serve for this purpose in man, and because there is no near prospect that this information can be obtained. Storage and filtration. But while the Royal Commission appears to be disposed to attach more value than I do to the conditions I have mentioned as affording safety to the London population, it evidently regards as essential to this safety " that there is adequate storage and that the water be efficiently filtered before delivery to the cousumer." Adequate storage is not absolutely defined by the Commission, beyond that it is to mean that the storage is sufficient to obviate the necessity of taking in turbid storm water and to allow of due settlement. " Efficient filtration" is still less defined by the Commission, and if we are to assume, as I think we must from the evidence given before the Commission and the statements made in the report, that filtration of this kind is to be regarded as essential to the safety of the London population, no uncertainty ought to attach to the meaning of this expression. The Commission thus refers to the action of filter-beds : " The action of a filter-bed appears to be partly mechanical, partly vital, but the mechanical action which is confined, or almost confined, to the holding back of the comparatively grosser substances suspended in the water, and which was supposed until recently to be the only operation in a filter, is now held to be of far less importance than the vital action which depends on the activities of the gelatinous layer of living matter gradually deposited on its surface. A new filter composed of perfectly purified sand has no effect in producing either chemical or bacteriological purification, but in course of use a layer charged with living microbes is deposited upoh the surface, and it is by these organisms which constantly increase in number, and also penetrate the sand to a slight distance, that both the nitrification of organic matter, and the arrest of other microbes is effected. Thus, the longer a filter has been in use the more efficient it becomes, provided of course that the surface layer has not acquired such density as to interfere with the passage of the water, and consequently the recommendation, which was commonly given in former times, that a filter-bed should be cleansed as often as possible, appears to have been a mistake; cleansing, by which the efficient superficial membrane is removed, should only be carried out when the filter has become unduly blocked." During the present year, Koch, writing on water filtration and cholera,* says "In the process of filtration the important point is first that a proper layer of slime should be formed, and that it should not be disturbed during the process of filtration, and that when by further continuous deposit it becomes too thick, and therefore to impermeable to water, it should be removed." Further he says that " it has also been discovered that in the gradual wearing out of the sand layer it should never be allowed to get below a certain thickness, about 30 centimetres, and that a certain speed, about 100 millimetres in the hour, must be allowed for the movement of the water through the sand layer to obtain the most perfect purification." Koch's definition of efficient filtration may be gathered from the following. " If a filter works satisfactorily in every respect, there will be found, as experience shows, less than 100 germs capable of developing in one cubic centimetre of filtered water; and this is independent of the amount of bacteria contained in the natural water, whether such amount should be 100,000 or only a few hundred in a centimetre. But the slightest disturbance in the process of filtration, for instance, the quickening of the rate of filtration to over 100 millimetres, disturbances of the surface, mud covering, &c., lead as a consequence to an immediate increase of germs in the filtered water," and again " water must be allowed to rest at least four-and-twenty hours over the sand in order to enable the filtering mud layer to be formed." In another part of this paper he says— " But I consider it to be very probable that, according to the investigations of Fraenkel and Piefke, if the pace of filtration is 100 millimetres the bacteria of cholera cannot be completely kept back by the sand filters." Beyond this, Koch has shown how the freezing of the sand layer during cleansing of the filter and the removal of ice from the surface of the filter, as well as the growth of microscopic plants in periods of the summer, interfere with the process of filtration. Although the advantage of slow filtration compared with rapid filtration has been for some time understood, there has been no such precise definition of the conditions required for efficient filtration. It is obvious that to comply with the requirements of Koch, there is needed not only an extensive provision of filter beds, but knowledge and skill as to their employment and the constant application of biological tests as to their efficiency. The Local Government Board, on 31st August, 1892, having regard to the prevalence of cholera on the continent and its possible spread to this country, addressed letters to the various companies supplied from the Thames and Lea, calling attention to the special necessity for efficient filtration, and recommending, inter alia, that the rate of filtration should be as slow as possible consistent with the required supply of water. It is evident that in future there should be no need for any qualification such as that introduced into the recommendation ; that the rate of filtration should be governed solely by the consideration of efficiency, and that the conditions of filtration should be strictly regulated so as to secure uninterruptedly a result which should be precisely defined. Evidence of experience. Considering now the evidence of experience, it must be fully recognised that the death rate of the London populatiou from typhoid fever is low, lower indeed than that of many other towns receiving a water supply not exposed to excremental pollution, and this is equally true, whether the death rate of London as a whole be considered or whether the rates of those parts supplied from different sources be considered separately. This of course does not absolutely negative the possibility that water has caused typhoid fever in London, but it is, so far as it goes, favourable to the London water companies. * Water filtration and cholera by Professor Koch, The Practitioner, Vol. 41, No. II. 5 The absence of evidence that the public supplies have been concerned in giving rise to typhoid fever in London, does not mean more than that they have not conspicuously done so. Avery small temporary increase of the number of typhoid cases in the area of a water company might be all that would result from the supply of slightly infected water, and this result might not affect the number of deaths so as to excite attention. The demonstration of any relation between such increase of cases and a water supply would be a work of extreme difficulty even if it were possible, and in view of the administrative arrangements of London in the past, it is quite conceivable this event might have occurred unnoticed. On the other hand it must be equally stated that no evidence is forthcoming that this has happened. A point well deserving of observation is the diminishing London typhoid fever death rate. To assume that this is due to improvements in the water supplies (whether due to better treatment of the sewage of towns above the intakes or to the operations of the water companies) would necessitate acceptance of the view that water had in the past caused this disease in the London population. It may be due to the general improvement in the sanitary condition of the metropolis, and it is quite conceivable that change in the nature of the virus may have played some part in a diminution which has been generally shared by the country as a whole. Experience of the value of natural processes of purification of rivers and of filtration must be sought out of London, and trustworthy knowledge can only be arrived at as the result of prolonged observation. There was one case in which the question was raised whether a river of considerable volume, after flowing some distance subsequent to receiving pollution, had given rise to epidemic prevalence of enteric fever among the consumers of the water. This case was that of the river Tees, which, according to the report of Dr. Barry, a medical inspector of the Local Government Board, had distributed through the mains of certain water companies, enteric fever among the tenants of these companies. So much importance attaches to the lessons to be learnt from the behaviour of typhoid fever in the Tees valley that it is necessary to make special reference to this report. The Royal Commission thus discussed the subject— " In 1890 a serious outbreak of enteric fever occurred in the Tees valley, and was attributed by Dr. Barry, the medical inspector, in a report published in the supplement to the twentieth annual report of the Local Government Board, 1890-91, to the consumption of water taken from the Tees, and delivered after filtration by the Darlington Corporation and Stockton and Middlesbrough Water Board. " This view he further upheld in a later and fuller report, which will appear in the supplement to the twenty-first annual report of the Local Government Board, in continuation of the report of the medical officer for 1891, and of which we were favoured with advance copies; and in this final report he extended his inquiries to a second outbreak in the year 1891, and assigned to this also an origin in the Tees water supply. " The conclusion at which Dr. Barry arrived in regard to the 1890 outbreak, to which we have more specially directed our attention, appears to have been mainly based on the following propositions— " (a) That the fever was so vastly more prevalent in the districts supplied with Tees water than in the districts supplied from other sources, that it may be said to have been practically confined to them. " (b) That the attacks were spread over all the districts supplied with Tees water with very great, though not of course with mathematically perfect, uniformity, and that the several districts were attacked simultaneously. " (c) That water supply apart, there was no other difference of any importance between the Tees-drinking and the other districts. " (d) That there was an accumulation of filth upon the banks of the Tees at places above the intake, and notably at Barnard Castle, and that a flood, which happened on August 13th, 1890, must necessarilly have washed this filth into the river; and that the time when the outbreak declared itself, after allowing for the incubation period, tallied with the view that the outbreak was caused by this pollution." " This series of propositions doubtless constitutes a formidable indictment against the water supply. They are, however, one and all traversed by Mr. Wilson, the representative of the Stockton and Middlesborough Water Board, and the chief objections that can be made to them severally may be stated as follows— " As regards the proposition lettered (a) it is admitted, speaking generally, that the fever was much more prevalent in the Tees-drinking than in the surrounding districts ; but it is said that the difference in this respect between the two was very much smaller than represented by the inspector, inasmuch as notification of cases was compulsory in the former, with the exception of one sanitary district out of ten, while it was voluntary in the latter, with the exception of seven sanitary districts out of twenty-two; and that in consequence of this the number of cases was largely overstated in the Tees-drinking districts, and largely understated in the other districts ; and in support of this, appeal is made to the respective case-mortalities, as deduced from the inspector's own tables. " To the proposition lettered (b) it is answered that not only did numerous villages or hamlets that were supplied with Tees water altogether escape, but that, in districts which were attacked, the attacks were not spread with uniformity over the area, but occurred, either exclusively or preferentially, in certain parts, and that this distribution coincided with marked difference in the sewerage arrangements, which were so faulty that previous outbreaks of fever had been attributed to them by official inspectors, and the probability of further outbreaks asserted. " To the proposition lettered (c) it is answered that he water supply does not constitute the only important difference between the two sets of districts ; that the Tees-drinking districts are almost exclusively urban, and the other districts almost exclusively rural; and that, if the 32 sanitary districts dealt with in Dr. Barry's report he divided into urban and rural without regard to their water supply, it is found that the reported fever cases were four or five times as numerous in the urban as in the rural group ; and that the conditions of urban life, with its common sewerage and its closer aggregation 6 of inhabitants, are notoriously more favourable to the diffusion of disease than are the conditions 01 rural life. " To the proposition lettered (d), it is replied that though the flood of August 13th must have washed down such filth as was on the banks, that filth can only have been such as had accumulated since the next preceding heavy flood, which was on July 1st, and that in this interval there had been no traceable case of enteric fever in the area above the intake, and that consequently the filth cannot have contained the specific poison which is essential for the production of enteric fever, and that the suggestion that there may have been cases of fever unknown to the medical men above the intake is a perfectly unsupported hypothesis. " Dr. Barry, as we understand him, admits with some qualifications the truth of these criticisms, but maintains that, when all due allowance has been made for them, there remains a body of evidence which they are not weighty enough to counterbalance, and which, though it does not actually demonstrate, constitutes a strong presumption that the explanation of the outbreak adopted by him was the true one. "We felt strongly that without very minute and accurate acquaintance with the locality, and without much more elaborate knowledge of all the complicated circumstances of this and previous outbreaks of fever in the Tees valley than it was practically possible for us to acquire, it was out of the question that we should decide between these conflicting opinions. " Although, therefore, we have printed the evidence put before us concerning this outbreak, and have attempted to sum up as fairly as we could the main arguments on either side, we refrain from expressing any judgment as to its origin. This much, however, we may say, that the pollution on a given day of a river like the Tees, with a flow in time of flood of at least 1,000 million gallons in the 24 hours, by what must at most have been a very small amount of active enteric poison at a point 17 miles above the intake, should so seriously affect the water that the admission of a certain limited amount of it into the reservoirs should produce, notwithstanding filtration, an extensive outbreak lasting for some six weeks, is a hypothesis so startliug, and so entirely unsupported by previous experience in other places, that it is fair to demand the most conclusive evidence before accepting as proven ; and, though we attach great importance to the opinion of such an experienced inspector as Dr. Barry, we cannot say that such conclusive evidence has in our opinion been brought before us." On this subject I desire to offer the following observations— Dr. Barry deals with an area containing ten registration districts. When enteric fever prevalence, during two six-weeks periods, one at the end of 1890 and the other at the beginning of 1891, was considered as affecting each of these registration districts as a whole, it was found that excess of this disease was limited to three, viz., Darlington, Stockton, and Middlesbrough. The ten registration districts are divisable into 32 sanitary districts, and the special incidence of the disease was manifested in only ten, nine of which are comprised in the Darlington, Stockton and Middlesbrough registration districts, which are divisible into eleven sanitary districts, and the remaining sanitary district was comprised in the Guisbrough registration district, which is divisible into seven sanitary districts, of which it formed in respect to population less than one-tenth, and in which, therefore, manifest excess of incidence was not shown when this registration district is taken as a whole. Of the ten districts having excess of incidence, the excess was general throughout eight of the sanitary districts which were urban, and affected only parts of the remaining two which were rural. The excess of enteric fever was parallel to the distribution of the Tees water, selecting the three registration districts specially supplied with Tees water out of a total of ten registration districts, the remaining seven not being specially supplied; selecting ten sanitary districts specially supplied with Tees water out of thirty-two, the remaining twenty-two not being specially supplied; affecting eight urban districts generally, and two rural partially, and selecting out of these two rural districts only those parishes specially supplied with Tees water. With this striking parallelism between the special incidence of disease and distribution of Tees water has to be considered the absence of any other condition parallel to this incidence. Further, this special incidence was manifested on two occasions, both of which corresponded with floods in the river Tees, and on the second occasion at a time of the year when, as Dr. Barry says, enteric fever is unapt to be prevalent in this country. Apart from the reference to dilution of impurities, to which I shall return presently, the Commission in their report do not offer any reasons for not accepting Dr. Barry's conclusions other than those put forward by Mr. Wilson, and I shall therefore limit myself to making a few observations on the grounds which are indicated by the Commission as those on which Mr. Wilson relies as sufficient to negative these conclusions. 1. As to Mr. Wilson's objection to proposition (a), Dr. Barry gives the death rates as well as the attack rates, and it is found by examination of the death rates that these confirm the conclusions based upon the attack rates. 2. As to Mr. Wilson's objections to proposition (b), Dr. Barry gives in his report the attack rates for each of the thirty-two sanitary districts in the two six-weeks periods, and it is there seen that with the exception of a very few districts where the figures were too small to give reliable rates, the special incidence of the disease manifested itself in every district supplied with the Tees water, and practically only in these districts. The disease was of course not spread uniformly throughout every part of every district, and this is not matter for surprise when it is recollected that the virus is particulate and is not dissolved in the water. Assuming Mr. Wilson is correct in asserting that places where local insanitary conditions abounded suffered "exclusively or preferentially," this affords no explanation of the special incidence of enteric fever during two periods of six weeks in numerous localities included in a large area comprising ten registration districts. 3. As to Mr. Wilson's objection to proposition (c), this is met by comparing the rates of incidence of the disease on urban districts supplied with Tees water and those otherwise supplied, and 7 by comparing as far as possible the rates of incidence on rural districts supplied with Tees water, and on rural districts otherwise supplied. 4. The absence of known occurrence of one or more cases of enteric fever between July 1st and August 13th among the population draining into the Tees will not be regarded by medical men who are familiar with " ambulatory typhoid" as any sufficient reason for assuming that the specific virus of the disease had not had opportunity of finding its way into the river. The illness of the man who polluted the Caterham well would never have been heard of but for the detailed inquiries to which the outbreak in the Caterham valley gave rise. After study of Dr. Barry's report and the evidence of Mr. Wilson, I have no hesitation in stating that this evidence may be dismissed, as in no sense invalidating Dr. Barry's conclusions. His conclusions, indeed, I am satisfied, must be accepted as certainly as the evidence concerning the Broad-street well of 1854 and the Caterham well of 1875, evidence which the Royal Commission evidently accepts as amounting to proof.* Nor indeed do I regard Dr. Barry's conclusion as a startling hypothesis. The enormous power of water to disseminate disease has been demonstrated again and again, and although there is no case exactly parallel to that of the Tees valley outbreak, it is easy to understand how the cause of exceptional prevalence of disease ovc^" a large tract of country may be overlooked ; that it has occurred before without detection of the cause is well within the bounds of probability, and indeed the facts that have recently come to light as to the past behaviour of enteric fever in the Tees valley suggest that the occurrences of 1890-91 may not have been exceptional in that locality. Whether, however, these are the first occasions on which Tees water has disseminated enteric fever, or whether other similar outbreaks have occurred without being traced to this cause, it is clear that tbe purely negative evidence of former years has failed to give assurance of safety. In accepting Dr. Barry's conclusions as to the Tees valley outbreak I may again refer to the importance which the Royal Commission has attached to the dilution to which sewage entering the rivers is subjected by admixture with their waters, and to the comparison made in the Commission report between the amount of pollution of the Caterham well and the amount of pollution of the rivers Thames and Lea. What has taken place in the Tees valley illustrates the impossibity, in our present 'state of knowledge, of forming any useful estimate of the amount of specific matter which is required to render virulent any given volume of water. The Commission estimates that some half million cases of typhoid in the Thames valley would be required to pollute the Thames to the same extent as the man in the Caterham well polluted the water of that well, and then points out that the entire population of the valley above Hampton consists, men, women and children, of only about one million persons.* The Royal Commission's statement as to the Thames may be thus paraphrased for the purposes of the Tees— It appears from returns made by the chairman of the Caterham Water Company that the total amount of water pumped from the well in the 14 days during which it was being continually polluted was 1,861,000 gallons. But if the volume of water brought down by the Tees to the intakes be taken into account, and also the fact that at least 98 per cent. of the microbes in water are removed by filtration, it will be found on calculation that in order to produce an equal amount of pollution of the water supplied to the Tees water consumers to that of the Caterham well, nearly 17,000 cases of typhoid fever must occur in a fortnight in the Tees valley above the intakes, the discharges from all these cases passing into the river as directly and in as great a proportion as did the discharges of the workman into the Caterham well, and no part of these discharges being arrested or destroyed on their way down to the intakes, or during the sojourn in the subsidence tanks. But the entire population of the valley above the intakes consists—men, women and children—of only about 21,000 persons.† That nearly 17,000 cases of enteric fever should occur in a fortnight in the drainage area of the Tees above the intakes, the population of which is shown by Dr. Barry to number some 21,000 persons, is obviously practically impossible. Nevertheless the Tees was assuredly rendered virulent, although by how few cases cannot be stated. It is very much to be regretted that the circumstances in which the water supplied by Tees companies was able to disseminate typhoid fever among the tenants of those companies was not made the subject of complete investigation by the Royal Commission. For although there are important, differences between the Tees and the London rivers, the fact that filtration failed to protect the consumers of the Tees water raises questions as to the dependence which may be placed on filtration for complete and uninterrupted protection. * The medical officer of the Local Government Board thus concludes his prefatory comments on Dr. Barry's report, " seldom, if ever, has the proof of the relation of the use of water so befouled to wholesale occurrence of enteric fever been more obvious or patent." † The case as stated by the Commission as to the Thames is in effect ae follows—one case of typhoid fever in the case of Caterham rendered virulent 1,861,000 gallons of water distributed during 14 days. The average daily flow of the Thames is equal to 1,350 million gallons. Tn 14 davs the flow would be 1.350 million X 14=18.900 million grallons. To produce pollution of this same amount of water to the same extent as at Caterham, cases ot typhold fever would be required. If however, 98 per cent. of micro-orsranisms were removed bv filtration then cases would be required, whereas the population only numbered about one million. The case as to the Tees may thus be similarly stated. The flow per diem of the Tees in time ot drought has been estimated at 45.000.000 gallons, therefore apply. ing the preceding argument to the Tees cases in a fortnight would be required to pollute the Tees to the same extent as the Caterham well was polluted. A number which would be considerably larger were the average daily flow of the Tees considered, as in the calculations referred to concerning the Thames. 8 It is not now probable that those circumstances will ever be known, but Dr. Barry's report contains certain statements deserving of attention in this connection. Referring to the Darlington Corporation Waterworks, he says, "The rate of filtration is from 3 to 4 inches per hour, or about 45 gallons per 24 hours, per superficial foot of filter. The surface of each filter is stated to be cleansed on an average once in six weeks, on each occasion about 1½ inches of the sand being scraped off from the top and washed with water in a tub by agitation with rakes. The whole of the sand in such filter is washed on an average once in three years." Referring to the Stockton and Middlesbrough Water Works, Dr. Barry says, " The rate of filtration is about 6 inches per hour, or about 63 gallons per 24 hours per superficial foot of filter." Koch's standard would give approximately 49 gallons per superficial foot of filter per 24 hours, and the rate of filtration of the former waterworks is therefore 4 gallons less, and that of the latter 14 gallons more than this standard. The rates of filtration of the Tees waterworks may perhaps be averages, including periods of greater and less rapid flow through the filters. Under any circumstances the flow through the filters of the Stockton and Middlesbrough Water Board was such that it would, according to Koch, not be regarded as efficient filtration. And again there may have been periods when thorough cleaning of the filters, or when other circumstances already alluded to, interfered with the proper action of the filter beds of both companies. Definition of efficient filtration. Section 4 of the Metropolis Water Act, 1852, requires every company to effectually filter all water supplied by them within the metropolis for domestic use. Dr. Edward Frankland, in discussing the meaning of the expression "efficient filtration," as understood in 1852, said in his further statement " at that time, the definition of ' efficiently filtered' would doubtless be ' clear and transparent to the eye,' that is to say, free from all obvious suspended matters. . . . The definition, however, of efficient filtration, which was thought to be sufficiently stringent in 1852, when the bacteriological effect of the process was entirely unknown, has now become obsolete and ought to be amended. We now know that the possible noxious matters in river water are not the mineral or even organic, as distinguished from ' organised ' materials, but living microbes, and that the only efficient filtration, from a sanitary point of view, is that which removes the whole or nearly the whole of these microbes from the water." The Commission clearly states the need for the operations of the companies being in every way complete, and includes in its report the following paragraph— " The water that flows down to the intakes must be subjected to certain important processes, before it is brought into a suitable condition for delivery and consumption." " These processes consist of subsidence and filtration, and the quality of the water when delivered depends largely on the thoroughness with which they are carried out. It does not come within the terms of our reference to lay down what should be the exact regulations as regards filtration, that is to say, what should be the proportionate area of the filtering beds, the depth of sand, the frequency of renewal, or the rate at which the water should be allowed to percolate ; nor, as regards the subsidence tanks, how many days storage should be deemed sufficient so as to obviate the necessity of taking in turbid storm water, and to allow of due settlement; but we cannot shut our eyes to the fact that the provision for these purposes differs enormously in the different companies, and in some of them is to our mind quite inadequate." " Regulations on these matters should be drawn up after competent inquiry, and adherence to these regulations should be strictly enforced." This question is not of concern to London only, but to all communities supplied from running waters receiving pollutions, and the necessary corollary to the report of the Royal Commission on Metropolitan Water Supply is the issue of another Royal Commission to make such enquiry and such experimental investigation as may be required to determine the precise conditions to which polluted streams must be subjected in order to make their water uninterruptedly fit for domestic use. Conclusion. In view of the changes effected in the rivers, and subsequently in the filters, the risk to Londoners is, I believe, small and certainly intermittent, and indeed may be thought of as comparable to those possibilities of injury from accident in the street to which every human being is subject during the whole of his life. The risk, indeed, is to each a possibility, and not a probability, but such as it is, I believe it exists. If we recognise, as I believe we may, that the safety of London residents is dependent upon the efficiency with which deleterious matter in the London rivers is by artificial means removed from the water supplied to the metropolis, the conditions under which this removal is to be continuously ensured must obviously be determined with absolute precision, and an administration must be provided to secure that the object in view shall be attained. Shirley F. Murphy, Medical Officer of Health. Public Health Department, Spring Gardens, S.W., 17th January, 1894.