43/3 LCC 5 London County Council. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH of the ADMINISTRATIVE COUNTY OF LONDON. 1 896. {Ordered by the Council to be printed.) JAS. TRUSCOTT AND SON, PRINTERS, SUFFOLK LANE, CANNON STREET, E.C. [3149 TABLE OF CONTENTS. Statistics— pagB Population 5 Marriages 5 Marriages of minors in London, 1896 6 Births 6 Deaths 7 London mortality in the six years 1891-6, compared with the decennium 1881-90 9 Infant mortality 11 Deaths from several classes of disease 12 Principal zymotic diseases 13 Smallpox and vaccination 14 London vaccination returns 21 Measles 23 Scarlet fever 28 Scarlet fever and elementary schools 31 Proportion of cases and deaths in hospitals 32 Age and sex distribution 32 Seasonal variations in fatality 32 Seasonal variations in age distribution 33 Diphtheria 34 Diphtheria and elementary schools 36 Proportion of cases and deaths in hospitals 38 Age and sex distribution 38 Use of anti-toxic serum 39 Seasonal variations in fatality 40 Seasonal variations in age distribution 41 Whooping cough 42 Typhus 43 Enteric fever 44 Age and sex distribution 46 Diarrhoea 47 Cholera 48 Erysipelas 49 Puerperal fever 50 Influenza, bronchitis and pneumonia 50 Phthisis 51 Cancer 51 Anthrax 51 Bubonic plague 52 Meteorology 52 Administration— Dairies, cowsheds and milkshops 52 Offensive trades 53 Complaints to the London County Council 53 Nuisances 53 Trade nuisances 53 Smoke nuisances 54 Nuisance from deposit of offensive matter 55 Nuisance from stable manure 55 Removal of offensive refuse 55 Removal of house refuse 56 Dust shoots 58 Nuisance from sewer ventilators 58 Housing of the working classes 58 Schemes undertaken by the Council under Part I. of the Act 58 Schemes undertaken by the Council with cantributions by district authorities 59 Schemes undertaken by district authorities with contributions by the Council 59 Alleged insanitary area in Westminster 59 Snows-fields, Bermondsey, area 60 Proceedings in respect of houses represented as unfit for human habitation 60 Working class dwellings in Plumstead 60 Millbankprison site 61 Areas specially described in the reports of medical officers of health 61 Amendment of the Housing of the Working Classes Act, 1890 62 The regulation of houses let in lodgings 63 Common lodging-houses 65 Parker-street common lodging-house 66 Customs and Inland Revenue Acts, 1890 and 1891 66 Underground rooms 67 Factories and workshops 67 The inspection of bakehouses 69 Unsound food 69 The manufacture and sale of ice-cream 70 4 PAGE Water supply 70 Proceedings of the Council as to London water supply 72 Insufficiency of water supply 73 Constant water supply 73 River pollution 73 Disinfection 73 Provision and use of shelters 73 Hospital provision for infectious disease 74 Mortuaries 74 The London Equalization of Rates Act, 1894 75 Sanitary administration of districts 77 Medical officers of health and sanitary inspectors 77 Appendices— I.—Memorandum by the medical officer of health on a local prevalence of diphtheria in Camberwell. II.—Report on an outbreak of diphtheria in Lewisham. III.—Observations of the medical officer of health on the report of the medical officer of the London School Board on an outbreak of diphtheria in Lewisham. IV.—Report as to the operation of by-laws dealing with houses let in lodgings in London. V.—Report on shelters in the County of London. VI.—Report on the sanitary condition of Eltham. VII.—Report on the sanitary condition of Holborn. LIST OF DIAGRAMS. TO FACE PAGE Diagram I.—Marriages, 1851-96 5 II.—Births, 1851-96 5 „ III.—Deaths, 1841-96 7 „ IV.—Smallpox, 1841-96 14 „ V.—Measles, 1841-96 23 „ VI.—Scarlet fever, 1859-96 29 „ VII.—Scarlet fever; weekly notifications at certain age periods, 1896 31 „ VIII.—Scarlet fever; monthly notifications and case mortality, 1891-96 33 „ IX.—Scarlet fever; admissions to and deaths in hospitals of Metropolitan Asylums Board, per cent. of total cases and deaths in London 29 „ X.—Diphtheria and croup, 1859-96 34 „ XI.—Diphtheria; weekly notifications at certain age periods, 1896 38 „ XII.—Diphtheria; monthly notifications and case mortality, 1891-96 40 „ XIII.—Diphtheria; admissions to and deaths in hospitals of Metropolitan Asylums Board, per cent. of total cases and deaths in London 34 „ XIV.—Whooping cough, 1841-96 42 „ XV.—Typhus, 1869-96 42 „ XVI.—Enteric fever, 1869-96 44 „ XVII.—Enteric fever; weekly notifications, 1896, and mean weekly notifications, 1890-96 44 ,, XVIII.—Diarrhoea in relation to mean temperature (summer quarter), 1841-96 44 Diagram I. Marriages. Diagram II. Births. Administrative County of London. REPORT OF THE MEDICAL OFFICER OF HEALTH. 1896. STATISTICS. Population. The population of the Administrative County of London, estimated to the middle of 1896, was 4. 443.311. The estimated population of each of the 43 sanitary districts comprised in the Administrative County is shown in the following table— Sanitary district. Estimated population, 1896. Sanitary district. Estimated population, 1896. Sanitary district. Estimated population 1896. Paddington 124,838 St. Giles 38,158 St. George, Southwark 60,301 Kensington 170,660 St. Marfcin.in.the.Fields 13,003 Newington 121,191 Hammersmith 104,551 Strand 23,820 St. Olave, Southwark 11,673 Fulham 115,008 Holborn 30,932 Bermondsey 85,508 Chelsea 96,657 Clerkenwell 66,195 Rotherhithe 40,432 St. George, Hanover. square 80,041 St. Luke 41,478 Lambeth 296,036 City of London 31,409 Battersea 165,864 Westminster 53,477 Shoreditch 122,265 Wandsworth 188,908 St. James, Westminster 22,955 Bethnal.green 129,151 Camberwell 253,975 Marylebone 141,114 Whitechapel 78,886 Greenwich 176,293 Hampstead 75,812 St. George.in.the.East 47,589 Lee 38,714 St. Pancras 241,066 Limehouse 58,347 Lewisham 105,151 Islington 337,639 Mile.end Old.town 111,226 Woolwich 41,334 Stoke Newington 33,615 Po0plar 169,379 Plumstead 59,610 Hackney 213,774 St. Saviour, Southwark 25,276 The population of London was enumerated on the 29th March, 1896, in accordance with the provisions of the Equalisation of Rates Act, 1894. A statement of the increase or decrease of population of each sanitary district between the two census years 1891 and 1896 will be found in the preceding annual report. Marriages. The number of marriages in the registration County of London in 1896 (53 weeks) was 39,869, giving an annual rate of persons married of 18'0 per 1,000 living. marriage rate since 18/0 has been as follows— 1871 19.5 1878 18.5 1885 17.4 1891 17.7 1872 19.9 1879 18.0 1886 17.2 1892 17.4 1873 19.8 1880 18.1 1887 16.9 1893 17.2 1874 19.4 1881 18.1 1888 16.9 1894 17.0 1875 19.6 1882 18.4 1889 17.1 1895 17.2 1876 19.2 1883 18.1 1890 17.6 1896 18.0 1877 18.7 1884 17.9 The accompanying diagram (I.) shows the marriage rate in each year since 1850 in relation to the mean marriage rate of the period 1851.96. In the year 1896, among the males 4.89 per cent. married were under 21 years of age, and among the females 16.07 per cent. The proportions in preceding periods are shown in the following table; the proportions in England and Wales are also given for the purpose of comparison— 6 Marriages of minors per cent. of total marriages. London. England. Males. Females. Males. Females. 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 1893 4.75 16.80 5.59 18.08 1894 4.68 16.79 5.46 18.06 1895 4.37 15.85 5.20 17.42 In previous annual reports tables are published showing the number of minors married in each of the registration districts of London in the years 1885-95. The following table gives similar information for the year 1896— Marriages of minors in London, 1896. Registration districts. Men. Women. Registration districts. Men. Women. Paddington 29 119 Bethnal.green 145 362 Kensington 79 221 Whitechapel 23 78 Fulham 72 264 St. George.in.the.East 20 48 Chelsea 30 108 Stepney 29 92 St. George, Hanover.square 17 122 Mile.end Old.town 133 348 Westminister 14 57 Poplar 90 329 Marylebone 60 169 St. Saviour, Southwark 308 748 Hampstead 12 38 St. Olave, Southwark 76 220 St. Pancras 98 315 Lambeth 65 318 Islington 114 405 Wandsworth 95 342 Hackney 61 251 Camber well 58 248 St. Giles 16 49 Greenwich 30 180 Strand 11 39 Lewisham 9 68 Holborn 101 327 Woolwich 46 193 London, City 17 83 London 1,951 6,406 Shoreditch 93 265 Births. The number of births registered in the Administrative County of London in 1896 was 136,223 giving an annual birth rate of 30.2 per 1,000 persons living. The birth rate since 1870 has been as follows— 1871 34.5 1878 35.5 1885 33.4 1191 31.8 1872 35.6 1879 35.5 1886 33.4 1892 30.9 1873 35.3 1880 35.3 1887 32.9 1893 31.0 1874 35.6 1881 34.7 1888 32.1 1894 30.1 1875 35.4 1882 34.5 1889 31.9 1895 30.6 1876 35.9 1883 34.5 1890 30.7 1896 30.2 1877 35.6 1884 34.3 The corresponding figures for England and Wales are as follows— 1871 35.0 1878 35.6 1884 33.6 1890 30.2 1872 35.6 1879 34.7 1885 32.9 1891 31.4 1873 35.4 1880 34.2 1886 32.8 1892 30.5 1874 36.0 1881 33.9 1887 31.9 1893 30.8 1875 35.4 1882 33.8 1888 31.2 1894 29.6 1876 36.3 1883 33.5 1889 31.1 1895 30.4 1877 36.0 The accompanying diagram (II.) shows the London birth rate in each year in relation to the mean of the period 1851-96. The birth rate in each of the London sanitary districts in 1896 is shown in the following table— During the year the eastern group of districts had the highest birth rate (37.0), the western the lowest (24.8), the southern, central and northern groups having birth rates intermediate between these two groups (31.2, 314 and 28 5 respectively). The district having the highest birth rate was St. Luke (46*7) and the district having the lowest was St. Martin.in.the.Fields (16.2). Diagram, III. Deaths {All Causes } 7 Sanitary District. Births. Birth rate per 1,000 living. Births per 100 females aged 15.46. Paddington 3,068 24.2 7.29 Kensington 3,719 21.4 6.06 Hammersmith 3,007 28.3 10.48 Fulham 4,068 34.8 13.34 Chelsea 2,651 26.9 9.99 St. George, Hanover.square 1,407 17.3 4.95 Westminster 1,223 22.5 8.46 St. James 496 21.3 7.34 Marylebone 4,416 30.8 9.85 Hampstead 1,462 19.0 5.21 Pancras 7,040 28.7 11.12 Islington 9,924 28.9 10.97 Stoke Newington 841 24.6 8.12 Hackney 6,435 29.6 11.12 St. Giles 1,064 27.4 9.70 St. Martin.in.the.Fields 214 16.2 5.56 Strand 570 23.5 8.59 Holborn 883 28.1 11.13 Clerkenwell 2,223 33.7 13.59 St. Luke 1,968 46.7 19.28 London, City of 546 17.1 6.46 Shoreditch 4.387 35.9 14.88 Bethnal.green 4,869 37.8 16.04 Whitechapel 3,241 41.6 17.28 St. George.in.the.East 2,098 44.5 19.05 Limehouse 2,042 35.2 15.40 Mile.end Old.town 4,300 39.0 16.01 Poplar 6,011 35.7 15.92 St. Saviour, Southwark 790 30.9 13.87 St. George, Southwark 2,213 36.9 15.19 Newington 4,276 35.7 14.72 St. Olave 419 35.4 15.04 Bermondsey 3,203 37.6 16.33 Rotherhithe 1,346 33.6 15.36 Lambeth 9,579 32.9 12.25 Battersea 5,358 33.0 13.36 Wandsworth 4,825 26.5 8.61 Camberwell 7,662 30.7 11.87 Greenwich 5,723 33.0 13.33 Lewisbam 2,557 23.9 8.13 Woolwich 1,288 31.3 15.25 Lee 861 22.6 7.15 Plumstead 1,950 33.6 14.36 London 136.223 30.2 11.42 Deaths. The number of deaths registered in the administrative county of London in 1896 was 81,963, giving an annual death rate of 18*1 per 1,000 living. Since the year 1870 the London death rate has been as follows— 1871 24.6 1878 231 1885 20.4 1892 20.31 1872 21.5 1879 22.6 1886 20.6 1893 21.01 1873 22.4 1880 21.7 1887 20.3 1894 17.41 1874 22.4 1881 21.3 1888 19.3 1895 19.51 1875 23.6 1882 21.5 1889 18.4 1896 18.11 1876 21.9 1883 20.8 1890 21.4 1877 21.6 1884 20.9 1891 21.01 The death rate since 1840 in relation to the mean of the period 1841.96 is shown in Diagram III. The following table has been prepared for the purpose of comparing the death rate of the registration county of London with that of other English towns having populations which exceeded 200,000 persons at the census of 1891. The columns showing "death rates corrected for age and sex distribution " have been obtained by multiplying the crude death rates by the "factor for correction" published by the Registrar.General in the Annual Summary for 1896. • Lying.in hospitals are situaTed in these districts. 1 These death rates are fully corrected for institutions, i.e., by th« exclusions 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. 8 All causes. Towns. Estimated population middle of 1896. Crude death rate per 1,000 liying. Death rate per 1,000 living (corrected for age and sex distribution). 1886.95. 1896. 1886.95. 1896. London 4,421,955 20.1 18.62 21.4 19.8 Manchester 529,561 25.6 22.6 29.0 25.6 Liverpool 632,512 26.0 22.7 28.5 24.9 Birmingham 501,241 20.7 20.8 22.9 23.0 Leeds 402,449 21.2 18.8 235 20.8 Sheffield 347,278 21.6 19.3 24.0 21.5 West Ham 261,297 18.3 16.1 19.7 17.4 Bristol 230,623 19.2 16.9 20.1 17.7 Nottingham 229,775 19.4 17.5 20.9 18.8 Bradford 228,809 20.3 16.5 23.2 18.9 Hull 220,844 20.1 18.9 21.1 19.9 Salford 210,707 24.9 22.6 28.0 25.4 London had, therefore, (comparing the corrected death.rates) in 1896 a lower death rate than that of any of these towns except West 11am, Bristol, Nottingham and Bradford, and in the period 1886.95, a lower death rate than any except West Ham, Bristol, Nottingham and Hull. The following table enables comparison to be made of the death rate of London with those of several foreign cities—* All causes.—Death rates per 1,000 living. Towns. 1886.95. 1896. Towns. 1886.95. 1896. London 201 18'62 St. Petersburg 29.6 30.9 Paris ... 22.5 190 Berlin... 210 179 Brussels 207 182 Vienna 24.2 22 3 Amsterdam ... 20.8 17.4 Rome ... 23.3 191 Copenhagen ... 211 16.8 New York 24.6 214 Stockholm 198 16.8 It will be seen that whereas the death rate in London in 1886.95 was lower than any of these cities except Stockholm, in 1896 it exceeded the death rates of Brussels, Amsterdam, Copenhagen Stockholm and Berlin. The following table shows the crude death rates and the death rates corrected for differences in the age and sex constitution of the populations, obtaining in each of the sanitary districts of London for the year 1896, and the period 1886.95— Crude and corrected death rates3 per 1,000 persons living in sanitary districts of London. Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Crude death rate, 1886.95. Corrected death rate, 1886.95. Comparative mortality figure, 1886.95. (London 1,000.) Crude death rate, 1896. Corrected .death rate, 1896. Comparative mortality figure, 1896. (London 1,000.) England and Wales 19.15 London 17.96 106626 19.7 210 1000 18 l1 193 1000 Battersea 17.80 1.07584 — — — 17.7 19.0 984 Bermondsey 18.10 1.05801 22.4 23.7 1,129 21.6 22.9 1,187 Bethnal-green 18.89 1.04188 23.1 24.1 1,148 22.1 23.0 1,192 Camberwell 18.10 1.05801 18.4 19.5 929 17.8 18.8 974 Chelsea 17.95 1.06685 20.8 21.7 1,083 18.8 20.1 1,041 Clerkenwell 17.28 1.10822 28.0 25.5 1,214 20.7 22.9 1,187 Fulham 18.27 1.04817 — — 17.6 18.4 958 Greenwich 18.63 1.02791 19.3 19.8 948 18.5 19.0 984 Hackney 18.30 1.04645 — — 15.7 16.4 850 Hammersmith 18.05 106094 — — 17.2 18.2 948 Hampstead 16.63 1.15158 12.4 14.3 681 11.9 18.7 710 Holborn 17.62 1.08688 25.5 27.7 1,819 23.4 25.4 1,816 Islington 17.90 1.06988 180 19.8 919 17.1 18.8 948 Kensington 17.88 1.10184 17.0 18.7 890 16.8 18.5 959 Lambeth 18.24 1.04989 19.5 20.5 976 16.9 17.7 917 1 See footnote (1), page 7. 2 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals, and Lunatic Asylums situated outside Registration London, but excluding deaths of persons not belonging to London occurring in the Highgate Smallpox Hospital, in the London Fever Hospital, in the Middlesex County Lunatic Asylum at Wandsworth, and in the Metropolitan Asylums Boards Hospitals within Registration London. 3 All death rates in this report relating to London Sanitary Districts are fully corrected for institutions. (See footnote (1), page 7) * All death.rates in this report relating to foreign cities are calculated upon figures published by the Registrar.General. 9 Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Crude death rate, 1886.95. Corrected death rate, 1886.96. Comparative mortality figure, 1886.95. (London 1,000.) Crude death rate, 1896. Corrected death rate, 1896. Comparative mortality figure, 1896. (London 1,000.) Lee 17.67 1.08376 - - - 13.4 14.5 751 Lewisham 17.92 1.06864 14.4 15.4 733 13.6 14.5 751 Limehouse 17.59 1.08869 25.7 28.0 1,333 22.9 24.9 1,290 City of London 16.65 1.15015 22.4 25.8 1,229 19.6 22.5 1,166 Mile.end Old.town 18.58 1.03068 21.4 22.1 1,052 19.9 20.5 1,062 Newington 18.32 1.04531 22.5 23.5 1,119 20.5 21.4 1,109 Paddington 17.72 1.08070 16.7 18.0 857 15.3 16.5 855 Plumstead 19.09 1.00314 — — — 15.4 15.4 798 Poplar 18.49 1.03569 21.2 22.0 1,048 20.6 21.3 1,104 Rotherhithe 18.49 1.03569 21.5 22.3 1,062 20.3 21.0 1,088 St. George, Hanover.square 17.34 1.10438 16.4 18.1 862 13.6 15.0 777 St. George.in.the.East 18.43 1.03907 28.8 29.9 1,424 24.5 25.5 1,821 St. George, Southwark 17.35 1.10375 25.8 28.5 1,357 24.0 26.5 1,373 St. Giles 17.27 1.10886 23.6 26.2 1,218 19.0 21.1 1,093 St. James 17.16 1.11597 18.8 21.0 1,000 17.0 19.0 984 St. Luke 17.72 1.08070 27.1 29.3 1,395 25.1 27.1 1,404 St. Martin.in.the.Fields 15.74 1.21665 21.0 25.5 1,214 16.2 19.7 1,021 St. Marylebone 17.82 1.07464 20.9 22.5 1,071 19.9 21.4 1,109 St. Olave 18.42 1.03963 24.4 25.4 1,210 22.0 22.9 1,187 St. Pancras 17.89 1 07043 20.4 21.8 1,038 18.1 19.4 1,005 St. Saviour 18.29 1.04702 25.6 26.8 1,276 22.8 23.9 1,238 Shoreditch 18.45 1.03794 23.1 24.0 1,143 21.4 22.2 1,150 Stoke Newington 17.85 1.07283 — — — 12.7 13.6 705 Strand 16.24 1.17919 25.4 300 1,429 22.7 26.8 1,389 Wandsworth 17.93 1.06804 — — — 14.3 15.3 793 Westminster 16.94 1.13046 22.0 24.9 1,186 18.0 20.3 1,052 Whitechapel 17.74 1.07948 23.1 24.9 1,186 20.6 22.2 1,150 Woolwich 16.99 1.12713 20.4 23.0 1,095 20.5 23.1 1,197 The death rates of Battersea, Wandsworth, Hammersmith. Fulham, Stoke Newington, Hackney, Lee, and Plumstead cannot be given for the period 1886.95, as during some portion of this period Battersea was combined with Wandsworth, Hammersmith with Fulham, Stoke Newington with Hackney, and Lee with Plumstead; the death rates of the combined areas for this period, however, are shown in the following table— Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Crude death rate, 1886.95. Corrected death rate, 1886.95. Comparative mortality figure, 1886.95. [London 1,000.] Wandsworth (combined with Battersea) 17.86 1.07223 16.4 17.6 838 Fulham (combined with Hammersmith) 18.15 1.05510 19.2 20.3 967 Hackney (combined with Stoke Newington) 18.23 1.05047 17.2 18.1 862 Plumstead ("combined with Lee") 18.51 1.03458 15.1 15.6 743 All the Eastern and the Central districts had, therefore, in the year 1896, corrected death rates above the average of London; St. Luke had the highest death rate in London (27.1), and Stoke Newington the lowest (13.6). London mortality in the six years 1891.6 compared with the decennium 1881.90. The following table shows the mean death rates obtaining in London at the several age periods, and for each sex in the decennium 1881.90, and the six years 1891.96— Age period. Males. Females. Mean death rate 1881.90. Mean death rate 1891-96. Differences per cent. Mean death rate 1881.80. Mean death rate 1891.96. Difference per cent. 0— 73.09 71.31 — 2.4 63.26 61.39 — 3.0 5— 5.93 5.30 —10.6 5.82 5.50 — 5.5 10— 2.92 2.58 —11.6 2.89 2.60 —10.0 15— 4.05 3.73 — 7.9 3.58 3.17 —11.5 20— 5.44 4.92 — 9.6 4.40 3.81 —13.4 25— 8.65 7.81 — 9.7 6.82 6.08 —10.9 35— 14.96 14.56 — 2.7 11.42 11.11 — 2.7 45— 23.87 23.75 — 0.5 17.23 17.09 — 0.8 55— 41.33 41.93 + 1.5 30.77 31.40 + 2.0 65— 77.97 77.73 — 0.3 63.28 62.89 — 0.6 75— 155.93 154.67 — 0.8 134.28 135.09 + 0.6 85 and upwards 297.63 279.18 — 6.2 264.77 259.04 — 2.2 All acres. 22.10 21.18 — 4.2 18.83 18.16 — 3.6 [2] 10 In previous annual reports it has been shown that a more accurate estimate of the effect on the community of fluctuations of mortality could be obtained by the use of a " life table " and the following figures, calculated from the Ex and Qx columns of the life table for London, 1881-90,* were utilized for this purpose— Table I. Mean future lifetime of males and females in groups of ages (calculated from London life tables, 1881-90.) Age groups. Males. Females. Age groups. Males. Females. Tears. Years. Years. Years. 0— 4906 52.69 35— 24.19 27.24 5— 4894 52.68 45— 18.15 20.57 10— 45-05 48.80 55— 12.95 14.56 15— 40-79 44.55 65— 8.89 9.78 20— 36-70 40.39 75— 6.35 6.74 25— 3104 34.51 85 and upwards 2.75 2.85 By comparing the mean deaths occurring at each age-period in 1891-6 with the deaths which would have occurred at these age-periods if the death-rates of 1881-90 had still been maintained, the difference between the two sets of figures will be the number of lives gained or lost at each age-period by fluctuations of mortality, and by applying to these differences the figures in the preceding table the actual gain or loss may be expressed in " life capital." The result of this process is shown in the following table— Table II. Age groups. Deaths calculated according to mean rates 1881-90. Mean deaths occurring in the six years 1891-6. Mean annual gain (+) or loss (—) of lives in the six years 1891-6 by fluctuations of mortality. Mean annual gain (+) or Ions (—) oflife capital "in the Fix years 1891-6 by fluctuat ions of mortality. Males. 0— 18,695 18,239 + 456 +22,371 5— 1,374 1,229 + 145 + 7,096 10— 618 546 + 72 + 3,244 15— 820 756 + 64 + 2,611 20— 1,083 980 + 103 + 3,780 25— 2,961 2,673 + 288 + 8,940 35— 3,779 3,678 + 101 + 2,443 45— 4,240 4,218 + 22 + 399 55— 4,189 4,249 — 60 — 777 65— 4,032 4,020 + 12 + 107 75— 2,251 2,233 + 18 + 114 85 and upwards 461 432 + 29 + 80 All ages 44,503 43,253 + 1,250 +50,408 Females. 0— 16,376 15,891 + 485 +25,555 5— 1,363 1,289 + 74 + 3,898 10— 623 561 + 62 + 3,026 15— 806 714 + 92 + 4,099 20— 1,058 917 + 141 + 5,695 25— 2,686 2,395 + 291 + 10,042 35— 3,203 3,116 + 87 + 2,370 45— 3,455 3,426 + 29 + 597 55— 3,876 3,955 — 79 — 1,150 65— 4,695 4,666 + 29 + 284 75— 3,458 3,479 — 21 — 142 85 and upwards 982 961 + 21 + 60 All ages 42,581 41,370 + 1,211 +54,334 Total 87,084 84,623 + 2,46] + 104,742 * See Annual Report of the Medical Officer of Health, 1893, pp. 10. 11 This table shows, therefore, that during the period 1891-6 as compared with the decennium 1881-90 there has been a mean annual saving of 2,461 lives, and that this represents 104,742 years of " life capital," annually saved to the community. In previous annual reports I have similarly dealt with the mortality figures of the periods 1891-4 and 1891-5, and it is interesting to compare the results obtained for the three periods, viz.— Periods compared with 1881-90. Mean annual number of lives gained. Mean annual amount of "life capital" gained. Proportion of "life capital" gained to each life gained. years. years. 1891-4 1,042 79,606 76.4 1891-5 1,304 85,519 656 1891-6 2,461 104,742 42.6 It will thus be seen that the mean annual number of lives saved has increased in each of the three periods, while the amount of "life capital," in proportion to the number of lives saved, has decreased, this decrease being particularly marked in the period 1891-6. The latter result is of course due to fluctuations in the mortality from certain diseases affecting particular ages, and it is of interest, as an example, to note the fluctuations in the death rates of diarrhoea and influenza in this connection. The following table shows the mean annual death rates from diarrhoea and influenza in London in the period 1891-4, and the years 1895 and 1896. Period. Death rate per 1,000 living. Diarrhoea. Influenza. 1891-4 0.60 0.40 1895 0.82 0.49 1896 07.1 0.11 Thus, in the period 1891-5, the proportionate decrease shown in the saving of "life capital," compared with the period 1891-4, may be explained by the reduction in the saving of life at ages 0-5 on account of the high diarrhceal death rate of 1895, while, on the other hand, the increased death rate in 1895 from influenza, affecting mostly older ages, would tend to neutralize the effect of the high diarrhoeal death rate on the proportionate saving of "life capital." In the period 1891-6, however, the high diarrhoeal death rate and the low influenza death rate of 1896 would each tend to reduce the proportionate saving of " life capital," and to this fact is doubtless in large measure due the greater decrease in the proportionate saving of "life capital" in the period 1891-6, as compared with the decrease in the period 1891-5. Infant mortality. The deaths of children under one year of age in the administrative county of London during 1896 numbered 21,740, being in the proportion of 160 per 1,000 births. The infant mortality in London may be compared with that in other English towns having more than 200,000 inhabitants by reference to the following table— Deaths under one year of age per 1,000 births. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London 155 1611 West Ham 153 165 Manchester 185 176 Bristol 145 142 Liverpool 189 173 Nottingham 171 168 Birmirgham 174 197 Bradford 173 143 Leeds 177 169 Hull 170 173 Sheffield 178 173 Salford 195 199 London had therefore, in 1886-95, a lower infant mortality than any of these towns except West Ham and Bristol, and in 1896 a lower infant mortality than any except Bristol. 1 See footnote (2), page 8. 12 The infant mortality in 1896 and in the period 1886-95 in the several London sanitary districts was as follows— Sanitary district. Deaths under 1 year of age, 1896. Deaths under one year of age per 1,000 births. 1886-95. 1896. Paddington 479 144 156 Kensington 661 163 178 Hammersmith 537 160 179 Fulham 710 167 175 Chelsea 446 155 168 St. George, Hanover-square 209 139 149 Westminster 208 167 170 St. James 74 162 149 Marylebone 624 140 141 Hampstead 180 117 123 Pancras 1,182 159 168 Islington 1,489 147 150 Stoke Newington 106 138 126 Hackney 937 146 St. Giles 156 152 147 St. Martin-in-the-Fields 35 199 164 Strand 110 202 193 Holborn 171 205 194 Clerkenwell 408 173 184 St. Luke 303 150 154 London, City of 75 153 137 Shoreditch 791 174 180 Bethnal-green 826 161 170 Whitechapel 456 164 141 St. George-in-the-East 323 193 154 Limehouse 360 189 176 Mile-end Old-town 677 151 157 Poplar 1,057 155 176 St. Saviour, Southwark 168 183 213 St. George, Southwark 401 188 181 Newington 788 170 184 St. Olave 64 175 153 Bermondsey 513 158 160 Rotherhithe 214 159 159 Lambeth 1,303 145 136 Battersea 948 158 177 Wandsworth 723 130 150 Camberwell 1,193 151 156 Greenwich 897 148 157 Lewisham 336 136 131 Woolwich 221 154 172 Lee 121 117 141 Plumstead 260 133 London 21,740 155 1601 The western group of districts had the highest infant mortality (169), the northern the lowest (150), the infant mortality of the central and eastern groups being nearly equal to that of the western (168 and 167 respectively). Of the districts, St. Saviour, Southwark, had the highest infant mortality (213), and Hampstead the lowest (123). Deaths from several classes of disease. The deaths from the several classes of disease registered in the registration county of Londor (including the lunatic asylums and hospitals for infectious disease belonging to the county) are giver by the Registrar-General in the Annual Summary of Births, Deaths and Causes of Death, and the following table has been prepared from the figures contained in the summary relating to the year 1896— 1 See footnote (1), page 7. 13 Corrected annual average 1886-95. 1896. Zymotic diseases 14,756 15,751 Parasitic „ 90 41 Dietetic „ 529 602 Constitutional diseases 17,334 16,517 Developmental „ 5,633 5,496 Nervous „ 9,823 8,475 Diseases of organs of special sense 150 190 Circulatory diseases 7,188 6,881 Respiratory „ 19,695 14,664 Diseases of the Digestive system, 4,950 5,238 Lymphatic „ 118 119 Urinary 2,314 2,277 „ „ Generative „ 547 560 „ „ Locomotive ,, 359 256 ,, „ Integumentary system 308 286 Violence (accident) 2,828 2,936 Violence (other than accident) 527 503 Other causes 3,216 2,719 All Causes 90,365 83,511 Principal Zymotic Diseases. The number of deaths in the administrative county of London from the principal zymotic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping cough, typhus, enteric and illdefined fevers, and diarrhoea during 1896 was 14,028 giving an annual death rate of 3.11 per 1,000 living compared with 2.62 in 1895, 265 in 1894, 3.04 in 1893, 2.80 in 1892 and 2.27 in 1891. It will be seen from the following table that London, in the period 1886-95, had a higher death rate from the principal zymotic diseases than any of the undermentioned towns except Manchester, Liverpool, Birmingham, Leeds, Sheffield, Salford and West Ham, and in 1895 a higher death rate than any except Manchester, Birmingham, Hull and Salford. Principal zymotic diseases—Death rates per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896.[/##] London 2.72 3.142 Bristol 2.02 1.90 Manchester 3.46 3.42 Nottingham 2.46 2.47 Liverpool 3.57 3.01 Bradford 2.46 1.58 Birmingham 2.73 3.57 Hull 2.57 3.32 Leeds 2.83 2.28 Salford 4.42 4.10 Sheffield 3.27 2.91 West Ham 3.03 3.00 The following table shows that the London death rate from the first six of these principal zymotic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping cough, and fever was in 1886-95 higher than that of Paris, Brussels, Amsterdam, Berlin and Vienna, and in 1896 was only exceeded by that of St. Petersburg. Six principal zymotic diseases—Death-rates per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London 2.02 2.423 St. Petersburg 3.08 4.32 Paris 1.69 0.73 Berlin 1.65 1.04 Brussels 1.08 0.92 Vienna 1.81 1.45 Amsterdam 1.26 1.10 Rome 2.10 1.10 Copenhagen 2.11 0.81 New York 2.42 1.75 Stockholm 2.36 1.09 2 See footnote (2), page 8. 14 The death-rates from the principal zymotic diseases in the several sanitary districts of London in 1896 and the period 1886-95 are shown in the following table— Sanitary district. Deaths in 1896. Death rate per 1,000 living. Sanitary district. Deaths in 1896. Death rate per 1,0(10 living. 1886-95. 1896. 1886—95. 1896. Paddington 320 2.01 2.52 Shoreditch 536 3.65 4.31 Kensington 459 2.05 2.65 Bethnal-green 557 3.74 4.25 Hammersmith 298 3.11 2.80 Whitechapel 210 3.01 2.62 Fulham 419 3.59 St. George-in-the-East 158 4.55 3.26 Chelsea 388 2.79 3.94 Limehouse0 236 4.18 3.99 St. George, Hanoversquare 112 1.65 1.39 Mile-end Old-town 409 3.41 3.61 Poplar 637 3.21 3.70 Westminster 117 2.53 2.15 St. Saviour, Southwark 83 3.24 3.23 St. James 52 1.01 2.24 St. George, Southwark 260 3.69 4.24 Marylebone 453 2.16 3.16 Newington 410 3.17 3.35 Hampstead 141 1.31 1.83 St. Olave 57 2.93 4.81 Pancras 608 2.66 2.47 Bermondsey 328 3.17 3.78 Islingtou 1,043 2.52 3.04 Rotherhithe 157 3.10 3.82 Stoke Newington 80 2.47 2.35 Lambeth 729 2.64 2.42 Hackney 612 2.81 Battersea 614 2.47 3.64 St. Giles 89 2.49 2.29 Wandsworth 520 2.71 St. Martin - in - the Fields 30 1.97 2.28 Camberwell 928 2.62 3.59 Greenwich 666 2.74 3.72 Strand 59 2.45 2.44 Lewisham 237 1.60 2.22 Holborn 101 2.95 3.21 Woolwich 165 2.07 3.92 Clerkenwell 255 3.51 3.78 Lee 74 1.98 1.88 St. Luke 161 3.79 3.82 Plumstead 214 3.54 London, City of 46 1.44 1.44 London 14,028 2.71 3.111 The Eastern group of districts had the highest zymotic mortality (3.77); the western and northern groups the lowest (2.77 each). The district of St. Olave had the highest (4.81), and St. George, Hanover-square, the lowest (1.39). Smallpox and Vaccination. The deaths from smallpox in the administrative county of London numbered nine in 1896, and seven deaths were attributed to cowpox and vaccination. The death rates from smallpox in successive periods have been as follows— Period. Smallpox death rate per 1,000 living. Period. Smallpox death rate per 1,000 living. 1851-60 0.28 1892 0.0071 1861-70 0.28 1893 0.0401 1871-80 0.46 1894 0.0201 1881-90 0.14 1895 0.0121 1891 i 1896 0.0021 The death rate in each year in relation to the mean death rate of the period 1841-96 is shown in diagram IV. During the complete years in which the notification of infectious diseases has been obligatory the number of cases of smallpox notified to the medical officers of health in the administrative county has been as follows— Year. Cases notified. Case rate per 1,000 living. 1890 60 0.014 1891 114 0.027 1892 425 0.100 1893 2,815 0.653 1894 1,193 0.274 1895 980 0.223 1896 225 0.050 If the London smallpox death rate be compared with the death rates of the following large English towns, it will be seen that in the period 1886-95, the London death rate was exceeded by the death rates of all except Leeds, Nottingham and Salford, while in 1896 the London rate was only exceeded by the rates of West Ham and Bristol. 1 See footnote (1) page 7. 15 Smallpox—Death rate per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London .01 .002 West Ham .05 .02 Manchester .02 — Bristol .04 .02 Liverpool .02 — Nottingham .01 — Birmingham .05 — Bradford .07 .00 Leeds .01 .00 Hull .02 — Sheffield .23 — Salford .01 — If the London smallpox death rate be compared with the rates of the following foreign cities it will be seen that in the period 1886-95 the London rate was exceeded by all these cities except Amsterdam, Copenhagen, Stockholm and Berlin and in 1896 by that of St. Petersburg only. Smallpox—Death rates per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London .01 .002 St. Petersburg .13 .15 Paris .07 .00 Berlin .00 .00 Brussels .11 .00 Vienna .08 .00 Amsterdam .00 .00 Rome .26 .00 Copenhagen .00 .00 New York .03 .00 Stockholm .00 .00 The cases notified in the administrative county were distributed throughout the year as follows— No. of week. Week ending No. of cases notified. No. of week. Week ending No. of cases notified. No. of week. Weekending No. of cases notified. 1 4 January 5 19 9 May 2 37 12 September 3 2 11 „ 11 20 16 „ 3 38 19 „ — 3 18 „ 12 21 23 „ 4 39 26 „ 1 4 25 „ 8 22 30 „ 3 40 3 October — 5 1 February 14 23 6 June 6 41 10 „ 1 6 8 „ 4 24 13 „ 2 42 17 „ — 7 15 „ 9 25 20 „ 25 43 24 „ — 8 22 „ 8 26 27 „ 8 44 31 „ 1 9 29 „ 1 27 4 July 12 45 7 November 10 7 March 9 28 11 „ 11 46 14 „ 11 14 „ 3 29 18 „ — 47 21 „ 12 21 „ 6 30 25 „ 4 48 28 „ 13 28 „ 4 31 1 August 4 49 5 December 1 14 4 April 2 32 8 „ 3 50 12 „ 1 15 11 „ 3 33 15 „ 3 51 19 „ 16 18 „ 4 34 22 „ 3 52 26 „ 17 25 „ 9 35 29 „ 6 53 2 January 1 18 2 May 4 36 5 September 1 The following table shows the number of cases notified in successive periods of four weeks in each of the several sanitary districts— 2 See footnote (2) page 8. The following table shows the number of cases of and deaths from smallpox belonging to each district in 1896, the case rate of each district in the period 1891.5 and in 1896, and the death.rate of each district in the period 1886.95 and in 1896. Sanitary district. Cases, 1896. Case rate per 1,000 living. Deaths, 1895. Death rate per 1,000 living. 1891.5. 1896. 1886.95. 1896. Paddington 4 .18 .03 1 .008 .008 Kensington 13 .16 .07 . .007 . Hammersmith 3 .07 .03 . .006 . Falham 2 .15 .02 . . Chelsea 2 .14 .02 . .003 . St. George, Hanover.square 1 .10 .01 . .006 . Westminster 2 .20 .04 . . . St. James 3 .51 .13 . .008 . Marylebone 4 .85 .03 . .032 . Hampstead . .10 . . .008 . Pancras 6 .23 .02 . .010 . Islington 51 .17 .15 1 .004 .003 Stoke Newington 2 .12 .06 . .004 . Hackney 8 .04 . . 16 Sanitary district. Four weeks ended Five weeks ended Jan. 2, 1897. Jan. 25. Feb. 22. Mar. 21. Apr. 18. May 16. June 13. July 11. Aug. 8. Sept. 5. Oct. 3. Oct. 31. Nov. 28. Paddington 1 1 1 1 Kensington 4 5 1 1 Hammersmith 2 1 Fulham 2 Chelsea 1 1 St. George, Hanover.square 1 Westminster 1 1 St. James 2 1 Marylebone 1 1 1 1 Hampstead Pancras 3 2 1 Islington 2 3 7 1 3 22 5 6 2 Stoke Newington 1 1 Hackney 3 1 1 1 1 1 St. Giles St. Martin.in.the.Fields 1 Strand Holborn 1 Clerkenwell 2 1 2 St. Luke 2 London, City of 1 1 Shoreditch 1 Bethnal .green 2 Whitechapel 2 2 St. George.in.the.East 1 1 Limehouse 1 6 Mile.end Old.town 1 1 1 Poplar 6 1 2 St. Saviour, Southwark 1 2 St. George, Southwark 1 1 Newington 1 1 1 St. Olave Bermondsey 2 2 Rotherhithe 1 4 Lambeth 4 4 4 4 2 Battersea 1 2 4 Wandsworth 1 Camberwell 1 1 1 1 8 1 Greenwich 3 8 1 1 1 Lewisham 1 Woolwich 1 Lee 1 Plumstead 1 2 1 Port of London 1 2 1 1 Total 36 35 19 13 18 15 56 11 13 4 2 3 17 Sanitary district. Cases, 1896. Case rate per 1,000 living. Deaths, 1895. Death rate per 1,000 living. 1891.5. 1896. 1886.95. 1896. St. Giles _ .52 _ _ .020 _ St. Martin.in.the.Fields 1 .21 .08 _ .020 _ Strand _ .40 _ _ .015 _ Holborn 1 .45 .03 1 .003 .032 Clerkenwell 5 .12 .07 _ .002 _ St. Luke 2 .21 .05 _ .014 _ London, City of 2 .23 06 _ .010 _ Shoreditch 1 .26 .01 1 .009 .008 Bethnal.green 2 .46 .02 _ .018 _ Whitecliapel 4 .62 .05 _ .012 _ St. George.in.the.East 2 .36 .04 _ .006 _ Limehouse 7 .41 .12 _ .017 _ Mile.end Old.town 2 .42 .02 _ .015 _ Poplar 9 .44 .05 _ .015 _ St. Saviour, Southwark 4 .18 .02 _ _ _ St. George, Southwark 3 .46 .05 _ .015 _ Newington 3 .17 .02 1 .010 .008 St. Olave _ .21 _ _ .016 _ Bermondsey 4 .19 .05 _ .006 _ Rotherhithe 5 .77 .12 _ .038 _ Lambeth 18 .15 .06 2 .005 .007 Battersea 8 .20 .05 _ .007 _ Wandsworth 2 .07 .01 _ _ Camberwell 13 .22 .05 _ .011 _ Greenwich 14 .34 .08 2 .015 .011 Lewisham 1 .09 .01 _ .006 _ Woolwich 1 .38 .02 _ .012 _ Lee 1 .28 .03 _ .016 _ Plumstead 4 .07 _ _ Port of London 5 _ _ _ _ _ London 225 26 .05 9 .010 002* The reports of the medical officers of health supply the following more detailed information as to cases of smallpox occurring in 1896. Kensington..The report of the medical officer of health contains the following statement. As already stated, thirteen cases of the disease were notified during the year; four of these cases were recorded in January. The first case was that of a married woman, whose illness began three weeks after her confinement, she not having been out of the house since that event. How the infection was conveyed to her remains a mystery. Her baby subsequently fell ill of the disease, having been infected by the mother. The other cases were a mother and an adult son, who fell ill almost simultaneously; the common source of infection was not discovered. In the fourth report a group of five cases was recorded, which, as illustrative of a common mode of the spread of this highly infectious disease, is deserving of notice. The first case was that of a tinker, named Christopher C., aged 17, an inmate of a common lodging.house in the Potteries district, Notting.dale, who was removed to hospital on the 24th March from the West London Hospital, at which he had applied for medical treatment. He was stated to have been ill since the 19th March, having been tramping about the country with a brother both before and after that date. During the first week in March he had spent some time at a lodging.house at Little. hampton, the landlady of which was removed to hospital whilst he was there, suffering, as alleged, from smallpox. From her it is supposed that he contracted the disease. The men tramped thence to Worthing, putting up for a few nights at a lodging.house, whence, it is said, a man was removed to hospital suffering from smallpox during their stay. This man had previously been at Littlehampton. The brothers next moved to Shoreham, where C. C. fell sick. Thence they walked to Brighton, and on 21st March they came to London by train, going to the common lodging.house referred to above. The second case was that of a boy, Walter M., aged two years. He lived at a little house, practically within the curtilage of the common lodging.house, where he came in contact with C. C., and in due time he fell ill with smallpox. He was removed to hospital on April 7th. This boy's father, at some date not exactly fixed, but after the child fell ill, left town on the tramp. His wife, Jane M., aged 23, fell ill on the 19th April, and was removed to hospital on the 21st. The fourth case was that of Annie H., aged 23, wife of the keeper of the common lodging.hguse. She fell ill about the same time, and was also removed on the 21st. The last case was that of Walter M., aged 31, who, having gone from London after his boy's illness developed, returned home on April 23rd, having fallen ill on the 21st. He was removed to hospital on the 24th. It was stated that this man had stayed at Kingston on the 16th April, at Horsham on the 17th, at Worthing on the 18th, at Shoreham on the 19th, at Brighton on the 20th, at Eastbourne (where he was alleged to have fallen ill) on the 21st, and at Lewes on the 22nd. From the latter town he came home by train, as stated, on the 23rd. I need hardly say that all necessary steps were taken for preventing the spread of the disease, viz., by vaccination and by closing the common lodging and the other house for disinfection, with the result that no further cases occurred. I communicated the facts of the outbreak to the medical officers of health for Littlehampton and Worthing, and for Eastbourne and Lewes, so that they might be on the look.out for cases of the disease at the due dates, but happily there were none. Hammersmith..During the year one case of smallpox occurred in this district; the sufferer * See footnote (1), page 7. [3] 18 was a commercial traveller employed in London only. A few months before a child in the same street had been certified to have smallpox, but the malady was later regarded as chickenpox. Fulham._The medical officer of health reports_ "Two cases were notified in a house in Jerdan.place. In the first case the disease was contracted in Kensington where the patient had been living up to the time of his illness. The second patient, unlike the other inmates of the house, refused to be vaccinated." Chelsea._The medical officer of health reports that the malady of the two persons who were certified to be suffering from smallpox was found later to be chickenpox. St. James, Westminster._A tabular statement in the report of the medical officer of health shows that each of the three cases occurring in this district was an adult, two of the cases residing in the same house ; all were removed to hospital. Islington._The medical officer of health reports that of the persons certified to be suffering from smallpox during the year one did not suffer from this disease. In point of time the cases were distributed as follows_12 in the first quarter, 13 in the second and 20 in the third quarter, Of this number the source of infection was unknown in 14 cases, and in 7 was stated to be uncertain, but 4 of the latter lived in houses adjoining others in which recognised smallpox occurred. Information as to 2 cases of smallpox in Keighley (Yorks), was received from the medical officer of health of that district. Both sufferers had, previous to their illness, stayed at a public.house in Hornsey.rise. The knowledge of this circumstance led to the discovery of antecedent smallpox in that neighbourhood, it having come to sanitary inspector Ward's recollection that some time previously he had seen a man standing at a door in Hornsey.rise with a sore face from which matter was oozing. He was at once sought out, and was found at work, and it was noticed that his face showed unmistakable signs of confluent smallpox. He had then completely recovered. It was further discovered that his wife had had two or three spots on her face. The man's illness had been thought to be chickenpox. No considerable extension of the disease from this case is known to have occurred. Prevalence of smallpox in Campbell.road and its vicinity led the sanitary authority to adopt special measures towards the end of June for its limitation. Dr. Leslie Thorne was therefore appointed " to make a house.to.house inspection in the streets in which smallpox had appeared, particularly in Campbell.road, in order to ascertain if any cases remained undiscovered and also to vaccinate, if permission were given, all persons who had been exposed to infection." Dr. Thorne " for weeks diligently kept watch and ward over those houses and streets in which smallpox had appeared. This action of the Public Health Committee was most prudent, and was the means of bringing to an end what might have proved a much more serious outbreak." Hackney._ The medical officer of health reports that of eight persons who were certified to be suffering from smallpox, and who were removed to hospital, two on admission were thought not to be suffering from this disease; of the remaining six, the source of infection was not known in the case of three ; two had been associated with other persons suffering from smallpox, the other was a rag.sorter and was supposed to have been infected by the rags. Holborn._One case was notified during the year, a child aged eight months, who died after 11 hours illness. An inquest was held, and the cause of death was returned as " a convulsive fit after some eruptive fever, probably smallpox." Concerning this case the medical officer of health writes " I afterwards found that another child in the same house had died three weeks previously of cerebrospinal meningitis, I think, taking this into consideration and the nature of the eruption, that the above was a case of cerebro.spinal fever." Shoreditch._One case of smallpox was dealt with during the year. A man who had been living in a common lodging.house in Limehouse removed to a common lodging.house in Shoreditch where he was taken ill the end of the year 1895. His attack of smallpox proved fatal. Whitechapel_Only two cases of smallpox occurred in Whitechapel in 1896, one of which came from Gloucester. Limehouse._Seven cases of smallpox occurred in this district during the year, one in the Home for Asiatics, three in a house in Maroon.street, the first of the three infecting the other two, one in a common lodging.house in St. Ann.street, and two in a house in Gill.street. The source of infection was only known in the second and third cases in Maroon.street. All the sufferers were adults, five had been vaccinated in infancy, the condition as to vaccination of one was unknown, and one was unvaccinated. All the patients were removed to hospital. Foplar._Eight persons in Poplar parish and one in Bow were certified during the year to be suffering from smallpox. Seven of the eight cases in Poplar were removed to hospital, two of which were returned to their homes as the diagnosis was not confirmed. The illness of the person who was not removed to hospital was eventually found not to be smallpox. The five persons retained in hospital were members of one family ; the history of this group was as follows_a mother and her son contracted the disease from visiting the daughter of the former in Canning.town, who was suffering from smallpox ; the mother infected her husband, the son infected his wife and child. The case in Bow parish was removed to hospital; the patient had been vaccinated in infancy, his wife and four children, who had also been vaccinated, escaped smallpox. Newington._Three cases of smallpox were notified in this district, one death occurred, that of an unvaccinated child. All the cases were removed to hospital. Lambeth._The report of the medical officer of health contains an interesting account of the behaviour of smallpox in houses which were invaded by this disease during the year, the condition as to vaccination of the inmates having been noted_ On December 8th, 1895, Emily F., aged 26 years, and vaccinated in infancy, was notified as suffering from smallpox, at 39, Wootton.street. and was removed to hospital next day. Her husband had been re.vaccinated, and their only child (Emily F.) aged nine months, and unvaccinated, was removed to 50, Ethelm.street, where she sickened 12 days after her mother had been removed to hospital. This child was not, however, removed to hospital (where it died) until four days after the appearance of the 19 rash, with the result that three other cases arose in the immediate neighbourhood, and, though they could not be definitely traced, it is probable that the patients contracted their disease indirectly from the child. The three cases were, Emily R., aged 27 years, vaccinated in infancy, of 30, Ethelm.street (sickened January 9th. 1896); Samuel B., aged 24 years, vaccinated in infancy, of 33, Wootton.street (sickened January 8th, 1896; Caroline R., aged 22 years, vaccinated in infancy, of 19, Wootton.street (sickened January 6th, 1896). One of the disinfecting men (William H., aged 34 years, and vaccinated in infancy), who went to 50, Ethelm.street on December 27, 1895, sickened at 2, Sail.street, with smallpox 14 days afterwards, i.e., on January 10th, 1896, ar.d was removed to hospital. In connection with this case it is satisfactory to report that all the members of the disinfecting staff have now been re.vaccinated or have had small.pox. At 50, Ethelm.street, at the time of the outbreak of smallpox, there were twelve inmates, six adults (vaccinated) and six children under 12 years of age (four vaccinated, and two who were vaccinated at once); no other case occurred. A second outbreak of smallpox occurred in Ufford.street, and is interesting as showing how easily the disease may spread, and how important it is to follow up and watch those persons who may have come in contact with it. The connection of this outbreak with the previous one could not be definitely traced, but was highly probable. The facts are as follows_A child, Lucy A., aged 7 years, and unvaccinated, died at 30, Ufford.street, on January 24th, 1896, after three days' illness, and was certified by the medical attendant as having died from " measles with congestion of the lungs and cardiac syncope." Another child (William A.), aged 10 years, and vaccinated in infancy, developed spots on January 26th, and was treated for chickenpox at home, being ill altogether about 10 day3, whilst the mother, (Sarah A.), aged 30 years, and vaccinated in infancy, also developed a few spots (principally on the face) on January 29th, and was confined of a female child on the following day. The maturation of the spots in the case of Sarah A. left no doubt as to the disease being smallpox, but unfortunately (owing to the confinement) this patient was not removed to hospital until February 19th, and the infant developed spots on February 14th, i.e., exactly 14 days after it was born and came in contact with its mother, who was suffering from smallpox at the time. The infant was unvaccinated (vaccination being refused when it was first horn), and had a severe attack of confluent small.pox at the hospital, whither it was removed on February 19th. In the upstairs rooms at 30, Ufford.street were living at the time the N. family_a man, his wife, and three children under 10 years of age. The husband and wife had been vaccinated in infancy, and two of the children had also been vaccinated. None of these sickened; but the unvaccinated child (Emily N.), who was born on February 11th, sickened on February 23rd, i.e., exactly 12 days after it was born, into a smallpox infected house. The mother was re.vaccinated at once, and did not develop the disease, and the infant was taken to the hospital and died. There was evidence to show that the two vaccinated children, aged 2 and 5 years respective^', had been in the midst of smallpox contagion_ actually in the same house_for a period of four weeks without contracting the disease, whilst during the same period two unvaccinated children caught the disease, and one died. Henry A. (aged 15 years and vaccinated in infancy) and Phoebe B. (aged 25 years and vaccinated in infancy) sickened at 31 Wake.street, with smallpox on 25th February and March 4th respectively, and on inquiry it was found that they had visited their sister.in.law (Sarah A.) at 30, Ufford.street, whilst she was suffering from smallpox". They were removed to hospital on March 3rd and 9th respectively, and their brother (Sidney A., aged 17 years, and vaccinated in infancy) sickened March 17th, and was also removed to hospital. In connection with these last cases the vestry allowed compensation to the mother for four weeks' loss of work at a jam factory, at 9s. per week. A third outbreak occurred in another part of the parish, and is equally interesting as showing how smallpox can be spread, and how important it is to examine the immediate neighbourhood for cases which may otherwise be missed, and if missed, may give rise to a large outbreak. At 51, Warrior.road (a domestic workshop) a child (Christopher A.), aged seven months and unvaccinated, developed " spots," which were treated by the medical attendant as those of severe chickenpox, with the result that the child was kept at home (being ill for about four weeks from May 20th to June 20th) in a house where articles of clothing were being made, and where three young women from the neighbourhood were working. Two of these three young women sickened with smallpox, viz._Constance J. (aged 15 years and unvaccinated), of 46, Warrior.road, on June 11th, and Daisy G. (aged 21 years and vaccinated in infancy), of 3, Warrior.road, on June 7th. A house.to.house inspection was made in the immediate neighbourhood, but no other cases were found, though many persons had to be watched during the incubation period of the disease. Battersea._Of eight cases of smallpox notified during the year, "four were not genuine cases of the disease, but of other diseases difficult to differentiate in the early stages." All the eight persons were removed to hospital. The four actual cases of small.pox were adults who had been vaccinated in infancy and all recovered. Camheru'ell._The report of the medical officer of health supplies information as to an outbreak of smallpox in Toulon.street. " The first to be attacked was an unvaccinated infant two years of age, ten days later a second case was notified from the same house, the patient this time being a boy ten years old. After this two more persons were notified, with a further notification of three fresh attacks at an interval of two days all from the same house." In addition to the house being visited, vaccination advised and the premises disinfected, inquiry was made at the schools attended by the children, with a view to obtaining information as to children who were absent through illness. A purveyor of cats'. meat who lived in the invaded house was dissuaded from going on his rounds. Greenwich,_In Greenwich parish three cases of smallpox were notified, one of which proved fatal. Of the cases notified in Deptford parish nine only were found to be actually cases of smallpox; of these four occurred in one house, two each in two houses and one in a fourth house. Woolwich._One case of smallpox was notified during the year. The sufferer was the steward of a steamship who had attended a passenger supposed to be suffering from chickenpox. He was removed to hospital. Lee._One case of smallpox occurred in Charlton parish during the year. The sufferer had visited a house in Sheerness in which resided a woman who had recently come from Gloucester " where she had been more or less in contact with some of the afflicted people." PlumsteacL._The medical officer of health called the attention of the Vestry of Plumstead to the neglect of vaccination in West Ham. He writes_ I found that whereas in Plumstead of the children born in 1894 there were only two still unvaccinated, and prosecutions had taken place in both cases, in West Ham there were 975 unvaccinated, and no prosecutions had taken place. A letter was sent to the Local Government Board pointing out this danger to Plumstead. I also advised, as on previous occasions, that handbills should be printed recommending voluntary re.vaccination in view of the serious prevalence of smallpox in several parts of 20 the country. The health committee ordered me to prepare a bill, but unfortunately it was found that the Plumstead Vestry had no power to spend money in the way recommended by the .Royal Commission. Smallpox in common lodging.houses.—During 1896, 12 cases of smallpox in common lodging. houses in London were reported to the Council's Public Health Department. One group of cases occurred in connection with a common lodging.house in Hesketh.road, Kensington, the particulars of which have already been given in the report of the medical officer of health of that district. Another group occurred in two common lodging.houses in Campbell.road, Islington, the disease being introduced into one of the houses by the children of the deputy, who had contracted it from the inmate of a furnished lodging kept by the keeper. An isolated case occurred in another common longing.house in Queensland.road, Islington, the sufferer having before his illness lived in a lodging with his sister. A second isolated case occurred in a common lodging.house in St. Ann's.street, Limehouse. The sufferer was employed as a kitchen man in this house, and was observed by the Council's inspector to have an eruption on his face, which the inspector thought resembled smallpox. Medical opinion confirmed this view. All the cases of smallpox was removed to hospital, and from the two isolated cases referred to no extension of the disease was discovered. Since 1880 the Registrar.General has classified the deaths from smallpox under the heads, viz., "vaccinated," "unvaccinated," and "no statement." The totals of the 16 years, 1881.96, are as follows— Smallpox deaths, London, 1881.96. Age period. All ages. 0.1 1.5 5.20 20.40 40.60 60.80 80 and upwards. Vaccinated 1,277 22 33 228 728 224 39 3 Unvaccinated 2,028 337 485 667 415 105 18 1 No statement 1,898 242 224 455 665 247 62 3 The following table, in which the number of deaths at each age period is expressed as a percentage of the total deaths from smallpox at "all ages," more clearly indicates the relative age incidence of this disease in the three classes under consideration— " All ages " taken as 100. Age period. All ages. 0.1 1.5 5.20 20.40 40.60 60.80 80 and upwards. Vaccinated 100 1.7 2.6 17.9 57.0 17.5 3.1 0.2 Unvaccinated 100 16.6 23.9 32.9 20.5 5.2 0.9 0.0 No statement 100 2.7 11.8 24.0 35.0 13.0 3.3 0.2 " Vaccinated" and "no statement" combined. "Vaccinated" and "Nostatement" 100 8.3 8.1 21.5 43.9 14.8 3.2 0.2 Unvaccinated 100 16.6 23.9 32.9 20.5 5.2 0.9 0.0 These tables show a marked difference in the age distribution of smallpox mortality among the vaccinated and unvaccinated. The report of the Statistical Committee of the Metropolitan Asylums Board for 1896 supplies the following figures, showing the state as to vaccination of the patients suffering from smallpox, admitted into the institutions of the Board during the year— Age period. Vaccinated. No evidence as to vaccination, f Vaccination cicatrices absent. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. 0— — — — — 4 3 1— — — — — 6 — 2— — — — — 1 — 3— — — — — 5 — 4— — — — — 4 — 5— — — — — 4 — 6 — — — — — 1 — 7— 1 — 1 — 1 1 8— 1 — — — 3 1 9— — — — — 2 1 lO. 1 — — — 3 — ll— — — — — 2 — 12— 2 — — — 6 — 13— — — — — 1 — 14— 4 — — — 2 — 15— 24 — — — 9 — 20— 23 — 3 — 5 1 25— 28 — 1 — 1 — 30— 11 — 1 — 2 — 35— 12 1 2 — — 1 40— 5 — 1 — 2 — 50 and upwards All ages 4 — 1 — — — 116 1 10 — 64 8 t Theae cases include cases stated to have been vaccinated, but bearing no visible evidence of the operation, and also those in which no Btatement was made, but the nature of the eruption or other cause prevented any observation of the marks, if any existed. 21 The table shows that the unvaccinated population in London has in proportion to its size contributed more largely to the admissions into the hospitals of the managers than the vaccinated population ; that the unvaccinated smallpox patients are of younger age than the vaccinated, and that the mortality of the former has been much greater than that of the latter. I have in recent reports referred to the increasing proportion of children born in London, who appear in the vaccination returns as " not finally accounted for," a proportion which has especially increased during the period since the appointment of the Royal Commission on Vaccination. The proportion in successive years has been as follows— London vaccination returns. Year. Children not finally accounted for (including cases postponed) per cent. of total birtti8. Year. Children not finally. accounted for (including cases postponed) per cent. of total births. 1872 8.8 1883 6.5 1873 8.7 1884 6.8 1874 8.8 1885 7.0 1875 9.3 1886 7.8 1876 6.5 1887 9.0 1877 7.1 1888 10.3 1878 7.1 1889 11.6 1879 7.8 1890 139 1880 7.0 1891 16.4 1881 5.7 1892 184 1882 6.6 1893 18.2 1894 20.6 In my last report I published a table showing the proportion of such children in each of the metropolitan unions in each year from 1881 to 1893 inclusive. No returns are as yet available which supply later information, but I extract from the 26th annual report of the Local Government Board the following paragraph— With regard to the metropolis the returns for 1894 show that the number of cases not finally accounted for as regards vaccination amounted to 20'6 per cent., whereas, in the previous year, the percentage of default was 182. In several of the Unions the percentage of cases not finally accounted for was exceedingly high. For instance, in Bethnal.green it was 64.4, in Hackney 57.0, in Mile.end Old Town 53.0, in Shoreditch 33.9, and in Westminster 30.7. On the other hand the work of some of the vaccination officers has been carried out so efficiently that the proportion of children escaping vaccination has been comparatively low. Thus in 1894 the percentage of default in Woolwich, Whitechapel, St. George Hanover.square, and Greenwich was 3.9, 5.1, 6.0, and 7.1 respectively. Several of the annual reports of the medical officers of health contain tables exhibiting the extent of vaccination default in the year 1895, and a comparison of these figures with those of previous years shows that the amount of default in London was steadily increasing, the districts in which the largest proportions of children "not finally accounted for" were found being Hackney, Mile.end Old. town, Stoke Newington, and Lambeth. Probable explanation of this neglect may be found in the following paragraph in the report of the Royal Commission— (513.) We were anxious to learn to what extent the guardians in England and Wales had ceased to put the law requiring the vaccination of children in force. We accordingly made inquiry of the guardians throughout the country. Answers were received from 620 out of 618 Unions. We found that the law was not being enforced in 122 out of the 620 districts; in 46 of the 122, however, the guardians based their action upon the fact that a Royal Commission had been appointed to inquire into the subject of vaccination, and had not yet reported. The Royal Commission having recommended alteration in the law, this neglect to enforce existing law will probably be continued until the subject has been dealt with by Parliament. The need for the early consideration of this subject by the legislature is therefore very urgent. In the year 1896 the Royal Commission on Vaccination presented its final report. I extract from this report some of the more important conclusions of the Commission. Referring to vaccination the report states— (377.) We think:— 1. That it diminishes the liability to be attacked by the disease [smallpox]. 2. That it modifies the character of the disease, and renders it (a) less fatal and (b) of a milder or less severe type. 3. That the protection it affords against attacks of the disease is greatest during the years immediately succeeding the operation of vaccination. It is impossible to fix with precision the length of this period of highest protection. Though not in all cases the same, if a period is to be fixed, it might, we think, fairly be said to cover in general a period of nine or ten years. 4. That after the lapse of the period of highest protective potency, the efficacy of vaccination to protect against attack rapidly diminishes, but that it is still considerable in the next quinquennium, and possibly never altogether ceases. 5. That its power to modify the character of the disease is also greatest in the period in which its power to protect from attack is greatest, but that its power thus to modify the disease does not diminish as rapidly as its protective influence against attacks, and its efficacy during the later periods of life to modify the disease is still very considerable. 6. That re.vaccination restores the protection which lapse of time has diminished, but the evidence shows that this protection again diminishes, and that, to ensure the highest degree of protection which vaccination can give, the operation should be at intervals repeated. 7. That the beneficial effects of vaccination are most experienced by those in whose case it has been 22 most thorough. We think it may fairly be concluded that where the vaccine matter is inserted in three or four places, it is more effectual than when introduced into one or two places only and that if the vaccination marks are of an area of half a square inch, they indicate a better state of protection than if their area be at all considerably below this. In respect to the risks of vaccination the Commission reports— (434.) A careful examination of the facts which have been brought under our notice has enabled us to arrive at the conclusion that, although some of the dangers said to attend vaccination are undoubtedly real and not inconsiderable in gross amount, yet when considered in relation to the extent of vaccination work done they are insignificant. There is reason further to believe that they are diminishing under the better precautions of the present day, and with the addition of the further precautions which experience suggests will do so still more in the future. On the value of isolation in replacement of vaccination the Commission thus expresses itself— (503.) We can see nothing then to warrant the conclusion that in this country vaccination might safely be abandoned and replaced by a system of isolation. If such a change were made in our method of dealing with smallpox, and that which had been substituted for vaccination proved ineffectual to prevent the spread of the disease (it is not suggested that it could diminish its severity in those attacked) it is impossible to contemplate the consequences without dismay. To avoid misunderstanding it may be well to repeat that we are very far from underrating the value of a system of isolation, we have already dwelt upon its importance. But what it can accomplish as an auxiliary to vaccination is one thing, whether it can be relied on in its stead is quite another thing. Among the opinions expressed relating to changes in administration are the following— (437.) That parents should not be required to submit their children to vaccination by means of any but calf lymph, but this should not preclude the use of humanized lymph in case they so desire. (438.) That it would be well, at all events, to extend the age period in England and Wales and in Ireland (within which vaccination is obligatory) to six months from the date of birth. (443.) If children were vaccinated and inspected as a rule at their own homes instead of being brought to a public station, we believe the risk of injury would he sensibly lessened. The following paragraphs indicate the opinion of the Royal Commission on the question of compulsion— (524.) After careful consideration, and much study of the subject, we have arrived at the conclusion that it would conduce to increased vaccination if a scheme could be devised which would preclude the attempt (so often a vain one) to compel those who are honestly opposed to the practice to iiubmit their children to vaccination, and, at the same time, leave the law to operate, as at present, to prevent children remaining unvaccinated owing to the neglect or indifference of the parent. When we speak of an honest opposition to the practice, we intend to confine our remarks to cases in which the objection is to the operation itself, and to exclude cases in which the objection arises merely from an indisposition to incur the trouble involved. We do not think such a scheme impossible. (525.) It must of course be a necessary condition of a scheme of this description, that it should be such as would prevent an objection to the practice being alleged merely as an excuse to save the trouble connected with the vaccination of the child. We may give the following as examples of the methods which might be adopted. It might be provided that if a parent attended before the local authority, and satisfied them that he entertained such an objection, no proceedings should be taken against him. Or, again, a statutory declaration to that effect before any one now authorised to take such declaration, or some other specified official or officials, might be made a bar to proceedings. We do not think it would be any real gain to parents who had no conviction that the vaccination of their children was calculated to do mischief, to take either of these steps rather than submit them to the operation. The subject of re.vaccination is thus referred to— (533.) We have already adverted to the importance which we attach to re.vaccination. It has been suggested that the operation should be made compulsory by law. Wo are quite alive to the protective value of general re.vaccination. At the same time we are not insensible of the difficulties necessarily involved in rendering it compulsory. It is, comparatively speaking, easy in the case of infants to ascertain whether the law requiring vaccination has been complied with. The constant movement of the population would render it much more difficult to ascertain whether at the more advanced age at which it would become applicable, a law providing for compulsory re.vaccination had been observed. Again, it is impossible to leave out of sight the effect that such an extension of the present compulsory law might have in intensifying hostility, where it at present exists, and even in extending its area ; though if our recommendations, especially that which exempts from penalty those who honestly object to the practice, were adopted, this objection would be much diminished. After full consideration of the question we are, however, deterred by the considerations to which we have adverted from proposing that re.vaccination should be made compulsory. At the same time, in view of the great importance of re.vaccination, we think it should be in every way encouraged. If an adequate fee were allowed in every case of successful re.vaccination, by whatever medical man it was performed, we think there would probably be a large extension of the practice. We think steps should be taken to impress on parents the importance of having their children re.vaccinated not later than at the age of twelve years. We recommend further that when smallpox shows signs of becoming epidemic, special facilities should be afforded both for vaccination and re.vaccination. The report is signed by all the members of the Royal Commission except two, i.e., by Lord Herschell, Sir James Paget. Sir Charles Dalrymple, Sir W. Guyer Hunter, Sir Edwin H. Galsworthy, Mr. John S. Dugdale, Professor Michael Foster, Mr. Jonathan Hutchinson, Mr. Frederick Meadows White, Mr. Samuel Whitbread and Mr. John A. Bright (the exceptions being Dr. Collins and Mr. Picton, who present a separate report). The following paragraphs are appended. 1. Signed by Sir W. Guyer Hunter and Mr. Jonathan Hutchinson to the following effect— The undersigned do not find themselves able to go so far in recommending relaxation of the law as is implied in paragraphs 524, 525, 526 and 527. We think that in all cases in which a parent or guardian refuses to allow vaccination, the person so refusing should be summoned before a magistrate, as at present, and that the only change made should be to permit the magistrate to accept a sworn deposition of conscientious objection, and to abstain from the infliction of a fine. We are also of opinion that, in spite of the difficulties as set forth in paragraph 533, a second vaccination at the age of twelve ought to be made compulsory. 2. Signed by Mr. Whitbread, Mr. Bright, Dr. Collins and Mr. Picton to the following effect— We, the undersigned, desire to express our dissent from the proposal to retain in any form compulsory vaccination. (Paragraphs 509, 511, 522, 523, 524, 525, 529.) Diagram. V. Measles. Mean Death rate, 1841 . 96 584 per million 23 We cordially concur in the recommendation that conscientious objection to vaccination should be respected. The objection that mere negligence or unwillingness on the part of parents to take trouble might keep many children from being vaccinated would be largely, if not wholly, removed by the adoption of the Scotch system of offering vaccination at the home of the child and by providing for medical treatment of any untoward results which may arise. We therefore think that the modified form of compulsion recommended by our colleagues is unnecessary, and that in practice it could not be carried out. The hostility which compulsion has evoked in the past toward the practice of vaccination is fully acknowledged in the Report. In our opinion the retention of compulsion in any form will in the future cause irritation and hostility of the same kind. The right of the parent on grounds of conscience to refuse vaccination for his child being conceded, and the offer of vaccination under improved conditions being made at the home of the child, it would in our opinion be best to leave the parent free to accept or reject this offer. The position of the Royal Commission may be sufficiently understood from the paragraphs in its report which appear above. It recognizes the necessity of maintaining vaccination as the principle means of prevention of smallpox. It recommends some relaxation of the compulsory law, not on account of mistrust of vaccination, but solely with the object of lessening the hostility to vaccination which results from the enforcement of the present compulsory law. It recognizes that infantile vaccination is not to be relied upon for protection against attack after nine or ten years, and is of opinion that children should be re.vaccinated not later than at the age of twelve years, but declines to recommend compulsory re.vaccination, first on account of the difficulties resulting from movement of population, secondly on account of the risk of intensifying hostility to the law. Whatever necessity there has been in the past for the re.vaccination of children approaching twelve years of age, this necessity will become more urgent if the suggested relaxation of the compulsory law in favour of the conscientious objector should materially augment the number of children entirely unprotected against smallpox. Again, whatever objection might be urged against a compulsory re.vaccination law practically disappears if the conscientious objector is exempted from the requirement as to the re.vaccination of his child as suggested in the case of primary vaccination. At the present time the question whether a child shall be re.vaccinated is probably never seriously considered in many homes in the absence of any requirement as to re.vaccination. There is no period in the child's life when the parent has to come to definite decision in the matter, and hence in many cases from sheer apathy, re.vaccination is neglected. The number of parents who had devoted attention to the subject of re.vaccination is probably small, the greater number have never considered the matter. A requirement by the State (with exemption for the conscientious objector of the sort which may be adopted in the case of primary vaccination) that every child approaching the age of 12 shall be re.vaccinated would ensure the re.vaccination of a vast number of children who are now never re.vaccinated. This requirement would lead to the transference of a large proportion of the children of such parents from the population which is susceptible to smallpox to the population which is insusceptible to this disease. The very fact that the State made the requirement would have an influence which would bs more operative in this respect than any system of recommendation that sanitary or vaccination authorities could design; and in so far as it was successful it would tend to secure benefits not only to the children who were re.vaccinated but also to the children of the conscientious objector, by reducing the opportunities of exposure to infection. The Royal Commission's reason for the maintenance of a compulsory law for securing primary vaccination may be equally urged as necessary for the purpose of securing re.vaccination. (523.) Why, it is asked, should not vaccination cease to be compulsory altogether, and be left to the free choice of the parents. If no penalty were attached to the failure to vaccinate, it is, we think, certain that a large number of children would remain unvaccinated from mere neglect on the part of their parents, or indisposition to incur the trouble involved, and not because they thought it better in the interest of their children. On the question of the difficulty of carrying out such administration which the movement of population presents, 1 would desire to refer to a statement in a recent work published by the authority of the German Imperial Board of Health. The lists of children on whom the first vaccination is obligatory are obtained from the register of births. Under existing circumstances, in Germany the inspection of those who should be presented for the second vaccination can be best effected in the schools. When, however, children of this age do not attend any school they can escape re.vaccination, in fact almost insuperable difficulties stand in the way of controlling such children, but from the health administration point of view such exceptional cases are without importance.* Measles. The deaths from measles in the administrative county of London in 1896 numbered 3,697, as compared with 2,630 in 1895 and 3,303 in 1894. The death rates from this disease per 1,000 living in 1896 and preceding periods have been as follows— 1851.60 0.53 1861.70 0.58 1871.80 0.51 1881.90 0.64 1891 0.431 1892 0.791 1893 0.381 1894 0.761 1895 0.601 1896 0.821 The death rate in each year since 1840, in relation to the mean of the period 1841.96, is shown in diagram V. The measles death rate of 1896 has been higher than that of any previous year since 1864. In this disease in London years of high mortality alternate with years of low mortality, the former being probably due to accumulation of susceptible infants. Study of the diagram leads to the conclusion that during the last ten years measles has been a more fatal disease than during the preceding ten years, a circumstance that may be due to two conditions, the one being a natural alteration in the quality of the disease, the other, larger opportunity for its diffusion, such as would * Blattern and Schutzpockenjmpfung. Denkschrift zur Beurtheilung des Nutzens des Impfgesetzes vom 8th April, 1874, page 78. † See footnote (l) page 7. 24 result from increase of aggregation of children in schools. The former of these is probably the governing factor. If the London death rate be compared with the death rates of other large towns in England having more than 200,000 inhabitants, it will be seen that in the period 1886.95 the London death rate exceeded that of any of these towns except Manchester, Liverpool, West Ham and Salford, and in 1896 exceeded that of any except Manchester, Nottingham, Hull and Salford. Measles—Death rates per 1,000 living. Towns. 1886.95. 1896. Towns. 1886.95. 1896. London 0.61 0.821 West Ham 0.66 0.44 Manchester 0.79 1.06 Bristol 0.49 0.61 Liverpool 0.77 0.48 Nottingham 0.41 0.88 Birmingham 0.52 0.60 Bradford 0.49 0.46 Leeds 0.59 0.49 Hull 0.43 1.16 Sheffield 0.56 0.57 Salford 0.87 0.94 The following table shows that the measles death rate in London was higher than that of any of the undermentioned foreign cities in 1896, and in the period 1886.95 was higher than that of any except St. Peterburg. Measles —Death rates per 1,000 living. Towns. 1886.95. 1896. Towns. 1886.95. 1896. London .61 .821 St. Petersburg .69 .74 Paris .46 .26 Berlin .21 .13 Brussels .37 .39 Vienna .56 .60 Amsterdam .40 .35 Rome .54 .39 Copenhagen .41 .21 New York .38 .37 Stockholm .45 .11 In the distribution of this disease in London throughout the year, measles mortality was, in the first quarter of the year, above the average of London in the northern and central groups of districts. In the second quarter there was increase of measles mortality in London as a whole, and the mortality of all the groups of districts except the northern exceeded the London average. In the third quarter the measles death rate of London fell and this fall was shared by each group ; the eastern group of districts alone had a death rate above the London average. In the fourth quarter the death rate from measles again fell and of the several groups of districts the eastern alone had a death rate above the London average. In the year as a whole the eastern group of districts had the highest death rate and the northern group the lowest. Of the several districts Woolwich had the highest death rate and Stoke Newington the lowest. The high death rate of Woolwich was especially due to prevalence in the second quarter. It is interesting to observe that while in London the deaths from measles of infants under one and from one to five years of age constituted 21.4, and 72.8 per cent. of the total deaths respectivelv, the deaths in Woolwich at these aces were 16.7 and 77.8 per cent. The measles death rate of each district in 1896 and in the preceding ten years is shown in the following table— Sanitary area. Deaths in 1896. Death rate per 1,000 living. Sanitary district. Deaths in 1896. Death rate per 1,000 living. 1886.95. 1896. 1886.95. 1896. Paddington 103 .39 .81 Whitechapel 51 .74 .64 Kensington 173 .45 1.00 St. George . in . the . 28 1.10 .58 Hammersmith 62 .70 1.58 East Limehouse 62 1.08 1.05 Fulham 101 .86 Chelsea 110 .60 1.12 Mile.end Old.town 84 .75 .74 St. George, Hanover. square 32 .33 .39 Poplar 147 .77 .85 St. Saviour, South. wark 17 .89 .66 Westminster 18 .58 •33 St. James 31 .43 1.33 St. George, South. 77 .91 1.26 Marylebone 195 .51 1.36 wark Hampstead 58 .23 .75 Newington 98 .78 .80 Pancras 133 .62 .54 St. Olave 11 .76 .93 Islington 275 .57 .80 Bermondsey 75 .83 .86 Stoke Newington 5 .49 .15 Rotherhithe 43 .64 1.05 Hackney 95 .44 Lambeth 182 .55 .60 St. Giles 41 .64 1.06 Battersea 179 .51 1.06 St. Martin . in . the . 11 .42 .83 Wandsworth 151 1 .79 Fields Camberwell 206 .57 .80 Strand 28 .61 1.16 Greenwich 193 .60 1.08 Holborn 33 .79 1.05 Lewisham 44 .26 .41 Clerkenwell 53 .93 .79 Woolwich 72 .54 1.71 St. Luke 35 1.08 .83 Lee 14 .44 .36 London, City of 6 .28 .19 Plumstead 69 1.14 Shoreditch 143 .80 1.15 London 3,697 .61 .822 Bethnal.green 153 .87 1.17 1 See footnote (2) page 8. 2 See footnote (') page 7. 25 The annual reports of medical officers of health contain the following references to the spread of measles by schools— Hampstead.—"Measles occasioned 58 deaths, and proved to be the most fatal cause of death among the zymotic class. . . . The epidemic commenced in this parish towards the end of 1895, and attacked large numbers of young children in the Netherwood Board School, spreading from that centre to the children's homes in the adjacent streets." Islington.—The medical officer of health gives account of the effort made by him to obtain information as to measles which was prevalent in Islington, and especially prevalent in South.West Islington, in the first quarter of the year. A circular letter was issued to the head teacher of every school in the south.west registration sub.district, recommending that children attending the infant school should be carefully examined with the object of excluding children suspected to be suffering from this disease. The principal symptoms to be looked for were specified. A leaflet accompanied this letter, in which advice was given as to the steps to be taken by head teachers with the object of lessening the risk of prevalence of measles among school children. This circular and leaflet became matter of correspondence between the London School Board and the Islington Vestry, the Board informing the vestry "the Board have issued instructions to their teachers on the question of dealing with infectious illnesses, and expect their teachers not to take orders from any other body or person." The correspondence was forwarded by the Vestry of Islington to the Local Government Board, whose reply contained the following paragraphs— In reply, I am to inform the vestry that since the circular which was issued with the medical officer of health's letter of the 16th January last to the proprietors of schools, school managers and teachers, and which appears to have been limited to the case of measles, was only in the form of advice and recommendation, the Board consider that the medical officer of health merely fulfilled his duty which devolves upon him under article 18 (6) of the Board's General Order of 8th December, 1891. I am at the same time to state that in view of the instructions to which reference is made in the letter of the clerk to the School Board of the 4th ultimo, and which, as the Board assume, relate to cases of notifiable disease as well as to those which are not notifiable, it may be well for the vestry, in dealing with the subject of infectious diseases of the former class, to consider whether, as regards cases in which they may in the future be advised that the exclusion of particular children is desirable, they should not rely on the exercise of their powers under article 88 of the Education Code. I am, however, to add that in any case where the medical officer of health finds it expedient to take such action as in the present instance, the Board consider that it is very desirable that he should communicate with the medical officer of the School Board on the subject, with a view to secure, as far as possible, his co.operation in the matter." To the statement in the last paragraph that the medical officer of health should communicate with the medical officer of the School Board the medical officer of health of Islington takes exception as involving delay. He refers moreover to the following regulation of the London School Board for the guidance of managers, correspondents and teachers, and states that the information indicated therein did not reach him. II.—Any child showing symptoms of an infectious disease, or any child coming from a house where an infectious disease exists, must be sent home at once and the superintendent of visitors must be immediately informed of the case, in order that enquiries may at once be made with a view to proper steps being taken to prevent the children living in the same house or tenement from attending school. The medical officer of health for the district must also at the same time be informed of the child's exclusion, and furnished with the name and address of the child and the reason of its exclusion on a form with which the teachers will be supplied by the head office. Hackney.—The medical officer of health writes.— During the year one of the schools under the control of the London School Board was closed owing to an outbreak of measles amongst the scholars attending it. My attention was called to the circumstance immediately prior to the closure of the school. I made some enquiries, which resulted in the following particulars:—As far as I could ascertain the first cases appeared in the infants' school about the 18th May. After a few days—about a week—the disease appears to have spread rapidly, so that on the 14th of June, when the department was closed, no less than 65 infants were absent owing to this cause. The disease seems to have been introduced into the boys' and girls' school later, about the first week in June. Here it also spread rapidly, so that by the 17th of June, when this department was closed, 46 scholars were absent owing to the disease. Not all of the absentees were suffering from measles—some being excluded owing to other members of their family being ill with the disease. The boys' and girls' school was re.opened on the 22nd of June. In this school the effect of closure was not very marked, for I find 55 scholars still absent on the 30th of June. The infants' school was closed for a longer period, re.opening not taking place until July 5th. Here closure seems to have been more effectual, for I learned on enquiry that only two scholars were absent on the 15th of July. This subject of school closure requires much more thorough study than appears hitherto to have been given to it, if the greatest amount of benefit in the prevention of disease, with the least amount of interference with school studies, is to be obtained. Strand.—The medical officer of health reports as follows— Measles was very prevalent in the district in the early part of the year. During the first quarter the outbreak was worst in St. Anne's sub.district, but during thesecona quarter it was very severely felt in the Strand sub.district; and it became necessary to require the exclusion of the children in affected houses from the schools under section 88 of the Day School Code. Shoreditch.—The report of the medical officer of health contains the following paragraphs— "On May 20th, my attention being called to the number of children on the roll of the infants' department of the Catherine.street Board School who were absent through illness, I visited the school and ascertained that between 40 and 50 per cent. of the children were absent owing to illness from measles and mumps. The question arose as to the closure of the infants' department. So far as mumps was concerned, being a disease involving little or no danger to life, the interests of the school were principally to be considered, and beyond the exclusion of infected children, no further action would be required. With regard to measles, however, the case is different. Having ascertained that measles was the prevailing complaint, the infants' department was kept under observation for a few [4] 26 days and it being found that the number of absentees through measles continued to increase I put myself into communication with the medical officer of the School Board, who informed me on the 29th that the infants department had been closed. The department was closed for three weeks, and so far as I have been able to ascertain, with beneficial results with regard to the prevalence of measles in connection with the school." Poplar.—The medical officer of health of Poplar and Bromley states that "a large number of children at one time of the year were away from Cubitt.town board school with measles, but there was no need to take steps to close the school." Wandsworth.—The medical officer of health of Putney and Roehampton reports as follows— On the 25th February the National schools in both Putney and Roehampton were closed for three weeks and at the same time the managers of the various Sunday schools were requested to do the same. The closure of the elementary schools is the only effective means in our power of putting a stop to the spread of these epidemics. In this case it was followed by a marked diminution in the number of cases. Unfortunately the closure of schools cannot come in force at so early a period as we could wish, as we have no certain means of knowing to what extent it is epidemic, and are sometimes made aware of it only when the certificates of death resulting therefrom are registered. The medical officer of health of Wandsworth states— The public schools were, as is usually the case, the principal means of spreading the disease, and I advised that the infant department of the schools chiefly affected should be closed for a period of three weeks. The infants' departments of Waldron.road, Garratt.lane and Swaffield.road schools were closed from the 14th of May to the 8th June, and the same department of Eltringham.street school from May 22nd to June 15th. Standard I. department of the last school was also closed from 29th May to 15th J une. These measures seemed to have a beneficial effect, as only three deaths occurred after the 10th of June. On the subject of notification of measles the following opinions are expressed— Plumstead.—The medical officer of health writes— The primary schools are the great means of spreading the infection of measles, and it is probably to the school managers and teachers that we must mainly look for contending with the spread of infection. The present School Board regulations are excellent as far as they go, but they do not go far enough. The teachers of the various schools act independently, and are neither in communication with each other nor with the medical officer of health. I have therefore proposed a school notification of measles, viz., that teachers should send me word of any children they exclude from school on this account. If this were done I should know at once when measles was prevalent among the children of any one school, and in special cases should know ill,time when it was wise to recommend the closure, say of the infant department of a school, a proceeding which I have no doubt might at times greatly assist in staying an epidemic. I should also be able, in cases where children in one house attend two or more schools, to warn the teachers of the other schools to exclude those children. The health committee approved of my recommendation, and I found that the great majority of the teachers would willingly co.operate in the proposed plan. The vestry has not yet, however, authorised me to incur the small expense requisite for printing notification forms, &c. I would again strongly urge that no moderate expenditure should be allowed to weigh against the health and lives of the children of the parish. Paddington.—The medical officer of health thus writes— What the sanitary authority requires, to be in a position to cope with the disease, is a knowledge of the first case in each house or family, so that the children may be excluded from the schools, the families kept under observation, and the necessary disinfection carried out. Notification of the first case in the family by the medical practitioner, when called in, and systematic reports of absentees by school teachers are the most promising methods of keeping the sanitary authority in touch with the disease. Hospital isolation would, except under special circumstances, appear to be unnecessary. Having regard to the highly infectious condition of the patient from the first onset of symptoms, before even a diagnosis can be made, removal to hospital does not afford much promise of effect towards limiting the spread of infection. Kensington.—The medical officer of health refers to a previous report by him on this subject in which he expressed the opinion— That it would be little or no use to have notification of measles unless hospital accommodation was provided on a large scale for the use of the sufferers therefrom. Fulham.—The medical officer of health refers to a previous report by him in which he expressed the opinion— That, at any rate, a modified system of notification of measles should be tried, by which the first attack in every house invaded shall be notified, but no subsequent case arising in the same house within thirty days. Westminster.—The medical officer of health writes— During the past year the attention of the Public Health Committee has been directed to the question of compulsory notification of this disease, by more than one metropolitan sanitary authority ; but having had practical experience in the matter of notification of measles the committee have decided to take no action in the matter. Hampstead.—The annual report of the medical officer of health contains the following paragraph— The question as to the desirability of adding measles to the list of infectious diseases notifiable under the provisions of the Act has been considered by the Public Health Committee more than once. Having regard to the general susceptibility to measles, the young ages at which children are attacked, and the highly infectious pre.eruptive stage, when it is difficult to distinguish the complaint from an ordinary catarrh, it did not appear that the advantages to be gained were adequate, or that public opinion was ripe for the measure. With notification must go hospital isolation, and it is probable that if measles is to be provided for by the Asylums Board, the present accommodation of beds would have to be doubled. 27 Hackney.—The medical officer of health having stated that the chief objections to compulsory notification of measles are (1) that mild cases would not be notified owing to no medical man being called in, (2.) the early infectiousness of the disease, (3) the difficulties and cost of isolation, and (4) the costs of notification and of the sanitary staff which would be necessary, says— The first objection is no doubt valid; but the same applies to some extent to scarlatina. I am frequently having my attention drawn to convalescing cases of this disease which have never been under medical treatment, the acuter symptoms having been brief and mild. The same may be said of cases of diphtheria. I have no doubt that many of the mild cases arc not placed under medical treatment and accordingly are not notified. But the notification of these two diseases is, I believe, operating favourably in the diminution of their prevalence. The second is a strong objection, but it is not insuperable. The disease is still infectious for several days after the rash appears; therefore, because mischief may be done before the real nature of the disease is known, this surely is not an irresistible argument against adopting measures which might prevent further mischief after the disease is known. The difficulty of providing isolation in the homes of patients is one that we often experience during unusual epidemics of scarlatina and diphtheria ; nevertheless, where isolation is possible, the enforcement of it diminishes to an equivalent degree the spread of the disease. Hospital accommodation would have to be enormous, certainly if every case required it, but I do not think such a large amount of accommodation would be needed. The question of expense is obviously dependent upon the value set upon human life. If a low estimate is held, the cost will be a bar to any effort being made to save some of the lives which annually are lost owing to this disease; if the estimate is a high one, the cost of increased sanitary staff and hospital accommodation will occupy a subordinate position. St. Giles.—The medical officer of health writes— In October last your Board addressed a further communication to the Local Government Board urging that an early decision should be given to their proposal that measles should be included in the list of notifiable diseases. Strand.—The medical officer of health states— The question of adding measles to the list of diseases which have to be notified has been brought under the consideration of your Board on several occasions in communications from other authorities, but the reasons advanced in favour of the proposal have not been sufficiently convincing to induce the Board to alter a previous decision that measles should not be notified. Clerlcenwell — After referring to the fact that during the last ten years scarlet fever has caused 68 and measles 598 deaths in the district, the medical officer of health writes— This enormous preponderance in mortality of the non.notifiable disease measles, over the notifiable disease scarlet fever, has led to much comment, and the vestry has on more than one occasion been asked to give an opinion as to the advisability of adding measles to the list of diseases which have to bo notified, influenced by the belief that notification would be of little benefit without isolation, and that the difficulties in the way of securing effective isolation cannot at the present time be wisely faced, they have without disagreeing either with the gravity of present conditions, or the desire that they should be improved, considered the present moment inopportune for making the proposed change. St. George.in.the.East.—The medical officer of health states— The question of making measles a notifiable disease was also before the committee, when it was resolved that no action be taken. This disease is highly infectious before it can be diagnosed, and is more fatal among children of about two years of age. In some places where this affection has been made notifiable, it had been subsequently decided to discontinue its compulsory notification, it apparently having no effect in modifying the mortality. For these reasons, and looking at the fact that there is no hospital in which such cases could be isolated, it can hardly be recommended at present that this disease should be made notifiable in this parish, although something would be gained by being able to notify the schools. Poplar (Bow).—The following paragraph appears in the report of the medical officer of health— Personally, I have no hesitation in expressing the firm opinion that one of the first steps should be notification. At present measles, though classed as a zymotic disease, is not included amongst the diseases that are notifiable under the Public Health (London) Act of 1891. So there is only the mortality data to convey any information as to its prevalence during any given period. Desirable as it is that the principle of providing hospital accommodation for notifiable diseases should be preserved, yet, with the circumstances of 1896 before us, I feel inclined to modify my former opinion that notification and hospital accommodation for measles must make their debut together. St. George, Southward—The medical officer of health writes— As frequently pointed out by me before, I think that the compulsory notification of cases of measles throughout London, with subsequent hospital treatment and disinfection, could not fail in a poor parish like St. George's to result in a great saving of life. Newivgton.—The medical officer of health presented a special report on the notification of measles, as follows— At your request I have written to the medical officer of every sanitary authority in England where the practice of having measles notified has been adopted by them. They number 54, and I have received replies from 36. For the convenience of the Committee I have summarised the opinions expressed. It will be seen at once that nearly the whole of the authorities who have adopted the notification are urban, and their medical officers express views more or less in favour of having measles notified, whilst in the very few rural authorities on the list their medical officers have hesitated to say much as to the benefit that has been received from its adoption. The important points are these: (1) they all say that measles is much less satisfactory in its notification than scarlet fever and other diseases on the list; (2) that the early infectiousness of the complaint, as early even as the incubation stage, is a great obstacle to the prevention of the disease from spreading; (3) that effective isolation in hospital would be too costly for many authorities to bear; (4) that many think it is a very good thing to have notification, even if you have not hospital accommodation, as the cases have so much better attention and care when visits are made to them by the officials of the authority; (5) that the feeling in the matter is highly progressive, in the way that all infectious diseases, it is thought, ought to be reported to the local centre ; (6) that if the full notification of all the cases is expensive, the first case in the family might be the one alone notified. Personally I think that if any district could be benefited by this notification, it is ours, with its poor and overcrowded population. If the notification embraced all the cases, I estimate the number to be 1,500 in the year, but if only the first cases, 400. I would advise the Committee to recommend that only the first case in the family be paid for ; and to support the petition to the Local Government Board with that qualification. 28 The vestry, after a discussion, decided not to petition the Local Government Board, as it was thought not advisable to have measles included in the list of infectious diseases compulsorily notified. St. Olave.—The medical officer of health expresses the following opinion— Hospitals for those cases that cannot be isolated at home and for those that cannot receive proper nursing and treatment at home, which is usually the case in crowded one or two.room tenements, are very much required, and would be the means of very much reducing the death.rate of this disease. Notification by the head of the family should be compulsory, so that children from infected houses could be excluded from school. Lambeth.—The following paragraphs appear in the annual report of the medical officer of health— It is perfectly true that measles causes a large number of deaths yearly, and it is also true that the notification of measles might be useful in the sense that infected houses would be visited, and insanitary conditions (when found) remedied, children more rigorously (than at present) kept from school, infected houses be disinfected, and the officers of a sanitary authority brought more into contact with the mothers of infected children, and so a process (slow though it might be) of education in sanitary matters, and in the dangers and proper treatment of measles, result; but whether the good that would accrue in this way would be at all proportionate to the expense, is quite another matter, and one that needs the careful and serious consideration of an officer of health before he ventures to advise his authority to incur it, more especially when we consider the peculiarities of this particular disease, and the difficulties already pointed out in connection therewith. Further, a large increase in the sanitary staff would be necessary for the purpose of carrying out this additional inspection of measles.infected houses, and for the proper carrying out of the subsequent disinfection. To sum up the matter shortly, it may be stated that simple notification of measles is not advisable, and that notification followed by isolation, disinfection &c., impossible at present (at least in London) conclusions which appear (to me at least) to be borne out by the experience of those sanitary districts that have already adopted measles notification. I may add that I am satisfied from experience that the early closure of schools (more especially the infants' departments) at the commencement of an epidemic is of the very greatest use, and this can be effected by a system of simple notification between the school authorities and the medical officer of health. Theoretically, notification under the Act is necessary, followed by isolation, disinfection, &c., practically it is not advisable in London, at least, at the present time. Battersea—The medical officer of health writes— Thus from the two diseases combined (whooping cough and measles) 325 deaths occurred, comparing most unfavourably with a total of 151 deaths from all the notifiable zymotic diseases, an unanswerable argument in favour of the compulsory notification of all infectious diseases, they, in the pre.notification period, being said to be equally intractable to supervision and modification, an idea which the greatly diminished case mortality demonstrates to be incorrect. Wandsworth.—The medical officers of health in their joint report, in referring to the increased mortality from measles in this district write— We again point out, as in our report for 1895, the importance of something being done to stop this excessive mortality. It is largely a matter of educating the poor as to the necessity of taking care of measles. This we hold could be to some extent accomplished if we knew of cases of measles; at present we hear only of deaths. Plumstead.—In reference to the notification of first cases of measles in houses as distinguished from the notification of all cases of measles the medical officer of health says— It is doubtless true that in a disease like measles the onset of which is difficult to recognise, but which is very infectious in the early unrecognised stage, we cannot hope to diminish its prevalence to the same extent as in scarlet fever. But I believe a good deal can be done and if only a few lives can be saved every year, no pains and no moderate expense should be spared. I have never yet advocated the general notification of measles, as it appears doubtful from the experience of places where it has been tried whether the results are commensurate with the expense. It has been proposed lately that the first case only in a house should be notified and paid for. This plan would no doubt be very advantageous and much less expensive than a general notification, but I think it would not be enforced under the present Public Health Act. It might however be made voluntary, 2s. 6d. being paid for the notification of each first case in a house. Bnt the great difficulty is the fact that probably in the majority of cases of measles no doctor is called in. Scablet Fever. The cases of scarlet fever notified in the Administrative County of London in 1896 numbered 25,758, compared with 19,808 in 1895. The number of deaths registered from this cause in 1896 was 941 giving a death rate of 021 per 1,000 living per annum. The London rates in 1896 and previous periods are shown in the following table— Scarlet fever. Period. Death rate per 1,000 living. Case rate per 1,000 living. Case mortality per cent. 1861.70 1.13 —* — 1871.80 0.60 * — 1881.90 0.33 —* — 1891 0.141 2.7 5.1 1892 0.271 6.4 4.3 1893 0.371 8.6 4.3 1894 0.221 4.3 5.2 1895 0.191 4.5 4.2 1896 0.211 5.7 3.7 (1) See footnote (1), page 7. Scarlet Fever. Mean Death.rate 1859.96.589 per million. Diagram, IX. Xumber of deaths ocurriing in hospitals of the Metropolitan Asylums Board, per cent of total deaths in London , 1873.96. Number of admissions to hospitals of the Metro Asvlums Board,per cent of total cases notified in London,1890.96. 29 The death rate in each year in relation to the mean death rate of the period 1859.96 is shown in Diagram VI. This diagram shows greatly diminished mortality from this disease in recent years, and that this diminished mortality is in 1896 practically continued, although the death rate was slightly higher than in 1895. The case rate had in that year somewhat increased, and the fatality slightly decreased. It will be seen from the following table that in the period 1886.95 the London death rate from scarlet fever exceeded the death rates of Birmingham, Nottingham and Hull, while in the year 1896 the London death rate was lower than that of any of the undermentioned towns except Leeds, West Ham, Nottingham and Bradford. Scarlet fever—Death rates per 1,000 living. Towns. 1886.95. 1896. Towns. 1886.95. 1895. London .24 .212 West Ham .24 .21 Manchester .40 .37 Bristol .26 .25 Liverpool .50 .35 Nottingham .18 .11 Birmingham .20 .29 Bradford .32 .10 Leeds .25 .17 Hull .18 .25 Sheffield .42 .29 Salford .56 .49 If the London scarlet fever death rate be compared with the death rates of the undermentioned foreign cities, it will be seen that in the period 1886.95 the London death rate was higher than those of Paris, Brussels, Amsterdam, Berlin and Rome; and in 1895 exceeded those of Paris, Brussels, Amsterdam, Copenhagen, Stockholm and Rome. Scarlet fever—Death rates per 1,000 living. Towns. 1886.95. 1896. Towns. 1886.95. 1896. London .24 .212 St. Petersburg .71 .89 Paris .09 .07 Berlin .23 .23 Brussels .04 .05 Vienna .24 .29 Amsterdam .04 .07 Rome .04 .01 Copenhagen .31 .11 New York .46 .21 Stockholm .70 .15 In the distribution of scarlet fever mortality among the several districts of London, in the first quarter, the eastern group of districts suffered most heavily, and the northern group the least, all the eastern districts but Whitechapel having death rates above the London average for the quarter. In the second quarter the eastern group suffered most heavily, and the central the least. In the third quarter the eastern group had the highest mortality, and the southern the lowest; and in the fourth quarter the central group had the highest death rate, and the northern the lowest. In this quarter the death rate of St. Luke was especially high. During the year as a whole the eastern group of districts suffered most heavily, the northern the least. Of the several districts St. Luke had the highest death rate (0.50), while Holborn was the only district in which no death occurred. ihe case rate of each district in 1891.5 and in 1896, and the death rate of each district in 1886.95 and 1896, are shown in the following table— Sanitary area. Cases, 1896. Case rate per 1,000. Deaths, 1896. Death rate per 1,000. 1891.95. 1896. 1886.95. 1896. Paddington 795 3.8 6.3 22 .14 .17 Kensington 1,020 3.4 5.9 40 .17 .23 Hammersmith 532 4.1 5.0 21 .23 .20 Fulham 628 4.4 5.4 29 .25 Chelsea 571 4.6 5.8 23 .21 .23 St. George, Hanover.square 342 4.1 4.2 11 .16 .14 Westminster 224 4.2 4.1 10 .23 .18 St. James 75 3.2 3.2 3 .17 .13 Marylebone 811 4.3 5.7 26 .20 .18 Hampstead 289 4.2 3.8 7 .12 .09 Pancras 1,079 5.8 4.4 37 .21 .15 Islington 2,047 5.3 6.0 57 .18 .17 Stoke Newington 226 6.2 6.6 18 .25 .23 Hackney 1,533 7.1 36 .17 St. Giles 180 3.9 4.6 7 .17 .18 St. Martin.in.the.Fields 73 3.5 5.5 3 .21 .23 Strand 132 3.7 5.5 6 .21 .25 2 See footnote (2), page 8. 30 Sanitary area. Cases, 1896. Case rate per 1,000. Deaths, 1896. Death rate per 1,000. 1891.95. 1896. 1886-95. 1896. Holborn 123 5.7 3.9 — .24 — Clerkenwell 461 6.0 6.9 15 .29 .22 St. Luke 264 4.8 6.3 21 .35 .50 London, City of 197 4.9 6.2 7 .18 .22 Shoreditch 708 5.3 5.7 39 .28 .31 Bethnal.green 1,257 66 9.6 35 .39 .27 Whitechapel 638 5.9 8.0 20 .28 .25 St. George.in.the.East 378 5.9 7.8 18 .35 .37 Limehouse 350 7.5 5.9 15 .41 .25 Mile.end Old.town 764 6.6 6.8 34 .34 .30 Poplar 964 6.8 5.6 33 .31 .19 St. Saviour, Southwark 140 4.6 5.4 5 .36 .19 St. George, Southwark 335 5.5 5.5 17 .44 .28 Newington 677 5.6 5.5 29 .33 .24 St. Olave 62 4.8 5.2 5 .31 .42 Bermondsey 394 5.5 4.5 20 .33 .23 Rotherhithe 198 5.8 4.8 10 .27 .24 Lambeth 1,595 5.3 5.3 65 .25 .22 Battersea 1,175 6.2 7.0 32 .19 .19 Wandsworth 1,000 4.6 5.2 29 .15 Camberwell 1,222 4.8 4.7 52 .25 .20 Greenwich 1,163 6.2 6.5 51 .22 .28 Lewisham 454 3.7 4.2 8 .11 .07 Woolwich 146 5.4 3.5 9 .19 .21 Lee 168 6.5 4.3 8 .19 .20 Plumstead 363 6.0 18 .30 Port of London 5 — — — — — London 25,758 5.3 5.7 941 .24 .211 The reports show that prosecutions were instituted in Marylebone and Plumstead for wilful exposure in public places of persons while infectious from scarlet fever. Reference is made to return cases, or cases recurring in houses to which a patient recently discharged from a fever hospital had returned, in several of the reports ; thus in Westminster three such cases occurred, in Shoreditch six such cases, in St. Olave two. One of the children after discharge from the hospital was found to have rhinorrhœa, the other desquamation of a finger, but the mother in the latter case had recently visited a child suffering from scarlet fever. Six cases were noted in Wandsworth and four in Plumstead. One of these children was found after discharge from the hospital to have a copious discharge from the ear, another had enlarged tonsils and a chronic mucous discharge from the nose. The insufficiency of hospital accommodation for persons suffering from scarlet fever is referred to in the reports of the medical officers of health of Kensington, Hampstead, Hackney, Holborn, Shoreditch, Whitecjiapel, St. George in the East, Poplar, Mile.end Old.town, St. Olave and Plumstead. The medical officer of health of Kensington writes that " On some days in July as many as a dozen patients were detained at home awaiting removal, the majority of them suffering from scarlet fever, others from diphtheria. This state of things, which continued more or less throughout the latter half of the year, was mitigated to a certain extent by the opening of the Brook Hospital." The medical officer of health of Holborn suggested to the managers of the Metropolitan Asylums District that " It must surely be a much less evil that patients should have only 1,600 cubic feet, say, (instead of the 2,000 cubic feet now allowed) than to be kept in crowded rooms with probably less than 150 cubic feet, and at the same time mixed with healthy children, and a source of danger to many others." He states, "I am glad to find this recommendation was adopted, for while the certified normal accommodation for fever and diphtheria at the Board's disposal was less than 3,900 beds, this number was for many months largely exceeded." The medical officer of health of Hackney writes "Without imputing any blame to the Board for this want of accommodation I am of opinion that the inability to remove all cases led to an increase in their number in this district." Prevalences of scarlet fever in resident institutions are referred to in several of the reports of medical officers of health. Bethnal.green.—The annual report of the medical officer of Bethnal.green contains reference to two outbreaks of this disease in an orphanage home in Bonner.road, the particulars of which were given in a special report forwarded by him to the Council. Both outbreaks were due to personal contagion, the disease being in the first place introduced into the school by the child of an officer of the school, and in the second by one of the scholars, who appears to have been infected at Southgate a few days before his admission into the school. St. George, Southwark.—The medical officer of health reports that ten cases of scarlet fever occurred in a hospital within a fortnight. The cause was probably the reception into the hospital of an unrecognised case of scarlet fever, the patient dying a few hours after admission. Whitechapel.—The medical officer of health states that a number of cases of scarlet fever occurred in the Tower of London. Chelsea.—The report contains reference to the occurrence of 26 cases of scarlet fever in the Duke of York's Royal Military School. 1 See footnote (1), page 7. NOTIFIED CASES. Dragram.VII Scarlet Fever, 189. 31 Scarlet fever and elementary schools. The occurrence of scarlet fever among the pupils of elementary schools is referred to in the following reports— Paddington.—Some thirteen cases of scarlet fever having occurred among 656 children attending the St. Paul's Church Schools, the sanitary authority made an order requiring the school to be closed for three weeks. The number of cases in the immediate neighbourhood of the schools in successive periods of three weeks was as follows—6, 6, 9, 13 and 3. The school was closed during the last period. "There are close on 100 scholars in the school in excess of the accommodation." Lee.—The medical officer of health states that the number of cases in successive quarters of the year were 9, 2, 6, 7 and 5. He writes— Some of those in the first quarter were connected with the outbreak at the Pope-street Board School, which was entered into fully in my last year's report. Nearly all those in the second quarter were among children at New Eltham, and the Board school was again the focus of contagion. Plumstead.—Account is given of six children who were sent home from school by the teachers, who had observed that the children were desquamating. In two cases the parents were prosecuted, in one case successfully. The medical officer of health writes " the various teachers who by their watchfulness were enabled to detect these cases, and so further prevent infection, deserve great credit; and if similar vigilance were practised by all school teachers, I believe there would be a considerable reduction in the number of cases of scarlet fever." Wandsworth.—The following paragraphs appear in the reports of the medical officers of health of this district. (Clapham)—The prevention of the spread of scarlet fever is made much more difficult owing to the very mild type of the disease that has been prevalent. It has frequently occurred that children have been discovered in a peeling condition in whom the feverish stage had been very short and had not been noticed by the mother. In other instances it has seemed very probable that the illness had been concealed wilfully, the parents knowing what was the matter. One instance occurred in Clapham where information was given me by neighbours, and on visiting the house I found a child in the highly infectious or peeling stage. I was informed that the mother had stated to a neighbour that she would not have a doctor because then the other children would be stopped from going to school, and so would lose a medal. It was not possible, however, to get satisfactory evidence to prove the parents knowledge of the presence of scarlet fever without which it would be impossible to take proceedings for wilful exposure. The difficulty here is an illustration of what so frequently occurs and so often prevents anything being being done to prevent or punish the most reckless exposure. (WandsUorth)—During the month of March several cases occurred in No. 1 Ward, in children attending the infant department of the board sc hool there, and there was reason to think that infection was being spread by a case which had not been notified. I communicated the particulars to the medical officer of the School Board, suggesting that the infant department of the above school should be closed for 14 days. He accordingly advised the school to be closed from March 27th to 13th April with beneficial results. (Putney )—The report contains reference to the discovery by the teacher of a girls' school of a child who was attending school while desquamating. The teachers brought the case to the knowledge of the medical officer ot health, who writes. " Happily I have always found, in the prevention of the spread of disease, the sanitary authorities have most useful auxiliaries in the teachers of the National schools." Stoke Newington.—The medical officer of health states that of 220 cases occurring in 166 different houses school attendance was ascribed as the origin of the infection in 41 cases, infection from a preceding case (apart from school) in 10, and in one case there was strong reason for believing that infection was re-introduced by a patient dismissed from a fever hospital. One school was closed on account of this disease for five days. The following paragraphs appear in his report— As there was a grouping of cases around one of the board schools and the number of cases that had been attending the school was out of proportion to the numbers that had been attending other schools, I got the consent of the School Board medical officer to inspect the bulk of the scholars. As a result, three children presenting suspicious symptoms of mild or delayed scarlet fever were sent home and quarantined. It has now been abundantly demonstrated that school attendance is responsible for a considerable spread of infection during epidemic periods. When are we to reap the fruits of this knowledge and arrange for frequent and systematic medical inspection of the scholars in the board and other public schools. As in previous reports I have shown in diagram VII. the number of cases of scarlet fever appearing in each weekly notification list in relation to the mean of the year. The summer holiday of the London School Board schools began in 1896, at noon on Thursday, 23rd July, or the latter part of the 30th week, and the schools re-opened on Monday, the 24th August, or the beginning of the 35th week. The curve representing the number of attacks among children from 3-13 years of age showed some fall in the 31st to 34th weeks. If the number of cases notified in the four weeks which would be most subject to holiday influence be compared with the four preceding and four subsequent weeks, holiday influence be compared with the four preceding and four subsequent weeks, the following results are obtained— Period. Notified cases—Ages. Increase or decrease per cent. 0—3 3—13 13 and upwards. 0—3 3—13 13 and upwards. Four weeks preceding weeks of holiday influence (28th to 31st) 275 1,681 420 Four weeks of holiday influence (32nd to 35th) 348 1,632 496 +26-5 — 2-9 + 181 Four weeks following weeks of holiday influence (36th to 39th) 350 1,980 369 + 0-6 +21-3 —256 32 Scarlet fever—Proportion of cases and deaths in hospitals. It will be seen by reference to diagram IX. that while in 1896 a somewhat larger proportion of the London cases of scarlet fever were admitted into the hospitals of the Metropolitan Asylums Board than in 1895, the proportion of deaths occurring in these institutions was very slightly smaller. Scarlet fever, 1896—Age and sex distribution. In the following table are shown the age and sex distribution of the cases of scarlet fever notified in London during the year 1896, together with the deaths and case mortality at each age. As in preceding years males at all ages were attacked and died in greater proportion than females, and the case mortality of males was greater than that of females. The greatest incidence of attack was on children four years of age in the case of both males and females. The greatest incidence of death was on males of four years of age, and on females of three years of age. At most ages the case mortality, both of males and females, was lower than in 1895. Scarlet fever*, 1896. Age period. Males. 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. 12,261 471 3.8 587 23 13,386 450 3.4 574 19 0— 220 30 13.6 389 53 185 29 15.7 321 50 1— 491 67 13.6 968 132 483 59 12.2 944 115 2— 893 77 8.6 1,683 145 891 92 10.3 1,672 173 3— 1,176 93 7.9 2,289 181 1,179 78 6.6 2,242 148 4r- 1,193 55 4.6 2,387 110 1,228 51 4.2 2,447 102 5— 4,659 97 2.1 1,964 41 5,305 105 2.0 2,214 44 10— 2,201 29 1.3 1,017 13 2,409 14 0.6 1,092 6 15— 725 14 1.9 350 7 691 6 0.9 300 3 20— 331 4 1.2 162 2 430 9 2.1 175 4 25— 266 2 0.8 76 1 418 4 1.0 104 1 35— 75 1 1.3 29 — 125 3 2.4 44 1 45— 23 2 8.7 13 1 31 — — 15 — 55 and upwards, 8 — — 5 — 11 — — 5 — Scarlet fever—Seasonal variations in fatality. In my last annual report I published tables and diagrams showing that the statistics of 1892-5 gave strong indications of definite seasonal fatality, that is to say, that the highest seasonal fatality occurred in the early months of the year, and that the fatality declined generally in succeeding months until a minimum was reached in September or October, after which fatality increased. Correction made for difference in age and sex distribution of the cases of each month supplied reason for thinking that these differences were insufficient to account for the variations shown in the fatality. There was some arrest of the fall in the month of August, a result no doubt due in the main to the fact that schools are closed at that time, leading to the fatality being calculated more largely upon children of early life whose fatality is high. I supply in this report the figures of the year 1896, and of the period 1892-6, which it must be observed are uncorrected for differences of age and sex distribution. The figures of the additional year give no reasons for different statement of the subject (see also " Diphtheria," page 40). Scarlet fever—Case mortality, 1896. Month. No. of weeks. Cases. Deaths. Case mortality per cent. Mean case mortality taken as 100. January 5 2,073 111 5.35 147 February 4 1,401 71 5.07 139 March 4 1,294 81 6.26 172 April 5 1,495 55 3.68 101 May 4 1,558 60 3.85 106 June 4 1,834 69 3.76 103 July 5 2,959 87 2.94 81 August 4 2,492 70 2.81 77 September 5 3,479 97 2.79 77 October 4 2,706 60 2.22 61 November 4 2,213 85 3.84 105 December 5 2,143 87 4.06 112 * In the preparation of this table, the question whether the persons, who were attacked and who died, belonged to London is disregarded, the percentage 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. Diagram Scarlet Fever. 33 Scarlet fever—Case mortality, 1892-96. Month. Cases. Deaths. Case mortality per cent. Mean case mortality taken as 100. January 7,738 440 5.69 133 February 6,078 327 5.38 125 March 6,528 373 5.71 133 April 7,074 371 5.24 122 May 9,217 416 4.51 105 June 10,409 454 4.36 102 July 13,289 520 3.91 91 August 13,047 561 4.30 100 September 15,369 492 3.20 75 October 16,198 510 3.15 73 November 13,770 558 4.05 94 December 9,121 466 5.11 119 In diagram VIII. are shown the number of cases notified in each month during the years 1891-6 in relation to the mean of that period, and the case mortality of each month, also in relation to the mean. Corrections have not been made for differences of age and sex distribution. Scarlet fever—Seasonal variations in age distribution. The question deserves to be considered whether the London figures of notification afford reason for thinking that there is seasonal variation in age distribution of scarlet fever. There is now the experience of five years figures available for this purpose and they are stated in tabular form below. An examination of these figures shows that the children under five years of age who were attacked with scarlet fever constituted at the beginning and end of the year a larger proportion of the total number of persons attacked than at other times. There is, moreover, a general tendency for the proportion to decrease from the beginning of the year until September or October is reached and for the proportion to subsequently rise. There is notable exception to this rule in the month of August, due no doubt to the closing of schools for the holidays, but apart from this the proportion in the month of March is the only marked variation. an exception which may not improbably disappear when the statistics of future years can be added to those of the period 1892-6: (see also "Diphtheria," page 41). Scarlet fever—Notifications, 1892-6. Month. Notified cases, 1892-6. All ages. 0— 1— 2— 3- 4— Under 5. 5— 10— 15— 20 and upwards. January 7,552 129 312 519 678 715 2,353 2,952 1,284 433 530 F ebruary 5,914 84 244 376 484 614 1,802 2,297 1,012 353 450 March 6,381 93 264 444 583 601 1,985 2,396 1,125 413 462 April 6,925 117 284 450 586 656 2,093 2,617 1,235 438 542 May 9,015 133 364 633 781 822 2,733 3,392 1,654 572 664 June 10,175 167 391 661 895 933 3,047 4,070 1,734 645 679 July 12,976 194 451 814 1,105 1,219 3,783 5,090 2,422 808 873 August 12,722 214 569 950 1,131 1,176 4,040 4,639 2,260 893 890 September 15,006 236 505 890 1,304 1,366 4,301 6,295 2,757 821 832 October 15,864 256 561 1,029 1,350 1,417 4,613 6,498 2,891 901 961 November 13,481 250 503 850 1,156 1,235 3,994 5,316 2,441 847 883 December 8,927 155 350 583 824 866 2,778 3,440 1,555 494 660 Month. "All ages " taken as 1,000. All ages. 0— 1— 2— 3— 4— Under 5. 5— 10— 15— 20 and upwards. January 1,000 17 41 69 90 95 312 391 170 57 70 February 1,000 14 41 64 82 104 305 388 171 60 76 March 1,000 15 41 70 91 94 311 376 176 65 72 April 1,000 17 41 65 85 95 303 378 178 63 78 May 1,000 15 40 70 87 91 303 376 184 63 74 June 1,000 16 38 65 88 92 299 400 171 63 67 July 1,000 15 35 63 85 94 292 392 187 62 67 August 1,000 17 45 75 89 92 318 364 178 70 70 September 1,000 16 34 59 87 91 287 419 184 55 55 October 1,000 16 35 65 85 89 290 410 182 57 61 November 1,000 19 37 63 86 92 297 394 181 63 65 December 1,000 17 39 65 92 97 310 386 174 56 74 [5] 34 Diphtheria. The cases of diphtheria notified in the Administrative County of London in 1896 numbered 13,825 compared with 11,231 in 1895. The number of deaths registered from this cause in 1896 was 2,666 compared with 2,292 in 1895. The figures quoted for 1896 give an annual death rate of 0.59 per 1,000 living and a case mortality of 19.3 per cent. The diphtheria death and case rates in 1896 and preceding periods are shown in the table— Diphtheria. Period. Death rate per 1,000 living. Case rate per 1,000 living. Case mortality per cent. 1861-70 0.18 * - 1871-80 0.12 * — 1881-90 0.26 * — 1891 0.311 1.5 22.5 1892 0.441 2.0 22.2 1893 0.741 3.2 23.3 1894 0.611 2.6 23.6 1895 0.521 2.6 20.4 1896 0.591 3.1 19.3 The death rate in each year since 1858 in relation to the mean of the period 1859-96 is shown in diagram X. There was increase both of death rate and case rate in 1896 upon the rates of 1895 and decrease of fatality. If the London death rate from diphtheria be compared with the death rates of other large towns in England having populations of more than 200,000 persons, it will be seen that in the period 1886-95 the London rate exceeded the rates of any of these towns, while in 1896 the London rate was higher than the rates of any except West Ham. Diphtheria Death rates per 1,000 living. Towns. 188C-95. 1896. Towns. 1886-95. 1896. London .41 .602 Bristol .13 .16 Manchester .26 .15 Nottingham .07 .06 Liverpool .16 .24 Bradford .06 .07 Birmingham .16 .53 Hull .09 .23 Leeds .09 .12 Salford .39 .23 Sheffield .14 .16 West Ham .39 .70 It will be seen from the following table that the London death rate from diphtheria was in the period 1886-95 lower than the death rates of any of the undermentioned foreign cities except Brussels, Amsterdam and Rome, while in 1895 the London death rate was only exceeded by the death rates of St. Petersburg and New York. Diphtheria—Death rates per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London .41 .602 St. Petersburg .54 .90 Paris .58† .18† Berlin .82 .31 Brussels .13† .15+ Vienna .75† .40† Amsterdam .32 .32 Rome .36 .09 Copenhagen .83 .17 New York 1.05 .80 Stockholm .86† .11† In the distribution of diphtheria mortality in London throughout 1896 the western group of districts suffered most heavily, and the central the least, in the first quarter. In the second quarter the eastern group of districts had the highest death rate, and the western and the central had the lowest. In the third quarter the southern group suffered most heavily, and the central the least. In the fourth quarter the southern group again had the highest death rate, and the central group again had the lowest. In the whole year the eastern group of districts had the highest death rate (0.66), and the central the lowest (0.42), the London death rate being 0.59; the highest death rate occurred in Chelsea (1.17), and the lowest in St. James Westminster (0.09). 1 See footnote (1), page 7. 2 See footnote (2), page 8. * The Infectious Diseases (Notification) Act only came into force in 1889. † Including deaths from croup. 35 The case rate of each district in 1891-5 and in 1896, and the death rate in 1886-95 and in 1896, are shown in the following table— Sanitary district. Cases, 1896. Case rate per 1,000. Deaths, 1896. Death rate per 1,000. 1891-5. 1896. 1886-95. 1896. Paddington 247 2.1 1.9 65 .41 .51 Kensington 372 1.7 2.1 70 .37 .40 Hammersmith 218 2.5 2.1 52 .46 .49 Fulham 356 2.3 3.0 77 .66 Chelsea 488 2.5 5.0 115 .40 1.17 St. George, Hanover-square 124 1.3 1.5 24 .31 .30 Westminster 109 1.7 2.0 20 .40 .37 St. James 37 1.5 1.6 2 .24 .09 Marylebone 292 1.8 2.0 74 .27 .52 Hampstead 199 1.7 2.6 30 .27 .39 Pancras 482 2.2 2.0 99 .42 .40 Islington 1,117 2.4 3.3 255 .37 .74 Stoke Newington 80 2.7 2.3 19 .42 .56 Hackney 593 2.7 103 .47 St. Giles 60 1.4 1.5 7 .37 .18 St. Martin-in-the.Fields 16 1.3 1.2 3 .33 .23 Strand 37 1.6 1.5 3 .33 .12 Holborn 72 2.0 2.3 12 .38 .38 Clerkenwell 246 2.6 3.7 42 .45 .62 St. Luke 460 2.0 3.2 26 .40 .62 London, City of 133 1.6 2.3 11 .29 .34 Shoreditch 72 2.5 3.0 74 .47 .60 Bethnal-green 371 4.1 3.5 75 .67 .57 Whitechapel 351 2.9 4.4 48 .54 .60 St. George-in-the-East 214 3.8 4.4 30 .70 .62 Limehouse 270 2.7 4.6 49 .55 .83 Mile-end Old-town 551 2.9 4.9 97 .51 .86 Poplar 701 4.3 4.1 105 .48 .61 St. Saviour, Southwark 83 2.5 3.2 18 .41 .70 St. George, Southwark 193 2.1 3.1 40 .39 .65 Newington 407 2.3 3.3 71 .39 .58 St. Olave 44 1.8 3.7 9 .31 .76 Bermondsey 258 1.9 3.0 73 .36 .84 Rotherhithe 123 2.4 3.0 26 .38 .63 Lambeth 692 2.1 2.3 139 .42 .46 Battersea 419 2.9 2.5 82 .39 .49 Wandsworth 299 1.8 1.6 40 .21 Camberwell 1,430 2.2 5.5 260 .39 1.01 Greenwich 836 2.7 4.7 140 .47 .78 Lewisham 382 1.5 3.6 78 .27 .73 Woolwich 102 0.8 2.4 31 16 .74 Lee 75 1.7 1.9 17 .39 .43 Plumstead 208 3.4 55 .91 Port of London 6 — — — — — London 13.825 24 3.1 2.666 .41 .59' Outbreaks of disease are referred to in the reports of the medical officers of health of the following districts— Kensington.—The medical officer of health gives account of two instances in which diphtheria occurred in a child, and the disease not having been recognised, spread to other persons. In the first of these outbreaks the child first attacked had been accustomed to dabble in the water which lay in a hollow near to the ventilating opening of a sewer from which nuisance was experienced. Stoke Newinaton.—The medical officer of health writes that of 71 cases of diphtheria occurring in 65 different houses 12 were probably due to insanitary conditions. School attendance was alleged by parents or surmised by himself on sufficient grounds to be the cause of 9 cases and to be responsible for 12.7 per cent. Apart from school, 7 cases contracted the disease in all probability from a previous case ; three cases were imported into the parish, and in 38 cases the origin of the disease could not be traced in a satisfactory manner. St. George Southwark.—The medical officer of health reports that 14 cases, of which five died, occurred between the 14th July and the 8th October, all but two of the sufferers were under ten years of age. The circumstances of these cases were investigated; they occurred in two groups, and the prevailing cause was found to be the abundant opportunity that existed in the locality for communication of the disease from one person to another. There was an interval between the first and second groups but the first case of the second group was a young man who lodged in the same house occupied by a case 1 See footnote (1) page 7. 36 in the first group. The sanitary condition of these houses was found to be faulty, the drains defective and the sewer unventilated. In several of the reports of medical officers of health reference is made to the existence of insanitary conditions in houses in which cases of diphtheria occurred and the medical officers of health of Poplar (Bow) contains a tabular statement showing the state of each house invaded by the disease. Diphtheria, and elementary schools. The annual reports of medical officers of health contain the following references to diphtheria in association with schools. Paddington.—The medical officer of health gives account of nine cases and four deaths occurring in the "baby class" of the infant school Sultram-crescent High School. Due to the nine primary cases there were seven secondary cases occurring in the families of these infants. There were besides four other cases with two deaths among children living in Willesden, but attending this class, which had an average attendance of forty-five children. The class was closed by resolution of the sanitary authority from the 18th June to the 10th August. During August considerable defects were found in the drains of the school. The circumstances in which disease first came to be introduced into the school are not clear, but it is noted that the teacher had a sore throat some weeks before the outbreak, but her medical attendant was satisfied that this illness was not diphtheria. Fulham.—The medical officer of health writes— There was an outbreak of diphtheria among children attending the infants' department of Hugonroad Board School, in December, 1895; it was hoped that, as the school was closed from December 20th to January 6th this would have the effect of checking the disease, but a week after the school re-assembled several more cases were notified, and arrangements were made to close the school should any further cases occur; this, however, was not found to be necessary. Chelsea.—The medical officer of health gives details of the behaviour of diphtlieria in Chelsea in 1896. The number of cases notilied in each month were as follows— April 12 July 55 October 39 May 24 August 59 November 41 June 27 September 70 December 30 He states that closure of the schools in August had but little enect in arresting the progress of the epidemic, but among children from 3 to 13 years of age, there was diminution of cases in the period comprising the 33rd to 36th weeks, namely, 31 cases as compared with 38 cases in the tour-weekly period preceding. During February, March and April the cases at school age (3 to 13 years) formed 52 per cent. of the total cases. In May this percentage was increased to 58, in June to 69, and in July when the full force of the epidemic began to be felt, to 76 per cent. He adds— In view of this progressive increase in the proportionate numbers of cases at school-age, at a time when the epidemic was rapidly increasing in intensity, and having regard to other circumstances which are within my knowledge, I am much inclined to the opinion that the epidemic in July was, in some degree, facilitated by the existence at that time of mild unrecognised cases of the disease among children who continued school attendance. The marked increase in the number of cases at school age in June and July is very suggestive, whilst in August, when the schools were closed, the percentage of cases at school age at once fell to 63 from 76 in July, In view, then, of the very strong probability that the July outburst was facilitated by the continued attendance at school of cases of sore throat, which were in reality mild cases of diphtheria, it is my intention in future, should circumstances appear to demand it, to ask the school authorities to co-operate with me in an endeavour to exclude from attendance at school all children suffering from sore throat, and to concert such measures as may appear to be needful to carry this endeavour into practice. With diphtheria, as with other infectious diseases, an epidemic may be stamped out at its commencement by measures designed to prevent the diffusion of infection among the susceptible population, but once allowed to obtain headway, an epidemic gets beyond control, as indeed occurred in July last. In an interesting special report to the vestry on "Diphtheria in Chelsea from 1890 to 1896" the medical officer of health shows the annual average number of cases of this disease among children aged from 3-13 years which were notified in successive periods of four weeks during this time— Weeks 1-4 7 5-8 7 7-12 8 13-16 8 17-20 8 21-24 8 25-28 11 Weeks 29-32 15 33-36 6 37-40 13 41-44 14-5 „ 45-48 16 49-52 14 Hackney.—The medical officer of health gives a detailed account of the circumstances of prevalence of diphtheria in the fourth quarter of 1896. Examination of the distribution of these cases showed a special prevalence of the disease in Clapton-park and among the scholars of the Daubeneyroad Board School. A special area of six enumeration districts was selected for closer study, and it was found that in a period of eight weeks the attack rate per 1,000 persons was in the selected area 3'8, and in the remainder of Hackney .38. Again it was found that of children from 3 to 15 years of age the attack rate was in the affected area 11.05, and in the rest of Hackney .84 per 1,000. Of 48 children attacked with diphtheria in the selected area, 36 attended the Daubeney-road Board School, and 6, 5 and 1 attended three other schools, the average number of children attending each of which was in excess of that of the Daubeney-road Board School. Careful inquiry was made into the distribution of these 36 cases among the infants', girls' and boys' departments of this school, and it was found that while the percentage attacked was in the infants' department 7.5, it was 1.5 and .47 respectively in the girls' and boys'. Inquiry into milk supply and other possible causes was made, with the result that milk could be excluded, and only exceptionally were faulty conditions found in the houses. The drainage of the school was found to be satisfactory, but the latrines were very foul. 37 The medical officer of health says— I am consequently bound to fall back on personal infection at school as the cause of the majority of the cases amongst the scholars of the Daubeney-road Board School. On looking through the list there appears to be an almost unbroken series of cases at this school from the beginning to the end of the period treated of. Of course it is not possible to connect each case with a preceding one, neither is it at all necessary. It is agreed upon by all competent authorities that during diphtheria prevalence there often exist a large number of mild and unrecognised cases of throat disease, which are highly infectious and competent to spread the disease amongst the healthy. It is not unknown for those who dispute the importance of school influence in the spread of diphtheria to deny the existence of such mild cases as those alluded to, but the matter has been established beyond all power of denial Again, while making enquiries at the school as to the cause of this outbreak, I learned that several scholars were absent. On inquiry at the homes of these children, it was ascertained that several were suffering from sore throat and ulcerated throat; one or two of these were afterwards notified as diphtheria. Having carefully considered the whole of the circumstances connected with the outbreak amongst the scholars at Daubeney-road Board School, I am of opinion that the disease was spread chiefly by personal infection at school, especially in the infants' department, the infection being conveyed largely by means of unrecognised cases, for no doubt the head mister and mistress excluded'any cases immediately they were recognised as diphtheria. How the disease was introduced it is impossible to say; probably by an ill-defined case, or by some secondary case from an infected household. The medical officer of health makes the following recommendations with a view to preventing a recurrence of such an outbreak, (1) That during periods of diphtheria prevalence, the children attending the public elementary schools should be periodically examined by a medical man, in order to ascertain whether any of the scholars are suffering from throat disease of any kind. (2) That children suffering from throat disease of any kind should be immediately excluded from school. (3) That on the exclusion of any child from school on account of throat disease, notice of such exclusion, with the class and department attended by child, should be immediately sent to the medical officer of health for the district. St. Saviour, Southivark.—The medical officer of health reports that in two days in the early part of October, six children between the ages of 3 and 5½ years were certified to be suffering from diphtheria, and the usual enquiries as to the schools they attended and possible sources of infection elicited the fact that all the children belonged to the infant department of a school in the Christchurch district. The medical officer visited this school and examined the infants attending there, with the result that he found one case of undoubted diphtheria and four others which were of a suspicious nature. The case referred to was sent to hospital, where his diagnosis was confirmed. The school was accordingly closed and disinfected. On the re-assembling of the children he examined them all and found no child suffering from diphtheria, and since that time no case of diphtheria occurred among the children of that school. Wandsworth (Putney and Roehampton).—The medical officer of health reports on an outbreak of diphtheria in Roehampton. Nearly all the sufferers, 23 in number, were children from 6 to 11 years of age, and nearly all attended the National schools at Roehampton. There was no reason for thinking that milk, water, or the condition of the houses was responsible for the outbreak. Certain faults were found in the sanitary condition of the school, but the disease appeared to be due to personal infection from one child to another. The school was closed for four weeks. No death occurred. Gamberwell.—The medical officer of health gives account of an exceptional prevalence of diphtheria in 1896 in an area in Camberwell in which four schools are situated, and he supplies the material for comparing the incidence of attack in this area with that of the rest of Camberwell, both in 1896 and the preceding year. The following figures for these years are thus obtained— Attacks at certain age periods per cent, of total attacks. 0—4 4—13 13 and above. 1895 Specially affected area The rest of Camberwell 3 1.9 50.0 18.1 23.3 54.7 22.0 1896 Specially affected area The rest of Camberwell 21.1 60.0 18.9 21.6 54.0 24.4 A further point commented on is the falling off in the number of notified cases during August, 1896, when the schools were closed. In March, 1897, I presented to the Council's Public Health Committee a memorandum on the increase of diphtheria in that locality which will be found in the Appendix. (See Appendix I.) Lewisham.— Reference is made in the report of the medical officer of health to prevalence of diphtheria in this district. This prevalence was investigated by Dr. Hamer, on behalf of the London County Council, with the result that it was found to be due to the infection of children in a Board and National school. The outbreak presented no unusual features, and indeed the chief interest attaching to it is the fact that it was the occasion of a report by the medical officer of the London School Board, who traversed Dr. Hamer's conclusions. The Council's Public Health Committee instructed me to comment on this report, and in obedience to this instruction I prepared a statement which, with Dr. Hamer's report, will be found in the Appendix (see Appendices II. and III.). In connection with this subject I have only to add that since these papers were published it has been found that the population 38 of a certain industrial school was not included in the population of an enumeration district in which the institution was situated, but was separately returned. Some modification of Dr. Hamer's figures are therefore necessary, with the result that the very strong evidence Dr. Hamer's report contains in support of his conclusions is still further strengthened.* A copy of Dr. Hamer's report, and my own observations on the report of the medical officer of the London School Board, were communicated by the Public Health Committee to the Local Government Board. Woolwich.—The medical officer of health, referring to increased prevalence of diphtheria in Woolwich. writes— The most careful investigation has been made with the view of determining the cause of the increased prevalence of diphtheria, but with no satisfactory result. Crops of cases occurred in the neighbourhood of three schools, viz., Eglinton-street and Union-street Board Schools and St. Thomas Church School. In no single instance could any possibility of infection at school be found. The sanitary arrangements in all the houses attacked were good, but in three or four cases overcrowding was found. Notices have, however, since been served, and the conditions remedied. In no instance could the disease be traced to the milk supply. Plumstead.—The medical officer of health writes, " The south-west ward was more affected than in recent years. Bloomfield and Ancona road schools were most affected. For the purpose of ascertaining whether, as in previous years, there was decrease of diphtheria prevalence among children of school ages during the summer holiday, diagram XI. has been prepared. The summer holiday of the schools of the London School Board began at noon on Thursday, 23rd July, or the later part of the 30th week, and the schools re-opened on Monday, the 24th August, or the beginning of the 35th week. The diagram shows a decrease in the number ot attacks among children aged 3-13 in the 32nd-35th week, a decrease among infants being manifested a little later, suggesting, as I have before pointed out, a lessening of the infection of the younger by the older children. If the number of cases in the four weeks which would be most subject to the influence of the holidays be compared with the numbers in the four preceding and subsequent weeks the following results are obtained— Period. Notified cases—Ages. Increase or decrease per cent. 0 - 3 3—13 13 and upw is. 0—3 3—13 13 and upwards. Four weeks preceding weeks of holiday influence ('28th to 31st) 170 643 287 — — — Four weeks of holiday influence (32nd to 35th) 154 547 300 — 9.4 —14.9 + 4.5 Four weeks following weeks of holiday influence (36th to 39th) 183 733 278 + 18.8 + 340 —7.3 Diphtheria—Proportion of cases and deaths in hospitals. In diagram XIII. will be found the proportion of London cases of diphtheria admitted into the hospitals of the Metropolitan Asylums Board in 1896, and the proportion of the deaths from this disease which occurred in these institutions in that year. These proportions were nearly the same as in 1895. Bacteriology as an aid to diagnosis.—Arrangements have been made in several districts to afford facilities to medical practitioners for the bacteriological examinations of material from doubtful cases of diphtheria. In St. Pancras, Holborn, St. Marylebone and St. Olave arrangements have been made and the necessary facilities given to medical practitioners for transmitting such material for this purpose. In the Strand, arrangements of a like kind came into force in 1897. In St. Marylebone material from 87 cases was examined with positive results in 46 ; in Holborn material from 17 cases was examined, with positive results in 10; in St. Olave material from four cases was examined; in Camberwell, Woolwich and Plumstead recommendations to adopt a similar course have been made by the medical officers of health of these districts. Diphtheria—Age and sex distribution. The age and sex distribution of the cases of diphtheria notified in London during 1896 are shown in the following table. Females during the first four years of life were attacked in a smaller * The industrial school, being a public institution with over 100 inmates, is dealt with separately in the census returns. The figures on pages 4 and 5 of Dr. Hamer's report require, therefore, some amendment if, as was originally intended, the population of the industrial school is to be included. This population at the census of 1891 comprised 156 persons, of whom 1 22. 119 and 14 belong to the age-groups 0-3, 3-10, 10-15 and 15 and upwards, respectively. I have had the figures, which result upon inclusion of this population, worked out. The proportions shown on the last line of the table on page 4 of Dr. Hamer's report, become 177 in place of 174 at age 0-3, 396 in place of 394 at age 3-10, 82 in place of 92 at age 10-15, the figure 12 given for the age 15 and upwards being unaffected. Again, the slight alteration produced in the attack rates given on page 5 renders it necessary to substitute "more than twice" for "nearly three times "in line 37; "more than 4" for "4½" in line 39; and "67" for "70" in line 41. The teaching of these figures, it will be seen is thus not materially affected by inclusion or exclusion of the industrial school population. The belief that the industrial school population was included in the total 1,726, given as the number of children aged 3-12 living in the area, led Dr. Hamer, however, to considerably underestimate the number of children aged 3-12 attending other schools than the board and national schools, or not attending any scho 1 (see his report, top of page 6, and footnote). The total number of children at the age of 3-12 should be 1,803 in place of 1,726 (77 inmates of the industrial school being between the ages 3 and 12). Hence "about 300" in line 5 becomes "about 450,"and the excessive incidence of disease upon the children attending the board and national schools, as compared with other children belonging to the same age-group, is seen to be 50 par cent. higher than Dr. Hamer had supposed to be the case. NOTIFIED CASES. Diagram XI Diphtheria, 1896. 39 proportion than males, but at each subsequent age in greater proportion. The incidence of attack at "all age3" was, as in preceding years, greater on females than on males; the incidence of death at "all ages" was, however, as in preceding years, greater on males than on females, this result being due to the greater incidence of death on males as compared with females in the first four years of life. After this period, the mortality among females was greater than that among males. The fatality (case mortality) of diphtheria was at "all ages" greater among males than females. When each age is considered it is seen that during the first two years of life the fatality among males was greater than that among females, but during the next three years the fatality among females was greater than that among males. Diphtheria, † 1896. Age period. Males. Females. Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages. 6,183 1,297 210 296 62 7,625 1,370 18.0 327 59 0— 151 79 52.3 267 140 139 70 50.4 241 121 1— 474 241 50.8 934 475 419 190 45.3 819 371 2— 624 236 37.8 1,176 445 550 213 38.7 1,032 400 3— 758 195 25.7 1,475 379 677 191 28.2 1,287 363 4— 728 178 24.5 1,457 356 783 209 26.7 1,560 416 6— 1,892 298 15.8 798 126 2,401 407 17.0 1,002 170 10— 641 41 6.4 296 19 960 51 5.3 435 23 15— 296 9 3.0 143 4 459 11 2.4 199 5 20— 232 3 1.3 114 1 384 6 1.6 156 2 25— 248 8 3.2 71 2 551 12 2.2 137 3 35— 84 4 4.8 32 2 200 7 3.5 70 2 45— 37 3 8.1 20 2 74 2 2.7 36 1 55 and upwards. 18 2 11.1 10 1 28 1 3.6 12 — Diphtheria—Use of anti-toxic serum. In my last report I referred to the more recent use of antitoxic serum in the treatment of diphtheria. A valuable report on this subject has been presented to the Metropolitan Asylums Board by the medical superintendents of the Board's hospitals, showing the results obtained by the use of this serum during 1896, and it is therefore possible to consider whether the lessening fatality of this disease in London is attributable, in any degree, to the employment of this remedy. The report of the medical superintendents compares the fatality among patients the large majority of whom were treated in the hospitals in 1896 with serum with that among patients not so treated in 1894, the result being that while in 1894 the fatality at all ages of 3,042 cases was 29.6 percent., the fatality of 4,175 cases in 1896 was 20.8 per cent., the reduction in fatality occurring at each age period. Beyond this it is shown that the amount of reduction of fatality is dependent on the day of illness on which the patient comes under treatment thus— Fatality per cent, all ages. 1894. 1896. First day 22.5 4.7 Second day 27.0 12.8 Third day 29.4 17.7 Fourth day 31.6 22.5 Fifth and after 30.8 24.6 It is pointed out that the age distribution of the cases in 1896 was less favourable to low fatality at "all ages" than that of the year 1894, a larger proportion of children at early ages being admitted in 1896 than in 1894, and although between one year and another there are probably differences in the fatality of infectious disease, independently, there is no reason for thinking that the differences indicated above are not substantially due to treatment. If we assume that the whole of this reduction of mortality has been due to this treatment of patients in the hospital of the Metropolitan Asylums Board, there would have been, without this treatment, 365 additional deaths* from diphtheria in London during 1896; instead therefore of a London diphtheria death rate of 059 per 1,000, this death rate would have been 0.68 per 1,000 and instead of a London case mortality of 19.3 per cent. there would have been a case mortality of 21.9 per cent. The death rate in 1894 was 0 61 per 1,000, and the case mortality 23.6 per cent. The year † See footnote *, page 32. * Referring to the figures for the whole of London, it may be pointed out that. if the case mortality at each age-group in 1896 had been the same as obtained in 1894, the number of deaths resulting would hare exceeded the number cf deaths which actually occurred by 754. 40 1896 would therefore, if such correction be made, show, as compared with 1894, a higher death rate and a diminished case mortality. Whether this diminished case mortality may be in part due to the treatment with anti-toxic serum of cases of diphtheria in their own homes can only be matter for speculation. It is, however, interesting to observe that at a time when the hospitals of the Metropolitan Asylums Board were so full as to prevent the admission of applicants, their medical attendants were furnished by the Metropolitan Asylums Board through the medical officers of health with warrants authorizing them to receive free of cost anti-toxic serum for the treatment of their patients. Reference to this matter is made in the reports of the medical officers of health of Fulham, Marylebone, Shoreditch, Whitechapel, Poplar, Lewisham and Deptford, and the report of the medical officer of health of Stoke Newington shows that his Vestry continues to authorize him to furnish to medical practitioners this material at cost price. "The provision," he says, "has been much appreciated, and a considerable number of tubes have been disposed of during the year." The following table shows the case mortality of diphtheria at certain ages and for each sex for each of the years 1893-6 inclusive— Age-period. Case mortality per cent. Males. Females. 1893. 1894. 1895. 1896. 1893. 1894. 1895. 1896. All ages. 26.4 25.8 22.7 21.0 21.8 23.1 19.6 18.0 0— 66.9 56.0 52.6 52.3 57.6 58.3 52.8 50.4 1— 65.8 59.5 48.5 50.8 67.2 58.6 50.0 45.3 2— 53.2 44.4 41.6 37.8 43.9 50.5 41.0 38.7 3— 45.9 40.5 33.0 25.7 45.3 37.5 31.9 28.2 4— 38.5 31.5 30.4 24.5 37.0 36.5 30.5 26.7 5— 20.9 18.5 15.6 15.8 24.2 21.6 17.7 17.0 10— 6.6 8.4 6.0 6.4 6.1 6.3 6.5 5.3 15— 2.8 3.9 2.0 3.0 3.3 2.9 4.0 2.4 20— 3.2 4.5 3.0 1.3 1.9 2.5 1.8 1.6 25— 2.8 2.4 1.7 3.2 2.9 2.9 1.5 2.2 Reference to the reports of the medical officers of the Metropolitan Asylums Board contained in the reports of the Statistical Committee of that Board shows that anti-toxin began to be used by them in the last few months of 1894. Diphtheria—Seasonal variations in fatality. The subject of seasonal variation in fatality has already been discussed in connection with scarlet fever (see page 32), and it will be sufficient here to show the results obtained by similar treatment of the cases of and deaths from diphtheria. The following table shows that the ligures supplied by diphtheria point in the same direction as those supplied by scarlet fever. The case mortality has not been corrected for differences of age and sex distribution. It will be observed that as in scarlet fever the fatality is greatest at the beginning and end of the year, and that it falls to a minimum in September and October, while there is in the month of August some increase of fatality, due no doubt to a decrease during the holiday of the proportion of attacks at school ages, at which ages the case mortality is less, and to the relative increase of attacks at the younger ages, at which ages the case mortality is greater. Diagram XII. shows the fatality of each month of the years 1891-6 in relation to the mean of that period. Diphtheria—Case mortality, 1896. Month. No. of weeks. Cases. Deaths. Case mortality per cent. Mean case mortality taken as 100. January 5 weeks 1,283 282 21.98 114 February 4 „ 970 186 19.18 99 March 4 „ 982 192 19.55 101 April 5 „ 986 201 20.39 105 May 4 „ 949 188 19.81 102 June ... 4 „ 1,021 167 16.36 85 July 5 „ 1,372 247 18.00 93 August 4 „ 1,006 198 19.68 102 September 5 „ 1,528 278 18.19 94 October 4 ,, 1,176 238 20.24 105 November 4 „ 1,131 224 19.81 102 December 5 „ 1,404 267 19.02 98 41 Diphtheria—Case mortality, 1891-96. Month. Cases. Deaths. Case mortality per cent. Mean case mortality taken as 100. January 4,707 1,109 23.56 108 February 3,889 925 23.79 109 March ... 4,142 979 23.64 108 April ... 4,2.58 947 22.24 102 May 4,972 1,070 21.52 98 June ... 4,976 1,041 20.92 96 July 5,915 1,197 20.24 93 August 5,335 1,152 21.59 99 September 6,581 1,340 20.36 93 October 7,084 1,464 20.67 95 November 6,558 1,443 22.00 101 December 5,749 1,347 23.43 107 Diphtheria—Seasonal variations in age distribution. In connection with scarlet fever the subject of seasonal variations of age distribution has already been mentioned (see page 33). The figures supplied by the years 1892-6 appear to indicate that the maximum proportion of children under five years of age among persons attacked by scarlet fever will be found in the early part and close of the year, and that this proportion gradually falls until the months of September or October, when the minimum is reached. Examination of the figures supplied by diphtheria and which are given below, suggests that the behaviour of diphtheria in this respect may not be identical with that of scarlet fever, and instead of cases under five years of age occurring in largest proportion at the beginning and end of the year that this largest proportion may eventually be found in diphtheria some two or three months later. The month of August causes an interruption to the fall to September, but as already stated, this fact is evidently due to the closure of schools in this month. The experience of further years is necessary to determine more precisely the curve of seasonal age-distribution. Diphtheria, 1892-6. Month. Notified cases, 1892-96. All ages. 0— 1— 2— 3— 4— Under 5. 5— 10— 15— 20 and upwards. January 4,211 115 302 380 447 399 1,643 1,219 446 255 648 February 3,347 97 239 305 346 337 1,324 978 344 178 523 March 3,624 98 274 309 385 397 1,463 1,059 387 186 529 April 3,669 112 261 313 389 396 1,471 1,054 365 217 562 May 4,526 112 321 381 462 433 1,709 1,282 526 297 712 June 4,549 81 293 367 439 460 1,640 1,306 523 307 773 July 5,315 126 297 370 500 512 1,805 1,528 675 389 918 August 4,841 126 289 403 476 405 1,699 1,155 586 411 990 September 5,810 114 307 389 527 544 1,881 1,716 719 464 1,030 October 6,365 152 369 463 542 597 2,123 1,875 775 427 1,165 November 5,858 132 367 460 587 571 2,117 1,725 628 384 1,004 December 4,995 121 324 434 545 476 1,900 1,500 555 278 762 Month. "All ages" taken as 1,000. All ages. 0— 1— 2 3— 4— Under 5. 5— 10— 15— 20 and upwards. January 1,000 27 72 90 106 95 390 289 106 61 154 February 1,000 29 72 91 103 101 396 292 103 53 156 March 1,000 27 76 85 106 110 404 292 107 51 146 April 1,000 31 71 85 106 108 401 287 100 59 153 May 1,000 25 71 84 102 96 378 283 116 66 157 June 1,000 18 64 81 97 101 361 287 115 67 170 July 1,000 24 56 70 94 96 340 287 127 73 173 August 1,000 26 60 83 98 84 351 238 121 85 205 September 1,000 20 53 67 91 94 325 295 123 80 177 October 1,000 24 58 73 85 94 334 294 122 67 183 November 1,000 23 63 79 100 97 362 294 107 66 171 December 1,000 24 65 87 109 95 380 300 111 56 153 42 Whooping Cough. The deaths from whooping cough in the administrative county of London during 1896 numbered 2,934, compared with 1,485 in 1895. The death rates from this disease in 1895 and preceding periods were as follows— Period. Death rate per 1,000 living. Period. Death rate per 1,000 living. 1851-60 0.88 1892 0.581 1861-70 0.88 1893 0.541 1871-80 0.81 1894 0.491 1881-90 0.69 1895 0.341 1891 0.681 1896 0.651 The mortality from whooping cough therefore in 1896 was nearly twice as great as the mortality in the preceding year. The death rate in each year since 1840 in relation to the mean death rate of the period 1841-96 is shown in diagram XIV. It is deserving of note that the death rate of each of the last 12 years has been below the mean of the last 56 years. The whooping cough death rate of London can be compared with that of other large towns England having a population of more than 200,000 inhabitants by reference to the following table— Whooping cough—heath rates per 1,000 living. Towns. Ten years, 1886-95. 1896. Towns. Ten years, 1886-95. 1896. London 0.60 0.652 Bristol 0.49 0.26 Manchester 0.61 0.67 Nottingham 0.46 0.39 Liverpool 0.62 0.46 Bradford 0.46 0.45 Birmingham 0.55 0.74 Hull 0.39 0.50 Leeds 0.42 0.60 Salford 0.71 0.88 Sheffield 0.52 0.58 West Ham 0.67 0.59 It will be seen that in the period 1886-95 the London death rate exceeded that of any of these towns except Manchester, Liverpool, West Ham and Salford, and in 1896 exceeded that of any except Manchester, Birmingham and Salford. The following table shows that the London death rate from whooping cough exceeded the death rates of all the undermentioned foreign cities in the period 1886-95 and exceeded all except Stockholm in 1896. Whooping cough—Death rates per 1,000 living. Towns. 1886-95. 1896. Towns. 1886-95. 1896. London .60 .652 St. Petersburg .25 .25 Paris .17 .11 Berlin .29 .32 Brussels .20 .14 Vienna .10 .11 Amsterdam .36 .33 Rome .08 .05 Copenhagen .45 .25 New York .27 .22 Stockholm .21 .66 In the year 1896, in the first quarter, the east group of districts suffered most heavily, the central the least. In the second quarter the east group again had the highest death rate and the west the lowest. In the third quarter the south group of districts suffered most severely and the west the least. In the fourth quarter the central group of districts had the highest death rate and the west again the lowest. For the whole year the east group had the highest death rate and the west the lowest. Of the districts, Bethnal-green had the highest death rate (1.22), and St. James, Westminster, the lowest (0.13). 1 See footnote (1), page 7. 1 See footnote (2), page 8. 43 The death rate of each district in 1896 and in the preceding ten years is shown in the following table— Sanitary district. Deaths in 1896. Death rates per 1,000 living. Sanitary district. Deaths in 1896. Death rates per 1,000 living. 1886-95. 1896. 1886-95. 1896. Paddington 49 .40 .39 Shoreditch 126 .88 1.01 Kensington 99 .42 .57 Bethnal-green 160 .79 1.22 Hammersmith 62 .63 .58 Whitechapel 36 .48 .45 Fulham 69 .59 St. George-in-the-East 17 .66 .35 Chelsea 63 .66 .64 Limehotise 61 .95 1.03 St. George, Hanover- 16 .33 .20 Mile-end Old-town 83 .75 .73 square Poplar 158 .72 .92 Westminster 25 .55 .46 St. Saviour, Southwark 19 .67 .74 St. James 3 .40 .13 St. George, Southwark 55 .89 .90 Marylebone 70 .45 .49 Newington 66 .79 .54 Hampstead 22 .29 .29 St. Olave 13 .53 1.10 Pancras 128 .59 .52 Bermondsey 97 .71 1.12 Islington 247 .59 .72 Rotherhithe 35 .67 .88 Stoke Newington 16 .53 .47 Lambeth 140 .60 .47 Hackney 147 .68 Battersea 138 .57 .82 St. Giles 14 .51 .36 Wandsworth 158 .82 St. Martin - in - the - 5 .39 .38 Camberwell 196 .62 .76 Fields Greenwich 127 .62 .71 Strand 8 .52 .33 Lewisham 31 .43 .29 Holborn 27 .69 .86 Woolwich 22 .48 .52 Clerkenwell 42 .72 .62 Lee 18 .42 .46 St. Luke 23 .72 .55 Plumstead 35 .58 London, City of 7 .26 .22 London 2,934 .60 .651 Typhus. During the year 1896 six cases of typhus were notified, and five deaths from this cause were registered in the administrative county of London. The death rates from this disease per 1,000 living in 1896 and preceding periods were as follows— 1871-80 .055 1893 .0011 1881-90 .008 1894 .0011 1891 .0021 1895 .0011 1892 .0031 1896 .0011 The death rate in each year since 1868 in relation to the mean death rate of the period 1869-96 is shown in diagram XV. Inquiry has been made with regard to the cases notified as typhus in London during the year, and the information obtained concerning these cases, and concerning certain other cases, which were diagnosed as typhus at the hospitals of the Metropolitan Asylums Board, may be summarised as follows— March.—On the 8th March a male, aged 35, living in Holborn, was certified to be suffering from typhus abdominalis. Dr. Bond writes, with reference to the case, "This is a case of typhoid (notified from the German Hospital as typhus abdominalis)." June.—During the last week of June and the first week of July three cases of typhus were notified in Camberwell. The three patients were all removed from the same house, and previous cases of illness had occurred in this house. Some of these previous cases had been notified as cases of typhoid, and removed to the South-Eastern Hospital. In all there were seven cases diagnosed at this hospital as cases of typhus. Of these cases, six came from one house, and the seventh from a second house in the same road as the first. On attempting to trace the origin of the disease it was found that illness of an obscure type had affected persons living in the house, which ultimately furnished six cases which were regarded as typhus, as early as the beginning of April. The information in my possession with regard to the series of cases is as follows— On April 12th the first case of illness occurred in a little girl between 2 and 3 years of age, a member of a family named B. This child suffered from "an ill-defined type of low fever," which the medical attendant " did not regard as enteric in one so young." She made a good recovery. S.B., aged 7, an elder brother of the above, was attacked in a similar way some two or three weeks after the commencement of his sister's illness. He had, however, some diarrhoea, and the case was notified as typhoid fever on April 29. Another boy, belonging to the same family, sickened next, and suffered from "catarrhal symptoms of the bronchiæ." This boy might, says the medical attendant, have " been labelled as a case of influenza." He recovered. On June 4th the father and mother of these children were removed to the South-Eastern Hospital. They were certified to be suffering from typhoid fever, but were found to be the subjects of typhus, and were later so notified. 1 See footnote (1), page 7. 44 On June 5th a boy, E.C., aged 7, living at a house in the same road as the house occupied by the five persons above referred to, was removed to the SouthEastern Hospital. This lad too was found to be suffering from typhus. On July 24th E.B., an elder sister, aged 16, of the "B" children, and on June 26th the boy, E.B, aged 7, referred to above and belonging to the same family, were removed to the South-Eastern Hospital. On June 30th another brother was removed to the hospital. Finally, on July 4th, a man, J.R., aged 76, living in the house occupied by the family B., was taken to hospital. He too was found to be the subject of typhus, and the case was notified. Dr. Stevens, the medical officer of health of Camberwell, informs me that the girl E. B., aged 16, (who was removed to hospital on June 24th) worked at a place where mattresses coming from Woolwich were unpicked. Dr. Stevens adds that as far as he can make out she last attended there j ust before Whitsuntide. Only one case belonging to this group was fatal. July.—On July 11th a girl aged 9, living in Hammersmith, was certified to be suffering from typhus. The child was not removed to hospital. She died on July 17th, and the case was certified as typhus fever, 17 days. No information could be obtained with regard to a possible source of infection. On July 29th a boy, aged 10, living in Lambeth, was certified to be suffering from typhus. The boy was taken ill on July 23rd. On that day he had been away from home and drank some water from a "frog-pond," and his illness was attributed to this circumstance. He was removed to the South-Western Hospital on July 26th, and he died there. With reference to the possible source of infection it was noted that an uncle of this boy had travelled as a steerage passenger from Australia, and arrived home 14 days before his nephew was taken ill. August.—On August 15th a man, aged 54, living in Hackney, was certified to be suffering from enteric fever. The patient died at his own home, and the cause of death was returned as typhus. The medical attendant gave it as his opinion that the malady was caused by sewer emanations some four weeks prior to the commencement of the illness. November.—On November 8th a male, aged 18, living in St Luke was certified to be suffering from typhoid fever. He was removed to the South-Eastern Hospital, and was there found to be the subject of typhus. The patient was a picture-frame maker. Inquiry was made at his home and at the place where he worked, but no source of infection could be traced. The illness did not prove fatal. Enteric Fever. The number of cases of enteric fever notified in the administrative county of London in 1896 was 3,196, and the number of deaths belonging to the administrative county was 564, compared with 3,521 cases and 598 deaths in 1895. The rates in 1896 and preceding periods were as follows— Enteric fever. Period. Death rate per 1,000 living. Case rate per 1,000 living. Case mortality per cent. 1871-80 0.24 — — 1881-90 0.19 — — 1891 0.121 0.8 15.6 1892 0.101 0.6 17.2 1893 0.161 0.9 18.4 1894 0.141 0.8 18.1 1895 0.141 0.8 17.0 1896 0.121 0.7 17.6 The death rate from this disease in each year since 1868, in relation to the mean death rate of the period 1869-96 is shown in diagram XVI. It will be observed that during the last twelve years the death rates from this disease have been below the mean of that period. In an appendix to my annual report for the year 1894, I discussed the question whether there was indication of any relation between certain exceptional floods in the Thames and Lea, and an exceptional increase of prevalence of enteric fever in the 49th, 50th, and 51st weeks of the year, and I published for purposes of comparison a diagram representing the number of cases of enteric fever included in the weekly notification lists in relation to the mean of the years 1890-93. Diagram XVII. is obtained by similar treatment of the cases notified in the years 1890-6, the notification figures for seven complete years being now available. Comparison of the two diagrams, the one based on the cases of 1890-3, the other on the cases 1890-6, shows that they are in substantial agreement. So far therefore the addition of the cases of subsequent years tends to show that the diagram of 1890-3 was one with which the diagram of 1894 could be properly compared. The diagram representing the cases notified in 1896 is also given. It affords no evidence of behaviour of enteric fever similar to that of 1894, nor indeed were floods experienced in the latter part of 1896, such as occurred in 1894. In the distribution of this disease in London throughout the year in the first quarter the central 1 See footnote (1), page 7. 45 group of districts had the highest death rate, the north, the lowest. In the second quarter the central and west group of districts had the highest death rates, and the east the lowest. In the third quarter the central group had the highest death rate, and the west the lowest. In the fourth quarter the central group again had the highest death rate, and the south the lowest. For the whole year the central group had the highest death rate, and the west the lowest, the district with the highest mortality being the City (0.31), the lowest being the Strand and St. Saviour Southwark (0.04). The case rate of each London district in 1890-5 and in 1896 and the death rate in 1886-95 and in 1896 is shown in the following table— Sanitary district. Cases, 1896. Case rate per 1,000. Deaths, 1896. Death rate per 1,000. 1891-95. 1896. 1886-95. 1896. Paddington 61 .5 .5 13 .13 .10 Kensington 95 .5 .5 16 .11 .09 Hammersmith 51 .5 .5 13 .13 .12 Fulham 54 .5 .5 9 .08 Chelsea 66 .7 .7 10 .14 .10 St. George, Hanover-square 54 .6 .7 9 .12 .11 Westminster 35 .6 .6 9 .09 .17 St. James 6 .7 .3 3 .17 .13 Maryleborne 107 .7 .7 20 .12 .14 Hampstead 58 .6 .8 7 .09 .09 Pancras 200 .7 .8 31 .14 .13 Islington 236 .7 .7 47 .13 .14 Stoke Newington 16 1.1 .5 5 .18 .15 Hackney 202 .9 37 .17 St. Giles 21 .7 .5 4 .17 .10 St. Martin-in-the-Fields 18 .7 1.4 3 .13 .23 Strand 8 .7 .3 1 .19 .04 Holborn 30 1.1 1.0 5 .17 .16 Clerkenwell 67 .9 1.0 15 .15 .22 St. Luke 38 .6 .9 4 .15 .09 London, City of 21 .8 .7 10 .13 .31 Shoreditch 117 .8 .9 17 .16 .14 Bethnal-green. 129 1.0 1.0 20 .18 .15 Whitechapel 62 .6 .8 9 .13 .11 St. George-in-the-East 33 .9 .7 5 .17 .10 Limehouse 27 1.1 .5 3 .19 .05 Mile-end Old-town 113 .9 1.0 16 .17 .14 Poplar 184 1.4 1.1 26 .21 .15 St. Saviour, Southwark 9 .4 .4 1 .11 .04 St. George, Southwark 48 .6 .8 7 .11 .11 Newington 88 .6 .7 18 .12 .15 St. Olave 9 .6 .8 2 .13 .17 Bermondsey 65 .6 ' 1 11 .13 .13 Rotherhithe 45 1.2 1.1 11 .18 .27 Lambeth 165 .6 .5 24 .12 .08 Battersea 109 .7 .6 16 .12 .09 Wandsworth 102 .6 .5 21 .11 Camberwell 175 .6 .7 37 .12 .14 Greenwich 113 1.3 .6 32 .15 .18 Lewisham 64 .5 .6 9 .09 .08 Woolwich 21 .6 .5 2 .14 .05 Lee 23 0.9 .7 2 .10 .05 Plumstead 29 .5 4 .07 Port of London 17 — — — — — London 3,196 .8 .7 564 .14 .121 During the year a report was submitted to the Local Government Board by their medical officer, on the cultivation and storage of oysters and certain other molluscs in relation to the occurrence of disease in man. To this report is appended a report by Dr. H. Timbrell Bulstrode on an inquiry into the conditions under which oysters and certain other edible molluscs are cultivated and stored along the coast of England and Wales; also a report by Dr. Klein, which related to an inquiry into the identification of the microbes on or within oysters derived from a number of different localities, and to the ability of oysters to admit to their interior the microbe of enteric fever and Koch's vibrio, and the ability of these organisms to subsist in sea-water. Dr. Bulstrode's inquiry showed that in some places where oysters were cultivated they were exposed to sewage pollution, especially in the fattening beds and ponds and pits resorted to for storage purposes. The results of Dr. Klein's investigations can be best appreciated by reference to the following paragraph in the report of the medical officer of the Local Government Board— The results of Dr. Klein's investigations which bear more immediately on the culture of oysters 1 See footnote (1), page 7. 46 would appear to be as follows—First, the cholera vibrio, and still more the typhoid bacillus, are difficult of demonstration in sewage known to have received them ; second, both these organisms may persist in sea-water tanks for two or more weeks, the typhoid bacillus retaining its characteristics unimpaired, whilst the cholera vibrio tends to lose them ; third, oysters from sources which appeared to be free from risk of sewage contamination exhibited none of the bacteria, specific or otherwise, which are commonly regarded as being concerned with sewage; fourth, oysters, from a few out of numerous batches derived from sources where they did appear to be exposed to risk of sewage contamination, were found to exhibit colon bacilli, a circumstance which, notwithstanding the comparative universality of this intestinal organism, may be regarded as having some significance by reason of the absence of this bacillus from oysters which appeared to have been exposed to no such risk; fifth, in one case where the circumstances were especially suspicious Eberth's typhoid bacillus was found in the mingled body and liquor of the oyster. In my report for the year 1894, I referred to an outbreak of enteric fever in Wesleyan College, Connecticut, in which a number of persons were attacked undoubtedly through eating specifically contaminated oysters, and in the report of that year and of 1895, I cited various instances in which London medical officers of health had directed attention to the fact that enteric fever had followed upon the eating of oysters. This year again, reference is made to the subject in the reports relating to the following districts— Marylebone.—" A few [of the cases of enteric fever] had some connection with sewage-polluted oysters." Stoke Newington.—" Seven of the cases were doubtless imported and three were ascribed by the sufferers themselves to the eating of oysters." Hackney.—" For some years I have had cases brought to my notice in Hackney where the disease had undoubtedly been contracted out of London during the summer holidays, mostly during visits to places on the coast; during 1896 no less than eight such cases were brought to light .... The interest of all this so far as Hackney is concerned lies in the fact that oyster eaters are as numerous in this district as in many others; and there is reasonable ground for suspicion that some of the cases of the past year have been due to this cause. I have notes that several of those who had suffered from typhoid fever had eaten freely of this mollusc at a period on or about the time when the disease must have been contracted. Two of the cases which I mentioned above as having been introduced into Hackney were certainly infected during a holiday at Southend, one of the places mentioned by Dr. Bulstrode where the oysters were exposed to pollution. I must add, however, that I am unable to prove these persons had eaten specifically polluted oysters." Wandsworth (Putney and Roehampton).—" The eating of contaminated oysters was again believed to be the cause of the disease in several cases." Lee (Eltham).—" Ten cases were reported but fortunately no deaths, nearly half of them were attributed by the medical attendants to eating oysters." Plumstead.—" In one case the patient was in the habit of eating oysters freely, in another case the disease was evidently contracted at the seaside." The report of medical officer of health of Shoreditch gives account, as follows, of a localized outbreak of enteric fever possibly due to insuction of sewage matter into a defective water main. Thirteen cases of enteric fever were notified between August 6th and November 4th in a small area comprising the west end of Watson's-place and the adjacent north end of Louisa-street. The persons attacked had an average age of 15 years, the average age of other cases in Shoreditch occurring at the same time being 22.2 years. They lived in ten houses, five on the south side of Watson's-place, one on the north side and the remainder in Louisa-street. "The drainage of the houses on the south side of Watson's-place was extremely defective, but that of the houses in Louisa-street and on the north side of Watson's-place was satisfactory. The invaded houses on the south side of Watson's-place were found to be drained by a common drain which was in a very defective condition throughout the whole of its extent to the sewer in Watson's-place, being broken in several places and leaking freely at every joint." In point of time there was some grouping of the cases of enteric fever, the illness of some not being notified until some three weeks after the commencement of their illness. Inquiry as to milk supply showed that this was from various sources. The following paragraphs in the report of the medical officer of health shows the probable cause of this outbreak— The defective drain was re-laid throughout the whole of its course, and intercepted from the vestry's sewer, the work being finished in October. Where it passed under the roadway to join the sewer in Watson's-place, the depth was iound to be between 9 and 10 feet below the crown of the road. I am informed that the water main supplying the houses passes down Watson's-place from east to west and then turns round to supply the houses in Louisa-street. It is about two feet below the crown of the road and where it crosses the defective drain there is a distance of about eight feet between them. The water main is a 4-inch iron pipe. It was found to be broken, and was repaired in September, 1896. As to the length of time the fracture had existed before it was discovered I have no knowledge. The distance of the fracture in the water main from the defective drain passing under the roadway was about 23 feet. Although the evidence as to the implication of the water supply through the defective drain is not conclusive, it is quite within the bounds of possibility that such was the case, and that this is the other factor in connection with the occurrences of these cases of typhoid fever. Enteric fever—Age and sex distribution. As in preceding years, males in London in 1896 had a greater attack rate and death rate from this disease than females, and this greater incidence upon males of attack and death is manifested at each age period. The case mortality of males at all ages was greater than that of females. This is due to the higher case mortality of males above five years of age, females below five years of age having a higher case mortality than males of like age. 47 Enteric fever, 1896. Males. Females. Age period. 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. 1,778 349 19.6 85 17 1,412 226 16.0 61 10 0— 2 2 15.2 38 6 5 3 17.1 31 5 1— 14 1 4 3 2— 17 2 9 2 3— 27 7 37 3 4— 39 3 27 3 5— 241 29 12.0 102 12 195 17 8.7 81 7 10— 283 28 9.9 131 13 229 24 10.5 104 11 15— 286 57 19.9 138 27 219 41 18.7 95 18 20— 238 53 22 3 117 26 197 33 16.7 80 13 25— 374 77 20.6 107 22 283 49 17.3 70 12 35— 156 50 32.1 60 19 125 26 20.8 44 9 45— 65 25 38.5 36 14 59 12 20.3 29 6 55 and up wards. 36 15 41.7 21 9 23 10 43.5 10 4 Diarrhcea. The deaths in the administrative county of London attributed to diarrhoea and dysentery in the year 1896 numbered 3,199, compared with 3,581 in 1895. The death rates per 1,000 living in 1896 and preceding periods were as follows— 1851-60 1.03 1892 0.601 1861-70 1.04 1893 0.80l 1871-80 0.95 1894 0.411 1881-90 0.75 1895 0.821 1891 0.571 1896 0 .711 The diarrhoea death rate each year since 1840 in relation to the mean death rate of the period 1841-96 is shown in diagram XVIII. The mean temperature of the summer quarter of each year in relation to the mean of the period 1841-96 is also shown. The intimate relation between the temperature of the summer quarter and the amount of diarrhoea mortality will be seen. The age distribution of the deaths from this disease in the registration county of London in 1896 was as follows— Under 1 1-5. 5-20 20-40. 40-60. 60-80. 80 and year. upwards. 2,572 413 11 19 43 127 38 It will be seen from the following table that the London death rate from diarrhcea was lower than that of any of the undermentioned towns except Bristol in the period 1886-95, and in the year 1896 was lower than that of any except Leeds, Bristol, Nottingham and Bradford. Diarrhcea—Death rates per 1000 living. Towns. Ten years, 1886-95. 1896. Towns. Ten years, 1886-95. 1896. London 70 .722 Bristol .49 .52 Manchester 110 .94 Nottingham 1.03 .69 Liverpool 113 1.16 Bradford .89 .38 Birmingham 110 1.20 Hull 1.24 .90 Leeds 113 .69 Salford 1.46 1.23 Sheffield 118 1.02 West Ham ... •80 •81 The London death rate from diarrhoea in the four quarters of the year was O.11 0"24, 2'37 and 0'16, In the third quarter the eastern group of districts had the highest death rate (3'08) and the north and west the lowest (2.02 and 2.01 respectively), while of the several districts Clerkenwell had the highest death rate (4.48) and the City the lowest (0.38). In the whole year the eastern group had the 1 See footnote ('), page 7. 2 See footnote (2), page 8. 48 highest death rate (0.91) and the north and west the lowest (0.61), while of the several districts St. Olave had the highest death rate (1.43) and the City the lowest (0.16). Death rate per 1,000 Death rate per 1,000 Sanitary district. Deaths, living. Sanitary district. Deaths, living. 1896. 1886—95. 1896. 1896. 18G8—95. 1896. Paddington 66 .53 .52 Shoreditch 136 1.04 1.09 Kensington 60 .51 .35 Bethnal-green 113 .81 .86 Hammersmith 85 .80 Whitechapel ... 45 .82 .56 Fulham 134 1.15 St. George-in-the-East 60 1.56 1.24 Chelsea 66 .76 .67 Limehouse 46 .97 .78 St. George, Hanover Mile-end Old-town 95 .87 .84 square 20 .38 .25 Poplar 168 .69 .98 Westminster 35 .66 .64 St. Saviour, Southwark 23 .79 .90 St. James 10 .38 .43 St. George, Southwark 64 .92 1.04 Marylebone 68 .57 .47 Newington 127 .74 1.03 Hampstead 17 .29 .22 St. Olave 17 .84 1.43 Pancras 180 .67 .73 Bermondsey 52 .79 .60 Islington 160 .66 .47 Rotlierhithe 31 .91 .75 Stoke Newington 27 .59 .79 Lambeth 175 .68 .58 Hackney 192 .88 Batter sea 166 .67 .98 St. Giles 16 .60 .41 Wandsworth 121 .63 St. Martin - in - the Camberwell 176 .65 .68 Fields 5 .44 .38 Greenwich 120 .66 .67 Strand 13 .57 .54 Lewisham 67 .43 .63 Holborn 22 .67 .70 Woolwich 28 .53 .67 Cler ken well 88 .96 1.31 Lee 15 .42 .38 St. Luke 52 1.06 1.23 Plumstead 33 .54 London, City of 5 .27 .16 London 3,199 .69 .711 The medical officer of health of Fulham states that nearly all the infants in his district who died from diarrhoea were hand fed, and that more than half the deaths of illegitimate children in July and August were due to diarrhoea. Cholera. The number of deaths attributed to cholera and choleraic diarrhoea registered in the year 1896 was 95, compared with 74 in 1895, while the number of cases notified as " cholera " in 1896 was 13, as compared with 29 in 1895. On the 9th July I reported to the Public Health Committee the fact that cases of cholera had occurred at Alexandria, and that one case of cholera had been reported at Dantzic. I advised that the arrangements adopted in former years, with reference to the institution of inquiries concerning suspected cases of Asiatic cholera in London, should be continued, and I was authorised to make use, if necessary, of Dr. Klein's services for the purpose of bacteriological examination. I thereupon communicated, as in previous years, with medical officers of health, informing them of the Committee's decision. Systematic inquiiy was instituted concerning all cases notified or certified as cholera or choleraic diarrhcea, and concerning all cases brought to my notice by medical officers of health. In three instances a bacteriological examination was made, but in each case the examination showed that there was no evidence pointing to the disease being Asiatic cholera. The following is a brief account of the three cases referred to— (i.) W. S., male, aged 50, a costermonger, dealing in fish and fruit, and living in Orbstreet, Newington. This man went on July 14th to Belvedere for a day's holiday. It is not known what he ate or drank on that day, save that he had some strawberries. On July 17th and 18th he suffered from diarrhcea. On July 19th he was compelled to keep in bed, as he began to have severe abdominal pains and cramps all over his body. Nothing is known as to the character of the evacuations. On July 20th he was pulseless and collapsed, and his condition rapidly becoming worse he died shortly after noon on that day. The medical man who attended the patient reported that the case was one of cholera, and Dr. Millson, medical officer of health of Newington, communicated with me, and it was arranged that a post-mortem examination should be made. This examination took place on July 21st. Beyond the fact that the liver showed indications of fatty degeneration, no obvious signs of disease was found in any organ of the body. The small intestines contained a little fluid material which was faintly bile-stained. A piece of the lower part of the ileum was taken to Dr. Klein, who found no evidence that the case was one of Asiatic cholera. (ii.) E. H., male, aged 53, a navvy living in Arpley-road, Penge, was taken ill on July 26th. He suffered at first from diarrhcea, vomiting and cramps supervened later in the day. The medical man who was called in regarded the case as a suspicious one, as did also his partner, who had had experience of cholera abroad, and who found the patient on July 27th collapsed and blue with complete loss of voice and suffering from cramping pain in the limbs. There was, moreover, profuse discharge from the lower bowel of fluid material like serum. The patient had passed urine at 8 a.m., but did not, so far as could be ascertained, subsequently pass any. The patient died at 4 p.m. on July 27th. E. H. had lived with his wife in Penge for many years, in eariy life he had been abroad and had suffered from malaria. For two or three days before the commencement of his 1 See footnote (1), page 7. 49 fatal illness he had been engaged on a " drainage job," but it seems that he was not actually brought in contact with any sewage material. On July 24th he ate a pennyworth of gooseberries. He is not known to have eaten any shellfish. A post-mortem examination was made on July 29th. The left ventricle of the heart was found to be hypertrophied, and the kidneys were found to be somewhat enlarged, capsule readily separable, cortex very pale, medulla injected. The small intestines contained a little fluid having the appearance of a mixture of milk and mucus. The stomach contained a number of gooseberry skins. A piece of the ileum was taken to Dr. Klein, who obtained no evidence that the case was one of Asiatic cholera. (iii.) M.O.,maleaged 40, a Danish seaman arrived in the s.s. Inverness at the mouth of the Thames about the end of July. He was suffering at the time from headache and was feverish. A second sailor was, moreover, affected in a similar manner. The vessel was inspected by the port medical officer on her arrival on August 1st, and the two men were found to be suffering from what was regarded as " malarial fever." The vessel came up to London, and on August 2nd M.O. applied at the Greenwich hospital for treatment. He returned to his ship, and was found dead in his bunk on the morning of August 6th. An inquest was held on August 7th. when the captain of the Inverness, a seaman, and a medical man who had made the post-mortem examination, gave evidence. The jury found the death was due to English cholera, and the same evening the case was notified to the medical officer of health of Plumstead. It was ascertained from the deputy coroner who had held the inquest that M. 0. had joined the Inverness on May 19th at Barry, near Cardiff, and it was further ascertained that the vessel left Barry for Cape Verde and Savannah on May 22nd, and left Savannah for London on July 12th. A portion of ileum, which had been preserved at the post-mortem examination, was obtained, and taken to Dr. Klein, who reported that he found no evidence that the case wa3 one of Asiatic cholera. Erysipelas. The deaths attributed to erysipelas in the registration County of London in 1896 numbered 207 the corrected annual average of the preceding ten years being 280. I he number of cases notified and the number of deaths registered in the registration county of London during the last six years have been as follows— Year. Cases. Case rate per 1,000 living. Deaths.1 Death rate per 1,000 living. 1891 4,764 1.13 214 .05 1892 6,934 1.63 292 .07 1893 9,700 2.26 424 .10 1894 6,080 1.40 221 .05 1895 5,660 1.30 179 .04 1896 6.436 1.43 207 .05 The case rate and death rate were therefore greater than the rates of the preceding year. The number of cases notified and the case rate of each district in 1896, together with the mean case rate of the period 1891-5 are given in the following table- Sanitary district. Cases, 1896. Case rate per 1,000 living. Sanitary district. Cases, 1896. Case rate per 1,000 living. 1891-95. 1896. 1891-95. 1896. Paddington 119 1.2 .9 Whitechapel 138 1.7 1.7 Kensington 275 1.3 1.6 St. George's-in-the-East 89 1.6 1.8 Hammersmith 121 11 11 Limehouse 110 1.8 1.9 Fulham 99 11 .8 Mile-end Old Town 197 1.9 1.7 Chelsea 120 1-7 1.2 Poplar 315 2.2 1.8 St. George, Hanover-sq. 56 0-8 .7 St. Saviour, Southwark 35 1.4 1.4 Westminster 79 11 1.4 St. George, Southwark 95 1.5 1.6 St. James 20 0-9 .9 Newington 194 1.6 1.6 Marylebone 248 1-8 1.7 St. Olave 21 1.5 1.8 Hampstead 54 0-8 .7 Bermondsey 131 1.6 1.5 Pancras... 355 2.0 1.4 Rotherhithe 113 22 2.8 Islington 394 1.4 1.1 Lambeth 355 1.4 1.2 Stoke Newington 40 1.4 1.2 Battersea 253 1.9 1.5 Hackney 311 1 .4 1.4 Wandsworth 265 1.5 1.4 St. Giles 80 2.0 21 Camberwell 319 1.3 1.2 St. Martin-in-the-Fields 12 0.8 .9 Greenwich 242 1.6 1.4 Strand 11 0.7 .5 Lewisham 91 11 .9 Holborn 65 2.2 2.1 Woolwich 45 0.9 11 Clerkenwell 108 2.1 1.6 Lee 37 1.0 .9 St. Luke 133 2.4 3.2 Plumstead 43 .7 London, City of 34 1.2 1.1 Port of London 2 1.5 Shoreditch 297 1.8 2.4 London 6,448 15 14 Bethnal-green 327 2.3 2.5 1 See footnote ('), page 8. [7] 50 Puerperal Fever. The deaths attributed to puerperal fever in 1896 amounted to 225 in the registration county of London, the corrected annual average of the preceding ten years being 283. The number of cases notified and the number of deaths registered in the registration county of London have been as follows— Year. Cases. Deaths.1 1891 221 222 1892 337 313 1893 397 352 1894 253 210 1895 236 208 1896 277 225 If these cases and deaths are considered in relation to the total population and total births, the following rates are obtained— Year. Case rate per 1,000 living. Case rate per 1,000 births. Death rate1 per 1,000 living. Death rate1 per 1,000 births. 1891 .05 1.64 .05 1.65 1892 .08 2.55 .07 2.37 1893 .09 2.98 .08 2.65 1894 .06 1.92 .05 1.60 1895 .05 1.76 .05 1.56 1896 .06 2.04 .05 1.66 There is therefore in 1896, as compared with 1895, increase in the case rate and in the death rate, calculated on the births. Comparison of the fluctuations of the rates of puerperal fever with those of erysipelas during these six years show close correspondence between the two diseases, that is to say, in each year they rise or fall together. The following references to puerperal fever are contained in the reports of the medical officers of health of Poplar (Bow) and Plumstead— Poplar (Bow)— Two fatal cases of puerperal fever occurred in the practice of one of the midwives to the Royal Maternity Society, residing in Old Ford. -As soon as he (the medical officer of health) received the notification of the first case he wrote both the midwife and the nurse, requesting them to retire for a time. The midwife had already given notice to her society, and was suspended; but before she became aware of the nature of the case she had attended another patient and infected her. Both women died. Through disobedience to the secretary's order to permit the Board's officials to disinfect her working clothes the midwife was dismissed from the society's service. Then, and then only, she gave up her clothes for disinfection. Plumstead— Three cases of puerperal fever having occurred in the practice of one midwife at the close of 1895, I requested her, at the beginning of 1896, besides taking the usual measures of disinfection, to abstain from attending any further cases for a month. This she agreed to do, and no more cases occurred in her practice. I have found that puerperal fever most often occurs in the practice of midwives. Accordingly I have, by the authorisation of the health committee, issued to the midwives practising in Plumstead a printed bill of recommendations for antiseptic measures, and other precautions, likely to tend to the avoidance of infection. Influenza, Bronchitis and Pneumonia. The deaths from influenza, which in 1895 numbered 2,156, fell in 1896 to 496, the corrected annual average for the preceding ten years being 1,039. The deaths attributed to bronchitis were considerably below the corrected average, while the deaths attributed to pneumonia were but slightly below the corrected average for the preceding ten years. The deaths from these diseases since 1889 have been as follows— Tear. Influenza. Bronchitis. Pneumonia. Deaths.1 Corrected annual average for preceding ten years. Deaths.1 Corrected annual average for preceding ten years. Deaths.1 Corrected annual average for preceding ten years. 1890 652 7.0 12,448 11,342.8 6,224 4,925.0 1891 2,336 74.0 13,136 10,887.3 6,915 4,883.0 1892 2,264 318.7 11,183 11,230.0 6,164 5,171.9 1893 1,526 556.2 10,413 11,250.0 7,198 5,341.6 1894 750 715.5 7,816 11,292.3 5,321 5,632.5 1895 2,156 795.2 10,633 11,167.1 5,989 5,755.7 1896 496 1,039.0 7,558 11,385.0 5,537 5,9960 * See footnote (2), page 8. 51 Phthisis. The deaths from phthisis in the administrative county of London during 1896 numbered 7,586. The death rates of this disease per 1,000 living in the registration county of London in successive periods have been as follows — 1851-60 2.86 1892 1.89 1861-70 2.84 1893 1.91 1871-80 2.51 1894 1.74 1881-90 2.09 1895 1.83 1891 2.02 1896 1.731 The Registrar-General in the annual summaries for 1895 and 1896 relatingto London has distributed the deaths from phthisis occurring in public institutions belonging to London to the sanitary districts to which they belong, and it is therefore possible to compare the phthisis death rates of the various sanitary districts. The death rates in the several groups of districts were in 1895 and 1896, as follows— 1895. 1896. Central group 2.65 2.53 East „ 2.05 1.89 South „ 1.70 1.60 North „ 1.63 1.58 West ,, 1.55 1.54 The following table shows the number of deaths from phthisis, and the death rate per 1,000 living in the various sanitary districts in 1896— Sanitary district. Deaths, 1896. Death rate per 1,000 living, 1896. Sanitary district. Deaths, 1896. Death rate per 1,000 living, 1896. Paddington 161 1.27 Bethnal-green 236 1.80 Kensington 247 1.42 Whitechapel 193 2.41 Hammersmith 149 1.40 St. George-in-the-East 124 2.56 Fulham 194 1.66 Limehouse 133 224 Chelsea 179 1.82 Mile-end Old-town 156 1.38 St. George, Hanover-sq. 104 1.28 Poplar 302 1.75 Westminster 122 2.24 St. Saviour, Southwark 80 3.11 St. James 44 1.89 St. George, Southwark 165 2.69 Marylebone 280 1.95 Newington 245 1.99 Hampstead 86 1.12 St. Olave 26 2.19 Pancras 474 1.93 Bermondsey 176 2.03 Islington 499 1.45 Rotherhithe 90 2.19 Stoke Newington 28 0.82 Lambeth 489 1.63 Hackney 306 1.41 Battersea 242 1.44 St. Giles 113 2.91 Wandsworth 187 0.97 St. Martin-in-the-Fields 26 1.97 Camberwell 398 1.54 Strand ... 70 2.89 Greenwich 281 1.57 Holborn 102 3.24 Lewisham 108 1.01 Clerkenwell 145 2.16 Woolwich 88 2.09 St. Luke 123 2.92 Lee 50 1.27 London, City of 51 1.60 Plumstead 82 1.35 Shoreditch 232 1.87 London 7,586 1.682 It will thus be seen that the death rate from phthisis in the several sanitary districts varied between 3.24 (Holborn) and 0.82 (Stoke Newington). The medical officer of health of Plumstead reports that the sanitary authority has undertaken to supply disinfectants to be used in connection with cases of phthisis, and to disinfect rooms after the removal or death of a person who has suffered from this disease. Cancer. The deaths from cancer in the registration county of London in 1896, numbered 3,864, the average for the preceding 16 years being 3,381. The death rates of this disease per 1,000 living in successive periods have been as follows_ 1851-60 .42 1892 .75 1861-70 .48 1893 .80 1871-80 .55 1894 .79 1881-90 .68 1895 .83 1891 .78 1896 .861 Anthrax. In my last report I stated that under the Factory and Workshops Act, 1895, notice of every case of anthrax occurring in a factory or workshop is required to be sent to the chief inspector of factories at 1 See footnote (2), page 8. 2 See footnote (1), page 7. 52 the Home Office. In view of this requirement the inquiries which had for some years been made by Dr. Hamer into anthrax in London were discontinued. The report of the medical officer of health of St. Olave contains particulars of 14 cases of anthrax admitted in 1896 into Guy's Hospital, details of which were given in my last annual report. His report also states that at all the wharves washing accommodation for the men who carry and sort hides has now been provided. Notices giving advice and suggestions to the workmen employed are also posted in the warehouses. Bubonic Plague. The report of the medical officer of health of the Port of London contains the following statement as to certain cases of bubonic plague admitted into the Seamen's Hospital in 1896— On September 19th, a native of Bombay was admitted into the Seamen's Hospital in a typhoid state, and died within four or five hours of his admission. He had been in London since the 7th September, and was apparently in good health at the time of arrival. The case did not attract much attention, and the probable nature of the case was not suspected until a second somewhat similar one occurred. On the 29th September, a native who had been ill for four days was admitted into the same hospital with high fever and well-marked enlargement of the inguinal and femoral glands. Without going into technical details, it is sufficient to state that his case was suspicious of bubonic plague, though no absolutely certain diagnosis could be made. He died on the 3rd October. In view of the uncertainty as to the nature of the disease, it was deemed advisable to take all such precautions as would have been necessary in the presence of an undoubted case. The body was buried in a leaden coffin, and the vessels were thoroughly disinfected. Bacteriological examination demonstrated the presence of the plague bacillus, which was separated and cultivated for the purpose of diagnosis. Inasmuch as there is no reason why plague, if introduced int > a suitable soil, should not prevail and spread in this country, careful instructions have been given to your boarding medical officers as to the steps to be taken in dealing with any vessel on which even suspected cases are found. These cases having been brought to my knowledge by the medical officer of health of the Port of London, detailed inquiry was at once made by Dr. Young at all common lodging-houses and other premises likely to be resorted to by seamen, with a view to ascertaining whether any cases of illness had occurred among such persons which in any way resembled the cases admitted to the Seamen's Hospital. No evidence of the existence of such cases could, however, be discovered. Meteorology. The tables published in the annual summary of the Registrar-General, and prepared by Mr. J. Glaisher, F.R.S., from observations at Greenwich, show that the mean temperature of the air in 1896 was 50.1 degrees Fahrenheit, or 1.6 degrees above the average of the 125 years, 1771-1895. The rainfall during the year amounted to 22.42 inches, and was 2'56 inches less than the mean of 81 years. The temperature and rainfall in each month of 1896 are shown in the following table— Month. Temperature of the Air. Departure from average of 125 years, 1771-1895. Rain. Highest by Day. Lowest by Night. Mean for Month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. inches. January 52.9 28.3 40.5 + 39 9 064 February 56.2 24.3 40.3 + 1*6 6 .035 March 67.7 32.1 45.7 + 4.6 22 3.00 April 69.0 33.6 48.6 + 2.5 10 0.56 May 78.4 35.8 54.8 + 22 5 0.27 June 86.7 39.8 63.4 + 51 14 1.94 July 91.1 47.3 65.2 + 36 7 1.07 August 76.2 45.7 59.2 — 1.7 15 2.06 September 71.5 40.3 56.7 + 01 23 5.54 October 634 31.5 46.5 — 2.9 19 2.80 November 509 26.5 40.6 — 1.9 9 119 December 51.5 26.9 40.2 + 1.2 22 300 ADMINISTRATION. Dairies, Cowsheds and Milkshops. During 1896 the Council's inspectors made 21,284 inspections of dairies and milkshops. In 30 instances legal proceedings under the Dairies, Cowsheds and Milkshops Orders were instituted, and in these penalties amounting in the aggregate to £46 4s. were imposed. 256 cases of infectious disease occurring at milkshop premises were dealt with during the year; these included 156 cases of scarlet fever, 76 cases of diphtheria and membranous croup, 15 cases of enteric fever, 7 cases of erysipelas, 1 case of measles and 1 case of small-pox. In all cases the Council's inspectors visited the premises with a view to ensure the adoption of measures to prevent contamination of the milk. The number of applications for renewal of existing licences to cowsheds dealt with during the year was 405, of these 393 were granted. 53 Offensive Trades. During 1896 the Council's inspectors made 4,631 inspections of premises upon which offensive trades (including that of a " slaughterer of cattle ") were carried on. In 11 instances legal proceedings were instituted, and in 7 of these, penalties, amounting in the aggregate to £16 6s., were imposed. The number of applications during the year for renewal of existing licences to slaughterhouse premises was 478, of which 470 were granted. In the case of knacker's yards 5 licences were renewed; 6 licences were granted in 1895, but, in respect of one of these, no application was made in During the year 7 offensive businesses which had been discontinued for a period of nine months or upwards were struck off the register. These businesses included those of 1 bone-boiler, 1 manure-manufacturer, 3 fat-melters and 2 tripe-boilers. The number of applications for the licence of slaughterhouses and the number of slaughterhouses licensed is diminishing each year, as will be seen from the following table*— Tear. Number of applications received. Number of licences granted. 1891 656 651 1892 547 537 1893 542 529 1894 518 506 1895 497 485 1896 478 470 Complaints to the London County Council. During the year the Council received 1,141 applications for assistance in securing the removal of conditions which it was alleged were dangerous to health. The sanitary authorities were communicated with, and the complainants were informed where they should apply for remedy. The Council's inspector made 1,490 inspections in connection with these complaints, and the subject of complaint was kept under observation with a view to ensuring that a remedy was provided. Nuisances. Trade nuisances. Marine stores.—The Public Health Committee of the Council had under consideration an application from the vestry of Kensington that the Council should make an order, declaring the business of a rag and bone dealer to be an offensive business within the meaning of Section 19 of the Public Health (London) Act, 1891. The Committee thus reported to the Council on the 16th November, 1896— We have had under consideration a letter from the Vestry of Kensington, asking the Council to make an order declaring the business of a rag and bone dealer to be an offensive trade within the meaning of section 19 of the Public Health (London) Act, 1891. The vestry state that their attention has been directed to offensive smells emanating from certain premises in the parish in the occupation of a rag and bone dealer, and they refer to the case of Passey v. Oxford Local Board (43 J.P., 622). In 1883 the Vestry of Kensington made representations to the Metropolitan Board of Works in favour of the business of a marine store dealer being declared to be an offensive trade under the provisions of the Slaughterhouses (Metropolis) Act, 1874 (now superseded by the Public Health Act of 1891) but the Metropolitan Board did not see their way to do this. Since that application was made, the Council's by-laws regulating the conditions under which offensive matter can be removed through the streets have come into operation, and hence sanitary authorities can now deal with that part of the vestry's complaint of 1883. The question which remains is whether regulations are required with respect to the deposit and retention of animal matter in the premises of marine store dealers. With regard to the question of nuisance from the particular premises referred to by the vestry, we thought it well to ascertain whether any attempt had been made by the vestry to deal with such premises under section 21 of the Act of 1891, which provides a remedy in cases of offensive effluvia from trade processes. We are informed by the vestry that nuisance notices have from time to time been served under section 4 of the Act, but that in each case the notices have been complied with, and we understood no steps have been taken under section 21. We are advised that, as a strict question of law, the Council can, if the Local Government Board confirm its order, declare the business of a marine store dealer (if carefully defined), or of a rag and bone merchant, to be an offensive business within section 19. We think, however, that the Council would hesitate to make, and the Local Government Board would hesitate to confirm, an order affecting the several hundreds of these businesses which there are, we understand, at the present time in London, and entailing the making of by-laws and arranging a system of inspection, without considerably more evidence than there seems to be at present that an evil exists in London which cannot be effectually dealt with without such an order and that such an order, is therefore necessary in the interests of the public health. We recommend— That the Vestry of Kensington be informed that the Council feels that the facts at present within its knowledge would not justify it in making the order asked for. The medical officer of health of Kensington in reporting to the vestry on this decision of the Council, points out that for the purpose of proceeding under section 21 of the Public Health (London) Act, " in each case the nuisance would have to be proved ; whereas, if the conduct of the business were regulated by by-laws it would only be necessary to prove breach of the by-laws in order to secure the infliction of a fine, &c., and this power to prevent nuisance from a trade which is undoubtedly a frequent cause of nuisance would be materially increased." With reference to the administration of by-laws he adds that if the Council would obtain an order and make by-laws, " the several sanitary authorities could do the work of inspection." The medical officer of health of St. Giles expresses the *These figures include applications dealt with in the intervals between the annual licensing meetings iu October of each year. 54 opinion that this trade should be regulated by by-laws under section 19 of the Public Health (London) Act. The medical officer of health of Holborn reports that proceedings under section 21 were instituted against a rag warehouse, and the business removed from the district. Brickfields.—The medical officer of health of Kensington states that no nuisance was experienced from brickburning during the year. The medical officer of health of Hammersmith had occasion to report on complaint of offensive odour from a brickfield in Shepherds-bush. Ballast burning in Camberwell gave rise to nuisance and was dealt with accordingly. Other trade nuisances referred to in the annual reports are as follows:— Hammersmith.—Nuisance from fumes from a shaft at carpet cleaning works ; effluvia from the roof of the retort house of the Great Western gas-works; nuisance caused by the discharge into the main sewer of a product of the compression of a mineral oil. Holborn.—Nuisance from fried-fish shops. The report also states that additional condensers have been constructed at a metal refiners, and coppers and tanks have been reconstructed at a tripeboilers to prevent nuisance. St. Olave.—Nuisance caused by the manufacture of articles from the windpipes and bladders of animals was abated. The medical officer of health thinks that the by-laws of the Council regulating the conduct of a trade in which gut or intestines are manipulated should have been made to include this business. Poplar (Poplar and Bromley).—Nuisance from discharge of chemical refuse into sewer, from escape of acid fumes from sulphuric acid works, from the condensing apparatus of lamp black works being out of order, from treating cuttings in indiarubber works with chemicals, from escape of fumes from wooden smoke-holes during fish-curing, scraping and drying of skate and other fish skins, from defective roof of waste-hole of bone-boiling works, from vapours from fat-melting pans, from burning paint-tins in the open, from deposit of fish offal. (Bow).—Nuisance from chimney of pipe-making kilns being below windows of adjoining houses, from vapours from mixing-tanks of felt-works from boiling whalebone in an open pot, from burning bass refuse, from burning cork in the open, from escape of noxious gases from the main shaft of chemical works. Battersea.—Nuisance caused by the furnace used for the cremation of dogs, nuisance caused in the cleansing and drying of hair of ox-tails, nuisance from throwing water over clinkers drawn from a furnace. Greenwich (Deptford).—Nuisance from the tripe-boiling factory in the foreign cattle market. Limehouse.—Nuisance from the premises of a gut-scraper. Smoke nuisances. References to the subject of smoke nuisance appear in the majority of the annual reports of medical officers of health, thus— Hammersmith.—The report of the vestry states that in several cases it became necessary for action to be taken for preventing the recurrence of smoke nuisance. Letters of caution were addressed, but in no case was it found necessary to institute proceedings against offenders. Chelsea.—In 8 cases smoke nuisance was dealt with. St. George, Hanover-square.—In 3 cases smoke nuisance was dealt with. Westminster.—The medical officer of health reports that nuisance from the shaft at the vestry's depot was the subject of complaint. An increase of the height of the shaft was recommended by him, but it was found that to comply with this recommendation the provisions of the Building Act would require the re-building of the shaft; no action was taken. A penalty of £20 and £5 costs was imposed upon the owners of Queen Anne's-mansions for allowing dense black smoke to issue from a chimneyshaft in the buildings. St. James, Westminster.—In 9 cases smoke nuisance was dealt with. Marylebone.—26 complaints of smoke nuisance were dealt with. St. Pancras.—" In 2 cases smoke nuisances were suppressed." Islington.—Among the duties of the male inspector of workshops is the dealing with smoky chimneys. Hackney.—The number of complaints was 14. The service of notices was found to be sufficient. Strand.—" During the year much good has been done in the district by abating nuisances caused by smoke. . . . Such orders have been made in regard to chimneys sending forth black smoke in such quantity as to be a nuisance, and in each case has been complied with." Holborn.—" The smoke inspector, Mr. Thomas Madden, reports that there are 59 furnaces and boilers on the register, and that he makes periodical inspection of them, to see that they are in a proper working order and consumed their own smoke. Three notices were served and complied with." Clerkenwell.—3 smoke nuisances were abated. City.—49 cases of smoke nuisance were dealt with. Shoreditch.—In 45 instances intimation as to smoke nuisance was received from the London County Council. In 29 instances smoke nuisance was abated ; in 1 case legal proceedings were instituted. The cause of complaint was the burning of wood turnings in a furnace, the charred remains escaping with the smoke to the annoyance of the neighbourhood. The vestry proceeded under section 23 (2) of the Public Health (London) Act, but it was held this section did not apply. Whitechapel.—In 7 cases smoke nuisance was abated. St. George-inr-the-East.—In 7 cases smoke nuisance was remedied. Mile-end Old-town.—In 2 cases smoke nuisance was abated. Poplar.—In 38 cases smoke nuisance was abated. The cause is stated to be the burning of inferior fuel and-the use of defective apparatus. St. George-tlie-Martyr.—Smoke nuisance was discontinued in 7 cases. 55 Newington.—In 5 instances smoke nuisance was abated. St. Olave.—2 cases of smoke nuisance were dealt with. Bermondsey.—11 statutory notices were served and 7 summonses were taken out, and fines and costs inflicted amounting to £23 14s. Rotherhithe.— In 18 instances smoke nuisance was abated. Lambeth.—The number of cases of smoke nuisances investigated was 18. Battersea.—12 smoke nuisances were dealt with. Wandsworth (Clapham).—The number of cases which came under notice was 13, and in 11 cases intimation notices were served and complied with. Camberwell.—In 40 instances smoke nuisances were dealt with. Greenwich (Deptford).—Notices for the abatement of smoke nuisances were served in 14 instances. Lee (Charlton).—Only in a few cases has interference been required. Plumstead.—In the autumn the medical officer of health wrote to the director-general, calling his attention to the frequency with which black smoke proceeded from the arsenal chimneys. Less smoke was observed during the last three months of the year. Nuisance from deposit of offensive matter. Nuisance arising from deposit of offensive matter on vacant land is from time to time cause of complaint in London. The duty of the owner of such land has been recently decided by the Court of Appeal, the vestry of the parishes of St. Margaret and St. John, Westminster, having applied for an injunction against the owners of a piece of vacant land in that district for allowing the land to be and remain in such a state as to be a nuisance and injurious to health. This application was refused, the learned judge pointing out that it would not be reasonable to impose upon the owner of the land the serious duty of preventing nuisances from arising on the land, and that the vestry could remove the obnoxious matter under the powers of the 35th section of the Public Health (London) Act, and recover the expenses from the owner. The vestry appealed against this decision, the case being heard in the Court of Appeal before Lords Justice Lindley, Smith and Rigby who reversed the decision. Nuisance from stable manure. Nuisances from stable manure is referred to in several of the reports of medical officers of health. Paddington.—The medical officer of health thus writes— " There has been some difficulty in securing the regular clearance of manure from stables, chiefly in the summer months, when its removal is most required. The ultimate disposal of manure is becoming every year a more difficult problem. Farmers will not trouble themselves about it except at such times as may be convenient to themselves, and the extension of the suburbs renders it necessary to remove the refuse further afield. The sanitary authorities are awaking to the nuisance arising from heaps of refuse in their districts, and have obtained injunctions in certain cases, and in others have made by-laws imposing restrictions on contractors. Under section 36 of the Public Health (London) Act, 1891, the vestry are empowered to agree with horse owners to undertake the removal of manure. Such procedure would ensure regular collection from the mews and stables, but what the vestry would do with the collected manure it is difficult to say. The section mentioned is, however, incomplete, as it does not empower the vestry to levy any special charge or rate for such removal." Kensington.—The medical officer of health states that since the Council's by-law regulating the construction of receptacles for dung has come into operation " complaints are now few in number, and as the cause of complaint, the sunken dung pit is now almost a thing of the past, we may reasonably hope to be free from annoyance on this score in future." He shows in tabular form the alterations which have been effected, among which are the erection of 1,563 iron cages and the abolition of 725 brick receptacles. Referring to the difficulty in securing the removal of stable refuse and to the need of the consent of the owner of manure when its removal is undertaken by the sanitary authority in accordance with the provisions of section 36, he writes— " The necessary consent would be forthcoming in most cases if it became known that the requirements of the law would be enforced in case of neglect by the owner to comply with the regulations. In many cases money is paid by the owners for the removal of the refuse, and there is no reason why they should not pay the sanitary authority a suitable fee for the service. Many persons would be glad to do so, and thus relieve themselves of a burdensome obligation. At the same time it is not improbable that the large amount of refuse produced in our numerous mews would have a value sufficient to defray the cost of an organized system of collection and removal to the country." Referring to nuisance caused by the use of peat litter, and mainly arising in the course of its removal, he points out that the vestry under section 36 (2) of the Public Health (London) Act now requires the removal of manure from stables three times every week, i.e., on alternate week days, and that this requirement is generally complied with by the occupiers of the premises where this nuisance had arisen. St. George, Hanover-square.—The medical officer of health reports that the mews of the parish are generally satisfactory, except during the summer months, when there is great difficulty in getting rid of the dung, because the farmers are too busy to fetch it away. Wandsworth ( Wandsworth parish).—" Accumulations of manure are still a source of trouble to the sanitary department. It seems to be increasingly difficult for owners of horses to get rid of the manure, especially at certain seasons." Removal of offensive refuse. The removal of offensive refuse, either in prohibited hours or in a vehicle or vessel not properly 56 constructed, was the subject of proceedings in several districts, thus, in Hammersmith, Fulham, Chelsea, St. Pancras, Hackney, Mile-end Old-town, Poplar (Bromley), Limehouse, Lambeth, Battersea, applications were made to the magistrates for penalties for infringement of the Council's by-laws. Such applications were almost always successful. The medical officer of health of Mile-end Old-town, writing of fish offal, says—" The removal of this refuse through the streets was, up to the last year or so, a standing disgrace ; but after the by-laws regulating this matter came into force we took action against a number of owners of vehicles who created a nuisance by reason of the imperfect construction of their vans; this had a very good effect on most of the removers of this offal. Although during last summer we were on the look-out for any breach of the by-laws being committed. we only succeeded in finding one van that was not in a proper condition; the owner was summoned at the police court, and fined £1." The medical officer of health of Kensington states that the prevention of nuisance in connection with the storage, the collection, and the conveyance through streets of offensive substances coming under the general description " refuse," which was formerly a matter of no little difficulty, has been made more easy by the County Council's by-laws made in 1893 under the provisions of section 16 of the Public Health (London) Act, 1891. He again refers to difficulty experienced by a fish and game dealer, owing to the by-law prescribing the hours of removal of offensive matter. The contractor declined to remove the offal on Saturday night, with the result that the refuse remained on the premises until Monday morning. The Commissioner of Metropolitan Police has, at the request of the Council, given directions to police constables to bring to the notice of sanitary authorities any cases of infringement of the by-law coming to their knowledge. Removal of house refuse. During the year inquiry was made in a number of London districts by an officer of the Council's Public Health Department, with a view to ascertaining how far there was compliance with the requirement of the Council's by-law that house refuse shall be removed from every house not less frequently than once a week; thus, this inquiry was made in Camberwell, Clerkenwell, Greenwich, Holborn, Mile-end Old-town, Newington and St. Luke. In all cases in which there was necessity, communications were addressed to the sanitary authority concerned. In my last report I referred to a decision by the Lord Chief Justice and Mr. Justice Wills in the Queen's Bench division of the High Court of Justice in which it was held that the refusal to allow the scavengers to come on to premises to remove house refuse " constituted obstruction " within the meaning of section 116 of the Public Health (London) Act, 1891. This decision was the subject of report by the Public Health Committee to the Council in June, and a copy of this report was communicated to every London sanitary authority for their information. The subject of the removal of house refuse was discussed in the annual reports of medical officers of health as follows— Paddington.—" The collection of house refuse is not within the jurisdiction of the department and is only under its notice when complaint is made of non-removal. Such complaints have been rarer during the past year, showing that the system of house-to-house collection recently inaugurated has been successful. As to the final disposal of the collected refuse, no changes have been introduced. During the year a special committee had the subject of the erection of a dust destructor under its consideration. A very complete report was issued in December last, strongly recommending that the refuse of the parish should be cremated but the proposal was rejected by the vestry. The present system of 'manufacturing' cannot persist much longer, as the markets for the sundries salvaged are shrinking, and land for shoots becoming every year more difficult to secure. The extra metropolitan authorities object to the deposit of house refuse equally to that of manure. . . The chief objections put forward against the committee's proposals were the loss of the return for sundries obtained from the manufacturing, and the nuisance likely to be created in the process of burning. As to the former the present return is likely to be a vanishing quantity, and what now brings in a set-off against the cost of collection may be expected to become an additional expense. The fear of nuisance from the process of burning is not supported by the experience of other towns." Kensington.—The medical officer of health after referring to the opinion he had expressed that " the process of cremation would appear to offer, in existing circumstances the most effectual and economical and the only sanitary method of dealing with the refuse of the parish," states that the Wharves and Plant Committee on the reference of the vestry " as to the possibility of securing, on advantageous terms, a suitable site for the erection of a cremator for the disposal of the refuse of the northern portion of the parish " reported (in October) that looking to the possible development of electric traction at an early date it is not advisable to take further action in the matter at present. Account is given of proceedings instituted by the Orsett Rural District Council against the Vestry of Kensington for nuisance caused by the deposit of the refuse of Kensington at Purfleet. The hearing of the case by the bench of county magistrates was adjourned with a view to enabling the medical officers of health of the Orsett Rural District of the County of Essex, of Kensington, and of the Port of London, to agree as to the steps which should be taken for the prevention of nuisance, and on the presentation of a joint memorandum on this subject the summons was withdrawn. The medical officer of health of Kensington reports that " the Purfleet depot has not since been used by your vestry, the house refuse having been more economically transferred, under contract, to another place." Fulham.—The service for the collection of house refuse has been fairly satisfactory, and there have been comparatively few complaints of non removal excepting after holidays, which somewhat dislocate the arrangements. The vestry have not yet definitely decided on the erection of a dust destructor but a committee have been appointed to visit destructors at work in various places, and advise the vestry as to the most suitable. Pancras.—A detailed account is given of the system of collection in this district which provides 57 for the removal of refuse from every house every week. The collection is made by a contractor who is required to report to the medical officer of health every instance in which he fails to effect removal. The liability to prosecution of persons, who refuse to deliver to the dust collector their refuse when this is demanded, is pointed out. Islington.—The annual report shows that in this district there were 245 applications in 1896 for the removal of house refuse. Hackney.—The medical officer of health writes " In my last year's report I announced the fact that a weekly house to house collection had been on trial during the greater part of the year with encouraging results. The system has been continued since with increasing success, not only have large accumulations of house refuse become rare in the parish, but the number of requests by householders to remove dust has decreased to an almost insignificant number. The requests, which in the year 1894 were 893, declined in the year 1895 to 552, and last year to 297. I am hopeful that this number will further lessen during 1897; but it can hardly be expected that requests will entirely vanish, for, on very rainy days, the dustmen are unable to complete their allotted rounds, and on bank holidays they do not, of course, visit." A tabular statement shows the number of persons refusing each week to permit their house refuse to be removed, this number frequently amounting to upwards of 10,000, or one-third of the houses at which call is made. The medical officer of health recommends that householders be informed by notice that they are liable to penalty. The adoption of this course and the institution of proceedings before the magistrate in some cases would no doubt materially reduce the number of refusals. Strand.—" Under the Board's system of dust collections, fixed bins are gradually being disused and abolished." Iiulborn.—" The Board made a contract, which came into operation on the 25th March, 1896, which provided for the removal of house refuse at least once a week, in accordance with the by-laws of the London County Council. However, during the year ending December 31st, 1896, 1,361 notices for the removal of house refuse were received and attended to. During the first six months of 1895, there were 1,309, and during the second 805 notices, making 2,114 during the year. This large number of notices, although considerably less than the number last year, shows that the contract has not been strictly carried out. Soon after the new contract this year the contractor appointed a special foreman to superintend this branch of the work, and see that a call is made for house refuse at each and every house or premises in the district in accordance with, and on the days mentioned in, the regulations for that purpose, once in every week at the least. Since the appointment of this additional foreman there has been a great reduction in the number of notices received for the removal of house refuse. A daily collection of house refuse in the Italian colony has been carried out since June last year. It now works very satisfactorily. The sanitary pails were provided at the expense of the owners (a building society). It is desirable that all the old large house dustbins, and public dustbins in courts and alleys, which are a constant source of nuisance, should be demolished and replaced by sanitary galvanized iron dust-pails. These can easily be moved, and at once emptied by the dustmen, with much less labour and nuisance to the occupiers and neighbours. Many such bins have been demolished during the year." Clerkenwell.—The medical officer of health writes—" In connection with the subject of diarrhoea, I have already pointed out the necessity for improvement in the matter of house refuse removal. Again and again, in visiting the district, one comes upon the familiar sight of a dustbin full to overflowing, with a rapidly-growing heap of refuse by its side. Clerkenwell houses used to be provided in nearly every case with a brick-built ash-pit, generally of a considerable size. While these were in existence the accumulation of refuse was not so much noticed, though the evils of such accumulations were not altered. Since these porous filth-saturated structures have been largely replaced by nonporous metal bins of smaller size, the defects of the present system have been brought into greater prominence. The emptying of every dust-bin in the parish, at least once a week, is essential to a satisfactory state of the public health, and should at once be arranged for. I am afraid this cannot be done without increased expenditure, but it is questionable if this need be at all considerable if the present insanitary and clumsy method of cartage of the dust to Lambeth, sorting and sifting by hand labour, and the removal of the refuse by barges, were replaced by a well thought-out scheme of dust destruction and utilization of heat, carried out in the parish." City.—The medical officer of health reports—" Respecting the collection of house refuse, great benefit has accrued from the extension of the ' skip system,' which has enabled us to take away most of the public bins from courts and alleys, where they were found to be a source of nuisance. We have now 741 skips in use, and many more will be wanted." Poplar (Bromley)—"At the beginning of the year the Board resolved to erect a destructor to destroy the refuse of the district." St. Olave.—" This important service continues to be carried out regularly and efficiently, as, for the third year in succession, not a single complaint of neglect or inattention has been received. On the contrary, 432 visits have been made to houses where the dustmen reported failure to obtain the refuse at appointed hours, and in 19 cases where the occupiers refused the dustmen's request to permit the removals, notices were served, but no further proceedings were necessary. 113 new sanitary dust-pails were provided in the place of old brick or wooden dust-bins." Rotlierhithe.—During the year a sub-committee appointed by the vestry inspected 15 destructors at work, and 2 in course of erection. Of the 15, 13 were in provincial towns, and 2 in the metropolis. The destructors were situated in Liverpool, Warrington, Oldham, Leeds, Leicester, Cambridge, Hornsey, St. Luke, Leyton, Whitechapel and Lewisham, and a report containing information relating to each was presented to the vestry. The committee also reported that they had given careful consideration to the various plans prepared by the surveyor and in the first instance they expressed their preference for a plan which showed a four-celled destructor with a boiler placed between each pair of cells, arranged [ 8 ] 58 upon the Wood and Brodie system, but subsequently they recommended the adoption of a plan showing a two-celled destructor with boilers behind upon the Beaman and Deas principle as at work in Warrington and in course of construction at Leyton. The recommendation of the committee was adopted. Woolwich.—"The pail system continues to work most satisfactorily, the dust is removed weekly from every house in the district and from some of the streets in the poorer parts of the town twice or thrice weekly." The surveyor reports that the cost of removal of refuse by barges would have been greater by £449 13s. Id., than the disposal of the same quantity by the destructor. Lee.—The reports show that but few complaints were received of non-removal of house refuse. Plumstead—The medical officer of health reports that " there is now no dust inspector, and it is impossible for the present staff of sanitary inspectors to look after the dust collection." A report of the Public Health Committee states that " another sanitary inspector will shortly be appointed." The same report also states " the necessary public announcement has been made under the London County Council's by-laws for a daily collection in High-street and Plumstead-road." Dust shoots. The medical officer of health of Battersea states that the chief sanitary inspector of the district " detected the Clapham parish authorities depositing road slop in an excavation in front of some houses on Clapham-common." A builder had excavated some 887 cubic yards of sand and gravel and the " Clapham authorities " had deposited this road slop in the excavation in contravention of the Council's by-laws under the Public Health (London) Act. The sanitary committee of the vestry allowed the matter which had been deposited to remain subject, inter alia, to the same being covered with 4 inches of lime in every part. The deposit and sorting of animal and vegetable matter upon ground and in railway arches at the rear of Stainforth-road was under the consideration of the sanitary committee who required the material to be removed more frequently. The medical officer of health of Plumstead states that so far as he saw or was able to learn no house refuse was deposited last year on private shoots within 300 yards of houses, " all went to the parish shoot on the levels. This, as I reported last year, was within the prescribed distance of houses but being carefully treated by burning and covering with soil produced no nuisance. Quite recently land has been procured beyond the 300 yards limit, and the dust is now being shot there." Nuisance from sewer ventilators. The subject of nuisance from sewer ventilators is referred to in the reports of the medical officers of health of Paddington, Kensington, Fulham, Hampstead, Strand, City, Limehouse, Poplar, Greenwich, Eltham and Plumstead. The Vestry of Fulham instituted proceedings against the Council in respect of nuisance from a ventilating opening to one of the Council's main sewers. The case was heard at the Kensington Petty Sessions and the bench decided that "the Public Health (London) Act, did not apply to public sewers constructed by the London County Council." " Against this decision the vestry appealed, and the bench having refused to state a case the Superior Court made a rule and directed the Kensington justice to state a special case for their consideration." The medical officer of health of the Strand district presented to the Health Committee of the District Board a summary of replies received from 58 local authorities within and beyond London to inquiries made by him as to injury to health caused by sewer air, as to the remedies for nuisances from sewer ventilators, and as to the desirability of sanitary authorities having compulsory powers to erect sewer ventilating shafts on private property. The replies show that ventilating shafts are largely used. The medical officer of health of Plumstead says that in that district " flap valves have been placed in the sewers at frequent intervals, which prevent, the ascent of the sewer gas and the sewer immediately below each valve is connected with a shaft ventilator. The grid openings are left to act as inlets." In Poplar experiments are being made with a gas lamp connected with a ventilation shaft with the object of determining the extent to which the air passing from the sewer through the lamp is sterilized. Housing of the working Classes. During 1896 the following steps were taken under the Housing of the Working Classes Act. Schemes undertaken by the Council under Part I. of the Act. Boundary-street, Betlinal-green.—During the year progress was made in the erection of buildings on the Boundary-street area. In February the Council approved the plans, estimates, &c., for the erection of dwellings and workshops on plot E., in March of dwellings on plot F., and in December of dwellings on plot J. In July the Council decided that elevated terraces should be formed of the central open space and that they should be made into a garden. In March, 1897, the number accommodated on the area was 1,537 and further provision was being made for 3.300. Trafalgar-road, Greenivicli. —In January the Public Health and Housing Committee reported that they had not succeeded in finding bidders for the erection of block dwellings on this site, but that they thought that if permitted to erect cottage dwellings purchasers might be found for the land. This would necessitate a further reduction in the number of persons to be accommodated, viz., from 245 to 191. The Council resolved to apply to the Home Secretary for an Order modifying the scheme with this object. In October the Committee reported that this application had been granted, and in December Council appointed an architect to design cottages for the site. Clare-market, Strand.—The Public Health and Housing Committee having taken the necessary steps to obtain the confirmation of this scheme a local inquiry was held by Mr. Stewart, on behalf of the Home Secretary, at the office of the Strand District Board , but the confirming order was not received in time for the introduction of a bill into Parliament during 1896. 59 Churchway, St. Pancras, scheme.—Similar inquiry as to the scheme for this area was held at the St. Pancras Vestry Hall, and there was like delay in the receipt of the confirming Order. Schemes undertaken by the Council with contributions by district authorities. Brooke's-market, Holborn.—In July the Council approved plans, estimates, &c., for the erection of dwellings to accommodate 60 persons in self-contained tenements on this area, and, in October, for the laying out of the rest of the site as an open space, the necessary modifying Order of the Local Government Board having been received. Mill-lane, Deptford.—The original scheme provided for the erection of block dwellings, and a common lodging-house to accommodate 570 persons on this area. On the representation of the district authority asking that cottages should be erected instead of block dwellings, the Council in March resolved to apply to the Local Government Board for an order modifying the scheme so as to reduce the number to be accommodated to not less than 300. In November the Housing of the Working Classes Committee reported that the houses on the area had been demolished, and that the widening of Mill-lane was in hand. Ann-street, Poplar.—In March the Council resolved to sell this site to the East End Dwellings Company for the erection of dwellings, the plans to be approved by the Council. Green-street and Gun-street, Southwark.—In March the Council approved plans, estimates, &c., for the erection of buildings to accommodate in self-contained tenements 156 persons and 264 persons on these sites, respectively. Falcon-court. Southwark.—With a view to providing accommodation for the persons to be displaced by this scheme, the Council in February resolved to purchase the lessee's interest in Gardenrow, Borough, and in March to purchase a site in the Borough-road. In February and March the necessary local inquiries under Part III. of the Act were held by Mr. Stewart, on behalf of the Home Secretary. In July the Council appointed an architect to design plans. In October the Housing of the Working Classes Committee reported to the Council that the bill confirming the provisional order prepared by the Home Secretary had not been introduced into Parliament in 1896, and that the acquisition of the Garden-row site would have to be abandoned. An alternative site was sought, and in November the Council adopted the recommendation of the Committee to purchase a site in Greenstreet. The local inquiry in connection with the Falcon-court area was held by an officer appointed by the Local Government Board in April, but the order confirming the scheme was not received during the year. Schemes undertaken by district authorities with contributions by the Council. King John's-court, Limehouse.— In May the Council passed a resolution for the contribution of one-half the cost of the scheme for improving this area. The contribution of the Council was a sum not exceeding £8,150. Queen Catherine-cotirt, Limehouse.—In October the Council passed a resolution for the contribution of a sum not exceeding £3,200, for the improvement of this area, this sum being half the cost. London-terrace, St. George-in-the-East.—In November the Committee reported that the estimate of the net cost of this scheme was £3,200 and the Council passed a resolution for the contribution of one-half the amount. Norfolk-square, Islington.—In November the Committee reported that they approved the application of the Islington vestry that the whole of this site should be devoted to open space. Moira-place and Plumber's-place, Shoreditch.—In March the Council passed a resolution for the contribution of £27,500, being half the cost of this scheme. Brantome-place and Prospect-terrace, St. Pancras.—The medical officer of health of St. Pancras reports that these schemes have been sealed by the vestry of St. Pancras, that notices have been served on the owners and petitions prepared and lodged with the Local Government Board. The local inquiries were held at the Vestry Hall, St. Pancras, in March, 1897. Area east of Chalton-street, St. Pancras.—The medical officer of health of St. Pancras reports that this scheme has been sealed and the valuers instructed to make a valuation of the property. Alleged insanitary area in Westminster. In 1896 I received a complaint from ratepayers in Westminster, requiring me to make a representation to the Council as to an area and certain houses in that district. The action taken thereon is shown in the following report made by the Housing of the Working Classes Committee to the Council in November— On the 5th ultimo a complaint, duly signed by 12 ratepayers of the parish of St. Margaret and St. John, Westminster, was made to the Council's medical officer of health under sec. 5 (2) of the Housing of the Working Classes Act, 1890, with respect to an alleged unhealthy area in the parish. The area referred to was that known as the Lewisham-street area, also the house No. 16, Dacre-street, and Abbeybuildings. In accordance with the provisions of the section above mentioned, the medical officer has made to us a representation of his opinion that all the houses referred to do not constitute an unhealthy area within the meaning of the Act, but that the property on the north side of Lewisham-street comprising houses less than ten in number, do constitute such an area. The Act provides that where an official representation relates to not more than ten houses, the Council " shall not take any proceedings on such representation, but shall direct the medical officer of health making the same to represent the case to the local authority under Part II. of this Act, and it shall be the duty of the local authority to deal with such case in manner provided by that part of this Act." We have accordingly instructed the medical officer to bring the matter to the notice of the local authority. We may mention that this is the first instance of a complaint of inhabitants as provided in section 5 (2) being made the basis of a representation to the Council. 60 Snow's-fields, Bermondsey, area. This area had been represented to the Metropolitan Board of Works in 1875, and to the Council in 1892, and since the latter year had received the attention of the Public Health and Housing Committee of the Council, but owing to the probability that important changes in its condition would be effected without an improvement scheme under the Act of 1890, the Council was not recommended to prepare. a scheme for its improvement. In July, 1896, the Housing of the Working Classes Committee reported to the Council concerning it, " that the land had been acquired by the trustees of the Guinness' Trust for the purpose of the erection of working-class dwellings. The culs de sac, which were the chief feature of this area, have been all abolished, and Kirby-street has been carried right through the area into Snow's-fields. Strips of the land forming part of the area will be given up to make Snow's-fields of a uniform width of 30 feet, though this, we understand, may be more easily effected by the straightening of the thoroughfare. The whole of the improvement of the area has been carried out by arrangement between the trustees of the Guinness' Trust, the London School Board and the Vestry of Bermondsey." Proceedings in respect of hoiises represented as unfit for human habitation. The following tabular statement shows the procedure of district authorities as to houses represented as unfit for human habitation, and concerning which the Council has received copies of representations from the 1st January to the 31st December, 1896 — Local Authority. Total number of houses conccrning which the Council has received information that representations have been made from the 1/1/96 to the 31/12/96. 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 11 - 10 - 10 - - 1 1 - - Bethnal-green 76 - 36 3 39 18 13 1 32 - 5 Camberwell - - - - - - - - - - - Chelsea - - - - - - • - - - - - Clerkenwell - - - - - - - - - - - Fulham 195 10 10 92 112 11 64 8 83 - - Greenwich - - - - - - - - - - - Hackney 5 - - 5 5 - - - - - - Hammersmith - - - - - - - - — - - Hampstead - - - - - - - - - - - Holborn 1 - - 1 .1 - - - - — — Islington - - - - - - - - - - - Kensington - — - - — - — - — — — Lambeth 94 23 2 33 58 — - 36 36 - - Lewisham - - - - - - - - - - • - Limehouse 6 - - - - - - 6 6 - - Mile-end Old-town 38 14 - 17 31 - - 1 1 - 6 Newington - - - - - - - - — - - Paddington - - - — - — - — — — — Plumstead - — — - — — — — — — — Poplar - - - - - - - - — - — Kotherhithe - - - — — — - — ~~ — St. George, Hanover-square - - - - - - - - - - - St. George-in-the-East 4 - - - - 2 2 — 4 — — St. George-the-Martyr 2 - - - - - - 2 2 — — St. Giles 16 3 5 8 16 - - — - - — St. James, Westminster - - - - - - - - - - - St. Luke - - - - - - - - - - - St. Martin-in-the-Fields - - - - - - - - - - - St. Marylebone 4 1 - - 1 1 - 2 3 - - St. Olave, Southwark 6 — - 6 6 — - — — — — St. Pancras - - - - - - - - - - - St. Saviour, Southwark - - - - - - - - - - - Shoreditch 35 19 - - 19 - 16 - 16 - - Strand - - - - - - - - - — - Wandsworth - - - - - - - - — — - Westminster 1 - - - - 1 - - 1 - - Whitechapel - - - - - - - — - — — Woolwich 3 — — 3 3 — — Total 497 70 63 168 301 33 95 57 185 11 Working class dwellings in Plumstead. During the year 1896 the Housing of the Working Classes Committee considered various representations as to the want of accommodation for workmen in Plumstead, and the Committee thu3 reported to the Council in December— We have had under consideration communications from various bodies representing the interests of the working classes in Plumstead, calling attention to the want of accommodation for workmen in that locality, and urging the Council to erect municipal lodging-houses and cottage dwellings. From inquiries which we have caused to be made, we are of opinion that there is need for further accommodation of the kind mentioned, but in the absence of the necessity of undertaking any scheme under the Housing of the 61 Working Classes Act, 1890, for the clearance of an unhealthy area in the district, we are not prepared to recommend the Council to embark upon any building operations which would compete with private enterprise and we have accordingly given instructions for a reply to this effect to be sent to the applicants. We trust, however, that having regard to the demand which exists for working-class dwellings in Plumstead, the attention of the artizans' dwellings companies may be directed to the matter, with a view to the erection of suitable dwellings as suggested. Millbanh-prison site. In December the Council sealed the agreement with Her Majesty's Commissioners of Works For the sale and purchase of the land on this site which the Council had decided to acquire. The Housing of the Working Classes Committee had estimated that accommodation could be provided on the land for 4,400 and that of this, accommodation for 1,500 persons would be required for those displaced from the Clare-market, Strand, area. Areas specially described in the reports of medical officers of health. Special reference is made in the reports of medical officers of health to particular localities in districts. In the report of the medical officer of health of Kensington account is given of an area in Nottingdale comprising St. Katherine's-road, William-street, Bangor-street, Crescent-street and part of St. Clement's-road. A special committee was appointed by the Vestry of Kensington to consider the causes of the high death rates in this locality which had been discussed in previous reports of the medical officer of health. This Committee reported in July, and the medical officer of health thus writes concerning their conclusions— In July the committee presented their report, in which, to put the matter briefly, they attributed the bad condition of the houses, and the evil state in which the inhabitants were found, or represented to be, to the vicious proclivities and evil habits of the people themselves. They stated that they did not find the area in question to be " an insanitary or unhealthy area;" they regarded " the situation as a healthy one; " the high death rate being " due to the habits and conditions of the people themselves " the " filth and dirt of the people " being " at once the cause and effect of the filth and dirt of their abodes," though " the houses as structures are not bad." . . The committee were of opinion that the necessity of sanitary inspection " can hardly be overstated," but they qualify their opinion by adding that " this does not necessarily mean an increase to our permanent staff of sanitary inspectors," which, in fact, had been reduced a few days prior to the appointment of the Committee. " A sufficient staff of sanitary inspectors " is stated to be "absolutely necessary " between April and August, when " under No. 7 of our by-laws, there is to be thorough cleansing " of houses let in lodgings or occupied by members of more than one family and registered—as " the evidence clearly shows that this cleansing is often done in the most perfunctory and unsatisfactory manner, even if it be done at all." It was " satisfactory to note that in the judgment of several witnesses, an immense amount of good could be done if the (said) bylaws were stringently and rigidly enforced," which I may add is not possible in present circumstances. The question of the sufficiency of the staff of sanitary inspectors in Kensington was during the year under the consideration of the Public Health Committee of the Council who had decided that inquiry into this matter should be made on behalf of the Council. Before, however, this inquiry had begun, the Council was informed that the Local Government Board had consented to a reduction of the staff for twelve months. It was obviously impossible for the committee to proceed further in the matter, the Local Government Board, before inquiry by the Council, having arrived at a decision. The committee therefore addressed a communication to the Local Government Board expressing the hope that at the end of the twelve months the Board would by inquiry in the district ascertain its needs in respect to the number of sanitary inspectors which should be employed. The report of the medical officer of health of Holborn contains reference to a special report presented by him in 1896 on the subject of an area in the neighbourhood of Union-buildings, Leather-lane, having a population of nearly 1,000 persons. The conditions existing in the area are described by the medical officer of health, who points out the powers of the d istrict board for reconstruction and rearrangement of the houses under Part II. of the Housing of the Working Classes Act, and expresses the opinion that this is " the only way of effecting a satisfactory and permanent improvement." The district board, however, decided that the sanitary defects in the houses in the area should be dealt with under the Public Health (London) Act. The subject is receiving the attention of the Council's Housing of the Working Classes Committee. The annual report of the medical officer of health of Plumstead contains a description of an area on the Reidhaven-road from which it appears that the death rates in this district have been high, that the area was occupied by a poor class of inhabitant, that the drainage was defective, the structural condition of the houses defective, and that there was overcrowding. He adds that some of the houses probably a large proportion, are built on a deposit of house refuse of recent date. The medical officer of health of St. James, Westminster recommends the construction of a new street parallel to the east side of Regent-street. His report contains the following paragraphs on this subject— " If a line be drawn from St. James's Palace diagonally across the parish to the junction of Oxfordstreet and Wardour-street, it will be seen that south of Regent's-quadrant the line traverses a rich and fashionable district, while north of Regent's-quadrant the line traverses a labyrinth of small streets, through which ordinary strangers would be unable to find their way. This northern area is covered to a great extent by old houses which have passed into the hands of tenement-mongers, and are let out as lodgings to the working claases who are dependent upon the splendid shops and busy warehouses of Regent-street, Bond-street, Piccadilly and St. James's-street. In these old tenement houses the rents paid by the working classes are high, while the conditions under which they live are bad. The houses are largely held by tenement-mongers on short leases, a tenure which practically shuts out both freeholder and leaseholder from re-building or substantial improvement. The houses are cramped, often with basement buildings covering their entire sites ; routes through the district are tortuous, and the streets are narrow. These houses, in fact, are old-fashioned gentlemen's dwelling houses, which have been 62 degraded and cut up into slices, and sub-let as lodgings for the working classes. Sanitary work, in the way of reconstructing drainage, the provision of additional water-closets, the repression of overcrowding, and the enforcement of periodical cleansings, has now been pushed with increasing severity for many years—as fast as public opinion and new Public Health Acts have supported and given power to the vestry and its sanitary officers. In this quarter the need for wholesale warehouses and workshops subservient to the great retail shops of St. James's has caused a gradual process of extrusion with regard to the worst houses and the dirtiest of the inhabitants. A question for the consideration of the vestry is whether the time has not arrived for quickening this process of extrusion by opening up a new street on the eastern side of and parallel to Regent-street. " Reference to the map will show that in this way the betterment of the eastern section of St. James's would be secured in combination with a great metropolitan improvement. Starting from the south, and going north by north-west, such new street might be run in alignment with Waterloo-place, or with the Haymarket, or with Suffolk-street, or with Whitcombe-street. Taking the Haymarket as the southern base, a new street running straight through to Poland-street would be of very great use both to the local property and to the metropolis. It would also add largely to the value of the extensive site on which the old workhouse now stands. At present the poor of the Westminster Union are consigned to a deplorable existence, and I earnestly ask whether a small receiving house in St. James's, with a comfortable and cheerful new workhouse in the country, would not be a great mercy to these aged people, and a great saving to the ratepayers. The wretched and dingy courtyard in which these aged people now hopelessly sit and walk, in an atmosphere grimy with the smoke of London, might be exchanged for pleasant fields and plots of garden ground, in which the inmates could occupy themselves with the cultivation of vegetables or flowers. Several acres of the most valuable ground in St. James's, with frontages on the new street, would be released for a splendid block of workmen's model dwellings, to which might be appended small workshops in which gas, water and steam, or electrical motor power could be let to the skilled artisans whose livelihood depends upon their proximity to the retail shops of St. James's. It is not necessary for me now to elaborate this proposal: it was suggested by me in 1875, but opinion was then adverse, and it was allowed to rest. Now that I am directed by the Local Government Board to indicate 'the measures of sanitary improvement required in St. James's,' I bring the idea seriously forward. The advantage of a series of model workshops for tailors, dressmakers, jewellers, engravers, and other chamber-master workers would conduce immensely to the prosperity of the splendid retail shops and warehouses which support St. James's. If a new street were cut through on the line here suggested, the new access would immensely increase the value of the large block of property lying between the new street and Regent-street, and the old houses on the eastern side of St. James's would disappear without further effort. I commend this question earnestly to the consideration of the Vestry of St. James's." Amendment of the Housing of the Working Classes Act, 1890. The Housing of the Working Classes Committee had under consideration during 1896 the question of the amendment of the Act of 1890. A report recommending that the Parliamentary and Housing of the Working Classes Committees should be instructed to approach Her Majesty's Government with a view to securing amendments of the Act was adopted by the Council in October. The amendments recommended by the Committee were as follows— Part I. (а) That an amendment of the Act be sought so as to make the period during three consecutive weeks of which advertisements under the section are to appear, a period of any three weeks running consecutively during the three months September, October and November. (б) That an amendment of the Act be sought so as to obtain power to modify a scheme, after the lapse of three years from the date of the clearance of the improvement area, in order to enable the Council to sell the land freed from the conditions imposed by the scheme, and with the money so obtained to purchase other lands to be devoted to the provision of accommodation for persons of the labouring class. Parts I. and II. (c) That an amendment of the Act be sought, so that power may be given to the local authority to insert in any scheme under the Act a betterment clause either to the effect of section 36 of the Council's Tower Bridge (Southern Approach) Act, 1895, or to such effect as experience or the circumstances of the particular scheme may render expedient. Part I. (d) That an amendment of the Act be sought by the substitution of a period of six for the period of thirteen weeks during which placards are required to be published advertising the Council's intention to take fifteen or more houses in pursuance of a scheme under Part J. of the Act. (e) That a provision be inserted in Part II. of the Act fixing the date of the service of the notice upon the person interested, as the date after which alterations to and improvements of property shall not increase the compensation payable. Part II. (/) That a provision be inserted in the Act empowering one local authority to purchase the interest of the other authority in cases where one contributes towards the cost of a scheme under Part II. which is carried into effect by the other. (g) That an amendment of the Act be sought so as to enable the vestries and district boards to proceed for closing orders in respect of property which cannot be rendered fit for human habitation without reconstruction, without first serving the owners of property with notice to repair. (h) That an amendment of the Act be sought by which an authority carrying out or contributing to the cost of carrying out a scheme under Part II. may be enabled to borrow for the purpose of paying or contributing to the payment of any expenses of or incidental to the scheme, and carrying the same intoeffect. (i) That an amendment of the Act be sought so that the contribution by the Council towards the expenses of the carrying of a scheme into effect by a vestry or district board shall be for such amount and 63 payable at such time or times as the Council and the vestry or district board shall agree, the reference to the Secretary of State to be only in default of agreement, with power to him to order payment from time to time and in such amounts as he shall determine. (j) That an amendment of the Act be sought which shall enable a vestry or district board to pay or contribute to the payment of the expenses of and incidental to a scheme, and carrying the same into effect —the application to the Secretary of State to be only necessary in cases where the Council and the vestry or district board do not agree. (k) That a provision be inserted in the Act empowering local authorities carrying out schemes under Part II. of the Act to acquire under such schemes neighbouring lands necessary for the better development of the area comprised in the schemes. Parts I. and II. (I) That an amendment of the Act be sought so as to enable a test award to be obtained from the standing arbitrator under any scheme; the minimum period to elapse between the service of any further offers and the sitting of the arbitrator to hear each case in connection therewith to be 21 days. (m) That an amendment of the Act be sought by the omission of the words which provide that the standing arbitrator shall ascertain the amount which the local authority may be willing to pay. Part I. (n) That an amendment of the Act be sought, so that the City of London shall in future contribute towards the expenses of schemes carried out by the Council, and so that the Council may in turn also contribute towards the expenses of schemes carried out by the City authorities. (o) That an amendment of the Act be sought by the insertion of a clause empowering the Council to acquire the superior interest only in property coloured blue in a scheme under Part I. of the Act, leaving the subordinate interests to expire by the effluxion of time. Parts I. and II. (p) That an amendment of the Act be sought in the direction of the repeal of the incorporation of section 193 of the Lands Clauses Consolidation Act, 1845, so far as it applies to Parts I. and II. of the Act. Parts II. or IV. (q) That an amendment of the Act be sought, so that the consent to the sale of any portion of the site of an obstructive building and the approval of the application of the proceeds of such sale shall rest with the same Government department. The regulation of houses let in lodgings. In June, 1896, I presented to the Public Health Committee a report showing the results of inquiries by Dr. Hamer as to the operation in London of by-laws concerning houses let in lodgings. It was found that in every London district either by-laws made under the Public Health (London) Act, 1891, or regulations made under the Sanitary Act, 1866, existed, but in very few districts had any serious effort been made to enforce them. A copy of this report will be found in the appendix (see Appendix IV.). In the few districts in which such effort has been made, the results have been distinctly encouraging, and it was obviously important that there should be no longer delay on the part of other sanitary authorities in applying these regulations to tenemented houses needing special treatment, particularly those in which overcrowding occurred and recurred. The Public Health Committee reported on this subject to the Council in November, and the Council in the following month, on the recommendation of the committee, adopted a resolution " to make further inquiry at Midsummer, 1897, as to the extent to which by-laws or regulations dealing with houses let in lodgings are enforced in the several sanitary districts of London with a view to the Council making a representation to the Local Government Board under section 101 of the Public Health (London) Act, 1891, in the case of any sanitary authority which is not by that time carrying out the provisions of section 94 of the Act." The Council also directed that a copy of the committee's report and of the Council's resolution thereon, be sent to each of the London sanitary authorities. The reports of medical officers of health contain the following references to this subject— Kensington.—The medical officer of health gives account of the proceedings in respect to the making of by-laws in supersession of existing regulations made under the Act of 1866. By-laws had been made by the Vestry of Kensington, and were subsequently returned by the Local Government Board with suggested amendments. He adds that " nothing has been done towards the registration of houses since the Public Health (London) Act, 1891, came into operation ; the Sanitary Committee considering it desirable that new registrations should be made subject to by-laws conforming to the provisions of that Act, as recommended by the Local Government Board in 1892." His report contains a tabular statement showing, with regard to certain streets, the number of houses registered in each street and the number of houses not so registered. A summary for the whole district showing 1,543 houses registered and 602 houses in these streets not registered. He writes, " inspections made in 1895 showed that many of the non-registered houses were at that time so occupied (i.e., let in lodgings or occupied by more than one family), and a report to that effect was made to the Sanitary Committee. The committee however decided not to register any more houses pending the confirmation by the Local Government Board of the proposed new by-laws." Hammersmith.—The report by the vestry contains the by-laws which were confirmed in April, 1896. St. George, Hanover-square.—There are 95 registered houses let in lodgings. They have been inspected and the regulations as to cleansing complied with. Westminster.—During the year under the by-laws for houses let in lodgings 1,811 inspections were made, 1,085 registration notices served, and 12 houses registered. A midnight inspection of 40 tenements in Lewisham-street showed most of the rooms to be slightly overcrowded. In four cases of excessive overcrowding penalties were obtained. Altogether, nine summonses were taken out for breach of by-laws, resulting in the recovery of £3 11s. fines and 18s. costs. St. Marylebone.—1,154 inspections were made. 64 Hampstead.—There are now 840 houses registered. These houses are regularly inspected, and orders made for cleansing when necessary. St. Pancras.—148 houses are registered. Islington.—An inspector has been especially employed in the inspection of houses let in lodgings. 74 such houses were registered during 1896, making a total of 458 on the register. During the year the inspector made 4,592 inspections, 1,593 calls, and had 1,309 improvements effected. "His visits have been for the most part gladly received by the tenants, who, as a rule, have assisted him in his efforts, especially when they came to understand that his object was to improve their surroundings." Hackney.—During the year 470 notices were issued, requiring landlords to furnish information, of which 380 were returned. Of the latter it was necessary to make further inquiries in 380 cases. The medical officer of health anticipated 500 houses would be registered and under periodical inspection during the year 1896. St. Giles.—The number of houses on the register wss 523, 51 additional houses being registered during the year. Proceedings were taken in three instances. St. Martin-in-the-Fields.—The inspector appointed permanently to inspect these houses has regularly carried out this duty. Strand.—Since the by-laws came into operation in 1894 the Board has resolved to register 77 houses. Of these five have since been closed. " The houses are inspected at least once a week with satisfactory results." Holborn.—There were 35 houses registered. " The board made an order that all were to be inspected and reported upon every month. Although this order was not strictly carried out, a great many sanitary improvements were effected." Twelve of these houses have been since closed. " Threefourths of the population live in tenements." Clerkenwell.—The medical officer of health states that by-laws were drafted which met the requirements of the Local Government Board. These have been since confirmed. St. Luke.—The medical officer reports that 16 houses have been registered, and writes, " The above are the only houses at present on the vestry's register, although a very large number exist in the parish which the by-laws were intended to include, and which, in my opinion, should be registered." City.—The by-laws made by the Commissioners of Sewers were confirmed in May, 1896. Shoreditch.—During the year 16 notices to supply information were served. The medical officer of health writes, " Where a house is registered under the by-laws the vestry are empowered to proceed directly for penalty without the serving of sanitary notices; and this is advantageous in dealing with insanitary conditions arising from want of attention to cleanliness and overcrowding." Bethnal-green.—The medical officer of health states that " So far not a single house has been placed upon this register, and therefore we have not had a chance to ascertain whether these by-laws are workable or not. Personally, I think they are." Referring to some houses in Fuller-street, he advised the sanitary committee to recommend the vestry to register the four worst. " Very unwillingly the sanitary committee agreed to do this; but on the discussion of the report at the full board so much opposition was manifested that it was agreed to refer the matter for re-consideration. At the next meeting of the committee it was decided to proceed no further with the proposal to register the houses, but to deal with the Fuller-street premises under the Public Health Act." He gives account of subsequent proceedings in the police court, which were especially protracted owing to frequent adjournments, and says that he was obliged to attend the Worship-street police court some seven times, " for we are compelled to be in a position to prove the nuisance by medical evidence on each occasion," and adds, " at any rate the time of your medical officer of health can be more profitably employed than in attendance at the police court to prove that a choked closet is a dangerous nuisance." Whitechapel.—The medical officer of health reports, " Already most of the ' furnished rooms' have been placed on the register, and I hope during the current year to be able to proceed with this special work." St. George-in-the-East.—It was found that of 28 houses previously registered under regulations only 17 could be registered under the by-laws, which exempt from registration unfurnished tenements having rents of 5s. and above. The medical officer of health states that the subject of registering houses let in lodgings was considered on receipt of a letter from the London County Council, and he expresses the opinion that " to carry out an extension to any very large degree of the operations of the by-laws for houses let in lodgings would not apparently be productive of the beneficial results commensurate with the expense of an increased staff. However, a moderate increase of the number already registered might be made gradually, and if carefully selected would be to the interest of the inhabitants." Limehouse.— Referring to communications from the London County Council, the medical officer of health writes, " From these communications it appeared that registration was not progressing so quickly in some districts as the Council would like. In your district, however, a number of houses have been so registered, and others are being added from time to time. I am of opinion that we are proceeding in this matter with due regard to the public health and the extent of our inspectorial staff." Mile-end Old-town.—The medical officer of health states that comparatively few houses in this district require to be registered, that the general provisions of the Public Health Act suffice, and that owing to frequent change of ownership of houses, registration would lead to delay of proceedings. St. George, Southwark.—The number of houses registered is 228 and the vestry hasappointed a female inspector to secure the better carrying out of by-laws. The medical officer of health states that "in this parish houses built on the so-called model or block system and accommodating 12,800 inmates, at present escape the statutory provisions of the new by-laws. These dwellings, often inhabited by the uneducated and unruly poor, are for the most part badly supervised." He recommends an amendment of the Public Health Act to make these buildings subject to the by-laws. 65 Newington.—The medical officer of health reported two houses as suitable to be placed on the register. St. Olave.—In 1896, 498 rooms of 238 dwellings were measured. Bermondsey.—The total number of houses on the register is 307. Rotherhithe.— Five houses were registered. Lambeth.—By-laws were made in January, 1896, and confirmed in May, 1897. Wandsworth.—The medical officers of health state that all the houses let in lodgings have been visited at least once in every two years and defects remedied. Latterly, however, there has not been enough of this systematic house to house inspection done in two at all events of the sub-districts, owing to there not being sufficient inspectors. They add " we think it would be a retrograde step to give this system up, with which we have every reason to be satisfied, for the sake of picking out particular houses which happen to be let in lodgings, to the neglect of their fellows in the same street." The report does not show why the registration and regulation of certain houses should imply or necessitate neglect to deal with others under the general provisions of the Public Health Act. The medical officer of health of Clapham reports that the by-laws have been applied to one street " of a particularly unsatisfactory kind," and states that there has been considerable improvement from the action of the by-laws in the direction of cleanliness of houses, and that this and the more ready dealing with overcrowding appear to be practically the only benefits derived from the by-laws. He thinks that conditions of general dilapidation should also be made subject to the by-laws. Camberwell.—In this district the number of houses let in lodgings inspected was 246. Greenwich.— By-laws have been confirmed by the Local Government Board. Lewisham.—Fifteen houses in Penge are on the register. Woolwich.—Fifty-nine houses were registered. Plumstead.—Two houses were registered in 1896, and two ceased to be registered. Four houses are on the register. Proposals to register other houses " had the effect of turning the tenants out and reducing the occupation of the house to that of one family." Common Lodging-houses. The year 1896 was the third year in which common lodging-houses in the county of London have been subject to regulation by the Council. The number of houses on the register at the end of the year was 596, providing accommodation for 29,140 persons. Nine of these houses were registered for the first time in 1896. In the supervision of these houses the Council's inspectors made 28,331 inspections. In 334 cases preliminary notices were served to compel the keepers to comply with various requirements, and statutory notices were served in 14 cases. Proceedings before the magistrate were instituted against 31 keepers, and in 30 cases fines were inflicted amounting in the aggregate to £108 10s., and £4 6s. costs. In the remaining case, the Council's requirements having been complied with, the keeper was ordered to pay the cost of the summons. The number of cases of infectious disease reported in these houses were as follows—erysipelas, 11 ; smallpox, 10 ; diphtheria, 7 ; measles, 6; scarlet fever, 5 ; enteric fever, 2 ; or 71 in all. The number of deaths from various causes reported in these houses was 65. The following table shows the number of common lodging-houses, the number of authorised lodgers in such houses, and the number of houses registered in each sanitary district in 1896— Common lodging-houses. Number of common lodging-houses. Authorised number of lodgers. Number of houses registered by the Council in 1896. Paddington 3 66 Kensington 32 943 — Hammersmith 8 533 — Fulham 3 86 — Chelsea 18 875 — St. George, Hanover-square — — — Westminster 21 1,397 — St. James 1 88 — Marylebone 22 881 — Hampstead 1 35 — Pancras 26 910 1 Islington 45 1,236 1 Stoke Newington 1 41 — Hackney 10 392 1 St. Giles 32 1,807 — St. Martin-in-the-Fields 4 170 — Strand 11 623 — Holborn 11 611 — Clerkenwell 5 249 1 St. Luke 4 242 — Shoreditch 15 663 1 Bethnal-green 13 313 1 Whitechapel 65 5,587 1 Carried forward 351 17,748 7 [9] 66 [$###] Number of common lodging-houses. Authorised number of persons. Number of houses registered by the Coui cil in 1896. Brought forward 351 17,748 7 St. George-in-the-East 19 506 — Limehouse 22 825 1 Mile-end Old-town 6 226 — Poplar 12 855 — St. Saviour, Southwark 19 932 — St. George, Southwark 32 1,571 — Newington 14 1,592 — St. Olave 1 533 — Bermondsey 4 226 — Rotherhithe 3 116 — Lambeth 19 1,279 — Battersea 6 227 — Wandsworth 13 281 — Camberwell 9 504 — Greenwich 17 711 1 Lewisham 10 131 — Woolwich 38 867 — Lee 1 10 — Plumstead — — — Port of London — — — Totals 596 29,140 9 Parker-street common lodging-house. In July the Housing of the Working Classes Committee reported to the Council concerning the common lodging-house erected by the Council that the statements of accounts for the year ending March, 1896, showed a balance of £119 10s. 2d. after payment of all costs in management, for repairs and for interest and sinking fund. The report of the Committee was as follows— In accordance with the Council's standing order, we submit statement of accounts showing the receipts and expenditure in respect of the Parker-street lodging-house for the year ending 31st March, 1896. From the statement it will be seen that the financial condition of the lodging-house is satisfactory, but in submitting the accounts we take the opportunity of pointing out that more important than, and apart from the financial question, the Council may be well satisfied with the impetus that this undertaking has given to the work of improving lodging-houses, not only in London but in other large cities. Committees and public bodies and officials from many large towns have visited the lodging-house from time to time, and have expressed themselves as being much pleased with the building and the arrangements generally, and there is no doubt that the Council has advanced the improvement of this class of building. Parties of students from the Sanitary Institute have on more than one occasion visited the lodging-house, and the institute has intimated that their classes have derived great benefit from these visits. That this class of building is filling a public want is patent, from the fact that since the house has been opened applicants for beds have, with the exception of a few weeks in the year, been turned away nightly for want of room. Our experience leads us to believe that a model common lodginghouse for women would meet a want, and that if such a house were erected, it might initiate a movement that is much required. Common shelters.—In May, 1896, the Public Health Committee reported to the Council the result of proceedings instituted by the Vestry of St. George, Southwark, in respect of overcrowding in a salvation army shelter in that district, the vestry having received a copy of a special report which the medical officer of health of that district had presented to his authority. The Committee, later, presented to the Council a report showing the results of inquiries made by Dr. Young as to the character of the accommodation which the various shelters in London provided. It was found that in a considerable proportion the cubic space per head in the dormitories was less than that required in common lodging-houses, and that in like manner the provision of water-closet accommodation and for washing was below the common lodging-house standard. A copy of the report will be found in the Appendix (see Appendix V.). Customs and Inland Revenue Acts, 1890 and 1891. The annual reports of medical officers of health show that certificates were granted in the following districts— Fulham.—" Certificates for exemption from inhabited house duty were granted in respect of 38 houses and refused in respect of 45." Westminster.—" Certificates were granted to the owners of Peabody-buildings (Old Pye-street and Orchard-street), Lime-buildings, Westminster-chambers, St. John's-chambers and No. 1, Dorsetstreet. In the cases of Lion-buildings and St. John's-chambers the certificates were not granted until extensive alterations and repairs had been carried out." Hackney.—There was only one application for a certificate which was granted. Strand.—340 applications for certificates were received, certificates were granted in 279 and refused in 61 cases. Holborn.—During the last four months of the year applications for certificates were received in respect of some 20 buildings representing 917 tenements, of which a large proportion are one or two 67 room tenements. Themedicalofficerof health writes "Griffin's, lleid'sand Portpool buildings and the flats at 16, Little James-street were found to be in good sanitary condition, and certificates were soon given. At Grays-inn building very little was found that required to be attended to. In all the remaining premises there were sanitary defects, and in many cases much work had to be done before certificates could be granted. At St. Alban's, Duncan, Leather-lane and Evelyn-buildings, 11, 19 and 21, Portpool-lane our requirements were not completed till this year. I have not been able to give certificates for 6, 7, 8 and 9, Half Moon-court." Shoreditch.—The number of applications received was 111. In 35 instances certificates were granted. St. George the Martyr.— The medical officer of health reports that his attention was drawn, under the provisions of these Acts to the sanitary condition of between 800 and 900 dwellings. He states that he inquired of the Inland Revenue Department whether a form of certificate which he had prepared would be accepted, and was answered in the affirmative. This form included a statement to be signed by the sanitary inspector that the house complied with certain conditions, among others that the drainage complied with the requirements of the statute, by-laws and regulations in force in the district. The health committee of the vestry, however, refused to permit the sanitary inspector to sign such statement. St. Olave.—The medical officer of health gave a certificate in respect of Jordan-chambers " but was unable to do so for two large blocks of dwellings for which certificates were asked." Wandsworth (Putney and Roehampton).—One application in respect of several houses in Roskell was received and the certificate granted. Underground Rooms. In the following districts underground rooms illegally occupied were dealt with—Chelsea 6, St. George Hanover-square 10, Westminster 10, in one case penalty recovered, St. James Westminster 10, St. Pancras 18, Islington 39, Strand 5, Holborn 24, Clerkenwell 18, St. Luke 9, Bethnal-green 4, Whitechapel 22, St. George-in-the-East 20, Limehouse 1, Mile-end Old-town 2, St. George Southwark 11, Lambeth 21, Battersea 19, Greenwich 13. St. Marylebone, number of inspections 613 (in four cases summonses taken but adjourned sine die on discontinuance of use of room.) St. Giles 10, and in four other cases which complied with the requirements of the Metropolis Local Management Act but not with those of the Public Health Act, continued use was permitted. The medical officer of health of Wandsworth (Clapham) regards as unsatisfactory the provisions relating to this subject, because an underground room which could not be occupied legally if let separately could be legally occupied if let with another room. Factories and Workshops. The following information concerning the proceedings of London sanitary authorities in connection with workshops is contained in the several annual reports of medical officers of health— Puddinqton.—Under the 26th section of the Factory and Workshops Act, 1891, H.M. Inspector of Factories forwards to the sanitary authority notices of new workshops opened in the district. The number of such notices received was 16. The workshops were inspected, and entered on the register, which, at the end of the year, contained particulars of 46 work places. Cards are issued to owners indicating how many persons may be employed in each room, each card being hung in its proper room. The number of complaints of insanitary conditions received from the Home Office inspector was nine. Kensington.—A tabular statement in the report shows that 625 workshops and 1,184 workrooms therein are on the register. There were 2,372 inspections of workrooms; 24 were found to be overcrowded; 28 insufficiently ventilated, and 143 in a dirty condition. The medical officer of health states that with respect to workshops where men only are employed that nothing can be done comparable with the work which is done where women are employed. " It is time these establishments should be taken in hand, but it cannot be done in any effective way with the present limited and reduced staff of sanitary inspectors without letting other and more immediately pressing work fall into arrear." Hammersmith.—An inspector was specially appointed for the inspection of factories and workshops, and subsequent to his appointment in June 196 notices were served. Fulham.—A considerable amount of work has been done, and most of the factories and laundries inspected, and improvements effected in their condition. St. George, Hanover-sqiuire.—The number of workshops and workplaces inspected was 77. The sanitary condition of 47 was found defective, and the drains of 17 had to be re-constructed. In these premises 25 rooms were overcrowded, and 14 in a dirty condition. Westminster.—The report contains an account of the statutory provisions relating to factories and workshops. One notice has been received from the Home Office inspector as to the opening of new premises. All the factories and workshops have been inspected during the year. Several notices requiring the lime-whiting and cleansing of premises were served. St. James, Westminster.— In 17 instances workshops were whitewashed and cleansed, in one, overcrowding was abated, and in 6 the ventilation was improved. Marylebone.—The number of visits to outworkers was 476. In 193 cases workrooms were measured and cards issued, in 263 cases the ventilation investigated, in 10 cases new places of business were reported on. There are 125 entries on the register relating to over 2,000 employees, 1,883 of these being females engaged in dressmaking or allied work. On the first inspection the majority of workshops were overcrowded. St. Pancras.—The medical officer of health discusses at length the duties of London sanitary authorities in connection with the provision of proper water-closet accommodation in factories and workshops, and he states in summary that " it appears to be the duty of H.M. inspectors of factories to recover 68 penalties for the non-provision of sanitary conveniences in factories, and to give notice in writing to sanitary authorities for the remedies to be applied, to require to be informed by sanitary authorities of the proceedings taken, and if not taken within one month to proceed as sanitary authorities might have proceeded. It appears to be the duty of London sanitary authorities to receive complaints from anybody, including their own officers, and also from H.M. inspectors of factories, to order sanitary convenience to be provided in factories, to see that they are constructed according to by-laws and regulations, and to supervise their construction." A large number of workshops employing male labour were entered on the register, but they represent only a small proportion of the number in the whole parish. Except for the abatement of nuisances, under notice, no re-inspections of the workshops entered in the register have yet been made. The female inspector made 3,203 inspections and 286 re-inspections, and inspected all the workshops and laundries in the district where women are employed. Islington.—In this district it was stated that the work was of the most satisfactory character, the female inspector made 1,251 inspections of workshops, containing 1,900 workrooms. It was found that in 27 there was overcrowding, in 10 the ventilation was bad, and in 50 there was uncleanliness. Other sanitary defects "341 in number" were remedied. As many as 547 cards were distributed, showing the number of persons the rooms could accommodate. Stoke Neuiington.—The factories and workshops have been inspected during the year, and the list of out-workers kept up to date. llackney—The number of workshops registered during the year was 103. Various conditions were found requiring remedy. St. Giles.—The number of visits made to factories and workshops was 109; special attention was given to the requirements of the Public Health Act as to watercloset accommodation. Strand.— There are about 600 places where persons are employed in some kind of mechanical labour, 18 of these are laundries in which the necessary improvements have been effected. Holborn.— There is no register of factories and workshops in this district, but 100 were inspected during the year. St. Luke.— There were 90 workshops inspected, of which 30 were found to be satisfactory. The defects in the others included dirty water closets, defective drains, want of cleanliness, and overcrowding. City.—H.M. inspectors gave 102 notices concerning workshops; 75 of these notices related to intended occupation or change of occupation of premises and 27 to sanitary defects. Shoreditch.—During the year 54 notices were received from the factory inspector relating to defects. Apart from the work arising out of these notices, numerous workshops and workplaces received attention and a large amount of work was executed. Bethnal-green.—No periodical supervision of workshops has been undertaken, but trade premises have been dealt with when discovered in the ordinary course. All notices from H.M. factory inspectors have received attention and insanitary conditions have been remedied. The Sanitary Committee has declined to endorse the complaint of a sanitary inspector and refused to require the owner of a small workshop to provide two water-closets where only one or two workers of each sex were employed. The medical officer of health thinks that the infliction of a penalty would be that very few additional waterclosets would be erected, while women would lose their employment. Whitechapel.—A good deal of time was given to workshops during the year ; very many night visits were made. St. George-in-the-East.—The number of workshops inspected was 306. Complaints from H.M. inspector have received attention. Limehouse.—The workshops have been inspected. Mile-end: Old-town.—In this district 242 workshops are periodically inspected with beneficial effect, over-crowding is rarely found, and for the most part they are kept in a cleanly condition. Inquiries showed that in the whole districts there were only 30 workshops where women and not men were employed, and 212 where men and women were employed, and in the latter proper separate sanitary conveniences were provided for each sex. There did not appear to the medical officer of health need for the employment of a female inspector. Poplar.—A tabular statement shows that in 42 instances improvements were effected in workshops. St. George, Southwark.—There are 338 workshops on the register, 96 of which have been added during the past year. The registration has led to the removal of nuisances such as filth, overcrowding and bad ventilation. More pressing duties have militated against the enforcement of the requirements of the order under section 27 (1) of the Act of 1891. The appointment of a special inspector is recommended for the purposes of this order. The requirements of the Act of 1895 are set out in the report. St. Olave.—A tabular statement shows that the improvement of factories or workshops was effected in 19 instances. Bermondsei/.—In this district 219 factories and workshops were inspected, and improvements effected in a number of them. Rotherhiihe.—The report shows that 17 factories and workshops were improved. Lambeth.—Workshops, numbering 255, were entered on the register. Batter sea.—The sanitary authority received notice as to a number of workshops from H.M. inspector of factories, some of which required cleansing, or were overcrowded, steps were taken in connection with the complaints, water-closet accommodation was improved in other cases. Wandsworth.—The medical officers of health state that the Act of 1895 has undoubtedly already done much good. In Clapham 1,581 workshops were inspected, and the condition of a number improved. 69 In Putney and Roehampton all were inspected, and found in a satisfactory condition with the exception of-two, concerning which notices were served. In Streatham in 21 factories and workshops defects were found and the necessary notices served. In Wandsworth (parish) there are 16 factories and 72 workshops on the register, of which 9 are steam laundries, and 52 laundries coming under the Act, in respect of 25 of these laundries notices were served, 6 notices were received from H.M.'s inspector and the necessary steps taken. Camberwell.—There were 220 inspections of workshops during the year. Greenwich (Deptford).—The number of inspections of factories, workshops and laundries was 73, overcrowding was abated and sanitary conveniences were provided. In Greenwich 59 factories and workshops were inspected. Plumstead.—The principal workshops are occupied as laundries or by dressmakers and a few by tailors. The medical officer of health visited several with a view to preventing overcrowding. Other insanitary conditions, such as insufficient water-closet accommodation, have been remedied. The inspection of bakehouses. The reports of the medical officers of health (with the exception of four) show that the bakehouses in their districts have been duly inspected during the year. in their districts have been duly inspected during the year. From some of the reports the number 01 bakehouses in occupation, and the number of these which are underground, can be ascertained, thus— Number in occupation. Number underground. Paddington 81 74 Kensington 138 Not stated Hammersmith 61 39 Chelsea 57 4-6 St. George, Hanover-square 46 Not stated St. James, Westminster 27 '' Haiiipstead 30 '' St. Pancras 200 170 St. Giles 27 21 Strand 23 28 Holborn 22 Not stated Clerkenwell 59 '' City 43 '' Shoreditch 88 '' Beth nal-green 91 '' St. George-in-the-East 27 17 Mile-end Old-town 76 22 St. George, Southwark 58 Not stated Newington 75 24 St. Olave 7 5 Bermondsey 67 34 Battersea 108 54 Wandsworth (Clapham) 46 Not stated „ (Wandsworth) 40 Lewisham 93 Woolwich 42 '' Lee (Charlton) 9 '' „ (Eltham) 8 '' Plumstead 38 '' The medical officer of health of St. Pancras shows in diagrammatic form the extent to which the bake-houses are below the ground level, and he states that nearly three-fourths of the 200 have the floor six feet or more below the level of the ground. The medical officer of health of Kensington states, in reference to the provision that a place underground shall not be used as a bakehouse unless it is so used at the commencement of the Act that this has been held by magistrates not to prohibit the subsequent re-occupation of an underground bakehouse which existed, but was not in use at the commencement of the Act. On the other hand the medical officer of health of Woolwich states that during the year three applications have been refused for the re-opening of underground bakehouses. The Battersea Vestry instituted proceedings in the South Western police-court, the offence being the use of an underground bakehouse after the commencement of the Act which had been in occupation before, but not at the time of, the commencement of the Act. The magistrate's decision was that the Factory and Workshops Act had been contravened, and the continued use of the bakehouse was prohibited by him pending an appeal to a higher court. The medical officer of health of Clerkenwell includes in his annual report a special report on the condition of bakehouses in that district, which he presented to the vestry in October, 1896. He found dirty conditions of walls, ceilings and passages, requiring notice to be served in 20 instances, and defective floors in 17 ; and he says that on the whole in too many cases the standard of cleanliness is much too low. Experience showed that biennial inspection of bakehouses was insufficient. Unsound Food. In a number of districts seizures were made of food considered unsound and unfit for human consumption. The food seized generally consisted of meat, tish, fruit, vegetables, eggs, rabbits and 70 poultry. The seizures were made in Fulham. Westminster, Chelsea, Marylebone, St. Pancras, Hackney, St. Giles, Strand, Holborn, St. Luke, City, Shoreditch, Bethnal-green, Whitechapel, St. George-in-theEast, Limehouse, Mile-end Old-town, Poplar, St. Saviour Southwark, St. George Southwark, St Olave, Bermondsey, Rotherhithe, Battersea, Wandsworth, (Clapham, Wandsworth) Camberwell,. Greenwich (Greenwich, Deptford), Woolwich. In the City, 915 tons of meat were seized in the markets, 82 per cent, of this meat having become putrid, and 12 per cent, being diseased. The medical officer of health recommends the appointment of additional inspectors. Prosecutions were instituted in 9 cases, fines were inflicted in 6, and in three the def ndants were sent to prison for periods varying from one to three months. Fish to the amount of 1,212 tons was condemned and destroyed by the " fish meters " of the Fishmongers' Company. The work done by the special meat inspector appointed in Holborn leads to the conclusion that a large amount of unsound meat must previously have passed through that district. During the year 1896, 7,131 stones of diseased meat and 5,381 stones of decomposed meat wrere seized, and this amount is independent of the offal which was seized. The medical officer of health reports that of 248 seizures of diseased meat in 86 cases, or one-third, the carcases were tuberculous. In numerous instances legal proceedings were instituted. The extent of these is shown by the fact that during the year the medical officer of health attended various courts of law on 116 separate occasions. He states that the amount of diseased meat seized in the first quarter of the year was less than one fourth of the amount seized during the corresponding period of the preceding year, and he adds that since Easter, 1897, when one of the meat salesmen was sentenced to four months imprisonment with hard labour, without the option of a fine, there have been very few seizures of diseased meat. The excellent work done in Holborn in connection with meat inspection deserves recognition ; it is matter of the greatest importance that it ahould be continued, for any relaxation of the vigilance of the sanitary authority would no doubt lead to the re-development of the diseased meat trade in this district. So long as the premises of meat salesmen are constantly visited by the officers of the sanitary authority, the trade in diseased meat can be less readily carried on, it cannot, however, prevent the consignment of diseased meat from the country direct to retail vendors nor to those who manufacture sausages. In Poplar (Bow), a sausage manufacturer was fined £150, and in default of payment was sent to prison for having on his premises unsound meat which was being cut up at the time of seizure. Other seizures were made in this district. In Mile-end Old-town 2 tons of unsound food were seized on premises, which were partly used as a cheap eating house. In Shoreditch unsound bief which was seized on a stall was alleged to have been purchased in the meat market. Unsound meat was seized in private slaughterhouses on two occasions, viz., the carcase of a tuberculous cow in Mile-end Old-town, and the carcases of pigs in Battersea. Tinned food amongst other articles was seized in St. Giles, St. Olave, and St. Pancras. The medical officer of the last district states that much of the tinned foods in the cheaper markets is derived from old ships' stores ; he suggests that there would be advantage in a requirement " that all tins containing tinned food shall have stamped upon the bottom the date of tinning." The manufacture and sale of ice-cream. In my last report I stated that a representation had been made to the Local Government Board by the Clerkenwell Vestry and some other London sanitary authorities, asking for legislation to provide for the registration of vendors of ice-cream, and for the regulation of the conditions under which icecream is manufactured. The annual reports of medical officers of health show that the public health committee of the Vestry of Westminster, after considering a report by their medical officer, came to the conclusion that it was urgent and necessary that the vendors of ice-cream should be registered. The medical officer of health of Deptford made an inspection of all premises in the district where icecream was made and stored, and " found all in a fairly satisfactory condition." A register was made of such places. In Limehouse samples of ice-cream were submitted to analysis, and the analysis did not reveal, so far as the ingredients went, anything of a deleterious nature. " Evidence of the unsatisfactory surroundings under which these delicacies were prepared was, however, abundantly present, and led to an inspection of the ice-cream shops in the district. A regular inspection of these premises will now be made." Water Supply. The report of the water examiner appointed under the Metropolis Water Act, 1871, supplies the following information as to the capacity of the subsidence reservoirs, and the monthly average rate of filtration of the several companies in 1896— Number of days' supply. Monthly rate of filtration per square foot per hour. Mean monthly average. Gallons. Maximum monthly average. Gallons. Chelsea 10.0 1.75 1.75 East London 20.3 1.33 1.33 Grand Junction 3.4 1.67 1.90 Lambeth 5.6 1.94 2.60 New River 4.7 2.7 2.50 Southwark and Vauxhall 4.1 1.50 1.50 West Middlesex 13.8 1.34 1.50 As to storage reservoirs, Major-General Scott writes— " The river-deriving companies, with one exception, are actually engaged in constructing, or in making arrangements for the construction of, additional storage reservoirs. The Chelsea Company 71 which formerly held a prominent position in this respect, has lost ground to a considerable extent, and unless measures of a similar nature are adopted, this company, within the next few years, will find itself surpassed as regards the provision of storage reservoirs by all the other companies deriving their supplies from the Thames and the Lee. It is, in fact, necessary that the storage reservoirs should be capable of containing a quantity of water equal to 20 days' average supply, instead of 10 days, as at present." Concerning the opportunity which exists for ascertaining the efficiency of each filter, he points out " It is desirable that the water issued from each filter should be delivered into a distinct well, so that distinctive examples may be obtained for examination, and failure in the efficiency of filtration may be traced to the particular filter which is at fault. In the cases of the Chelsea and West Middlesex Companies the filtered water collects in a general receptacle or well and no means exist of determining the character of the filtration of each filter bed." Sir Edward Frankland's report on the results of his monthly bacterioscopic examination of the water supplied by the several companies contains the following statements— Chelsea Company.—" Except in June this company delivered water of uniformly excellent quality, rivalling, in many cases, deep-well water in this respect." West Middlesex Company.—" Excepting in June and December, this company delivered water of most excellent bacterial quality, [not infrequently rivalling or excelling in this respect the deep well water of the Kent Company. The infraction of the standard (100 microbes per c.c.) in December was only slight (120), but that in June was more serious." Southwarh and Vauxhall.—" The filtration plants of the Chelsea and West Middlesex Companies deliver the filtered water into general receptacles or wells, from which the samples for bacterioscopic examination were drawn, and there was consequently no opportunity at these works for obtaining separate samples from each of the filter beds. At the South wark Company's works, however, I have been able to obtain samples from several separate filters, and the above table, giving the results of the examination of these samples, shows several cases in which effective bacterial filtration was not attained. Thus, No. 3 filter was not working satisfactorily in July, Nos. 4 and 5 filters were uniformly and highly satisfactory on every cccasion when samples were drawn from them, the water issuing from No. 4, on September 9th, being absolutely sterile; but filter No. 8 yielded on four out of ten occasions unsatisfactory results. Although No. 8 filter leaves much to be desired, the company's record is, on the whole, greatly superior to that of 1895." Grand Junction Company.—"The small amount of storage possessed by this company renders it difficult at all times to maintain efficient bacterial filtration, and six out of the 12 samples collected at the Hampton works during the year contained an excess of microbes, or their spores, over 100 per c.c.; whilst five out of the 22 samples collected at the Kew works also contained an abnormal number. As was the case with nearly all the other companies, the most serious infractions of the standard occurred in June." Lambeth Company.—"Excepting in June and December, this company delivered water of excellent bacterial quality, the infraction of the standard in June being the only serious one, but even in this month of abnormal results, the number of microbes was much less than that found in the water of three of the other Thames companies. Altogether, the record of this company is very good, and is free from violent fluctuations. In December, for instance, when the Thames contained the enormous number of 160,000 microbes per c.c., and the stored water supplying the filters as many as 56,000, the number was reduced to 116 per c.c." New Rixer Company.—" This table shows that out of 31 samples colbcted during the year only three transgressed the standard of 100 microbes per c.c , whilst one was absolutely sterile. Two out of the three transgressions occurred in November and December, when extensive repairs were being made in the filtered water culverts. The samples collected on six occasions from the general filter-well compare favourably, in respect of bacterial purity, with the deep-well water of the Kent Company." East London Company.—" From this table it is S3en that out of 31 samples nine contained a number of microbes in excess of the standard; three of these were taken from three different filterwells in the month of June, when the filtration plants of nearly every metropolitan water company, for some unexplained reason, were simultaneously unable to perform efficiently their work of bacterial purification. Up to the present time I have endeavoured in vain to find an explanation of this singular phenomenon. If it had occurred only in one or two cases it might have been attributed to accident or carelessness ; but its general occurrence proves that the cause must be some condition or conditions affecting both metropolitan rivers. Of the five companies drawing from the Thames, all except the South wark were smitten with this microbial epidemic in June, and even the Southwark had got it on the 2nd of the following month. Of the two companies drawing from the Lee, the New River alone escaped, owing no doubt, to the exceptional sources from which it derives its raw water. The East London Company had it rather severely, every one of its filter-wells yielding in June water containing an excess of microbes." The report of Sir Edward Frankland also includes the following paragraph— In nature, even the purest waters contain, almost invariably, minute quantities of organic matter; but in river water the presence of even a small proportion is considered objectionable, partly on sentimental and partly on hygienic grounds, by reason of the possible origin of some portions of this organic matter. The water both of the Thames and Lee receives, above the points where it is abstracted for the purpose of the metropolitan supply, various contributions of organic matter of animal origin, such as the drainage from manured land, and the effluents of sewage works. This animal matter, though innocuous in itself, may at any time be accompanied by zymotic matters dangerous to health. But, although the sentimental objection to the presence of animal matter cannot be removed, it is gratifying to find, as the result of recent researches, that the zymotic matters of the pathogenic kind are rapidly destroyed in running water, so that the most minute microscopic inspection of the water as it reaches the intakes of the various companies has hitherto failed to discover in it a single pathogenic germ. Further, it is now an established fact that efficient sand filtration would prevent the passage of such germs into 72 the filtered water, even should they arrive in a living condition at the intakes of the companies. Thus the hygienic objection to the use of filtered water taken from the Thames and Lee is removed. The result of recent observations conducted in this country, in Germany, and especially in the United States of America, is confirmed by the absence in London since the year 1866 of zymotic diseases traceable to the water supply. To secure this desirable result, however, efficient filtration is essential; and there can be no doubt that the serious loss of life during the cholera epidemics of 1849, 1854 and 1866 was due to the war.t of attention to filtration. The weight that deservedly attaches to statements By Sir Edward Frankland, and the fact that his report is included in the report of the Local Government Board, the principal health authority of this country, makes it necessary that I should submit certain considerations which I think should be held in view in any effort to define the actual amount of risk to London inhabitants from water derived from the Thames and Lee. In the first place, it is necessary to point out that the absence of discovery of pathogenic organisms in the rivers at the intakes must not be accepted as proofthat these organisms are not from time to time present in the river water in those localities. All that can be assured is that they were not present in sufficient numbers to be discovered in certain samples of water which were examined, samples which in relation to the volume of water arriving at the intakes were infinitely small. These organisms might be present in one gallon of water, absent from another; they might be present near the intakes at one time, absent at another time. In the second place Sir Edward Frankland states that efficient sand filtration would prevent the passage of pathogenic germs into the filtered water. To effect this result the filters must be able to prevent the passage of all organisms, for there is no reason for thinking that the filters have any power of selection which would lead them to treat pathogenic organisms differently from non-pathogenic organisms, and Sir Edward Frankland's reports only show that the filters very largely reduce the number of organisms. In the third place, Sir Edward Frankland's statement that zymotic diseases traceable to the water supply have been absent in London since 1866 leads me to point out that under the conditions which have existed, and still exist, there has been no sufficient opportunity for determining whether enteric fever has or has not been caused by water supply. It is no doubt true there has been no mortality from this cause sufficiently large to manifest itself in the absence of a proper system of observation, but, in view of the experience of 1894, I cannot assent to the statement as to "the absence in London since the year 1866 of zymotic diseases traceable to the water supply." In his last sentence Sir Edward Frankland insists, and properly insists, that efficient filtration is essential to secure the absence of water-borne disease ; it need hardly be added that everything in this connection depends upon the meaning which is to attach to the word " efficient." In writing thus, I am not actuated by any fear that under existing circumstances the London inhabitants are not substantially protected against any such disasters as those of past years to which Sir Edward Frankland refers. Nor, indeed, is it probable that there will be greater indications of relationship between enteric fever in London and water supply than those afforded by the experience of the year 1894, and which I have discussed in my annual report for that year. Indeed, even if no further improvements be effected in filtration, such indications might readily be lost as water companies come more largely to interchange their water. But it may be that the conditions of the present time may not always continue, that with growth of population in the river valleys above the intake there may be increase of pollution, and that as between the opposing forces of increase of pollution and the filtration of the water companies the former may become the more powerful. It appears to me therefore, seeing that the rivers are a polluted source, matter of the greatest importance that opportunities should be given and should continually exist for determining whether at any time there is relationship between the enteric fever of London and water supply. Proceedings of the Council as to London water supply. On the 28th January, 1896, the Council received from the Water Committee a report stating that after inspection of the water areas of the Usk and Wye they were of opinion that one of the advantages of the Welsh scheme is that it may be carried out by instalments, and that assuming the present sources of supply to be maintained, a supplementary supply of purer and more wholesome water may be obtained from Wales sufficient for the requirements of London forty years hence, at a cost little, if at all, exceeding that which would be incurred by the formation of reservoirs in the Thames valley. On the 25th February, the Committee presented a further and more detailed report on the Welsh sources of supply, and making recommendations to the Council of which the following were adopted on the 21st April. (1.) That it is in the interests of London that the requisite augmentation to its supplies of water to meet the needs that may ultimately be felt should be derived from some source other than the rivers Thames and Lee. (2.) That the valleys of the Usk, the Wye and the Towy, with their tributaries, furnish a suitable area from some parts of which supplies might be derived. (3.) That the Usk and Llangorse section of the Welsh scheme, as set out in the report, should be undertaken in the first instance. On the 14th July the Council received a report from the Water Committee, stating that it was the Committee's intention as soon as possible to obtain further engineering advice upon the whole scheme of a supply from Wales, and that they had engaged the assistance of Sir Benjamin Baker and Mr. G. F. Deacon. On the 21st July the Council resolved that in view of the desirability that the authority or authorities which may he entrusted by Parliament with the administration of the London water supply should be in a position to undertake the purchase of the water companies' interests, the Council, without in any way committing itself at this stage to the terms of the purchase, the form or provisions of the bill or bills, do hereby resolve that a bill or bills be prepared for introduction in the session of 1897 for the purchase of the undertakings of the eight metropolitan water companies, The Council postponed 73 the consideration of a recommendation that application should be made to Parliament for power to bring additional supplies of water to London from the watersheds of the Usk and Llangorse. Insufficiency of water supply. In the reports of the medical officers of health of Hackney, Shoreditch, Whitechapel, St. Georgein-the East, Limehouse, Mile-end Old-town and Poplar, reference is made to the failure of constant water supply by the East London Waterworks Company during the summer months. From the 21st of July to the 10th of September the company found it necessary to restrict the supply of water to certain hours of the day; considerable inconvenience was caused owing to the absence of storage cisterns in the houses. To meet the difficulty the company erected stand-pipes in the most desirable places, and supplied earthenware receptacles for distribution among the inhabitants. Constant water supply. The annual report of the chief officer of the Council's Public Control department shows that constant water supply was extended during the year ending March 31st, 1897, so that at that date 93 6 per cent.of the houses in London were thus receiving their water. River pollution. The condition of the river Lee is discussed at length in the report of the medical officer of health of Hackney who states that, the summer being hot and dry the water became offensive, due chiefly to the sewage effluents of Walthamstow and Leyton which are poured into the river at that part. A memorial was presented by the sanitary committee of the Hackney Vestry asking the Council to take immediate steps to obtain the appointment of a Select Committee by the House of Commons to continue the evidence which was taken by a committee in 1886, on the pollution of the river Lee, which committee was unable to complete its labour owing to the dissolution of Parliament. The memorial was considered by the Rivers Committee and the following recommendation was adopted by the Council on the 10th November, 1896— " That the Council do ask Her Majesty's Government to take steps to appoint a Select Committee in the next session of Parliament to inquire into the present condition of the river Lee." The medical officer of health of Poplar called attention to the condition of the banks of the river Lea and suggested " that the Conservancy ought to cleanse the banks of Bow-creek, as at low tide they were covered with thick black slimy mud and emitted odours no doubt dangerous to health." A letter was addressed to the Lea Conservancy Board on the subject. Disinfection. In my last report I stated that 24 districts had provided themselves with apparatus in which disinfection is effected by steam, and 6 districts, viz., Hammersmith. Marylebone, Clerkenwell, St. Luke, Limehouse and St. Saviour, had dry heat apparatus. Since that time the sanitary authorities of Marylebone, St. Luke and Limehouse have provided themselves with steam apparatus, and those of Hammersmith, Clerkenwell and St. Saviour have decided to do so. Beyond these, the district of St. Olave is now provided with its own disinfector, disinfection having previously been done in the apparatus at Guy's Hospital. The Vestry of Lambeth has decided to provide a second steam disinfecting machine, in order to avoid the expense incurred in the employment of a contractor whenever the existing apparatus required repair. The Vestry of St. George-in-the-East has arranged for infected articles to be disinfected in the apparatus of the London Hospital. Eight districts still rely upon the services of contractors, steam apparatus being used. The medical officer of health of Kensington reported that many hundreds of pounds per annum might be saved on the present cost of disinfection were the vestry to undertake the work without the intervention of a contractor, but a committee of the vestry decided not to make any change in the existing arrangements. On the other hand, the medical officer of St. Martin-in-the-Fields finds the employment of a contractor the most convenient arrangement for the district, no site being available for the erection of apparatus. The steam apparatus in Mile-end Old-town is merely a converted Fraser's oven, which the medical officer regards as unsatisfactory; he strongly urges the provision of efficient apparatus. Nearly all the reports contain information as to the number of rooms and articles disinfected after the occurrence of infectious disease, and in the report relating to Lambeth account is given in some detail of the arrangements for disinfection made in that district. The subject of disinfection of rooms was specially considered by a committee of the Vestry of St. George, Southwark, and was also reported on by the medical officer of health, effort being made to secure efficiency in respect to each detail. It appears that a shelter is especially required in this district for the accommodation of persons during the disinfection of their rooms owing to the proportionately large number of persons living in one and two rooms. The vestry has decided to make this provision. The method of disinfection of rooms is mentioned in a few of the reports : In Whitechapel the wall and floor surfaces are washed with a solution of corrosive sublimate, and the rooms are also fumigated with sulphur di-oxide; in Fulham the walls are sprayed with sublimate, but fumigation cannot always be practised owing to the absence of any shelter for the use of the inmates while excluded from their rooms. Difficulty is also experienced in Kensington for the same reason. In two districts (Marylebone and Islington) cremators have recently been constructed. The number of cabs and carriages disinfected are shown in the reports of the City, Battersea and Lambeth. Provision and use of shelters. The provision of accommodation for persons during the disinfection of their homes makes but slow progress, but the annual reports afford reason for thinking that where suitable accommodation has been provided, this is increasingly used. In Paddington, in 1896, 41 families, comprising 350 persons, [10] 74 were received. In Kensington, no provision has yet been made, the medical officer of health has been unable to find suitable premises, and has reported that in his opinion the only satisfactory plan would be to erect a shelter and provide it with a proper equipment; in the meantime the sanitary inspectors have been authorised to pay for lodgings for people thus dispossessed of their rooms, but the medical officer of health states that difficulty in finding lodgings is experienced, and that the inspector, having charge of the disinfecting arrangements, had reported that in many cases the doors of rooms which had been closed during fumigation had been burst open after he left the premises, with the result that practically no disinfection was effected. In Fulham, as stated above, no shelter has been provided. In St. George Hanover-square, the shelter has been used but once, it consists of basement rooms. The Westminster shelter received 45 families. The Marylebone shelter, which is now open, was used in some ten months 27 times and received 57 adults and 30 children. The St. Pancras shelter received 20 adults and 19 children during the year. In January last it was decided that sleeping accommodation should be provided. The Strand shelter was used by several families; the District Board had the year before addressed a communication to other London sanitary authorities on the question of the repeal of the statutory requirement that temporary shelters should be provided. A suitable house for a shelter could not be found in Holborn, the district board therefore arranged with the Clerkenwell Vestry for the use of the latter's shelter by Holborn inhabitants. In the City the shelter was used by 31 families, comprising 59 adults and 48 children ; of the 31 families, 21 families had been living in one room and 10 in two rooms. The Shoreditch shelter was used on seven occasions and received 23 persons. The shelter in St. George-in-the-East was used three times by 13 persons. The St. Saviour District Board has decided to erect a shelter on land to be used also for mortuary, coroner's court, and disinfecting apparatus. In St.George Southwark, the Local Government Board has sanctioned a loan for the erection of a shelter. In St. Olave the shelter was used 18 times and received 83 persons, 75 of whom were provided with sleeping accommodation. In Bermondsey efforts were made to secure suitable premises which could be used as a temporary shelter. " No less than 54 families have been obliged to vacate their homes while their rooms were being disinfected, and although care has been taken in all cases to minimise as far as possible the inconvenience to the persons, yet it is evident that there has been considerable hardship in many instances." The shelter in Lambeth was only opened towards the end of the year, when two families were admitted. The shelter consists of two sets of two rooms, each set provided with a bath and lavatory, one of each of the two rooms is fitted with a kitchenrange and cupboards. The medical officer of health of Greenwich states that " the house has been partly furnished, and during the year was inhabited by 11 families, Deptford 2, Greenwich 9." The shelter in Woolwich was used by 13 families, comprising 40 persons. The Plumstead shelter was used on two occasions, and by 10 persons; it has been decided to build a new shelter which is approaching completion. Hospital provision for infectious disease. The report of the statistical committee of the Metropolitan Asylums Board for the year 1896 states that the managers were able to bring into use during the year the new Brook Hospital at Shooter's-hill, Woolwich, thus adding 488 beds to the total normal accommodation of their hospitals. At the Western Hospital works are in progress which, when completed, will raise its accommodation to a total of 450 beds. The report also states that " the erection of the Park Hospital and the Grove Hospital ... is being proceeded with as expeditiously as possible, and it is anticipated that the former will be ready for the reception of patients in the autumn of 1897, and the latter in the following summer." " The managers' scheme of hospital provision will then be complete, with the exception of the reconstruction of the North-Eastern Hospital and the erection of a hospital for convalescent fever patients on the southern side of London." " The completion of the scheme . . . will place the managers in the possession of nearly 6,000 beds for infectious diseases other than smallpox." During the year 1896 the managers removed from their houses to the hospitals of the board 22,417 fever, diphtheria and smallpox patients, and 433 private persons were removed on payment to other places than the managers' hospitals ; 1,287 patients were taken from the out-patient departments of general hospitals to their homes owing to there being no vacant beds in the managers' hospitals, and 109 enteric fever patients were removed from their homes to the general hospitals, where arrangements for their reception had been made by the managers. Mortuaries. From the reports of medical officers of health it appears that mortuaries are being more largely used for the reception of dead bodies pending burial, either from homes where the accommodation is limited, or because the deceased have died from infectious diseases. The Paddington mortuary was used on several occasions for the reception of bodies of persons dying from infectious disease, and the medical officer of health thinks further provision is necessary. In Kensington the mortuary was used for the reception of 289 bodies, of which 204 bodies were received either at the request of the coroner or were brought in by the police; of the remaining 85 bodies, 14 were of persons who had died from infectious disease. The Fulham mortuary received 124 bodies, 120 at the request of the coroner or brought in by the police and four were of persons who had died from infectious disease. Of 135 bodies admitted in the Hammersmith mortuary, 6 were the bodies of persons who had died from infectious disease and 2 were bodies for which there was no proper accommodation at home. The erection of a suitable mortuary is under consideration. There were 19 bodies received into the Chelsea mortuary for " sanitary reasons." The number of bodies brought to the mortuary of St. George, Hanover-square, was 176, of which 28 were brought because there was insufficient accommodation for them at home. Of 124 bodies admitted into the Westminster mortuary, 75 20 were to await burial. The mortuary in St. James, Westminster, received 29 bodies. In the Marylebone mortuary 538 bodies were received, of which 301 were to await burial, and of these 26 were the bodies of persons who had died from infectious disease. Of 71 bodies received into the Hampstead mortuary 8 were so received at the request of friends or of medical men. In St. Pancras, of 485 bodies received, 19 were admitted into the infectious mortuary. In Islington, 757 bodies were received into the mortuary, inquests were held on 463. The number of bodies received in the Stoke Newington mortuary was 23, inquests were held on 18. The Hackney mortuary received 365 bodies, 352 for the purpose of inquest, 13 to await burial. In St. Giles, 64 bodies were received into the mortuary. Of 77 bodies received into the Strand mortuaries, one was the body of a person who had died from infectious disease. There were 157 bodies brought into the Holborn mortuary, on 51 of which inquests were held. The Clerkenwell mortuary received 253 bodies, 194 of which were brought from dwellings of parishioners, and 16 of these were bodies of persons who had died of infectious disease. In St. Luke, 289 bodies were received into the mortuary, on 83 inquests were held. In the City, 94 bodies were received into the mortuary, pending their removal for interment. The number of bodies received into the Shoreditch mortuary was 404, on 301 inquests were held, 9 were the bodies of persons dying from infectious disease; the medical officer of health says that the figures show an increasing disposition on the part of the public to make use of the mortuary. In Whitechapel 156 bodies were deposited in the mortuary, 16 to await burial and on the remaining 140 inquests were held. The mortuary in St. George-in-the-East received 207 bodies, 13 of which were admitted into the infectious mortuary. The Limehouse mortuary, during the last two months of the year, received 37 bodies, 33 of which were on the order of the coroner. There were 160 bodies admitted into the Mile-end Old-town mortuary, several were the bodies of persons who had died from infectious disease. In St. George, Southwark, 212 bodies were deposited in the mortuary, five on account of infectious disease. Of 165 bodies received into the Newington mortuary, 8 were bodies of persons who had died from infectious disease, and 18 others were bodies awaiting burial. In St. Olave inquests were held on 21 of 32 bodies brought into the mortuary. The number of dead bodies in Bermondsey which were removed from rooms to the mortuary was 64, being an increase of 26. In Rotherhithe, 8 bodies were removed to the mortuary. The number of bodies received into the Lambeth (High-street) mortuary was 373. The Battersea mortuary received 293 bodies, 17 of which were for " sanitary reasons." The Streatham mortuary received 25 bodies. In Camberwell, 240 bodies were removed to the mortuary; 211 inquests were held. In Plumstead, 23 bodies were admitted to the mortuary. The reports also show that in St. Saviour, Southwark, it has been decided to erect a mortuary on land purchased for the purpose; that in Lambeth a second mortuary was in course of erection in Wanless-road, and that a site for a third mortuary had been purchased in Norwood; that plans for the erection of a new mortuary in Woolwich have been prepared ; that the medical officer of health of Lee (Eltham) suggests that the two parishes of Eltham and Lee should combine for the purpose of erection of a mortuary; that the new mortuary in Plumstead has not been commenced. The London Equalisation of Rates Act, 1894. The Equalisation of Rates Act provides that the London County Council shall in each year form a fund equal to a rate of sixpence in the pound on the rateable value of London. The contribution from each parish to the fund is to be in proportion to its rateable value. The fund thus formed is to be distributed among the sanitary districts in proportion to their population. Where a sanitary district comprises two or more parishes, and the aggregate of the contributions from such parishes is less than the grant apportioned to the district, the difference shall be paid out of the fund to the sanitary authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish; and if it exceeds the grant due to the parish, the Council shall, for the special purpose of meeting the excess, levy on the parish a county contribution as a separate item of the county rate. Every sum paid to a sanitary authority must be applied in defraying the expenses of the sanitary authority incurred under the Public Health (London) Act, 1891, and so far as not required for that purpose those incurred in respect of lighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to the parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid, and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned, and have made an order limiting a time for the performance of the duty of the authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund a census shall be taken on the 29th March, 1896, which census was taken on that date as provided. In other years an estimate of population on the 6th April will be made by the Registrar-General upon returns which the Local Government Board will receive from the authority making the poor rate in each parish, showing the total number of houses entered in the rate book of the parish. 76 The following table shows the enumerated population at the census taken 29th March, 189G, and the amount of excess of contribution over grant or of grant over contribution in respect of each district for the vear ended 31st March, 1897. In accordance with section 3 (1) of the London (Equalisation of Rates) Act, 1894, the expenses incurred in respect of the census taken on the 29th March, 1896, viz., £7,720 9s. 4d., has been deducted from the total contributions received, the amount of contributions remaining being then distributed among the sanitary districts in proportion to population. Sanitary District. Enumerated population 29th March, 1896. Equalisation charge being excess of contribution over grant. Net grant being excess of grant over contribution. £ s. d. £ s. d. Paddington 124,506 8,351 16 10 — — — Kensington 170,465 17,622 7 6 — — — Hammersmith 104,199 — — — 6,219 5 2 Fulham 113,781 — — — 8,775 12 6 Chelsea 96,646 126 4 2 — — — St. George, Hanover-square 79,967 33,546 17 4 — — — Westminster 53,234 11,033 12 — — — — St. James 23,050 15,531 8 7 — — — Marylebone 141,188 11,754 19 8 — — — Hampstead 75,449 4,554 — 5 — — — Pancras 240,764 — — — 7,041 12 1 Islington 336,764 — — — 23,196 4 — Stoke Newington 33,485 — — — 1,493 10 10 Hackney 213,044 — — — 16,327 14 11 St. Giles 38,237 2,999 — 10 — — — St. Martin-in-the-Fields 13,077 11,562 9 5 — — — Strand 23,782 10,940 18 5 — — — Holborn 31,208 4,027 12 1 — — — Clerkenwell 66 202 — — — 3,417 19 9 St. Luke 41,527 358 10 1 — — — London, City of 30,970 104,842 7 10 — — — Shoreditch 122,348 — — — 7,213 12 1 Bethnal-green 129,162 — — — 14,616 4 3 Whitechapel 77,717 — — — 4,838 2 11 St. George-in-the-East 47,506 — — — 4,617 9 8 Limehouse 58,305 — — — 4,097 3 10 Mile-end Old-town 111,060 — — — 12,268 1 2 Poplar 169,267 — — — 15,431 1 9 St. Saviour, Southwark 25,365 3,707 4 10 — — — St. George, Southwark 60,278 — — — 4,921 2 6 Newington 120,939 — — — 11,936 11 4 St. Olave 11,731 2,957 17 2 — — — Bermondsey 85,475 — — — 6,704 19 10 Rotherhithe 40,379 — — — 2,674 16 1 Lambeth 295,033 — — — 17,340 4 7 Battersea 165,115 — — — 11,370 18 6 Wandsworth 187,264 — — — 6,479 8 7 Camberwell 253,076 — — — 22,130 17 4 Greenwich 175,774 — — — 12,570 17 1 Lewisham 104,521 — — — 3,660 10 7 Woolwich 41,314 — — — 1,508 3 4 Lee 38,588 — — — 656 5 2 Plumstead 59,252 — — — 6,869 18 1 The Charterhouse 137 265 15 5 — — — Gray's-inn 264 353 10 6 — — — The Close of the Collegiate Church 355 28 — 9 — — — of St. Peter Inner Temple 148 557 8 4 — — — Middle Temple Lincoln's-inn 105 344 1 2 — — — 19 467 15 4 Staple-inn 10 60 6 11 Furnival's inn 47 104 11 8 Amount of the expenses certified by the Registrar-General to have been incurred in respect of the census taken on the 29th March, 7,720 9 4 1896, and payable out of the Equalisation Fund [London (Equalization of Rates) Act, 1894, sec. 3 (1)]. Total 4,432,099* 246,098 17 3 246,098 17 3 * This is exclusive of the Tower of London, the population of which was 919. 77 Sanitary Administration of Districts. Bethnal-green.—In 1895 the Public Health Committee had under consideration a report by Dr. Young on the sanitary condition and administration of Bethnal-green. This report showed the need for an additional sanitary inspector and further clerical aid. The Committee communicated with the vestry of Betinal-green on this subject, and in January, 1896, reported that the vestry had decided to appoint one of its present sanitary inspectors to be chief sanitary inspector, and to engage an additional sanitary inspector and an additional clerk in the sanitary office. The Committee further reported that, for the reasons given in the medical officer's report, they were of opinion that a staff of six inspectors and two clerks is the smallest that would suffice for the needs of the parish, if all the inspectors were exclusively occupied in the work of inspection, and inasmuch as the time of the chief inspector would not be entirely devoted to such work in the district, the Committee expressed the hope that the vestry would at a later date, after a trial had been given to the present staff, consider the question of further strengthening it. A further need in the district, pointed out by Dr. Young, was a shelter for persons during the disinfection of their rooms; the vestry considered that it was not expedient or necessary to establish a permanent shelter. In May, the Committee reported that the whole work of the sanitary department had been re-organised, an additional sanitary inspector having been appointed and a systematic house-to-house inspection of the district had been instituted. Eltham.—Question having arisen as to the efficiency of sanitary inspection in Eltham, Dr. Young was instructed to report upon the condition and administration of the parish. The sanitary inspector employed in this parish was also employed as road foreman, and on hearing of the Committee's intention to institute inquiry, the Lee District Board intimated their decision to relieve the sanitary inspector of his duties as road foreman. The result of Dr. Young's inquiry was to show that the better arrangement would have been to have appointed a separate sanitary inspector, and further that the work of the sanitary inspector should be to a greater extent superintended and controlled by the medical officer of health ; the question of the sufficiency of the office accommodation was also discussed in his report (see Appendix VI.). In July, the Committee reported that the Lee District Board was unwilling to make further change, and they had therefore decided after a year's interval to have further inquiry made. Holborn.—In 1896 Dr. Young was instructed to report on the sanitary condition and administration of Holborn, and in October of that year I presented his report to the Public Health Committee. This report showed that the number of sanitary inspectors employed in the district was insufficient; that the arrangements for the removal of house refuse failed to effect such removal once a week; that the district board had not provided a permanent shelter for the accommodation of poor persons during the disinfection of their rooms; and that, with respect to certain areas, little short of demolition of houses and re-arrangement would be productive of satisfactory results (see Appendix VII.). After correspondence with the Holborn District Board, the Council in July, 1897, made representation to the Local Government Board that the Holborn District Board had made default in not appointing sufficient sanitary inspectors for the district. Medical Officers of Health and Sanitary Inspectors. The Public Health (London) Act, 1891, requires that the Council shall pay a moiety of the salary of every medical officer of health and sanitary inspector appointed or re-appointed after the passing of the Act. Up to the end of the year 1896, 42 medical officers of health and 182 sanitary inspectors had been thus appointed or re-appointed. * Appointment or re-appointment sanctioned by the Local Government Board. A moiety of the salary appertaining to these appointments is payable by the London County Council. The following table indicates those London districts in which the medical officer of health has been elected in accordance with the above requirement of the Public Health (London) Act, up to the end of 1896— District. District. District. District. *Battersea *Holborn *Poplar Bow) *St. Pancras Bermondsey *Islington * ,, (Bromley and Poplar) *St. Saviour, Southwrrk *Bethnal-green *Kensington Rotherhithe *Shoreditch *Camberwell *Lambeth St. George, Hanoversquare *Stoke Newington *Chelsea Lee (Charlton) *Strand *City * „ (Eltham) *St. George-in-the-East Wandsworth (Clapham) *Clerkenwell „ (Lee) St. George-the-Martyr „ (Putney ) *Fulham Lewisham *St. Giles „ (Streatham) Greenwich (Deptford) *Limehouse *St. James, Westminster „ (Tooting) „ (Greenwich) *Mile-end Old-town *St. Luke „ ( Wandsworth ) *Hackney *Newington *St. Martin-in-the-Fieids *Westminster *Hammersmith *Paddington St. Marylebone Whitechapel Hampstead Plumstead *St. Olave *Woolwich Sanitary districts mentioned in Schedule C. of the Metropolis Local Managemnt Act, 1855. *St. Peter, Westminster (close of the Collegiate Church) *Gray's-inn *Inner Temple *Furnival's-inn, Stapleinn, and Liberty-of-the Chai-terhouse *Lincoln's-inn *Middle Temple 78 During the year 1896, in addition to duties more immediately connected with the Public Health and Housing Committees of the Council, the Public Health department was concerned in enquiries arising out of a number of references from other committees of the Council, among which the Reformatory and Industrial Schools, Asylums, Building Act, Appeal, Parliamentary, Local Government, Parks and Open Spaces, and Water Committees may be mentioned. In previous reports I have stated that the date on which an annual report relating to London could be presented to the Council depended on the dates on which the annual reports of the medical officers of health were received. The following table shows the month in which the reports for the year were received— March, 1897 3 July 1897 10 April „ 1 August „ 4 May ,, 10 September „ 1 June „ 13 October „ 3 Shirley F. Murphy, 30th November, 1897. Medical Officer of Health. Appendix I. London County Council. DIPHTHERIA. Memorandum by the Medical Officer of Health on a local prevalence of Diphtheria in Camberwell. (Printed by order of the Public Health Committee, 4th March, 1897.) The attention of the committee has been directed to diphtheria prevalence in Camberwell. I have therefore prepared certain statistics on this subject, which I beg to submit for the committee's consideration. Comparison may be made between the diphtheria case and death rates in London and Camberwell thus— Diphtheria. Year. London. Camberwell. Case rate per 1,000. Death rate per 1,000. Case rate per 1,000. Death rate per 1,000. 1892 2.0 .44 1.3 .33 1893 3.2 .74 2.1 .53 1894 2.6 .61 2.9 .77 1895 2.6 .52 3.6 .72 1896 3.1 .60 5.7 1.03 During the last three years, therefore, both the diphtheria case rate and death rate of Camberwell have been greater than those of London as a whole. Interest for the moment, however, centres in an area extending on both sides of that portion of Rye-lane, Peckham, which is situated between the points where Rye-lane is crossed by the railway line, and where it meets East Dulwich-road. This area has during 1896 suffered exceptionally from diphtheria, and with a view to the convenient statement of the statistics I have selected a group of 12 enumeration districts which practically represent it. This group, which at the census of 1896 had a population of 20,777 persons, I shall in this statement describe as the " affected area." The following case rates for the year 1896 deserve consideration*— Diphtheria case rates, 1896. Per 1,000 living. London 3.1 Camberwell (less the affected area) 4.8 " Affected area " 14.6 The affected area is, however, deserving of consideration from another point of view, viz., the age incidence of the disease. For the purpose of comparison it is necessary to use the London figures of 1895, the last year for which the notified cases of diphtheria, have been distributed into ages. The following results are thus obtained— All ages. 0—3. 3—5. 5—10. 10—15. 15 and upwards. Notified cases of diphtheria— " Affected area," 1896 304 38 55 124 47 40 London, 1895 11,223 2,007 2,316 3,313 1,287 2,300 Case rate per 1,000 living— "Affected area," 1896 14.63 25.50 52.58 49.46 20.46 2.98 London, 1895 2.56 6.28 11.45 7.01 2.97 0.78 Excess per cent. of rates of affected area over London rates + 471 + 306 + 359 + 606 + 589 + 282 It will be seen therefore that children of school age have, as compared with London in 1895, suffered in the affected area in much greater proportion than persons of the other ages given. Again, if comparison be made between the age incidence of the disease on persons who were first attacked in households and those who were subsequently attacked, it is found that the incidence on the school age is greater in the case of the former than in the case of the latter,† thus— Age period. Number of " fitst attacks " in households. Number of subsequent attacks. Number of " first attacks " at each age per cent, of " first attacks " at " all ages." Number of subsequent attacks at each age per cent. of subsequent attacks at " all ages." Ages 0—3 26 12 10.7 19.7 ,, 3-5 44 11 18.1 18.0 „ 5-10 104 20 42.8 32.8 „ 10—13 33 4 13.6 6.6 „ 13 and upwards 36 14 14.8 22.9 All ages 243 61 100.0 100.0 * The only material relating to the affected area I have for examination is that contained in the notification lists of the Metropolitan Asylums Board. †These figures are derived from the notification lists of the Metropolitan Asylums Board, which have been examined to see whether a previous case had occurred in any invaded house within a month antecedent to the date of certification. [830—3149 2 This tendency of the disease to attack especially children of school age in the area had already manifested itself before 1896. The following figures are supplied by the notification lists of the Metropolitan Asylums Board, and it will be seen that although they are based upon a small number of cases, the figures afford indication of progressive increase of incidence on the school age. Number of notified cases at ages 3—13 per cent, of cases notified at " all ages." In 1893 46 In 1895 68 „ 1894 60 „ 1896 71 There are, however, two further points deserving consideration, viz.— 1. In the earlier part of the year 1896 the disease exhibited a tendency to attack girls from 5-10 years of age, and not to attack boys of this age. It was only in the middle of the year that boys of this age began to suffer in any similar proportion. 2. There was decrease of disease in the spring and summer holidays, especially among children of age from 5-10. This will be seen from the following tables. Number of " first attacks in households " notified in affected area in 1896— Week ending. Males. Females. All ages. 0-3 3- 4- 5-10 10- 11- 12- 13 and upwards. All ages 0-3 3- 4- 5-10 10- 11- 12- 13 and upwards. 1896 Jan. 4 1 1 ,, 11 1 1 1 1 ,, 18 ,, 25 1 1 1 1 Feb. 1 1 1 ,, 8 1 1 ,, 15 2 1 1 6 2 1 1 1 1 ,, 22 1 1 1 1 ,, 29 1 1 March 7 1 1 ,, 14 21 2 2 1 1 1 1 8 8 2 1 1 1 6 2 1 1 1 ,, 28 2 1 1 3 2 1 April 4 2 1 1 1 1 ,,,, 11 ,, 18 ,, 25 1 1 2 1 1 May 2 1 1 4 1 2 1 ,, 9 4 3 1 4 4 ,, 16 3 2 1 4 4 ,,,, 23 1 1 ,, 30 1 1 4 1 1 1 1 June 6 5 1 2 2 4 1 2 1 ,, 13 5 1 3 1 ,, 20 3 1 1 1 6 2 2 I 1 ,, 27 2 1 1 4 1 L 2 July 4 2 1 1 1 1 ,, 11 5 1 2 2 6 3 1 2 ,, 18 2 2 1 1 ,, Aug. 25 7 1 6 7 1 4 2 1 2 1 1 2 1 1 ,, 8 4 1 1 2 1 1 ,, 15 1 1 5 1 1 1 1 1 ,, 22 2 1 1 3 1 2 ,, 29 2 2 Sept. 5 4 1 2 1 4 2 1 1 ,, 12 4 1 1 2 3 3 ,, 19 26 2 1 1 1 1 2 3 1 2 1 I Oct. 3 3 1 2 3 2 1 ,, 10 5 2 1 1 1 ,, 17 1 1 2 1 1 ,, 24 1 1 6 1 1 4 ,, 31 1 1 3 1 1 1 Nov. 7 2 2 3 3 ,, 14 1 1 1 1 ,, 21 28 4 1 2 1 1 1 ] 8 1 2 1 Dec. 5 2 I 1 2 1 1 ,, 12 4 1 1 2 2 2 ,, 19 2 1 1 2 1 1 ,, 26 1 1 2 1 L 1897. Jan. 2 4 1 2 1 Total 107 13 9 17 39 5 3 4 17 136 13 9 9 65 5 8 8 19 3 Number of " subsequent attacks in households " notified in affected area in 1896— Week ending. Males. Females. All ages. 0-3 3- 4- 5-10 10- 11- 12- 13 and All upwards, ages. 0-3 3- 4- 5-10 10- 11- 12- 13 and upwards. 1896. Jan. 4 „ 11 ,, 18 1 ,, 25 Feb. I ,, 8 „ 15 1 1 ,, 22 ,, 29 Mar. 7 „ 14 1 1 „ 21 ,, 28 1 1 April 4 „ 11 1 1 „ 18 „ 25 2 1 1 May 2 ,, 9 „ 16 „ 23 1 1 „ 30 1 1 June 6 2 1 1 „ 13 3 1 1 1 1 1 ,, 20 1 1 1 1 „ 27 1 1 July 4 3 2 1 „ 11 „ 18 1 1 1 1 „ 25 Aug. 1 2 1 1 2 1 1 ,, 8 1 1 1 1 „ 15 1 1 „ 22 „ 29 1 1 Sept. 5 2 I I 1 1 „ 12 1 1 1 1 „ 19 „ 26 Oct. 3 1 1 1 1 „ 10 1 1 1 1 „ 17 „ 24 1 1 1 1 „ 31 4 1 1 2 Nov. 7 1 1 ,, 14 ,, 21 1 1 „ 28 1 1 2 1 1 Dec. 5 1 I 2 1 1 ,, 12 „ 19 1 1 I 1 „ 26 1897 Jan. 2 4 1 1 1 1 1 1 Total 34 5 4 5 13 1 — 3 3 27 7 1 7 — — — 11 I may summarise what I have stated as follows— 1. In 1896 the diphtheria case rate in Camberwell was greater than the diphtheria case rate of London, and that of the affected area greater than that of Camberwell. 2. The disease showed in the affected area a greater tendency to attack children of school age than in London in 1895. 3. This tendency of the disease to especially attack children of school age is particularly marked when first attacks of houses are considered. 4. There was tendency in the earlier part of the year for the disease to attack especially girls aged 5—10. 5. There was decrease of diphtheria in the affected area at the times of school holidays among children of school age. These circumstances point to some condition especially affecting children at the school age, and suggest that diphtheria lias been spreading in the schools in that locality. Public Health Department, Shirley F. Murphy, Spring Gardens, S.W., Medical Officer of Health. 4th March, 1897. 3 a common condition met with being that the two floors of the house are let to separate tenants. In about half the houses in which cases of diphtheria had occurred drainage defects of one kind or another had been noted by the sanitary inspector as requiring remedy. On the other hand in several instances it was found that diphtheria had broken out in a house in which the drainage system had, within the last year or two, undergone complete reconstruction. In a few cases houses were found to be in a dirty and neglected condition, and in a smaller number of cases there was reason for supposing that overcrowding existed. Almost every street included in the second class of bouses contributed one or more instances of families attacked by diphtheria. The few exceptions (in the case of streets containing any considerable number of houses) were instances of streets containing houses which it may be assumed would let at a rental above that of the majority of the houses belonging to the second of the classes already referred to. Water supply.—Almost all the houses in which cases of diphtheria occurred, as is the case in the district generally, were supplied with water by the Kent Water Company. In one instance it was noted that the supply of water was from a well. Milk supply.—Inquiry as to this matter was made in all the cases investigated, the sources from which milk was derived were found to be numerous, and no single vendor had been supplying more than a very limited number of the families attacked. In several instances it was ascertained that condensed milk only was consumed by persons who had suffered from diphtheria, but inasmuch as four or five different brands of condensed milk were found to have been used, it appeared that no one particular variety had been consumed in any considerable number of the families invaded. Seivers.—A few complaints of smells from sewer ventilators came under notice during the inquiry. The hot weather and the smallness of the rainfall during several weeks prior to [the outbreak possibly tended to render smells of this kind more noticeable tban is ordinarily the case. There are certain dead ends of sewers in the affected area, but on the other hand several flushing tanks with automatic syphons are in use. Diphtheria prevalence.—During the year 1893, in which London suffered markedly from diphtheria, there were only 5 cases of diphtheria and membranous croup notified in the " affected area." The number of such cases notified in Lewisham parish, i.e., in the whole of the area under the jurisdiction of the Lewisham Board of Works, with the exception of Penge, was 207. In 1894, 9 cases of diphtheria and membranous croup were notified in the affected area, and 153 in Lewisham parish. In 1895, 29 cases were notified in the affected area, and 128 in Lewisham parish. The affected area therefore suffered from diphtheria prevalence to a distinctly greater extent in this year than had been the case in either of the two preceding years. During the first 26 weeks of 1896, 23 cases were notified in the affected area and 127 in Lewisham parish, and thus during the first half of the present year the somewhat increased incidence of diphtheria upon the affected area, which had already manifested itself during 1895, was maintained. From the 27th-44th weeks of the present year 158 cases were notified in the entire parish, and of these no fewer than 108 were in the affected area. Before proceeding to study more in detail this last period during which so great an increase in the incidence of diphtheria in the affected area was manifested, it may be well to show the extent to which the diphtheria during the period of special prevalence was limited to that area, and for this purpose it may be well to compare the affected area with a less extensive district than that of the entire parish of Lewisham. The area under the jurisdiction of the Lewisham Board is divided into three districts for administrative purposes. The affected area forms part of what is known as the " Blackheath and Lewisham " district. The other two districts are those of " Penge " and of " Sydenham and Forest-hill." In the annexed table the cases notified week by week in the affected area are compared with those notified from the whole of the " Blackheath and Lewisham " district, of which the affected area forms part. Notified cases of diphtheria and membranous croup. Blackheath and Lewisham (Population, 45,G12). Affected area (Population, 7,882). 27th week ending July 4th — — 28th „ „ 11th 1 29th „ „ 18th 2 1 30th „ „ 25 th 1 1 31st „ August 1st 7 6 32nd „ „ 8th 2 2 33rd „ „ 15th 2 1 34th „ ,, 22nd 2 2 35th „ „ 29th 3 3 36th „ September 5th 1 1 37th „ „ 12th 8 5 38th „ „ 19th 6 6 39th ,, ,, 26th 16 14 40tli „ October 3rd 23 20 41st „ „ 10th 21 18 42nd „ „ 17th 19 15 43rd „ „ 24th 5 5 44th „ „ 31st 13 8 From this table it is clear that during the period under consideration (viz., from the 27th to the 44th weeks) the diphtheria in " Blackheath and Lewisham " was practically limited to what has been defined as the " affected area." 4 It must now be noted that the prevalence of diphtheria in the affected area which is under consideration, was accompanied by a special incidence of the disease upon children at school ages. This fact may be rendered evident in several ways. I. In the first place comparison maybe made between the behaviour of diphtheria in the area affected during the period of special prevalence, and its behaviour in this area at other times. During 1893, 1894, 1895 and the first 36 weeks of 1896, 83 cases of diphtheria and membranous croup were notified in the " affected area." In 82 of these cases the age of the patient is specified, and of these 82 notifications, 15 related to infants from 0-3 years of age, 48 to children between 3 and 12 years of age, and 19 to persons aged 12 and upwards. On the other hand, of the 91 notifications received from the same area during the 37th-44th weeks of 1896, 13 related to infants from 0-3 years of age, 67 to children between 3 and 12 years of age, and 11 to persons aged 12 and upwards. Thus, whereas the percentage of sufferers in each of the three age periods was for the period from 1893 to the 36th week of 1896— 18.3 per cent. in the case of infants 0-3. 58.5 „ „ children 3-12. 23.2 „ ,, persons aged 12 and upwards. the corresponding percentages for the period from the 37th-44th weeks of 1896 were— 14.3 per cent. in the case of infants 0-3. 73.6 „ „ children 3.12. 12-1 „ ,, persons aged 12 and upwards. The special incidence upon children at ages 3 to 12 in the recent outbreak is here apparent, but the question may be studied in another manner. II. The notifications of diphtheria in the whole of London during the years 1893-4-5 have been analysed by the medical officer of the Council, and grouped according to the ages of persons attacked. By making use of these results, and of the census figures, the attack rates from diphtheria per 1,000 living at the several age periods in London can be obtained. These rates may be compared with the rates obtaining in the affected area during the recent outbreak. It is necessary for the purpose of making such comparison to know the population at the several age periods in the affected area. Now the affected area comprises five enumeration districts, and it has therefore been possible to learn the age constitution of its population at the time of the 1891 census. Further, it has been possible to obtain the total population in these five enumeration districts at the census of March, 1896, By applying the former results to the latter the numbers for the several age periods in 1896 are obtained. The age distribution of the London population is given in the census returns for certain defined periods of years, and it has been necessary, therefore, in proceeding to make the comparison in contemplation, to deal with these periods. It is for this reason that in the annexed table the figures for the age periods 3-12, and 12 and upwards have not been given, but those for the periods 3-10, 10-15, and 15 and upwards, have been quoted. It will be found, however, that the new division into age periods throws a further light upon the age incidence of diphtheria in Lewisham during the weeks in which the recent outbreak occurred. DIPHTHERIA. All ages. 0-3. 3-10. 10-15. 15 and upwards. London. Total populations, 1893-4-5 13,022,362 949,781 2,005,418 1,287,551 8,779,612 Diphtheria notifications, 1893-4-5 36,107 6,078 17,175 4,139 8,715 Case rate per 1,000 living 2.77 6.40 8.56 3.21 .99 Do., "all ages," taken as 100 100 231 309 116 36 Lewisham (Enumeration Districts 1, 2, 3, 4 and 17). Total populations, 1896 census 7,882 647 1,362 851 5,022 Diphtheria notifications, 37th to 44th weeks of 1896 91 13 62 9 7 Mean annual case rate per 1,000 living 75.25 130.95 296.71 68.93 9.08 Do., " all ages," taken as 100 100 174 394 92 12 From this table it is clear that children at the age period 3-10 have been specially attacked during the recent diphtheria prevalence in Lewisham, for when the case rate at all ages is taken as 100, it transpires that the Lewisham rate for the age 3-10 is nearly one-third greater than that of the London rate for the same age period, while the Lewisham rates for the three other age periods dealt with (0-3, 10-15, and 15 and upwards), fall markedly below the London rates. III. So far all cases notified have been dealt with, and no attempt has been made to discriminate between primary attacks in particular houses and secondary cases occurring in households which had been already invaded. There is advantage, however, in further considering the matter from this point of view, for the age incidence observed in the case of persons primarily attacked is to be looked upon as furnishing an important indication of any peculiarities in the age distribution of the disease. Again, comparison has been made, in a series of reports upon outbreaks of diphtheria published in the reports of the medical officer of the Local Government Board, between the age distribution of the cases primarily occurring in families, and " behaviour of throat illness towards persons of various ages in the families that had become invaded." This method of inquiry furnished, in the absence of a large number of recorded notifications from which attack rates could be deduced, a particularly valuable Appendix ii. London County Council. DIPHTHERIA IN LEWISHAM. Report of the Medical Officer of Health, presenting Dr. Hamer's report on an outbreak of Diphtheria in the district of Lewisham. (Printed by order of the Public Health Committee, 12th November, 1896.) On the 15th October the Public Health Committee instructed me to report to them on the circumstances of an outbreak of diphtheria in Lewisham. The following day, accompanied by Dr. Hamer, I called on the clerk and medical officer of health of the Lewisham District Board at the board's office. It had been ascertained that a considerable number of cases of diphtheria had occurred among children attending the Lewisham Bridge Board School, and that a smaller number had occurred among children attending the St. Stephen's National School, but it was not known to what extent the schools had actually contributed to this prevalence, and particularly whether the schools were at the time operative in spreading the disease. This evidently was the point which needed first to be determined, and it was arranged that Dr. Hamer should at once proceed with an inquiry with this object. In the mean time I thought it was desirable that a medical examination should be made of children still attending school so as to ensure as far as possible the exclusion from attendance of any child whose state of health suggested that it might be a source of danger to its schoolfellows. In a very short time Dr. Hamer had ascertained that whatever part the schools had played in contributing to diphtheria prevalence earlier in the outbreak, this influence was not then operative. A few fresh cases of diphtheria, it was true, were occurring, but these were in all instances limited to persons belonging to families having no child then attending either of these schools. Indeed, subsequent to the beginning of Dr. Hamer's inquiry only two school attendants were attacked, the one attending the Board school the other the National school. So far as the schools were concerned, the action of the sanitary authority was therefore limited to the examination of children, and the disinfecting, first of the Board school, and later of the National school. Dr. Hamer's inquiry was then directed to ascertaining the cause of the outbreak. He found that as long ago as the preceding year the neighbourhood, in which these schools were situated, had begun to suffer from an amount of diphtheria somewhat in excess of that which had been observed in previous years, and in the few weeks antecedent to the August holiday several cases of throat illness had occurred among children attending school. Within a fortnight after the schools reopened cases began to manifest themselves among school children, who were the first persons in their respective families to be attacked. From the facts ascertained by Dr. Hamer, it is clear that up to the middle of September the incidence of such attacks was mainly on the younger classes of the boys' department of the Board school, and that later the disease affected chiefly the infants' department of the Board school and the girls' department of the National school. There was no evidence forthcoming that milk, or indeed any other condition than that of personal intercourse, was responsible for the earlier cases, and Dr. Hamer's report conclusively shows that the larger prevalence of September and early October was due to disease contracted at school. The question necessarily arises whether closure of the Board school would have limited the spread of the disease, and in this connection the coincidence in point of time between the termination of the attacks affecting school attendants and the decrease in the number of children attending the school through the action of parents is instructive. It is deserving of note that unrecognised diphtheria in a boy whose illness occurred in early September was very likely responsible for much of the prevalence which followed, and there is certainly a probability that, if the younger classes of the boys' department had been closed at an early stage, this course would have been productive of good. But unless the exclusion had extended to the brothers and sisters of those attending excluded classes, such action would not have had the effect of excluding from the infants' classes two brothers of the boy who had suffered from unrecognised diphtheria, and who may possibly have been concerned in infecting their class-mates. After the invasion of the infants' department of the board school, nothing less than the closing of that department and the younger classes of the boys' department would have sufficed. Dr. Hamer's observations as to the duties of the staff of inspectors and as to the need of a shelter for the accommodation of persons whose rooms are undergoing disinfection should receive the attention of the district board. Shirley F. Murphy, Medical Officer of Health. No. 315. Price 4d. Sold by Edward Stanford, 26 and 27, Cockspur-street, Charing-cross, S.W. [9575 2 Dr. Hamer's Report. The district under the jurisdiction of the Lewisham Board of Works comprises the parish of Lewisham and the hamlet of Penge, and extends over an area of 6,543 acres, and had at the census of 1896, a population of 104,521. The parish of Lewisham comprises 5,773 acres, and had in March, 1896, a population of 83,213. This parish includes, besides Lewisham village, the localities commonly referred to as Blackheath, Ladywell, Brockley (part of), Catford, Forest-hill, Upper and Lower Sydenham and Southend. It had become apparent at the end of September, 1896, that diphtheria was showing exceptional prevalence in Lewisham parish, and that a locality situated at the northern part of the parish was particularly involved. Before the date of the commencement of the present inquiry (October 19th) an area had been marked off by the officers of the Lewisham Board of Works as " the affected area," and it was to this area that my attention was in the first instance directed. It was at once manifest that this " affected area " had, during the preceding three or four weeks, suffered in an altogether exceptional manner from diphtheria prevalence, and as knowledge of attacks of diphtheria which had recently occurred came to hand, it was plain that the locality was, though in less degree, still so suffering. The area was marked out in the first instance in quite an arbitrary manner, and it appeared, subsequently, convenient for the purposes of statistical inquiry to deviate slightly from the boundaries as originally defined. It was found, in fact, that the special incidence of the diphtheria had been manifested in five of the twenty-four areas into which the Lewisham registration sub-district had been divided in the year 1896 for the purposes of the census. These five " enumeration districts," originally defined for census purposes, fitted with considerable exactness the area specially affected by diphtheria prevalence, and it was obviously convenient therefore to slightly extend the boundaries of the " affected area " as prescribed in the first instance, so as to enable the results of the census enumeration to be made use of in connection with the inquiry. In speaking therefore of the " affected area," it must be understood that the area comprised by these five districts (enumeration districts Nos. 1, 2, 3, 4 and 17) is referred to. This area extends on the north to the limit which divides Lewisham from the adjoining sanitary district of Greenwich. In pursuing eastwards the boundary of the affected area this limiting line must be abandoned at the point where it meets the Ravensbourne river, the course of that river followed to its junction with the Quaggy, and the course of the Quaggy to the point where that stream crosses Highstreet, Lewisham. The boundary then follows the High-street, but leaves it at Romer-place (including the houses on the south side of that place) and proceeds westwards, joining the Ravensbourne just below Riverdale-mill. It then follows the course of the river to the South Eastern Railway line, and proceeds southwards in the direction of that line as far as Ladywell station. From this point, passing round the southern end of Algiers-road, the western boundary of the area traverses in a northerly direction the slope of the "Hilly-fields," and runs east of Tyrwhitt-road to the point of junction of Lewisham and Greenwich districts. The area thus defined comprises about ¼ of a square mile, and contained in March, 1896, 1,442 inhabited houses, with a population of 7,882 persons; the shape of the area is irregular, a general idea of its position and surroundings must however be given. The valley of the Ravensbourne, in the neighbourhood of Lewisham village, runs north and south, having the high ground of Hillyfields on the west, and the slopes leading to Blackheath and Lee on the east. The Tunbridge line of the South Eastern Railway pursues at this point a course almost parallel to the Ravensbourne, running between the river and the ridge of high ground on its western side. The affected area lies in the Ravensbourne valley, and is approximately rectangular in shape, the long sides of the rectangle running north and south, in the same direction as the Ravensbourne river and the line of railway. The river and the railway both traverse the area, the railway dividing it into two nearly equal parts, the river lying nearer to its eastern than to its western boundary. The area thus comprises a belt of land on the east of the river, and on the west of the river includes a similar low-lying belt of land situated between the river and the railway. On the west of the railway the area also includes a strip of ground of greater altitude lying between the railway and the crest of the ridge of Hilly-fields. The highest ground included in the area is thus at its western limit, and is for the most part not built over, the inhabited portions of the area lying west of the South Eastern Railway are situated at from 35 to 70 feet above Ordnance datum, while the lower lying ground on the eastern side of the railway is, speaking generally, elevated only from 20 to 35 feet above that datum. Over the whole of that part of the area which lies to the east of the railway line there is a superficial deposit of river gravel. In the north-western corner of the area is situated a chalk pit in which there is a well known exposure of the strata superimposed upon the chalk. Some of the surface ground in this part of the area, and lying to the west of the railway line is chalk, further south the Thauet sand, which immediately overlies the chalk, and still further south the Woolwich and Reading beds come to the surface. In the south-western part of the area the surface soil is formed by an outlier of the London clay. Thus over a considerable part of the affected area the subsoil is porous, and inquiries made at several houses in which cases of diphtheria had occurred showed the walls of the ground-floor rooms to be free from evidence of damp. Having regard to the position of the low-lying parts of the area, it may be assumed that the ground water level is liable to sudden and considerable fluctuations, and it appears that in times of heavy rain damage to property and inconvenience have been caused by floods. The houses may be broadly divided into two classes, in the first class may be placed the houses fronting on Lewisham High-street and on Loampit-vale, and in the second class the (for the most part) more recently constructed houses situated in streets communicating with these two main thoroughfares. The houses of the second group are usually two storeys high, and they possess in most cases a fair amount of space in front and at the rear. They are often occupied by more than one family ; Table giving dates of attach and class (if any) attended in one or other of two schools in the rase of all persons first attacked in the households invaded by diphtheria in a particular area in Lewisham. D. Signifies Diphtheria. S . Sore throal occurring in a, household subsequently invaded by recognised Diphtheria. This boy lived in Greenwich district, and not in Lewisham † Several "sore throats "occurred in this family but none of the cases were regarded as diphtheria ‡ These children lived in Lee Parish, and net in Lewisham 7 The history of a particular group of cases of throat illness is deserving of special mention. A few cases of diphtheria occurred in the two mouths preceding the holidays in a particular street in the affected area. On May 23rd, a boy, a Board school attendant, who was living in this street, was attacked, and from time to time other families living in the same street developed throat illness, and there is reason to suspect that the first sufferers in these households were boys attending the Board school. A boy living in this street returned to school after the summer holidays, but did not continue to attend after September 7th, as he developed an attack of "influenza." His two younger brothers, however, continued to attend the infants' department of the Board school. Towards the end of September the boy who had suffered from " influenza " began to develope symptoms which led to his again coming under medical treatment, and it was ultimately found, on October 5th, that this boy and a younger sister (not a school attendant), were suffering from well-marked diphtheritic paralysis. The boy and his two younger brothers attended classes in each of which a number of cases of diphtheria, subsequently developed. The regulations issued by the London School Board direct with reference to infectious diseases', that any child " showing symptoms of an infectious disease, or any child coming from a house where an infectious disease exists, must be sent home at once, and the superintendent of visitors must be immediately informed of the case in order that inquiries may at once be made with a view to proper steps being taken to prevent the children living in the same house or tenement from attending school. The medical officer of health for the district must also at the same time he informed of the child's exclusion, and furnished with the name and address of the child and the reason for its exclusion on a form with which the teachers will be supplied by the head office." The interpretation of the expression " showing symptoms of an infectious disease " is left to the teacher, and it may be assumed that it is intended that the teacher should under certain circumstances act upon the merest suspicion. Action of this kind on the part of teachers in the Lewisham schools appears to have had a good deal to do with limiting the spread of disease. Moreover, prompt steps were taken by the Lewisham Board's sanitary inspector in the direction of warning parents in infected households against allowing their children to attend school. In the case of those attending the boys' department of the Board school, such illness as occurred in June and July was for the most part so mild as to make its real nature difficult of recognition, and for the first fortnight after reassembling subsequent to the holidays no diphtheria was notified. In the infants' department, on the other hand, two notified cases had already occurred before the holidays in infants who belonged to families in which the boys appear to have been first sufferers from throat illness, and in the girls' department one such case had occurred. The headmistress of the girls' department seems to have been apprehensive that fresh cases might, develop after the holidays, and indeed on the day after the school commenced it was found that one of the children was suffering from sore throat, and she and her sisters were sent home. This child's illness proved to be diphtheria; but it appears probable that the malady was contracted while she was away from Lewisham on a visit. The occurrence of this case of illness led to particular attention being directed to ensuring that every available precaution was taken, and it may be that the care exercised was in part responsible for the subsequent comparative freedom of the girls' department from attack. When, after the middle of September, a special incidence of the disease upon the Board school was manifested the question whether the school should be closed naturally presented itself. This step was however not taken. At this time it may be noted that the chief incidence of the disease had been upon the boys' department of the Board school, and that the National school had almost entirely escaped. The prevalence of the disease, however, continued, and during the latter part of September the infants' department of the Board school, and the girls' department of the National school contributed the majority of first sufferers in households. It will be seen, however, that although the schools were not closed this continued prevalence of diphtheria at lencth brought about a greatly reduced attendance through the action of the parents. The effect of the continued prevalence of diphtheria upon school attendance may be seen on examining the appended table— Board school. Boys. Girls. Infants. Average attendance in week ending August 28th 356 317 299 ,, „ September 5th 362 331 301 ,, ,, ,, 12th 352 320 299 ,, ,, 19th 345 321 303 ,, „ 26th 322 319 273 „ „ October 3rd 318 317 255 ,, „ 10th 240 217 152 ,, ,, ,, 17th 150 125 78 >» » ,, 24th 123 101 74 It appears therefore that in the week which began on Monday, September 21st (week ending September 26th), there was already a distinct falling off in the attendances at the boys' and infants' schools, and that in the week beginning October 5th the attendances recorded in all three departments of the school become materially reduced. The attendances at the National school (particularly in the girls' and infants' departments) were also seriously affected at this time. It will be noticed that the average attendance recorded in the Board school for the week which began on October 12th (week ending October 17th) had fallen to only a little more than a third of what it was when school re-assembled after the holidays. During this week the disease practically ceased to manifest a tendency to spread 8 among children attending the Board and National schools. The circumstances certainly suggest that the keeping away from school of so large a number of children was one of the factors at work in serving to check the spread of diphtheria, and the early closing of the affected classes would, I believe, have more speedily brought about this result. At the date of the commencement of my inquiry but comparatively few children were attending school, and I could not learn that in any family which had been recently attacked the first sufferer had been a school attendant, and it may be stated that a medical examination of the throats of the children attending the Board school which was made on October 19th, on behalf of the sanitary authority, showed that in no instance did the throat of a child present any suspicious appearance. With two exceptions, that of a child attending the infants' department of the National school who sickened on October 24th, and that of a boy attending the boys' department of the Board school who sickened on October 20th, this freedom from attack of children attending the Board and National schools has continued to the present time. On October 17th the Board school buildings were disinfected by the officers of the sanitary authority, and on October 23rd the National schools were disinfected. As regards the mortality caused by the outbreak, Dr. Jolly, the medical officer of health for the district, has ascertained that 28 deaths had occurred up to the end of October (two in August, seven in September, and 19 in October). It may be noted that patients who began to be ill during the latter part of September suffered, generally speaking, from a more severe form of disease than did those attacked either shortly before or immediately subsequent to that period. In other words, when the outbreak was at its height the case mortality also attained its maximum. The ages of the patients affected at the different periods no doubt had influence in this connection, but this consideration does not appear to fully explain the fact that nearly 50 per cent. of the attacks which began between September 17th and September 30th were fatal, while the mortality for the rest of the attacks commencing between September 4th and October 20th was only about 13 per cent. The facts observed during the recent outbreak in Lewisham in regard to the spread of diphtheria in particular classes, emphasize the need for immediate inquiry into the details of school attendance in connection with notified cases of infectious disease. If information of this kind be available it is possible to decide whether or no the exclusion of particular classes from school attendance is necessary. Such exclusion, if decided upon, might of course be accompanied by the exclusion from school of all children belonging to a family of which a pupil in one of the excluded classes was a member and who are in other classes of the school. Early action of the kind indicated may have an important influence upon the spread of disease and may obviate the need for the larger interference with school work which closure of an entire school entails. Certain further lessons in connection with sanitary administration are to be learnt from the Lewisham outbreak. Difficulties in connection with the isolation of cases were acutely felt in Lewisham in September and October last. There was unavoidable delay therefore in connection with the removal of some of the cases. The Board fortunately had at its disposal a cottage hospital to which a number of cases were removed. There is, moreover, no public mortuary in Lewisham, and this fact led to the retention of dead bodies in houses under circumstances in wbich, had a mortuary been available, there would have been opportunity for the exercise of the powers of section 89 of the Public Health (London) Act, 1891, which relate to the removal of a dead body to a mortuary. It is due to the Lewisham Board to point out that they are not responsible for the temporary dearth of hospital accommodation ; and that the Board has decided to provide a mortuary and coroner's court at Ladywell, and has applied to the Council for a loan for this purpose. The delay in the erection of the building is due to an unexpected legal difficulty connected with the granting of loans by the Council. No shelter for the accommodation of persons who are compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the sanitary authority has been erected in Lewisham. The want of such a shelter was much felt during the recent outbreak. In several of the households invaded difficulties were experienced in carrying out the work of disinfection which would not have been felt had a shelter been available. Moreover there appears to be need for consideration being given to the question whether the system of disinfecting rooms which has been practised in Lewisham is sufficiently complete. I ought not to omit reference to the opinion as to the sufficiency of the sanitary staff, to which I was led as the result of my inquiry. The duties in connection with that part of the Lewisham district which is known as Lewisham and Blackheath were allotted to an inspector and an assistant inspector. The latter was mainly engaged in house to house inspection, and all the other ordinary duties of a sanitary inspector in a district containing upwards of 40,000 inhabitants thus had to be performed by a single individual. When the need for increased assistance became apparent, it was temporarily supplied by taking inspectors from other parts of the district over which the Lewisham Board has jurisdiction, and, shortly after the outbreak, a second assistant inspector was appointed for the purposes of inspection in Lewisham and Blackheath. I was much impressed with the excellent services rendered by the inspector of the district, but experience of the administration gained during my inquiry satisfied me that even at times when there is no exceptional prevalence of disease, the work, which under ordinary circumstances he is called upon to undertake, is in excess of that which can be efficiently performed by one inspector. In conclusion, I have to express my indebtedness to the officers of the Lewisham Board and the teachers in the schools for the assistance they have rendered in the course of this inquiry. W. H. Hamer, Public Health Department, Assistant Medical Officer of Health. Spring Gardens, S.W., 12th November, 1896. 5 standard for comparison. It was first used by Mr. W. H. Power in 1876 in relation to the circumstances of an outbreak of diphtheria at Brailes in Warwickshire. Mr. Power says in his report on this outbreak, " I addressed my inquiry to the exact circumstances of the 25 families that were actually invaded by the disease, and found that information of one sort was to be gained from the conditions of the 25 first sufferers in their respective families, and information of another sort from the circumstances of the 131 other persons who made up the 25 families." The method of comparison then instituted has since been frequently made use of, and was notably employed in a report by Mr. Power on diphtheria at Pirbright. The method of the report last referred to will be followed in discussing the facts observed in connection with notified cases of diphtheria at Lewisham. With the object of obtaining the necessary data, I'made, in the course of my inquiry in Lewisham, a census of the persons living in invaded houses. Moreover, inquiry was made in all cases as to the date of commencement of the illness of persons attacked by diphtheria. On analysing, in the light of the information obtained, the notifications received from the affected area it is found that between July 9th and October 19th individuals belonging to 60 households began to suffer from diphtheria or from a throat illness which was followed by diphtheritic paralysis. In these households 45 secondary cases of diphtheria were notified. The 60 households included, apart from the original sufferers introducing diphtheria into each house, a population of 43 babies from 0-3 years of age, 106 children, from 3-12 years of age, 29 persons from 12-15 years of age, and 200 persons aged 15 years and upwards. The secondary cases included 11 babies, 26 children aged 3-12, 3 persons aged 12-15, and 5 persons aged 15 and upwards. As regards the behaviour of diphtheria therefore in respect to persons of various ages in the families that had become invaded, it appears that the percentage of attacks was for the four age periods in question, 256 per cent., 24.5 per cent., 10.3 per cent., and 25 per cent. According to the standard thus obtained babies aged 0-3, and children aged 3-12, are about equally affected, and the attack rate for these age periods is about 2½ times that for the period 12-15, and 10 times that for the period 15 and upwards. This standard may now be applied to the facts observed with regard to first sufferers in non-infected houses. There were living in the affected area— At ages 0-3 647, of whom 7 were first sufferers. „ 3-12 1,726 „ 48 „ 12-15 487 „ 3 „ 15 and upwards 5,022 „ 2 „ „ These figures give attack rates of 11 per cent., 2'8 per cent., 0'62 per cent., and 0.04 per cent. In other words, the actual circumstances with regard to houses newly invaded show that children 3-12 have suffered nearly 3 times as often as babies, 4½ times as often as children 12-15, and 70 times as often as those 15 and upwards. These results may be compared with those of the standard results thus— Children 3-12 have been first sufferers nearly 3 times as often as babies 0-3, instead of as in the standard results at about the same rate. Children 3-12 have been first sufferers 4½ times as often as persons aged 12-15, instead of as in the standard results at about 2½ times the rate. Children 3-12 have been first sufferers 70 times as often as persons aged 15 and upwards, instead of as in the standard results at about 10 times the rate. The results obtained from the three methods of comparison above described are so striking as to preclude any doubt as to their significance. The age period 3-12, and more particularly the age period 3-10, has clearly, in the Lewisham outbreak, suffered in a wholly exceptional manner. An important fact now requires to be stated, and it is this : that of the 48 children at the age period 3-12 who were the first sufferers in households, 42 had within a week of their showing symptoms of illness been attending one or other of two schools. If consideration be limited to the attacks occurring between September 1st and October 10th it will further be found that out of a total of 48 first sufferers 43 were children aged 3-12, and of these 40 had been recently attending one or other of the two schools. As regards the five cases not occurring in persons at the age periods 3-12, one was a school attendant aged 13, and in two instances a school attendant belonging to the family in which the case of diphtheria was notified had suffered from sore throat, prior to the development of the illness which was declared to be diphtheritic in character. The question as to the part played by " school influence " in promoting the spread of [disease was thus seen to call for special study. There are in the affected area three schools— (a) The Lswisham-bridge Board school, having 1,254 children on the register and an average attendance of 971 children (356 boys, 316 girls, and 299 infants) for the week ending August 28th. (b) The St. Stephen's National school, having 525 children on the register and an average attendance of 408 children (190 boys, 112 girls, and 106 infants) for the week ending August 28th. (c) An industrial school having 150 boys aged from 5-13. These boys lived and were educated in the school, and were not therefore in association with the general population. It may be added that the numbers given for the National school include about one hundred boys and infants belonging to an orphanage situated immediately outside the affected area. It has been already stated that among notified cases of diphtheria 42 children, aged 3-12, first sufferers in households, had been in recent attendance at one or other of these schools; it may now be added that 33 of these attended the Board school and 9 the National school. If consideration be limited to the attacks occurring between September 1st and October 10th, it will be found that out of a total of 43 first cases notified in households, among children aged 3-12, 31 cases were those of children attending the Board school and 9 were cases of children attending the National school. 6 There are therefore in the affected area four groups of persons at ages 3-12— (a) 9711 attendants at the Board school, of whom 31, or 3'2 per cent, were first sufferers. (b) 4081 ,, ,, National ,, ,, 9 „ 2.2 ,, „ (c) 150t inmates at the Industrial ,, ,, none were first sufferers. (d) About 300* children, aged 3-12, attending other schools, or not attending school at all, of whom 3,+ or 1 per cent, were first sufferers. The incidence of diphtheria upon the Board and National schools is thus seen to be quite unmistakable; moreover, the Board school has suffered to a somewhat greater extent than the National school. With regard to the sanitary condition of the Board school and National school careful investigation was made by the officers of the Lewisham District Board with result that no drainage defect which can be regarded as having influenced the spread of diphtheria was discovered in either school. The question as to the part played by personal contagion now requires to be considered. On making inquiry as to which class in the school was attended by the first sufferers in affected households, it transpired that the two schools to which attention has been directed were by no means affected equally throughout their whole extent. Thus, limiting consideration always to the case of first sufferers in families, it was found that the "girls" attending the Board school had suffered to a much less extent than the "boys" and "infants," and, further, that while the upper classes in the boys' school had escaped, the three lowest classes had suffered most severely. In the National school the "boys" had escaped altogether, and so had the upper classes of the " girls;" the lowest class of the girls had, however, suffered severely, and cases had occurred amongst the infants. It appears desirable to give the facts observed in some detail, and the annexed table has therefore been prepared, showing the dates of attack in the case of first sufferers in families, and the school attended, and indicating, in the case of school attendants, the class to which the said first sufferers belonged. In this table attention has been directed not only to cases notified as diphtheria, but also to cases of sore throat, concerning which knowledge was forthcoming, and in those instances in which such sore throat preceded a throat illness which was recognised as diphtheria, the person manifesting the sore throat has been classed as a " first sufferer." In all instances in which the disease was notified as diphtheria or membranous croup, the letter D is used to indicate the case ; in instances in which the sore throat attacking a " first sufferer " was not notified, the letter S is used. From the data afforded by this table, and with a knowledge of the average attendance in each class of the Board and National schools, the percentage of children attending each class who were attacked can be obtained. In calculating these percentages the average attendances during the week ending August 28th, have been taken, and all cases in which the throat illness commenced after the summer holidays, and prior to October 11th, have been included. The following are the results obtained— Percentage of Children in each class attacked (First sufferers). Board School. National School. Boys. Girls. Infants. Boys. Girls. Infants. i. ii. iii. iv. v. vi. vii. i. ii. iii. iv. v. vi vii. i. ii. iii iv v. vi. i. ii. iii. iv. v. vi vii. i. ii. iii. iv v. i. ii. iii. iv. 0 0 0 2 6 7 9 0 0 0 4 2 2 0 7 9 0 6 12 4 0 0 0 0 0 0 0 0 0 0 0 23 0 6 4 0 Hence in each of 9 classes upwards cf 5 per cent, of the children were attacked. It will be noted that the boys' department at the National school altogether escaped, and that the attacks in the girls' department affected one class only. In the girls' department at the Board school comparatively few cases developed, and the last class in this department presents a striking contrast to the corresponding class at the National school. In the infants' department at the Board school, classes I. and II. occupied one room, as did also classes IV. and V. Class VI., the " babies," had a room of its own, and suffered comparatively slightly, while class III., which also had a room of its own, escaped altogether. If the proportion of first sufferers in children attending the 9 classes most affected be compared with the proportion of first sufferers in other children of the same age in the affected area in this period, the former group of children will be found to have suffered at a rate eight times the rate of the latter. Consideration of what has been stated and an examination of the annexed table shows that, without doubt, particular classes in these two schools were largely operative in disseminating disease. It is worthy of note that the several departments of the two schools were not equally affected in point of time. The boys' department of the Board school was already involved for more than a week before the special incidence upon the infants' department of the same school, and upon the lowest class of the girls' department of the National school, was developed. It will also be noticed that cases of throat illness affecting boys belonging to the Board school occurred during the latter part of July. The history of cases of diphtheria occurring in the affected area for some time prior to the school holidays has been enquired into, and it transpires that children attending both schools had been attacked before the holidays; and in some instances there are indications that disease had spread by means of mild cases of illness, the nature of which had not been recognised. †These numbers include a certain number of children over 12, and there is therefore a slight understatement of the incidence upon the age period in question at the Board and National schoolo. ... * This number is arrived at by adding to the 1,726 persons, at the age period 3-12 living in the area, 100, as being the number belonging to the orphanage which is not included in the area, and then subtracting the numbers given under (a), (b) and (c). ‡It may be noted that two of these three children appear to have been infected by children who were school attendants Appendix III. London County Council. THE RECENT OUTBREAK OF DIPHTHERIA IN LEWISHAM. Medical Officer to report on the report of the Medical Officer of the London School Board as to an outbreak of diphtheria in Lewisham.—Public Health Committee, 4th February, 1897. In obedience to the instruction of the Committee, I beg to submit my observations on the report of the medical officer of the London School Board on "an outbreak of diphtheria at Lewisham and its alleged connection with the Lewisham-bridge Board school." This report was prepared by the medical officer of the London School Board in response to a resolution of the School Management Committee of that Board referring to him a report by Dr. Hamer, which I had presented to the Public Health Committee of the Council. It will be recollected that Dr. Hamer, as the result of his inquiry, had come to the conclusion that this outbreak was in the main due to disease contracted in the Lewisham-bridge Board school and the St. Stephen's National school. The chief reasons which led Dr. Hamer to this conclusion may be briefly summarized. He took, for the convenience of statement of the circumstances of the outbreak, an area consisting of five enumeration districts, which was that specially affected, and which had a known population, this population having been enumerated for the purposes of the census of 1896. This he called the "affected area." Considering the cases of diphtheria which occurred within this area, he found that— 1. There was a special incidence of the disease upon children who were of school age. 2. This special incidence was manifested in greater degree when consideration was limited to first sufferers in affected households. 3. Among children, aged from 3—12 years, who were first sufferers in households, those attending the Board and National schools suffered in greater degree than those not attending these schools. Children attending the Board school suffered more than four times, those attending the National school more than three times, as frequently as children not attending these schools. 4. When the distribution of these cases (first sufferers) in the several classes of these schools was considered it was found that certain classes were specially affected. A greater incidence of disease was therefore found on children attending these classes than on children attending these schools generally, and a much greater incidence on children attending these classes than on children not attending these schools. With respect to No. 1, study of the report of Dr. Smith, the medical officer of the London School Board (page 3, last paragraph), shows that he recognizes that " the special incidence has been on children of school ages," but throughout his report he offers no explanation of this circumstance. With respect to No. 2, Dr. Smith raises no objection. He publishes, however, a table (B) on page 16 of his report which shows the ages of persons who had first and subsequent attacks " in the parish of Lewisham and its immediate vicinity." In thus analysing the ages of persons who had first and subsequent attacks in a large area, he necessarily includes cases which are not connected with the outbreak under consideration. His figures, notwithstanding, teach the same lesson as those of Dr. Hamer, but again he offers no explanation of this circumstance. With respect to No. 3, Dr. Smith thinks that Dr. Hamer's "estimate of the small number of children not attending schools is so liable to error as to be practically useless for the purposes of comparison." It is necessaiy here to show how Dr. Hamer arrived at his estimate. In the first instance he ascertained that the average numbers of children attending the Lewisham-bridge Board and National schools in the week ending 28th August were 971 and 408 respectively. Some proportion of these children did not live in the affected area; indeed, among the children in the National school were 100 children living, in an orphanage situated outside the affected area. To estimate the number of children between the ages 3—12 living in the affected area attending other schools or not attending school, he deducted from the total number of children of this age living in the affected area (1,726)* the 971 children in the Board school and the 408 (less 100 children) attending the National school, and he thus arrived at the figure 447, 150! of which were living in an Industrial school situated in the affected area. He was thus able to compare the incidence of disease upon four populations, one which attended the Board school, another which attended the National school, a third which lived in the Industrial school, and a fourth (about 300 in number) which attended other schools or did not attend any school. Dr. Smith takes exception to this estimate of 300. He is of opinion that Dr. Hamer should have included in his Board and National school populations not the average number attending during *This figure was arrived at by the U9e of the census figures of 1891 and 1896. †None of these 150 children were attacked. No. 323.—Price 2d.] Sold by Edward Stanford, 26 and 27, Cockspur-street, Gharing-crons, S.W. [496—3149 2 a week but "all who were exposed at some time or other during the week to the risk of catching diphtheria at school." He thus takes for his populations attending the Board and National schools the total number of children on the register less those absent during the entire week. The children attending these schools, however, do not all live in the affected area; moreover, some of these children are over 12 years of age. Thus these populations are somewhat overstated for the purpose of applying cases of disease limited to the affected area. The effect of this on the rates of attack for these two schools is not, as a matter of fact, of great importance* ; but, inasmuch as the number of other children remaining in the population of the affected area is obtained by deducting from the total number of children in this area the children attending the schools, every addition to the estimate of school population leads to diminution of the estimate of the remaining child population, and thus Dr. Smith arrives at an estimate of 67 where Dr. Hamer arrives at 300, and thus practically multiplies Dr. Hamer's attack rate for this population by 4£, and makes it exceed the attack rates of the school populations. Now Dr. Hamer, in basing the school populations in the affected area on the average attendance of a week, had included in this population those who lived outside the affected area, and had thus amply compensated for any addition which might properly be made in view of the circumstance urged by Dr. Smith. I have however, to put the matter beyond doubt, had enquiries made by the Council's inspector, Mr. Jury, as to the number of children who were resident in the affected area immediately after the summer holiday of last year, who were of the ages 3-12, and who were not attending these schools. This inquiry was made at 575 houses situated in thirty streets in the affected area, with the result that 267 such children were found. The houses visited included those most likely to contain children not attending these schools; but it is a fair assumption that the remaining 33 children would be found if the remaining 867 houses in the rest of the area were visited. I have not thought it necessary to pursue the matter further, for I am satisfied that Dr. Hamer's estimate of 300 understates rather than overstates the number of such children, t Dr. Hamer's conclusion that there was much greater incidence of disease (first sufferers) upon children attending the Board and National schools than on other children is, therefore, fully confirmed by this inquiry. With respect to No. 4, Dr. Smith does not contest Dr. Hamer's statement that there was special incidence of attack (first sufferers), on certain classes in the Board and National schools, but again he offers no explanation of this circumstance. I now propose to refer to the additional points discussed by Dr. Smith in his report. 1. Dr. Smith's report contains the following statement— "The progressive tendency of the cases to occur in groups will be seen at once. The remarkable group of 14 cases, which includes 7 first attacks in families (subsequently referred to as 'first attacks'), occurred during the summer holidays in 1896, and appears to have escaped Dr. Hamer's notice, as his table shows only 5 first attacks as having occurred between July 24th and August 24th. This is unfortunate, as a group of 14 cases, beginning nearly a week after the closing of the schools, and all contained within the holidays, cannot fail to be valuable in an enquiry into the relative amounts of school influence and non-school influence, which go towards establishing an epidemic." Dr. Smith has, no doubt, failed to identify the seven first attacks in households occurring during the holidays in Dr. Hamer's chart, owing to the fact that Dr. Hamer's inquiry at the homes showed that in two instances the first sufferer in the household was attacked before the beginning of the holidays, that is to say, Dr. Hamer had obtained information of earlier invasion of these two households than appears to have been known to Dr. Smith. These seven first attacks, therefore, are fully indicated in Dr. Hamer's chart. 2. Dr. Smith sets out, in tabular form (table II.), and in order of date of notification, the fourteen cases thus referred to, and proceeds to discuss the first five, the only ones (he says) "occurring within a week of the closure of the school." He thus writes concerning them— "These five cases are the only ones occurring within a week of the closure of the school. Had infection been present in the school it is almost inconceivable that no case should have occurred within the ordinary period of incubation (2 to 4 days), and that four cases should occur almost simultaneously near the extreme limit (7 days) of the period of incubation. Had these cases occurred from 5 to 7 days after the children returned to school, instead of from 5 to 7 days after their holidays began, many would have considered it beyond dispute that infection occurred 2, 3 or 4 days after the reassembling of the school, and the possibility that infection might have occurred outside the school would have been summarily dismissed. The inference in the case, as it actually happened, is that infection occurred 2, 3 or 4 days after the children's last attendance at the school, and therefore indisputably outside the schools." Dr. Smith has fallen into error by not observing that the dates recorded in his table in connection with these cases are dates of notification of the cases, and not dates of the beginning of the illness; probably, in making this inference, he had before him his table A on page 14 of his report, in which the first seven cases (which include the five under consideration) have incorrectly against them, in the column headed "date of first symptoms," the date of notification, and he appears thus to have thought of the dates of notification as being the dates of first symptoms. *There were a few cases (first sufferers) anion? children attending the Lewisham-bridge school and living outside the "affected area" who were attacked between September 1st and October 10th. These cases Dr. Hamer ha* not included among the cases upon which he calculates his scho >1 attack rote, but be would obviously have to do so if he adopted Dr. Smith's larger school populations obtained by inclusion of school children living outside the " affected area." †Dr. Smith's discussion of this matter contains an error which it may be well to mention. He evidently confuses the Industrial school with the Orphanage, as he refers to "150 inmate* of the Industrial school (attending the National schooi)." The 150 children in the Indus:rial school do not attend the National school, wherea^ the 100 children in the Orphanage do. When he makes his subtraction from the child population in the affected area for the purpose of arriving at the number of children not attending the Board or National schools, he include* among the National tchool children 100 children from the Orphanage, which is not situated in the affected area, and makes no allowance for this fact. 3 Dr. Smith's inference, therefore, that "infection occurred 2, 3 or 4 days after the children's last attendance at the school, and therefore indisputably outside the schools" falls to the ground. Examination of the dates of attack shows that in each instance infection of the households in question occurred (allowing for period of incubation) at a time antecedent to the beginning of the school holidays. 3. Dr. Smith then further discusses the tables which he appends to his report. There are a number of differences in detail between Dr. Hamer's notes and the statements in Dr. Smith's tables. Perhaps the most important differences relate to table D. Dr. Smith bases upon this table the statement that 25 children "who had attended no school at all within seven days of attack were the first victims within their respective families." In addition to differences as to detail above referred to, it should be noted that these 25 cases are obtained by dealing with a longer period of time than that taken by Dr. Hamer, and with the much larger area of "the parish of Lewisham and its immediate vicinity," whereas Dr. Hamer's figures are obtained from cases occurring in the smaller "affected area." Again, Dr. Smith's tables only include cases which were notified. Dr. Hamer supplemented the information supplied by the notification lists by inquiry at the homes, and as the result of this inquiry has treated as " secondary cases " several which in Dr. Smith's tables appear as cases occurring in houses in which a previous case had not occurred. 4. Dr. Hamer has pointed to coincidence in point of time between the decrease in the number of children attending the Board school and the decrease in the number of primary attacks in the affected area. Dr. Smith publishes two tables (Tables IV. and V.) to show that the decrease in the number of attacks (first sufferers) among children in the boys' department occurred at a time when the decrease in the average attendance in this department had only fallen 10 per cent, and that there was an increase in the number of attacks (first sufferers) in the infants' department after the fall in average attendance had commenced. Dr. Hamer did not of course propose to suggest that there were precise proportions between variations in average attendance from week to week and attack rate, but only to show the general agreement in point of time between the falling off in the attendance at school and the decrease in the number of houses newly invaded by diphtheria in the "affected area." 5. On page 6 Dr. Smith states "It is to be noted further that the closure of the boys' department could only affect the scholars in attendance in that department, and not, as is implied, the infants and the girls; for the reason that the boys' department occupied premises on one side of the road, the girls' and infants' premises being on the other side, thus practically constituting two separate schools." In inquiry into the effect of school attendance and school closure upon the occurrence of diphtheria, it is proper, and indeed necessary, to take into account indirect as well as direct influence. The attendance of one child out of a family at an infected school has a bearing upon the safety of the rest of the family who attend other schools, differing in degree only from that of the reversed condition in which a child from an infected house attends a school. All authorities are agreed that in the latter instance the public safety is endangered by continuance of communication between school and infected home, and steps are taken to put an end to it. Similarly the closure of an infected school must be regarded as conferring some degree of safety upon children attending other schools from homes sending children to the 3chool which is to be closed. In his statement above Dr. Smith omits consideration of the fact that the boy who contracts diphtheria in the boys' department may by infecting his sister who is attending the girls' department, or his younger brother or sister attending the infants' department, introduce diphtheria into these latter departments. 6. On pages 7, 8 and 9 of his report Dr. Smith comments on the fact that certain children attended school on days " subsequent to the first symptoms of their illness " without such attendance being productive of disease in other children. I may mention that Dr. Hamer's knowledge of the cases cited leads him to different conclusions as to these cases, but the matter as affecting the results of Dr. Hamer's inquiry need not be discussed here, for it will hardly be contended that the negative evidence that certain children suffering from diphtheria attended school without obvious injury to other children is reason for setting aside the positive evidence which the history of the outbreak supplies. 7. Dr. Smith finds, as the result of examination of the dates of first symptoms, and of last attendance at school in the different classes, that of 137 cases inquired into, there are 116 "cases in which the evidence excludes the school as the source of infection," and that in 21 cases the " evidence as to school or non-school infection is insufficient." It may be pointed out— (i.) That Dr. Smith ascertains in what number of instances a child attacked by diphtheria was in attendance in a class or class-room in which a known previous sufferer had been in attendance within the period of incubation of the disease. These cases Dr. Smith groups under the heading " cases in which the evidence as to school or non-school infection is insufficient." (ii.) That in those instances, on the other hand, in which the sequence of events above referred to was not observable, Dr. Smith, with two or three exceptions to be immediately referred to, groups the cases under the heading " cases in which the evidence excludes the school as the source of infection." These headings are misleading. The first heading really includes the cases in which the evidence (so far as it goes) is of a positive character; the second heading, those in which it is of a negative character, but, judging by the words Dr. Smith employs, it might be inferred that the reverse was the case. It is necessary to realise that where Dr. Smith says the evidence is insufficient, the evidence available points to the school as the source of infection, and that where he says the evidence excludes the school, he, as a matter of a fact, in the majority of cases, merely means that he has not been able to show, with regard to an individual sufferer, that he or she was exposed to a recognised source of contagion in the class-room attended by that sufferer. The exceptions referred to above are found in one case in the St. Mary National School, one case in the girls' department of the Board school, concerning which (par. 1 on page 7), Dr. Smith speaks of the possibility 4 of infection at school when he says infection by a class-mate can be excluded, and apparently one case in the infants' department of the St. Stephen National School. This possibility of school infection as distinguished from class-room infection is, however, altogether ignored in his discussion of the details relating to the Board school, boys' and infants' departments ; in these schools the possibility of infection by class-room mates only is studied. This method of treatment requires no further comment from me; but it may be pointed out that even if other opportunities of infection in school be excluded than those the class-room itself affords, Dr. Hamer's notes supply evidence that Dr. Smith's figures require amendment. It should be noted that Dr. Smith is here only dealing with notified cases of diphtheria, and thus he obtains intervals between successive cases in class-rooms which exceed seven days ; while Dr. Hamer, who includes cases of sore throat occurring in families in which a case of recognised diphtheria subsequently occurred, in certain instances bridges over these intervals. Limiting consideration to children in the three schools specially affected: Lewisham-bridge (boys), Lewisham-bridge (infants), and the St. Stephen's National school, whereas Dr. Smith's Table VI, shows, only 10 cases, in which he will admit the possibility of class or school infection, out of 53 children attacked, Dr. Hamer finds 29 cases, which on this basis might be regarded as cases of class-room infection out of a total of 59 attacked. This 59, moreover, included, to comply with the conditions imposed by Dr. Smith, 14 or 15 children who were the first subjects of attack in their class-rooms, and who cannot, therefore, if his view is to obtain, have received infection in the school.* (8.) A further point to which reference is made by Dr. Smith is the question how far the opening of a cottage hospital by the sanitary authority and the removal of cases of diphtheria to the hospital brought the outbreak to an end. He writes (page 11, par. 2)— "In the latter weeks of September, owing to the great pressure on the space of the Metropolitan Asylums Board hospitals, cases of diphtheria in Lewisham were obliged to remain six, seven and eight days in their homes before removal was possible. The Lewisham Board of Works decided, therefore, to open one of the wards of their cottage hospital for the reception of these patients. This was done on October 4th, and as soon as the cases were promptly removed, so did the notification of fresh cases decrease—from twenty-one in the week ending October 11th, to five in the week ending October 25th. By this latter date, however, the ward was full, and the district becoming once more congested, fresh cases began to increase. A second ward was therefore opened, and—immediately on removal of the cases to hospital—a marked decrease in the notifications again occurred. The part played by cases which were nursed at home for a longer or shorter period in aiding the spread of the disease seems, therefore, to be clearly indicated." Dr. Hamer has expressed the opinion that the keeping away from school of so large a number of children was one of the factors at work in serving to check the spread of diphtheria. That this view is correct is, I think, sufficiently shown by the fact that when the dates of beginning of illness of first sufferers among the children at the two schools is considered, it is found (see Dr. Hamer's chart) that first attacks had practically ceased among the boys in the Board school and among the children in the National school by the end of September, when the reduction in attendance had occurred, and before the date (4th October) when the hospital was first opened. In the case of the infants' department of the Board school, first cases only subsequently manifested themselves during the first nine days of October. The remaining paragraphs in Dr. Smith's report are devoted (a) To a statement of what he "gathers" are the "suggestions" in Dr. Hamer's report as to administrative procedure, with a view to the limitation of the spread of diphtheria by school attendance; and (b) To a statement of the rules of the Board on this subject. Dr. Hamer did not discuss in all its details the general question of the prevention of the spread of diphtheria by school attendance; he commented upon the circumstances of the Lewisham outbreak, and upon those only, in order that any lesson they taught might not be lost. His view was, that the early closing of the affected classes would have more speedily brought the outbreak to an end. This opinion was, I submit, amply justified by the history of the outbreak. I would desire in conclusion to refer to the following methods adopted by Dr. Smith in his statement of the circumstances of this outbreak. (a) In his examination of a report dealing with a localised outbreak of diphtheria, which had in this report been attributed to a particular cause, he includes in his figures the cases occurring in a large area, and during a period which extends beyond that in which this cause had been said to be directly operative. (b) By excluding, save in a trifling number of instances, any consideration of the effect which may be produced by a child suffering from diphtheria upon its school-mates, who do not actually happen to share the same class-room with such child, he reduces the number of cases which may otherwise reasonably be thought of as school-infected. (c) In this manner he excludes from the number of children who may be reasonably thought of as school-infected every child who is the first recognised sufferer from disease in its class-room. Thus, inasmuch as 14 or 15 class-rooms in the schools above referred to were infected, this number of cases of diphtheria is included among his "cases in which the evidence excludes the school as the source of infection." (d) By exclusion from consideration of throat illness, other than recognized diphtheria, occurring among children attending school, even when these cases of throat illness are followed by recognized cases of diphtheria in the same homes, he is able to show, in a greater number of instances than he otherwise could, certain intervals of time between successive *Dr Smith may have treated one of these cases exceptionally. 5 cases of diphtheria in the same class-room, and to include in each instance the case occurring after such interval among his "cases in which the evidence excludes the school as the source of infection." In view of these methods it could not be expected that his results would closely agree with those of Dr. Hamer. Dr. Smith publishes, however, two tables, C and D, the study of which is not without interest. C contains a list of "cases which had attended school within seven days of first symptoms." The cases which had been preceded by an earlier case in the same house are printed in italics. Table D contains a list of cases under the heading "no attendance at school within seven days of first symptoms," and again cases which had been preceded by an earlier case in the same house are printed in italics. The following results are obtained by the addition of these cases— No. of cases which had attended school within 7 days of first symptoms. No. of such cases which had not been preceded by a previous case in the house. Per cent. 66 55 83.3 No. of cases which had not attended school within 7 days of first symptoms. No. of such cases which had not been preceded by a previous case in the house. Per cent. 71 31 43.7 It will thus be seen that whereas of the 66 children who had attended school (of whom be it noted 59 attended the Lewisham-bridge Board or National school) within 7 days of their first symptoms 83"3 per cent, were first sufferers in their houses. On the other hand, of 71 other cases, only 43"7 per cent, were first sufferers. These figures, therefore, point to the existence in Lewisham in the recent outbreak of some condition special to children who were attending school. (Signed) Shirley F. Murphy, Medical Officer of Health. Public Health Department, Spring-gardens, S.W., 27th February, 1897. APPENDIX IV. London County Council. HOUSES LET IN LODGINGS. Report by the Medical Officer of Health presenting report by Dr. Hamer, Assistant Medical Officer of Health, as to the operation of by-laws dealing with houses let in lodgings in London. (Printed by order of tlie Public Health Committee, 25th June, 1896.) I present Dr. Hamer's report on the result of his inquiries as to the operation in London of by-laws concerning houses let in lodgings. These inquiries show that in every district where by-laws or regulations have been given a fair trial, the opinions of those best qualified to judge are strongly in favour of this method of dealing with houses of this character. Any difficulty which has been anticipated in thus regulating such houses has always disappeared when the work is seriously undertaken and a sufficient staff provided for the purpose. The very fact that a house has been registered, and is subjected to inspection, has been found to be productive of good, and there is no doubt still better results would have been attained if larger use had been made of the power conferred by by-laws to proceed directly for penalty instead of adopting the method of serving notices. This would be particularly the case when the condition to be dealt with is that of overcrowding. In every London district by-laws or regulations for houses let in lodgings now exist, but in only a limited number of districts has any considerable effort been made to enforce them. Under these circumstances the Committee will no doubt desire to consider the course they should themselves adopt, having regard to the responsibilities of the Council under the Public Health Act, and to the fact that it is obligatory on sanitary authorities to make and enforce the by-laws. Shirley F. Murphy, Medical Officer of Health. Dr. Hamer's Report. I have made inquiry as to the extent to which by-laws or regulations dealing with houses let in lodgings have been enforced in London, and have endeavoured to obtain knowledge as to the advantages or disadvantages which have been found in practice to be associated with their use. More particularly an attempt has been made to learn whether or not the putting in force of a code of by-laws or regulations enables conditions to be dealt with which are not capable of being remedied, or can only with difficulty be remedied, under the general provisions of the Public Health Act. For these purposes I have consulted medical officers of health of London sanitary districts, to whom I am indebted for the information which they have placed at my disposal. In the following report I propose in the first place to indicate the circumstances which have led to the statutory provisions under which by-laws or regulations for houses let in lodgings have been made, and then to consider how far experience shows that advantage has accrued from their enforcement, and what degree of importance must be attached to some of the objections which have been raised to their use. Special difficulty appears to have been experienced in London with respect to tenement houses as long ago as the end of the 16th century, for an Act of Parliament of 1598 (35 Elizabeth, cap. 6), makes reference to the great mischiefs which " daily grow and increase by reason of pestering the houses with divers families, harbouring of inmates, and converting great houses into several tenements, and the erecting of new buildings in London and Westminster." When, however, the importance of remedying insanitary conditions began to be appreciated in the present century, overcrowding did not at first receive attention, indeed, no power of control of overcrowding is found in the earlier Public Health Acts beyond that of making by-laws for fixing the number of lodgers who might be received into any common lodging-house. Under the Nuisances Removal Act of 1855, the local authority was authorized to take proceedings to abate overcrowding in a house occupied by members of more than one family, and certain limited powers of entry were given to the authority and its officers. The recognition by the legislature of the fact that overcrowding constitutes a condition "dangerous or prejudicial to the health of the inhabitants " of a house was no doubt regarded at the time as a distinct new departure, and it is not matter for surprise that the application of the new provision was in the first instance limited to cases in which a house was occupied in the manner stated. While however the overcrowding section of the Nuisances Removal Act enunciated a principle, its value in its application to concrete instances was evidently limited, as may be judged bv the statement of Sir John Simon who, in commenting upon the working of the Nuisances Removal Acts in 1864, alluded to " the want of precision and efficiency in the law relating to overcrowded dwellings " as one of the points concerning which amendment was particularly required. Considerable advance was made in 1866 when section 35 of the Act of that year empowered the Secretary of State, on the application of the nuisance authority, to declare the enactment in force in a sanitary district authorising the authority to make regulations dealing with houses let in lodgings. The subject matter with which such regulations might deal was specified by the section and included fixing the number of persons who may occupy such house, and the registration, inspection, cleansing, Sold by Edward Stanford, 26 and 27, Gockspurstreet, Charing-cross, S. W. No. 302. Price 2d. [1412 2 and limewhiting of such houses. This list of subject matters was somewhat extended by the Sanitary Law Amendment Act of 1874. Sir John Simon, in referring in the course of his evidence before the Sanitary Commission of 1869-71 to the effect of the passing of the Sanitary Act of 1866 upon overcrowding in dwellings said—"There again immense progress has been made. Overcrowding as such is declared a nuisance, and the local authority, with the approval of the Home Secretary, is able to regulate the occupation and keeping of tenement houses. There is thus immense progress in principle, but we have been in chaos since then, so that it has not yet borne fruit. After the report of the Commission we may hope to get an effective working of those things." That this hope was not realised may be judged from the fact that the report of the Royal Commission on the Housing of the Working Classes, 1885, states that inquiry made by the Local Government Board as to the working of the regulations dealing with houses let in lodgings showed that "two authorities, Chelsea and Hackney, had been specially active, but that comparatively little had been done by others." Evidence was given before the Commission to the effect that 1,700 houses were on the register at Chelsea and 5,000 at Hackney, and Dr. Tripe, the medical officer of health of the latter district, stated that the great advantage of having regulations was that proceedings could be taken for breach of regulation, and that it was not necessary in each instance to convince the magistrate that what was complained of was a nuisance injurious to health. The evidence from other districts, however, showed that there was a strong feeling adverse to the enforcement of the regulations, and the Commissioners state, " it is therefore evident that the 35th section of the Sanitary Act, which contains a remedy for some of the evils which have been described, is likely to remain a dead letter in many districts of the metropolis until some improved means be devised for putting it in action." The Commissioners showed their own sense of the need of the general adoption of regulations under section 85 of the Sanitary Act, by placing first on their list of recommendations the following : " Your Majesty's Commissioners therefore recommend that the vestries and district boards which have not already made and enforced by-laws should proceed to do so, although it is not likely that in all cases such action will be taken until the people show a more active interest in the management of their local affairs." Following upon the action taken by the Local Government Board and this strong recommendation of the Commissioners, attention was more largely directed to the question of the adoption and enforcement of tenement regulations. The Sanitary and Special Purposes Committee of the Council in 1889 caused inquiry to be made as to the extent to which regulations had been adopted and enforced in London, and from a summary of replies received from vestries and district boards which was prepared by Captain J. Sinclair, at the request of the Committee, it appears that regulations had been adopted at various dates in 31 of the 40 London sanitary districts ; in 10 of these 31 districts however no attempt was being made to enforce the regulations, and in several of the remaining 21 districts the number of houses on the register was either not stated or was quite small. A considerable number of houses appears however to have been registered in some nine districts* in addition to the two districts wbich had employed the regulations prior to the Local Government Board's inquiry above referred to. The powers given under the Sanitary Act were optional powers, which were obtainable on application being made by the nuisance authority to the Secretary of State. The Local Government Board, to which had been transferred in 1871 the functions of the Secretary of State with regard to tenement regulations, in 1888 declared the enactment empowering the nuisance authority to make regulations to be in force in those districts (16 in number) which had not already made application. On the enactment of the Public Health (London) Act, 1891, a further and more important step was taken, inasmuch as under section 94 of the Act (which replaced section 35 of the Sanitary Act, 1866, and section 47 of the Sanitary Law Amendment Act, 1874) the enforcement of by-laws as to houses let in lodgings was for the first time declared to be obligatory. Beyond this the Act provided for the supersession by the Council of an authority which had made default in executing or enforcing provisions of the Act, among which is included that relating to the regulation of houses let in lodgings. A return prepared by the medical officer of health of the Council, and dated December, 1895, shows that regulations under the Sanitary Act of 1866 or by-laws under the Public Health Act of 1891 dealing with houses let in lodgings had been made in all the Londou districts. The return shows for each district the " number of houses on the register regulated at the present time " (December, 1895). From the figures supplied, it would appear that in eight London districts an appreciable proportion of the inhabited houses (that is to say, upwards of 2 per cent, of the total number of such houses) was under regulation. In 16 other districts the regulations were being used, though only to a limited extent. In a few of the remaining districts by-laws under section 94 of the Public Health (London) Act, 1891, had only recently been confirmed, and there had not, at the time of the return, been opportunity of enforcing them. Again, in a certain number of districts, the question of enforcing existing regulations had been postponed, apparently because the authority was in communication with the Local Government Board with reference to replacing the regulations by by-laws under the Act of 1891. The result of inquiry as to the operation of by-laws in those districts in which they have been extensively used, points unmistakeably in one direction. In the first place, it appears that the specific requirements of the by-laws with regard to cleansing have been found most useful. Considerable difficulty has been experienced with regard to this matter in some parts of London in districts in which the by-laws have not been made use of. Thus, at the end of 1894, an illustration was furnished by a decision of the magistrate at the Westminster Police Court under the following circumstances—The Chelsea Vestry had called upon an owner to cleanse and repair a dirty and dilapidated house. The magistrate held that the vestry could not proceed under section 2 of the Act, which deals with nuisances, and he dismissed the summons. The solicitors to the vestry reported upon the case as follows—" The evidence proved that the house was in a dirty and dilapidated state, but the magistrate did not consider *Bermondsey, Clerkenwell, Hampstead, Islington, Kensington, Limehouse, St. Giles, St. Martin-in-the-Fields and St. Marylebone. 3 that, this constituted a nuisance under the Act, or that the vestry had power to enforce cleansing and limewashing except under by-laws in the case of lodging-houses." The view taken in this case by the magistrate was no doubt an extreme one, and as was pointed out at the time, in districts in which such decisions are given, difficulties must arise in connection with maintaining cottage property, in which each house is occupied by a single family, in a cleanly and wholesome condition. There is, however, an almost unanimous consensus of opinion among medical officers of health to the effect that the hands of the sanitary authority are materially strengthened by the use of by-laws in cases in which they are applicable. The by-laws, in addition to formulating requirements as to cleansing, define overcrowding, and it might be anticipated that here too great advantage would result from their use. It is sometimes stated that in dealing with overcrowding, inasmuch as a notice to abate is almost always complied with, the necessity for by-laws relating to this subject is not apparent. It must not be forgotten, however, that compliance with a notice means in some cases little more than that the person responsible for overcrowding has learnt what answer it is necessary to give when inquiries are subsequently made concerning the matter. By-laws serve a double purpose ; in the first instance they enable penalties to be more easily obtained when overcrowding is found to exist; in the second they may provide for inspections of houses let in lodgings to be made at other times than those specified for the general powers of the Act, a provision necessary in view of the fact that there is much difficulty in proving the existence of overcrowding. It is necessary here to emphasize the advantages of proceeding for infringement of by-laws when overcrowding is found, because even at the present time with the increased powers by-laws give already in the hands of sanitary authorities, it is still the practice to proceed for abatement by notice rather than to apply directly for penalties. It is not possible to estimate exactly the extent to which overcrowding, as defined in the by-laws, exists in London. The returns of the 1891 census showed that 19*71 per cent, of the population were living under conditions of " overcrowding." " Overcrowding," as defined by the Registrar-General, is not, however, identical with the overcrowding which comes within the limits usually specified in by-laws, and the former is probably on the whole a somewhat more comprehensive term than the latter. As an indication however of the extent to which overcrowding as usually defined in by-laws is admitted to exist by the inhabitants of houses in some parts of London, the result of inspections made by Dr. Young and myself in six sanitary districts, two in the south, three in the east and one in the west of London, may be quoted. We found, as the average result of a large number of inspections, that there was at once forthcoming in about one house in every ten visited, clear evidence of overcrowding. Where overcrowding is so plentiful it is manifest that there is abundant scope for the operation of the by-law, and in the light of a result such as this the commonly expressed opinion that a notice to abate overcrowding is always complied with, and that proceedings for penalty are therefore unnecessary, seems to need justification. Presumably what happens in many cases is that the persons living under conditions of overcrowding are merely transferred from one tenement to another, while the amount of overcrowding in the district remains practically unaltered. In districts, however, in which the sanitary authority shows that it is its intention to enforce by-laws, the fact that a house is placed on the register comes to be accepted as an indication that overcrowding must no longer be permitted. I was told that an owner of tenement property, after a short experience of the working of by-laws, had expressed the opinion that "registering a house takes 25 per cent, off the rent." In order to comply with the by-laws he knew it would be necessary to considerably reduce the number of occupants of his tenements, and for this and other reasons he was anticipating, no doubt rightly, a considerable diminution in the amount of his receipts. Experience of the application of by-laws regulating houses let in lodgings is then, as regards cleansing, entirely favourable ; as regards overcrowding it is also favourable, but the powers conferred upon sanitary authorities under the by-laws have been to a large extent held in reserve, and use has not hitherto been made of the ability to proceed straightway for penalty on proof of infringement of the by-law. There are other matters which can be dealt with by by-law besides cleansing and overcrowding. These two are, however, the main questions to which the provisions of the by-laws are addressed, and they appear therefore at the present time to be most deserving of attention. It may be noted that the by-laws of a few districts contain a provision dealing with the separation of the sexes. These provisions do not appear, however, to have been as yet extensively applied. It now remains to consider difficulties which have been met with in connection with the regulation of houses let in lodgings. In the districts in which some effort has been made to deal with this subject, the chief difficulty which has arisen has been the fact that the sanitary inspectors have not been able to devote sufficient time to periodical inspection of tenement houses. The effective operation of by-laws necessarily implies systematic inspection, and the staff has frequently been found inadequate for this purpose. It may be noted that Chelsea and Hackney, the two districts which had made use of tenement regulations prior to 1885, have not continued to keep their registers up to date, and one of the reasons of this failure appears to be that the demands made upon the inspectors by other work have fully occupied all their time. Apart from this question of sufficiency of staff one or two minor difficulties have arisen. In the first place the procedure, in the event of its being found necessary to take a case into court, is in some respects rather more complicated than it is under the nuisance section of the Public Health Act. Thus formal proof of registration is usually required, and delay has arisen in some cases in which there has been a change of ownership from the fact that the person registered has been found to have disposed of his interest in the property. Inasmuch as a technical objection has been successfully sustained in one or two instances, it is clear that there is need for care in ensuring accuracy with regard to particulars of this kind. Again, questions have arisen in cases in which a house has been let and sub-let, as to the person who should be registered as the landlord of the premises. It has been suggested that the actual owner of tenement property might find it practicable to rid himself of responsibility by letting each 4 house to a single tenant, perhaps on weekly terms, who, in the event of sub-letting, would be accountable to the sanitary authority for securing the observance of the by-laws. In two districts it has been found that persons who had been recognised by the sanitary authority as "landlords," proved to be weekly tenants in very poor circumstances who were, or professed to be, quite ignorant of the fact that they were responsible in any way under the by-laws, and who, when convicted, declared themselves quite unable to pay the fine inflicted by the magistrate. In districts in which by-laws are being newly put into operation there is opportunity for misconception as to the extent of responsibility incurred by different individuals, but difficulties of this kind apparently disappear as soon as the scope and effect of the by-laws are appreciated. It may be stated that all the difficulties above referred to are difficulties which have been experienced in districts where the working of by-laws was being newly undertaken, and none of them appear to give rise to any serious trouble in districts in which by-laws have been extensively used. There is some difference of opinion as to whether all houses let in lodgings in a district should be registered, or whether registration should be limited to those houses in which the conditions the by-laws are designed to remedy are particularly frequently met with. It is impossible to require that precisely the same methods shall be applied in all districts, for the matter really resolves itself for the most part merely into a question as to how the office register shall be kept; it is not, therefore, surprising to find that the practice varies in different districts. What is really essential is that certain kinds of property should be inspected frequently and be subject to the by-laws. In some districts there is a large proportion of this kind of property ; in others not so much of it. In the case of the former districts the use of by-laws should necessarily be greater than in the case of the latter districts. Many of the codes of by-laws possess an exemption clause based upon a limit of rental. This is open to the objection that the limits assigned sometimes exclude from the operation of the by-laws tenements which may be found to require regulation. As an instance of this, the limits assigned in the Stoke Newington by-laws may be referred to. In these, by-laws unfurnished lodgings, the rent of which exceeds 2s. 6d., and furnished lodgings the rent of which exceeds 4s., are exempted, and the exemption is much too comprehensive. The following points are deserving of notice with reference to particular districts— Kensington.—Regulations were confirmed by the Local Government Board in 1886, and were largely worked with great advantage to the district. Since the passing of the Public Health (London) Act, 1891. the question of the substitution for the existing regulations of by-laws, under section 94 of that Act, has been under consideration, and houses have not been newly registered pending the settlement of this question. In the portion of Kensington which has been referred to as " a west-end Avernus," there are many houses to which the by-laws are applicable, and Dr. Dudfield, the medical officer of health of Kensington, has pointed out the need of increased inspectorial assistance for remedy of the conditions which exist in this locality. Recent changes have, however, caused diminution instead of increase in the amount of attention which it is found possible to devote to this part of Kensington. Hammersmith.—Regulations were confirmed in 1887, but no houses were found to be registered in 1895. By-laws under the Act of 1891 were confirmed by the Local Government Board on the 28th day of April, 1896. Fulham.—New by-laws were confirmed in 1895. They are not being enforced at present, as the time of the inspectors is fully occupied with other work, the question of increasing the staff of inspectors is, however, under consideration. Paddington.—New by-laws were confirmed in 1894. No houses are as yet on the register, the question of increasing the staff of inspectors is here also under consideration. Chelsea.— Regulations under the Sanitary Act of 1866 were largely used in former years, and great advantage was found to result from their operation by those who were concerned with their working. It may be noted that considerable clearances have taken place in Chelsea of late years, and some of the houses which formerly were registered have thus been demolished. The question of framing by-laws under section 94 of the Act of 1891 has been under consideration, but no decision has yet been arrived at, and the regulations have in the meantime unfortunately been allowed to fall into disuse. It appears obvious that before by-laws under section 94 can be enforced, an increase in the number of inspectors will be necessary. The vestry has recently decided to appoint an additional inspector. St. George, Hanover-square.—By-laws were confirmed in 1894, and their use is being gradually extended. There were only 73 houses however on the register in December last, and this number is small in comparison with the number of houses in the district to which by-laws might with advantage be applied. Westminster.—By-laws were confirmed in 1893, and they have since been extensively employed with entirely favourable results. About 1,000 houses are now registered. St. James, Westminster.—By-laws were confirmed in 1895, and the number of houses on the register is as yet small. Marylebone.—Regulations made under the Act of 1866 were confirmed in 1890, and nearly 1,000 houses have been registered. A larger use of the regulations could be made with an increased staff. There is no present intention of framing new by-laws. Hampstead.— Regulations were confirmed in 1885 and large use was made of them. By-laws under section 94 of the Act of 1891 were made in 1895, and at the present time there are about 840 houses on the register. Experience has shown that the regulations and by-laws are of great value in the remedy of certain defects which can only with difficulty be dealt with under the general provisions of the Public Health Act. St. Pancras.—By-laws were confirmed in 1893, and have so far only been applied to a very small proportion of the houses let in tenements in the parish. A considerable extension of the use of the bv-laws in this district appears to be impossible with the existing staff. 5 Islington.—By-laws were confirmed in 1894, and their use is being gradually extended. A special inspector is employed to carry out the work. It is obvious, however, that one inspector cannot deal with any considerable proportion of the tenement houses in this large district. Hackney.—Regulations under the Sanitary Act of 1866 were formerly enforced. The register has not, however, been kept up to date. By-laws under the Act of 1891 were confirmed in 18 95, and the question of appointing inspectors to put them in operation is under the consideration of the vestry. Stoke Newington.—By-laws were confirmed in 1895, but no houses have yet been registered. St. Giles.—Regulations were confirmed in 1887, and have been continuously employed since that date. They have been found very useful. There are at the present time 476 houses on the register. There is no present intention of replacing the regulations by new by-laws made under the Act of 1891. St. Martin-in-the-Fields.—In this district regulations were confirmed in 1884, and a number of houses have been registered and periodically inspected. About 180 houses are on the register at the present time. Strand.—By-laws were confirmed in 1894, and are being put in use with the most satisfactory results. At the end of April last 86 tenements had been dealt with, and a special inspector was engaged in making periodical inspections. Holborn.—Regulations were confirmed in 1885, and 35 houses are entered on the register. Very little use appears to be marie of the existing regulations. Clerkenwell.—Regulations were confirmed in 1887. There are no houses at present on the register. The question of framing by-laws under the Act of 1891 is under the consideration of the vestry. St. Luke.—By-laws were confirmed in 1895. There are no houses at present on the register. Shoreditch.—By-laws were confirmed in 1894, and 38 houses have been put upon the register. There appears to be need for largely extending the operation of the by-laws in this district. Bethnal-green.—By-laws were confimed in 1895. There are no houses at present on the register. Whitechapel.—By-laws were confirmed in 1893. There are at the present time 25 houses on the register. The application of the by-laws has been limited in the first instance to " furnished rooms." Houses in which rooms are let out in this manner are not placed upon the register until they have been put into a satisfactory sanitary condition. St. George-in-the-East.—By-laws were confirmed in 1895, and but little use has as yet been made of them. Limehouse.—By-laws were confirmed in 1893, and their use is being slowly extended. Mile End Old Town.—About 174 houses are on the register. With the existing staff it does not appear to be possible to make any considerable use of the by-laws. Poplar.—New by-laws have recently been confirmed. No houses have as yet been registered. St. Saviour, Soidhwark.—By-laws were confirmed in 1894; no houses, however, have as yet been registered. St. George-the-Martyr.—By-laws were confirmed in 1894, and have been found useful, but it will be necessary to strengthen the existing staff of inspectors in order to thoroughly enforce the by-laws, and this question is now under the consideration of the vestry. Newington.—Regulations were confirmed in 1890. No houses are at present on the register. By-laws, under the Act of 1891, have recently been framed by the vestry and sent to the Local Government Board for confirmation. Bermondsey.—About 300 houses are on the register, and the by-laws are found to be very useful, especially in dealing with dirty conditions and overcrowding. Prior to the confirmation of the existing by-laws, regulations had been in operation in Bermondsey for a number of years. Rotherhithe.—Regulations were confirmed in 1867. They are not, however, being enforced at the present time. The question of framing new by-laws under the Act of 1891 is being considered by the vestry. Lambeth.—A few houses were registered under the old regulations. New by-laws have now been submitted to the Local Government Board for approval. Battersea.— In this district all the houses, 8,046 in number, in which more than one family resides, are entered in the register. The by-laws are not, however, made use of in the manner in which they have been employed in other London districts, inasmuch as proceedings are not taken for breach of by-law but under the general provisions of the Public Health Act. No difficulty has hitherto been experienced in obtaining a conviction under these provisions in respect of dirty condition of rooms, and as regards overcrowding it is said to be always abated upon service of a notice. Wandsworth.—In Clapham parish only a few houses have been entered in the register, and the by-laws have been of use in enforcing cleanliness. Camberwell.—By-laws were confirmed in 1895, and a few houses are on the register. There appears to be considerable scope for the extension of their use in this district. Greenwich.—Regulations were confirmed in 1884, and nine houses are registered in Greenwich parish, but there are no houses on the register in Deptford parish. The question of making new by-laws is under consideration. Lewisham.—New by-laws were confirmed by the Local Government Board in 1895, and a few houses in Arpley-road, Penge, have been registered. Woolwich.—New by-laws have recently been confirmed, and notices have been served for the registration of a few houses. Plumstead.—By-laws were confirmed in 1894. At first very few houses were dealt with, but rather more use has been made of the by-laws lately. Lee.—New by-laws were confirmed in 1895. W. H. Hamer, Public Health Department, Assistant Medical Officer of Health. Spring Gardens, S.W. 25th June, 1896. Appendix V. London County Council. SHELTERS. Report by tlie Medical Officer of Health, presenting Report by Dr. C. W. F. Young on Shelters in the County of London. (Ordered by the Public Health and Housing Committee to be printed, 2nd March, 1896.) The question whether common shelters which are not subject to the Common Lodging Houses Acts should be made subject to these Acts has from time to time been before the Committee. With a view to obtaining more information concerning the several shelters in London, Dr. Young was instructed to inspect premises in which poor people are temporarily provided with night accommodation in rooms which they occupy in common. This instruction led Dr. Young to inspect numerous institutions which differ in their primary object as well as in the character of the accommodation they provide. Some aim especially at the reformation of the character of the inmates, providing them with a temporary home with a view to bringing them under wholesome influences; others have as their primary object the provision of a shelter for necessitous persons, although the moral improvement of the inmates is not lost sight of. In the former especially, efforts are made to assist the inmates in finding work, and in some, work is provided for them on the premises. Dr. Young's inspection of these places shows that while the accommodation provided at some was satisfactory, very different views are held in others as to the character of the accommodation which is thought to be necessary or sufficient. In all instances he found them clean at the time of his visit, but he also frequently found, in the absence of any standard for the guidance of those in charge of the shelters, want of sufficient air space for each person in the dormitories, the beds or bunks being often crowded in close juxtaposition to each other. Measurements which he obtained show that in some two-thirds of the dormitories the cubic space per head was materially less than that required in common lodging-houses in London. With regard to opportunity for personal cleanliness, the provision of wash-hand basins was in numerous instances inadequate, and in many the water-closets were faulty in arrangement and situation. It must of course be recollected that these shelters are not carried on for the purpose of profit, and it may be argued that they should not be required to provide accommodation equal in character to that which is insisted upon in common lodging-houses, which are a source of profit to the keepers ; that even if admittedly inadequate in this respect, they serve a useful purpose in providing a home for those who cannot afford to avail themselves of the common lodging-house, and that without these shelters many would be houseless. To this, however, it must be replied that the conditions of life of no human being ought to be allowed to sink below a certain minimum standard, that when this principle is infringed there is not only danger to the individual but to the community, and that the State has made provision available for those who are unable to procure this minimum for themselves. While fully recognising, therefore, the value of the work which is done in connection with these shelters, I think Dr. Young's report shows the necessity for subjecting those which are found to be inadequate, to regulations which shall prevent the accommodation they provide falling below a certain minimum. The fact that they are not carried on for profit does not appear to me to be sufficient reason for exempting them from the requirement that their dormitories shall not be overcrowded, that the opportunities for cleanliness shall be adequate, and the water-closet accommodation of a proper kind. There would, however, be further advantage in the exercise of control over these places such as would ensure that they were fit for the purposes of a shelter before they are actually occupied. Premises are sometimes taken for this purpose which have been erected for an entirely different object, and knowledge is required to determine whether they can be properly adapted for use as shelters. This knowledge has sometimes been wanting, and hence unsatisfactory conditions are found to exist which might have been prevented. Probably the best course to adopt is an application to Parliament for the amendment of the definition of a common lodging-house, so as to bring common shelters within the provisions of the Common Lodging-houses Acts, notwithstanding that the houses are not used for the purposes of profit, If it were desired in the treatment of any of these shelters to make any distinction between them and common lodging-houses it would be by modification of some of the requirements which are now usual in respect to houses occupied by day as well as by night, and by relaxation of the requirement of the exhibition of notices, rather than by any exemption from the requirements as to the sufficiency of air space, and of lavatory and water-closet accommodation. An alternative method would be to empower sanitary authorities to regulate shelters much in the same manner as they can houses let in lodgings. Shirley P. Murphy. Medical Officer of Health. No. 326.—Price 4d. Sold by Edward Stanford, 26 and 27, Cockspur Street, S.W. M. 96a 2 Dr. Young's Report. For the purpose of this inquiry inspection has been made of the following premises— The Church Army labour homes, and St. John's lodging-house for men. The Bessbrook Homes for men. Some free refuges. Medland Hall free shelter. Dr. Barnardo's free shelters for women and children. The Salvation Army shelters, lodging-houses or metropoles, and elevators or labour homes. The Shaftesbury Institute for women, and shelter for men. The several institutions comprised in the above list may all be regarded as being included within the meaning of the term "shelter," that is, premises the object of which is to provide lodging temporarily, either free of charge or for small payment, for persons who are homeless from some cause or other, this object being in most cases associated with an endeavour to assist the individual, either directly or indirectly, in obtaining employment should he or she want it. They differ, however, considerably amongst themselves as regards the methods by which persons can gain admission, the character of the accommodation which is provided, and the existence or absence of a limit as to the length of time during which persons are allowed to frequent the shelter. According to the differences in respect of admission, these shelters may be divided into two classes, namely, those at which inquiry into the antecedents of each applicant is made—admission into and stay in the shelter being subject to the result of this inquiry being satisfactory—and those at which no such inquiry is made. The former correspond more or less closely to those places at which no charge is made for lodging, and the latter chiefly to those at which a small fee is charged. The labour homes of the Church Army and the Bessbrook Homes appear to stand in a position apart from these. They may be regarded rather as institutions, the primary object of which is not so much to provide lodging or shelter for the many without homes as to reform men by bringing them into a place where they are engaged at work, and where they live according to certain rules and regulations, a breach of which entails discharge from the home. Methods of admission, duration of stay, and provision of food. The Church Army labour homes and St. John's lodging-house fov men.-—Before any applicant is admitted he is interviewed on two separate occasions by different individuals, and further inquiry into the case is also made by members of the army. A man before entering the home signs an agreement that he will live there according to its rules and regulations, and he stays generally for a period of two months. He may, on certain conditions, stay longer, or on the other hand if he obtain work after the first month, he may leave the home before the expiration of two months. The men are boarded and lodged, meals being served at fixed hours. In connection with each home there is a workshop (in most cases for wood chopping), in which the men are engaged during the daytime. Each man is credited with the value of his work, and if this amounts in any case to a greater sum than is necessary to pay for his board and lodging the surplus is put to the man's account, forming a small capital which is handed over to him when leaving the home, or upon which he is allowed to draw towards the end of his stay. At St. John's lodging-house nearly all the lodgers are men who have passed through one of the labour homes of the Church Army, and who have succeeded in obtaining situations. If, however, there are any vacancies, an ordinary applicant for a night's lodging would be admitted subject to the discretion of the captain in charge. A small proportion (about sixteen) are men who have been in one of the homes and who are engaged at work at the head-quarter offices of the Church Army; these are boarders, but the other lodgers are charged sixpence a-night for their lodging and provide and cook their own food. The lodging-house is managed under regulations as to hours of getting up and going to bed and as to taking baths. During the daytime the men are expected to be out at work or engaged in search of employment. The Bessbrook Homes and Agency.—Any applicant is admitted if upon inquiry by the superintendent it is found that the man is desirous and is really in need of the assistance afforded by the work which is carried on in connection with the homes, namely, the Bessbrook Agency for sandwich board carriers, for circular folding, addressing and delivering, and for clerks. In some instances men are taken in though the agency may not be able to find employment for them at once In these cases the men are allowed to continue any casual work they may be engaged in at the time, such as newspaper selling, until they can be employed in the work of the home. The superintendent states that many of the men are sent to the home by friends of the institution. A man admitted to these homes is not bound to stay any longer than he wishes, and is not asked to sign any agreement. The duration of his stay is an indefinite period varying according as the superintendent considers it would be to the man's advantage to stay for a longer or shorter period. If during his stay his conduct has been satisfactory, each man is assisted in obtaining work of a permanent character. The men are paid by the agency while in its employment, and they are charged sixpence and fourpence a night for their lodging. They provide and cook their own food. The premises are open to the lodgers all day. The work of the Bessbrook Agency is carried on at one of the homes. The free refuges.—The procedure as to admission into these refuges generally is as follows. Any person who applies for shelter is seen by the superintendent, who takes down the applicant's statements, and obtains the names of references for further inquiry, and if there is no immediate reason to the contrary on this score, or if the applicant be not in a dirty condition he is admitted at once, and allowed to remain till further investigation is made into the case, the person being given shelter for two or three nights until this has been completed. If the result be satisfactory he is then allowed to stay on fcr two or more weeks while he looks out for employment. If the man be successful in obtaining work 3 he may be allowed to stay on for another week or so till he obtains his first wages. Admission to these refuges begins about 5 p.m., and all persons have to leave by a given hour in the morning, the premises remaining empty during the daytime for cleansing purposes. Food, free of charge, is provided upon admission, and again in the morning before going out; this, in most cases, consists of bread and cocoa or soup. In some cases the person on admission is required to take a bath and to wash his shirt, or his clothes are fumigated. Medland Hall and Br. Barnardo's shelters.—Medland Hall shelter for men and Dr. Barnardo's shelter for women are similar to the free refuges in that no charge is made for lodging, but they differ in that it does not appear to be the practice to investigate every case, although the names and occupations of the applicants and the place where they last slept are entered into a book. In the case of Medland Hall a ticket which is available for six nights, not necessarily consecutive nights, is given to each individual. On the expiration of this ticket a renewal ticket is given if there is reason to believe that the man has honestly endeavoured to get work but without success, and is in other respects deserving of help. Men are also assisted in special instances in obtaining work by the London Congregational Union, by whom this shelter is maintained. At Dr. Barnardo's shelters for women and children an applicant is admitted for three nights in succession, after which she is not again admitted for an interval of seven days; but in some cases where a desire has been expressed for aid in obtaining employment, the case is further investigated, and lodging afforded during the time that work is being obtained. At these shelters a free meal of bread and cocoa is given at night, but a charge of one penny is made for the meal in the morning if the person wishes for it. At Medland Hall half-a-pound of bread is given to each man on admittance, and on Sundays half-a-pound of bread and butter and a pint of coffee. Medland Hall opens for admission at 9 p.m., and all the men have to leave by 5.45 a.m. At Dr. Barnardo's shelters the women and children are admitted about 7.30 p.m., and the shelter is closed in the morning at 9 o'clock. During the daytime the premises remain empty. The Salvation Army shelters.—At these shelters charges varying from one penny to sixpence per night are made for lodging, and, subject to the ability to pay these, it appears that all comers are admitted (so long as they are not disorderly) without any inquiry. There is no limit apparently as to the number of nights on which any one individual may frequent these shelters so long as he or she possesses the power to pay the nightly charge. At one of the Salvation Army shelters it was stated that a large proportion of the men frequenting it had been regular lodgers for many months, and some for years, and there was evidence of this continued stay in the fact that in one of the dormitories personal property of some lodgers was observed hanging on the wall immediately over some of the bunks. The premises belonging to the Salvation Army may be divided into three classes, namely— (1.) The cheap or ordinary shelter at which a charge of twopence or threepence a night for lodging is made according to the accommodation provided. (2.) A better class of lodging, the metropoles, at which fourpence or sixpence a night is charged. These resemble ordinary common lodging-houses ; and (3.) The elevators or labour homes, at which no charge is made, board and lodging being provided in exchange for and in proportion to the work done by the individual. The men who are admitted to the labour homes are, in most instances, men who have previously frequented Salvation Army shelters. They are not asked or bound in any way to stay for any given period, but are quite free to leave at any time they wish. In addition to these three classes there is, in connection with the shelter at Blackfriars-road, a fourth form of accommodation, for which a charge of one penny is made. For this sum men are admitted to the shelter and are allowed to remain during the night in the large hall (which serves as the day room or mission room), after the others have retired to their bunks. Each of these men is also provided with a large piece of bread and is allowed to make use of the lavatory. The premises at which is provided the cheaper form of lodging mentioned above open for admission about 5 p.m. in the winter months, and at 6 p.m. in the summer, and all lodgers have to leave the premises by 8-9 o'clock in the morning. During the daytime they remain empty for cleansing purposes. The lodging-houses or metropoles remain open to the lodgers during the daytime. The elevators are also open all day, the men being engaged in the workshops between definite hours. At all the Salvation Army shelters food can be obtained at cheap prices. It is not included in the charge made for lodging, except in the case of the penny shelter where a piece of bread is given, and at the fourpenny shelters where a man has the choice of a bunk for sleeping accommodation together with food, or an ordinary bedstead without food. At the elevators meals are provided at fixed hours three times daily. The men in return for their labour are given tickets, of which there are three classes, representing the value of the work done, and these are exchanged for food and accommodation corresponding to the class of ticket presented by each man. The Shaftesbury Institute, Marylebone.—This is a shelter for women, at which charges of twopence and sixpence a night are made for lodging according to the nature of the accommodation. In connection with this shelter and in the same premises there is a small labour home, many of the women in which have, in the first instance, made use of the shelter, and some of them are employed in keeping the premises clean. There is also a small night shelter for men at which a charge of twopence a night is made. This consists of one room in premises used as a men's labour home in Bell-street, Marylebone, and appears to have for its object the provision of cheap night accommodation for men temporarily engaged in work in the neighbourhood, although not residing in it. Both these shelters are closed during the daytime. The women are admitted from 7 p.m., and all must leave by 9 a.m. the following morning. The men are admitted from 8 p.m., and leave by 8 a.m. At the women's shelter provision is made for supplying food at cheap prices, but at the men's shelter no food can be obtained. 4 Nature of accommodation provided at the various classes of premises visited. The Church Army labour-homes, and St. John's lodging-house.—The Church Army maintain in the metropolis some eight labour-homes for tramps, criminals, inebriates and deserving unemployed, a boys' labour-home, and St. John's lodging-house for men, as well as a women's lodging-house and laundry and home. At the three labour-homes for men, which were visited, both day room and sleeping room accommodation is provided. The number of men at these homes is, as a rule, limited to twenty-five, and the premises are practically large-sized dwelling-houses, some of the rooms of which are used either as common dormitories, or are divided up into cubicles, each capable of accommodating one person. The sleeping accommodation consists of ordinary bedsteads and bedding. The day rooms are fitted up as ordinary sitting rooms furnished with tables upon which meals are served at fixed hours, food being prepared by one of the permanent staff in a separate kitchen. In addition to these day rooms there is at each house a workshop in which the men are engaged during the greater part of the day. The means of light and ventilation at the homes visited was found to be good. At each of these homes lavatories and bathrooms are provided. The water-closets were found to be in sufficient proportion to the number of men in the home. St. John's lodging-house for men has accommodation for fifty lodgers. Separate day and sleeping rooms are provided. The day room space has been divided by wood and glass partitions into three parts. One part is used as a room for meals for the boarders in the home, namely, men who are engaged in clerical work at the offices of the Church Army, and are provided with board and lodging at the lodging-house. Another part is reserved as a reading room, and the remaining part, which is fitted with a fireplace, is used as a common kitchen in which the ordinary lodgers cook and prepare their food. These premises, originally used as a public hall, are not well adapted in all respects for their present purpose. The provision made for lavatory accommodation is adequate if judged by the requirements which are demanded in the case of new common lodging-houses, but the room is badly lighted and ventilated. A bathroom is also provided, and both hot and cold water are obtainable. The water-closet accommodation is also adequately provided for, but is unsatisfactory as regards light and ventilation, and the position of one water-closet is decidedly objectionable, owing to its proximity to one of the dormitories and the absence of proper light and ventilation. A drying cupboard for the use of lodgers is also provided. The Bessbrooh Homes and Agency.—There are two of these homes, which are situated within a short distance of each other, and work is carried on at one only, where the superintendent resides, and where all applications for admission have to be made. The total accommodation is for one hundred and three men, there being sixty-nine beds at one set of premises and thirty-four at the other. At both homes day rooms apart from the dormitories are provided, but in neither case were these rooms found to be well lighted and ventilated. The dormitories are ordinary sized rooms capable of holding a small number of beds only, and the sleeping accommodation consists of ordinary bedsteads and bedding. The dormitories, generally speaking, are provided with good means of light and ventilation. At both of these homes the lavatory accommodation is badly situated and not well fitted up. The water-closet accommodation is also insufficient, and at one home badly situated. The refuges.—The premises included under this heading which have been visited are— Field-lane refuge (for men and women). Ham-yard hospice. Providence (row) night refuge (for men and women). House of shelter, Bagallay-street, Stepney. Newport market refuge (for men and women). At the refuges in Field-lane (male side) and Ham-yard no separate sitting room accommodation is provided, but at both these the lodgers have the use of rooms not used as dormitories in which they can sit before retiring to bed. Thus at the former they are allowed to use one of the rooms in the building which is used at other times for meetings and other purposes in connection with the work of the institution, at the latter they have their food and are allowed to sit in a room on the ground floor which during the daytime is used as a soup kitchen for people in the neighbourhood. At Providence-row large day room accommodation is provided. At the House of Shelter and Newport-market refuge (male side) there is no separate day room apart from the sleeping rooms. The sleeping accommodation provided at these places consists of— (1) Beds provided with ordinary bedding, in the case of Field-lane refuge, and Hamyard hospice. (2) Wooden bunks provided with mattresses, lined with American cloth, and a covering for the sleeper of American cloth generally padded with felt, in the case of Providence-row and the House of Shelter. (3) Swing hammocks provided with a small pillow and blankets in the case of Newportmarket refuge. There are also a few cubicles here. At all these premises, with the exception of Providence (row) refuge, the dormitories are of moderate size, capable of accommodating about thirty persons or under. At Providence (row) refuge two dormitories have accommodation for seventy persons each, and the third for one hundred and twelve persons. In all these premises the means of light and ventilation are well provided. In these respects the dormitories at Providence (row) refuge are specially well arranged. They consist of long narrow rooms having windows on either side, thus securing cross ventilation. The lavatory and watercloset accommodation, generally speaking, is also adequate in proportion to the number of persons who can be sheltered, and in all cases baths supplied with hot and cold water are provided. Medland Hall.—This building was built for and originally used as a chapel, and consists of a large hall with side galleries, a room over the entrance to chapel, and another room over the hall in the roof of the building. No part of the building is used separately for kitchen or sitting room as distinct from that used for sleeping. The hall and galleries are provided with chairs and 5 benches, upon which the men lie down when sleeping, each man being provided with a small wooden block to serve as a pillow. In the room over the hall there are no chairs, and the men sleep on the ground. At the time when the hall was visited, wooden bunks, similar to those used in the Salvation Army shelters and described later on, were being constructed for the use of the men.* The number of men admitted is limited to three hundred. This number was fixed as a maximum after proceedings had been taken by the local sanitary authority for the occurrence of overcrowding at the shelter. The means of light and ventilation here is such as is usually found in a building of this character, namely, windows on either side. The room in the roof is provided with skylights. The lavatory and water closet accommodation is provided in a narrow covered passage at one side of the building, which is approached directly from the hall. At one end of this there is a slate slab with four loose basins, the remainder of the passage being fitted up with a long trough closet divided into twelve seats, and a urinal. The separate seats of the closet are not provided with doors or sufficiently partitioned off from each other to secure privacy. In the sleeping room over the hall there is an old zinc tankf in which the men are allowed to urinate at night time should they require to do so. Dr. Barnardo's shelters for women and children.—At these two shelters both day rooms and dormitories are provided. At each of the two sets of premises visited, the day room accommodation was found to be a room in the basement. It is stated that one of these buildings was formerly used temporarily as a general hospital, and that the other was once a common lodging-house. At the former there are three dormitories, each consisting of a big room with windows on two sides, and accommodating from thirty-three to thirty-seven persons each. These dormitories are furnished with iron bedsteads, each provided with a seaweed and straw mattress, a pillow, and rugs. At the latter set of premises the dormitories are rooms of a size ordinarily found in dwelling-houses, and were found to have accommodation for either five or six persons, or as many as twenty. The sleeping accommodation here consists of raised platforms divided off into bunks by wooden partitions, each bunk being supplied with a mattress, pillow and rugs. The wooden partition between each sleeper is about fourteen inches high. At both these premises a chamber utensil for each bed is supplied. These dormitories were well-lighted and ventilated. The total number of beds at these two houses is one hundred and sixty-four, but thirty-six were not in use at time of my inspection. Lavatory accommodation with hot and cold water has been provided in connection with the day rooms, and at one house there is a bathroom. Tubs and soap are supplied to enable the women to wash their clothing. The water-closet accommodation in one case is inadequate and badly situated. The Salvation Army shelters, met/ropoles or lodging-houses, and elevators or labour homes.—The Salvation Army has fifteen sets of premises. This number includes one boys' home and one women's shelter. The army also maintains a home in which criminals are received on their discharge from prison. Excluding the last mentioned there was, at the time of my inspection accommodation in the dormitories at these premises for 3,481 persons; but I was informed that at the shelter in St. John'ssquare, Clerkenwell, some thirty bunks are on occasion placed in the day room for the use of late applicants, and that at Blackfriars-road shelter the day room affords accommodation to some 350 to 400 men, who pay one penny for the night's lodging. These numbers are not included in the above total. Further, since the date of my inspection, the shelter in Burne-street, Marylebone, has been enlarged, and as I was informed by one of the officers of the Salvation Army that alteration was contemplated as regards the numbers accommodated at some of the other shelters, the above figures must be taken as indicating approximately only the number of persons who can be housed in the premises of the Salvation Army. At all the premises separate and distinct accommodation for the purpose of sitting rooms and sleeping rooms is provided, except at the two shelters mentioned above, in which the day room space is also made use of for sleeping. The sleeping accommodation provided in the different shelters is as follows:— (1) Floor bunks. These consist of a four-sided wooden frame about one foot in depth, without a bottom, and about six feet long by two feet broad. These are put on the floor, and inside is placed a seaweed mattress lined with American cloth. Each bunk is also provided with a pillow and a covering consisting of two layers of American cloth with an intervening layer of felt. In a few instances the covering consisted of aprons of leather. In some cases, generally the threepenny bunks, in addition to the above an ordinary sheet is also provided. (2) "Jubilee" bunks. These consist of iron frames having two, three, or even four tiers of bunks, one above the other, and separated from each other by a height of some three feet, the lowest tier being raised about one foot above the floor level. Each tier may contain a single bunk, two bunks side by side, separated by a wooden partition a few inches high, or four bunks in pairs of two placed head to head. The bedding is similar in character to that of the floor bunks, except that the mattress rests upon a spring mattress. (3) Ordinary beds and bedding. The dormitories or sleeping rooms in the different shelters vary considerably, as may be anticipated from the fact that various kinds of premises have been adapted to their present use, such as ordinary houses, business premises and warehouses, and public halls or places originally erected for the assemblage of large numbers of persons, bat not with any view to their use as habitations. In most instances the dormitories are large and lofty rooms, accommodating a large number of persons. In the case of the metropoles or lodging-houses the dormitories are either rooms of average size capable of accommodating a few beds, as at the premises in Stanhope-street, Strand, or are large rooms which have been divided into cubicles for one or more beds, by the erection of galvanised iron partitions some seven or eight feet high. *Since the date of inspection of Medland Hall shelter, wooden bunks, each provided with a pillow and mattress covered with leather cloth, and with a covering of similar material for the sleeper, have been furnished for all the lodgers. †This zinc tank has been removed since first inspection and chamber utensils provided. 6 The form of accommodation provided varies according to the price which the individual is able to pay. Thus, for twopence, a man obtains either a floor or "jubilee" bunk; for threepence he has a similar bunk and is provided with an ordinary sheet in addition to the covering of American cloth, or obtains a bunk in a cubicle and so secures greater privacy ; for fourpence he has either a bunk in a cubicle, together with food, or a separate bedstead with ordinary bedding, but without food; for sixpence he can obtain an ordinary bed with better day room accommodation than in the cheaper shelters. Further, the "metropoles " or shelters at which the higher prices are charged are open throughout the daytime just as in the case of a common lodging-house, whereas the cheaper shelters are not. Many of the dormitories were found to be well-lighted and provided with good means of ventilation, but exceptions to these conditions existed in some cases where the means were either inadequate, or where the dormitory is in direct aerial communication with the space reserved for the use of the lavatories and water-closets. Dormitories of which the means of light or of ventilation are inadequate were seen at Horseferry-road, Burne-street, Edgware-road, and at Blackfriars-road shelters, and cases where their position in relation to lavatories or water-closets is objectionable at Blackfriars-road, St. John's-square Clerkenwell, 96, Southwark-street and Burne-street shelters. The lavatory accommodation at the different premises of the Salvation Army is in all cases fitted up in much the same manner. In each lavatory there are generally several long metal troughs on stands. These troughs are a few inches deep, and on them are placed loose metal bowls or small baths, which the lodgers use for washing in. The deep trough is apparently intended to prevent the spilling of water on the floor of the lavatory. In nearly all cases I found that bathrooms are provided for the lodgers. An additional charge of one penny is generally made for the use of these, this charge including a clean towel and soap. Hot and cold water are supplied in all the lavatories. At some of the lavatories special clothes-washing troughs and scrubbing boards are furnished to enable lodgers to wash their clothing, and facilities are provided for drying. In most instances at the time of my visit the number of basins in the lavatory was proportionately small for the number of lodgers which the premises accommodated. Thus, at the "Ark," in Southwark-street, which has sleeping accommodation for 180 men, there were only four metal troughs with nine loose basins. There are, however, four big baths, and five troughs for washing clothes in this lavatory. At Horseferry-road shelter there is a small well-lighted and well-paved lavatory, but I only saw eleven small hand baths; there is no bathroom here. At the shelter in Burnestreet, Marylebone, which at the time of my inspection had accommodation for 396 men, the lavatory contained five metal troughs, but there were no basins, and only a few small baths were seen. No bathroom had been provided. At the " Lifeboat," in Royal Mint-street East, which accommodates rather more than 100 men, the lavatory had six basins. It is possible that in some cases the small number of basins noticed in the lavatories is accounted for by the fact that in those shelters which are shut during the day-time the basins were being used for other purposes in connection with the cleansing of the premises. The position of the lavatories in some cases is not good. The water-closets in nearly all cases consist of trough closets, provided with large automatic flushing cisterns, and were found to be cleanly and well kept. Some were seen where the trough is divided by wooden partitions into separate seats or stalls, but these stalls are not provided with doors to secure privacy (Burne-street). In some cases the position was found to be objectionable, owing to the proximity to dormitories or day rooms, as in the case of Blackfriars-road shelter and the " Lifeboat," or to the absence of proper means of external light and ventilation, as at St. John's-square Clerkenwell, and Burne-street, Marylebone. The Shaftesbury Institute, Marylebone.—The honorary superintendent states that there is accommodation at the women's shelter for 72 persons. The sleeping accommodation consists of two kinds, (1) a few rooms with a small number of bedsteads provided with ordinary bedding, (2) rooms furnished with mattresses and chairs. The mattresses are covered with American cloth, and are placed at night time upon the ground, each being separated from the other by means of a chair placed at the head, upon which the lodger can place her clothing. At the date of inspection no coverings were in use, these, it was stated, having been stolen; a new stock, however, was being provided. One of these coverings, which had j ust been made, was seen to be made up of two layers of American cloth padded with felt. There is no separate day or sitting-room space provided for the use of the lodgers. The rooms at this shelter are well provided in respect to means of light and ventilation. The lavatory accommodation was found to be adequate in proportion to the number of persons which the shelter accommodated ; the number of water-closets is not equal to the proportion required in common lodging-houses. In the case of the men's shelter, the sleeping accommodation consists of wooden bunks and mattresses of the above-mentioned description. There is no separate day room, and no proper lavatory accommodation is provided, but the number of water-closets is adequate. There is accommodation for 20 men. Ventilation and amount of air space. Reference has already been made to the means of ventilation of the dormitories and day rooms of the different premises visited, and attention has been drawn to those premises where these appear to be inadequate. In all cases it was found that natural means of ventilation are depended upon, with one exception, namely, the large hall or day room at the Salvation Army shelter in Blackfriars-road, where artificial means for the extraction of the air from the hall have recently been adopted. In the large dormitories means are adopted for heating the room generally by hot-water pipes. Although in many cases the means of ventilation were good, it was found that the amount of cubic space for each person in some rooms was so small that it would be impracticable to maintain the atmosphere at a proper standard of purity by the ordinary means of natural ventilation. The amount of cubic space for each person in different premises was found to vary considerably. These 7 amounts have been calculated upon the number of beds or bunks found in the dormitories at the time of inspection, and give the following results— (1) In 14 dormitories the cubic space per head is under 200 cubic feet. (2) In 30 „ ,, „ over 200, but under 250 cubic feet. (3) In 27 „ „ „ „ 250 „ 300 (4) In 27 „ „ „ „ 300 „ 400 (5) In 14 „ „ „ „ 400 112 It is thus seen that in a large number of rooms the amount of cubic space is much below the standard adopted in common lodging-houses, while in others the amounts are greater, this being chiefly the case at premises where bedsteads or cubicles are provided. The amount of floor space must also be considered. Of the 112 dormitories mentioned above, I find, if the total area of each room is divided equally amongst the number of sleepers which it accommodated at date of inspection, that in 35 the floor space for each person is less than 24 superficial feet, or less than the floor area which would be occupied by two single bedsteads of ordinary size. In those shelters where bunks are in use it is customary to place them in rows, each bunk being separated from the adjoining one merely by the width of the wooden partitions, or at most by an interval of a few inches, while each row of bunks is separated from the next row by a narrow interval of about one foot. The floor surface thus becomes covered with rows of bunks, the only free space between the sleepers being one or more passage ways to enable lodgers to reach their bunks. When the bunks known as " Jubilee ' bunks are in use the proportion of floor space to each person is in some cases very low, namely, 13, 18, and 19 superficial feet. This form of bunk possesses some advantages over the floor bunk, in being more comfortable, and in having the lowest tier raised about one foot above the ground level, thus allowing a free play of air underneath the sleepers. It is also possible to obtain greater lateral separation of the bunks, but any advantage in these respects is counterbalanced by the disadvantage of having two or even three rows of sleepers placed one above the other at intervals of some three feet. Condit ion of premises in regard to cleanliness. At all the premises which I visited I found that due care was taken in maintaining the rooms in a state of cleanliness. Where beds are in use the bedding was cleanly, and at the shelters where bunks are provided it is stated to be the custom to have the mattresses taken out of the bunks and swept daily, and washed over with some disinfecting fluid occasionally. At the Shaftesbury Institute, at the time of inspection, the mattresses were placed in a heap in one corner of the room, an objectionable practice; at other shelters each wooden bunk during the daytime is turned on its end and the mattresses taken out and placed on top, so allowing a free play of air around each bunk before it is again used. In the appendix attached to this report particulars are given as to the accommodation which was found at each set of premises at the time of inspection. The figures concerning the amount of floor space and cubic space per bed are based upon the number of bunks or beds noticed in each room and measurements which were obtained during the visit. In the case of the Salvation Army shelters. Providence (Row) Refuge and Medland Hall, measurements have been kindly supplied, and these have in each instance been made use of. As regards the Salvation Army, Brigadier Lamb stated at the time that the inspection was made that it had been decided to confer with local sanitary authorities with a view to arriving at an agreement as to the greatest number which should be admitted to any shelters in the district of the authority, consequently the accommodation at the shelters may have changed in some degree since the information set out in the appendix was obtained. c. W. P. Young, Public Health Department, Assistant Medical Officer of Health. Spring Gardens, S.W. 8 9 APPENDIX. Situation and total accommodation. Dormitoy and nature of Bleeping accommodation. No. of beds or bunks at time of visit. Cubic space per bed or bunk. Floor space per bed or bunk. Lavatory accommodation. Water-closet accommodation. Whether separate day-room is provided or not. Church Army Homes— Tooting-court, Marylebone—Men; 25; only 14 at date of visit 8, Millbank-street, Westminster— Men; 17 at date of visit Cubic feet. Super feet. Good Good Yes. Common dormitory, beds 25 374 44 2nd floor, front, common dormitory, beds 6 231 32 Adequate 1 water-closet is badly situated, as it communicates directly with workshop Yes. 2nd floor, back, common dormitory (2 rooms), beds 5 239 33 1 bath-room 33, Whiteehapel-road (about to be vacated)—Men; 18 at date of visit Top floor, common dormitory, beds 6 210 34½ lst floor, cubicles (dismantled, and now a common dormitory), beds 11 522 64 Inadequate 1 water-closet for use of men, badly situated, being approached directly out of dormitory on first floor Yes. Top floor, front, common dormitory, beds 3 268 40 Top floor, front, common dormitory, beds 4 284 42 St. John's lodging-house—50 beds; men Ground floor, cubicle room, single bed cubicles 27 490 nearly 45 nearly Well fitted lavatory, but the room is dark, and not well ventilated 4 water-closets near entrance passage, inadequately ventilated 1 water-closet (not used) is situated under staircase, and approached directly from dormitory. No means of external lighting or proper ventilation Upper floor, cubicle room, single bed cubicles 17 337 „ 39 Upper floor, cubicles for boarders... 6 451 „ 48 The Bessbrook Homes and Agency— 39, Queen's-square.W.C.—63; men 3rd floor, No. 1, ordinary beds and bedding 3 198 27 Lavatory badly situated, not well fitted up A bath-room is being fitted up 3 water-closets and 1 urinal well situated in yard Yes, situated in basement. Not well lighted and ventilated. There is also a workroom on first floor in connection with the work of the Bessbrcok Agency. „ No. 2, „ 7 190 26 „ No. 3, „ 7 175 25 1st floor, No. 4, „ 7 253 26 „ No. 4a, 2 363 38 „ No. 5, „ 10 299 33 Rear building— 1st floor, No. 1, „ 9 261 27 No. 2, „ 4 241 32 No. 3, 4 253 34 No. 4, „ 15 241 26 167, High Holborn—34; men 3rd floor, No. 1, „ 6 220 33 Lavatory accommodation in a dark basement; inadequate and unsuitable 1 water-closet; badly situated in basement Day room provided on ground floor. Light and ventilation inadequately provided for. „ No. 3, „ 6 219 32 2nd floor, No. 4, „ 7 254 34 „ No. 6, „ 8 311 32 „ No. 7 „ 7 298 31 Free Refuges— House of Shelter, Stepney, E.— Men; 40 Ground floor, common dormitory, also used as sitting room; bunks 19 191 20 Adequate Adequate No. Top floor, common dormitory, bunks 21 164 20 Newport Market Refuge, Westminster—Men; 30. There is accommodation for women also here One common dormitory with swing hammocks, and a few cubicles 30 337 31 Good Good No. Field-lane—Men; 37 beds. Also accommodation for women Common dormitory, beds and one cubicle 18 338 29 No proper lavatory Adequate; 3 water-closets and urinals in yard No; but men have the use of meeting rooms in building if they are not being used for other purposes. Common dormitory, beds and one cubicle 19 397 33 2 bath-rooms Ham-yard Hospice—Men; 20 beds Common dormitory, beds 10 330 38 Good lavatory and bath-room accommodation Good Yes. The day-room is used as a soup kitchen in the daytime. „ „ „ 10 330 38 Providence (Row) Refuge, SpitalFields 140 men Common dormitory, bunks 70 337 23 Ample; well fitted up; 40 fixed basins; fixed footbath ; 4 large baths Ample, in yard, also indoors for night use Yes. 112 women „ „ „ 70 331 23 252 Females—Common dormitory,bunks 112 300 22 Ample Ample Medland Hall—Men; 300 Benches and wooden pillows, or lodgers lie on floor with wooden pillow About 250 cubic feet per man. Floor space per man not readily attainable These consist of wooden 4 basins; inadequate 12 trough closets; inadequate accommodation Bunks have now been provided for all lodgers. frames, mattresses and pillows, lined with American cloth, and a coverlet of same material. Dr. Barnardo's Shelters for Women and Children— Dock-street, E.; 58. Women and children, free 1st floor, common dormitory, bunks 22 355 30 Adequate 3 water-closets in yard at rear; in Yes; in basement, good condition 2nd floor, front „ „ 19 266 24 No bath-room „ back ,, ,, 6 280 26 3rd floor, front „ „ 6 228 30 ,, back „ ,, 5 203 26 Co nmercial-street, E.; 106. Women ar.d children, free 1st floor, common dormitory, beds (not in use) 36 214 21 Adequate 3 water-closets, badly situated off area Yes; in basement, and under street pavement 2nd floor, „ „ 37 208 20 1 bath-room 3rd floor, „ „ 33 234 23 [2] 10 11 Situation and total accommodation. Dormitory and nature of sleeping accommodation. No. of beds or bunks at time of visit. Cubic space per bed or bunk. Floor space per bed or bunk. Lavatory accommodation. Water-closet accommodation. Whether separate day-room is provided or not. The Salvation Army Shelters,&c- The Ark, Southwark-street, S.E.— 189 beds; men; fourpence ant sixpence a night Cubic feet. Super, feet. Large lavatory in basement. Badly lighted 4 metal stands with 9 loose basins. 5 troughs for washing clothes. 4 bath-rooms. 6 water-closets in basement Situation not good. Ventilation provided by an air shaft extending up through building to roof One water closet (not in use) opens directly out of a dormitory A water closet on 2nd, on 3rd, and on 4th floors, is in each case in direct communication with sleeping room Yes. (1) Common kitchen. (2) Reading-room, also used for mission services for lodgers. - Ground floor, dormitory, beds 8 378 36 floor, single bed cubicles 24 445 39 and one room with beds 8 2nd floor, cubicles 38 437 41 3rd floor, common dormitory 55 280 27 4th floor, cubicles 46 321 35 The Harbour, Stanhope-street Strand—105 beds; men; four pence a night Dormitory No. 3, beds 4 241 29 Lavatory accommodation, fair; 1 bath-room. Partly situated in common kitchen 5 water-closets Yes. (1) Common kitchen. (2) Reading-room; also used for mission services for lodgers. „ No. 4, „ 6 223 27 „ No. 5, „ . 7 236 29 „ No. 18, „ 6 193 25 „ No. 19, „ 5 223 29 „ No. 20, „ 4 219 28 The Anchor, Green-street, Bethnal green—159 beds; men; fourpence a night Ground floor, common dormitory, beds 24 330 30 Good lavatory. Inadequate number of basins, only 7 noticed. Troughs for clothes-washing. A bath-room, free 6 trough water-closets, and urinal accommodation situated in open yard. Internal water-closes, one on each floor. One on ground floor in bad situation, owing to proximity to food store-room Yes. Badly situated in basement. (1) Common kitchen; light and ventilation bad. (2) Reading or mission-room, the means of light and ventilation are better than in kitchen. „ „ „ „ „ 11 336 23 „ „ „ „ „ 12 246 28 lst floor 18 357 36 „ „ „ „ „ 9 357 36 „ „ „ „ „ 7 395 41 „ „ „ „ „ 4 526 30 „ landing, beds 2 504 51 2nd floor, common dormitory with beds 13 354 40 „ „ „ 9 330 37 „ „ „ 9 283 32 „ „ „ 4 556 56 „ landing, beds 5 538 60 3rd floor, cubicles 32 431 63 The Metropole, Charles-street, Holborn, E.C. — About 328; men twopence and threepence a night Ground floor, common dormitory, jubilee bunks, 2-tiers high 56 234 21 Lavatory in basement, approached from kitchen. It contains 3 metal stands, 7 loose basins and small baths, two bath-rooms 6 trough water-closets, automatically flushed. Situated in an open yard Yes; in basement. Light and ventilation inadequately provided for. 1st floor „ „ 69 212 20 2nd floor „ „ 70 193 20 3rd floor, common dormitory, floor bunks 64 209 22 The Lifeboat, Royal Mint-street, E. —135; men; twopence and fourpence a night 4th floor „ „ 69 244 21 1st floor, common dormitory, beds 22 412 42 Metal troughs with 6 loose basins. Lavatory approached direct from day room. Accommodation inadequate. 6 trough water-closets, automatically flushed. Situation objectionable owing to relation to day room and absence of a proper open air space separating water-closets from habitable part of shelter Yes, on ground floor. Badly lighted This room has through ventilation by communication with a narrow ventilated space at rear in which the lavatory and the waterclosets are situated. 2nd floor, common dormitory, floor bunks 55 179 24 3rd floor 58 154 23 The Net, Burne-street, N.W.—396; men; twopence a night Basement, dormitory, floor bunks 96 272 25 5 metal stands for loose basins. No baths. Lavatory accommodation inadequate and badly situated 6 trough water - closets, without doors, 5 urinals. Badly situated in an unlighted and badly ventilated space Yes. (1) In basement. Not good; room being in aerial communication with a sleeping room and also with two badly lighted and ventilated waterclosets. (2) Part of the ground floor is used during day time as a cheap food depot. At night this is used by lodgers as a sitting room Top, dormitory, floor bunks 300 304 22 St. John's-square Shelter, Clerkenwell—129 or more; men; twopence a night 1st floor, common dormitory, floor bunks 57 300 26 Lavatory accommodation in basement. A wooden bench has been fitted up, on this 8 basins and 8 small baths were noticed. 'No bathroom. Inadequate accommodation 7 trough-closets; urinals. Situated in basement; unlighted and inadequately ventilated. A watercloset on top floor communicates directly with dormitory Yes, on ground floor; badly lighted and ventilated. Also used as a sleeping room for late lodgers, if any; seldom more than 30. Top floor, common dormitory, floor bunks, and one jubilee bunk for six 72 258 24 A few bunks put up in day room for late comers, if necessary (about 20-30) Horseferry-road Shelter, Westminster— 218; men; twopence a night Ground floor, common dormitory, floor bunks 76 247 23 A small lavatory, with troughs and about 11 basins, and wash tub. No bath-room. Inadequate 7 trough water - closets near lavatory ; light and ventilation good Yes; badly lighted, and ventilation inadequately provided for by one window at end and several air shafts in roof. Top floor back, common dormitory, floor bunks 76 303 21 Top floor front, common dormitory, floor bunks 66 276 16 272; Whitechapel-road—270; men; twopence a night lst and 2nd floors (really one large room), floor bunks and jubilee bunks 270 216 22 A well-lighted and ventilated lavatory, with 6 metal trough stands for loose basins. 2 large baths 6 trough closets and a urinal in a covered-in space, provided with ventilation openings in roof. Position objectionable, owing to proximity to staircase leading to dormitorv The eating room used during daytime as public food depot, serves as sitting room for lodgers during evenings. Blackfriars-road Shelter—Sleeping accommodation, 396; one penny warm room, 350 to 400 ; or, a total of 746 or 796; men; one penny, twopence, or threepence a night Late bunk room, floor bunks and jubilee bunks of 3-tiers each 67 240 20 (1.) A lavatory, communicating with the large hall (from which it is separated by a wooden part ition) with 4 metal troughs on stands, on which were 4 loose basins; also troughs for washing clothes. Here also a urinal and 6 trough closets, provided with external ventilation and automatic flush (2.) A lavatory, in direct communication with dormitory, divided into two parts—one contains 2 bath rooms and 4 trough stands for loose basins, also washing troughs; the other contains 11 trough-closete, and is provided with separate external ventilation. No doors to closets. Position objectionable, owing to communication with sleeping room (3.) A small lavatory and 4 trough-closets, reserved for use of men in 3d. portion of shelter Yes. A large hall, well-lighted, and provided with artificial means of ventilation; also a glass-covered corridor. Both these are used throughout the night by those lodgers who only pay one penny for lodging. Ground floor, cubicles with bunks of 2-tiers each 49 276 23 Ground floor, common dormitory, floor bunks 120 217 22 1st floor, common dormitory, floor bunks, and 18 jubilee bunks of 3-tiers each 160 184 17 Warm room and corridor, seats and benches 350 to 400 202 or 177 13 or 12 12 13 Situation and total accommodation. Dormitory and nature of sleeping accommodation. No. of beds or bunks at time of visit. Cubic space per bed or bunk. Floor Space per bed or bunk. Lavatory accommodation. Water-closet accommodation. Whether separate day-room is provided or not. Cubic feet. Super, feet. The Boys' Home, 31, Fetter-lane— 81; boys; twopence and threepence a night 1st floor, common dormitory, jubilee bunks of two-tiers each 11 199 19 Lavatory accommodation is provided in basement 3 water-closets, one of them in a dark, badly-ventilated situation in basement Yes; on ground floor. 2nd floor, „ „ „ 26 163 18 3rd floor, „ „ „ 24 167 18 4th floor, common dormitory, floor bunks 20 237 31 The Women's Shelter, Hanburystreet, E.—277 Dormitory, jubilee bunks 44 273 12 Lavatory, good Water-closet accommodation good Yes. Dormitory for mothers and children, floor bunks 33 461 or 320 if height of 14 ft. only included 23 Dormitory, bunks 122 281 29 Gallery, bunks 78 24 Women's Metropole (in connection with above)—14 1 st floor, beds 7 242 28 Washstands in dormitories „ „ „ Ye s. 2nd floor, „ 7 241 23 Elevator or Labour Home, West India-dock-road—65-70; home for workshop men Common dormitory, floor and Jubilee bunks 65 to 70 278 23 Lavatory accommodation good, consisting of 2 bath-rooms, and lavatory with 12 basins; 4 band baths; also a tub for washing clothes, withwashingboards. Lavatory well lighted and ventilated 6 water-closets, well lighted and ventilated, but none have doors ; one urinal Yes. 258 22 Yes. (1) A well-lighted and ventilated room, also used as mission room. (2) A separate day room for separate use of foremen, clerks and higher grade workmen. (3) A small room where men can smoke. The Lighthouse, Quaker-street, E.— 267; home for workshop men Ground floor, common dormitory, floor and jubilee bunks 30 404 36 Good; 5 baths; 17 basins; troughs for washing clothes 15 trough water-closets and one urinal in an open yard, approached from lavatory lst floor, „ „ „ 183 269 18 „ 8 cubicles, beds 54 525 33 • The Wharf, Battcrsea—186; home for workshop men. The buildings here appear to be sheds on wharf, which have been adapted to present use Common dormitory, bedsteads and some jubilee bedsteads 31 348 28 Lavatory adjoins dining room. Baths also provided. Only nine basins were noted in lavatory, but it was stated there were more 12 trough water-closets in yard of wharf. These were very foul at time of visit Yes. A large room where meals are served. There is also on the premises a mission-room which is used as a reading-room by the men. Common dormitory, jubilee bunks of three tiers each 74 175 13 Common dormitory, floor bunks 81 265 19 The Shaftesbury Institute for Women and Shelter for Men— 21, Bell-street, Marylebone— Men's shelter; 20; twopence a night Common dormitory, floor bunks 20 280 24 No lavatory accommodation Adequate No. Shaftesbury Institute for Women, Union-street. Marylebone— Ground floor, common domitory, mattresses placed on ground 28 293 33 Good lavatory accommodation. One common lavatory in basement, another in upper part of house; 11 fixed basins in basement lavatory 9 basins in upper lavatory; 1 large bath, which lodgers can use on two days in the week; tubs for washing clothes 1 washstand to each bed in dormitory 2 water-closets in basement No. 2d. portion 72 total accommodation ; 59 only accounted for (a) 1st floor, common dormitory, mattresses placed on ground 5 251 27 (b) „ „ „ 10 267 30 6d. „ (c) „ „ „ 10 271 30 2 water-loseta (e) Ground floor, common dormitory, bedsteads 4 393 44 (f) „ „ „ 2 15 APPENDIX. Showing results of night inspection made on 21st January, 1897. (Ordered by the Public Health Committee to be printed, 4th February, 1897.) I present to the Committee notes of an inspection made by Dr. Young, the Council's chief inspector of common lodging-houses, and myself, of several "common shelters" during the night of the 21st January, 1897. In our inspection we were accompanied by the clerk of the Council. 82, Horseferry-road—Salvation Army shelter for men. Time of visit, 9.15—10.15 a.m., about. The number of bunks found in these dormitories at the hour of night inspection and at date of previous inspection made by Dr. Young during the daytime was as follows— (a) Ground floor dormitory (b) Top floor dormitory (back) (c) Top floor dormitory (front) Night inspection. 78 bunks, 52 occupied. 67 bunks, 58 occupied. 68 bunks, a few of these unoccupied Previous day inspection. 76 bunks. 76 bunks. 66 bunks. In the day room, at the time of inspection on the 21st January, there was a pile of mattresses in one corner, but none of them were at the time being made use of. The charge made to the inmates of this shelter is twopence per night. 8, Millbankstreet, Westminster—Church Army Home. Time of visit, 10.25—10.50 p.m., about. The number of beds in the second floor front dormitory on the occasions of the night and previous day inspection was as follows— Night inspection. Previous day inspection. Second floor front dormitory ...| 7 beds. [ 6 beds. Blackfriars-road—Salvation Army shelter for men. Time of visit, 11—11.80 p.m., about. We were told by the captain in charge that the total number of men admitted nightly is limited to 550, the number fixed by the magistrate after proceedings taken by the Vestry of St. George-theMartyr. The conditions found at the time of night inspection and at the date of previous inspection made in the daytime by Dr. Young were as follows— Night inspection. Previous day inspection. (a) Cubicle room (b) Bunk room (ground floor) Bunk room (top floor) (c) Mission hall or day room (d) Side corridor (e) Late bunk room All bunks occupied; not counted; cubicles closed. 117 bunks, all occupied but one. 123 bunks, 5 of these unoccupied. 150 bunks in Jubilee stands ; some unoccupied. About 50 bunks. About 67 bunks. 49 bunks. 120 bunks. 160 bunks. No bunks. Some 800-400 men admitted and allowed to sit on benches for night. This was previous to proceedings referred to above. 67 bunks. In the hall there was a small number of men who had not retired to their bunks. The number did not appear to be greater than would be accounted for by the empty bunks. The prices charged are (a) threepence, (b) and (e) twopence, (c) and (d) one penny, a piece of bread being also provided. The Ark, Southivark-street—Salvation Army. Time of visit, 11.40 p.m.—12.15 a.m., about. The number of beds in the dormitories on the third and fourth floors on the occasion of the night and previous day inspections was as follows— Night inspection. Previous day inspection Third floor 58 beds. 55 beds. Fourth floor 47 beds. 46 beds. Dr. Barnardo's shelter for women and children, Commercial-street, E. Time of visit, 12.40 a.m.—1 a.m., about. Conditions at time of visit and at previous day inspection were as follows— Previous day inspection. Night inspection. Second floor dormitory 80 beds, 5 of these unoccupied. 37 beds. The superintendent stated that a total of 60 had been admitted this evening; the total accommodation was about 120. No charge is made for admission into this shelter. At night food is given, but a charge is made for food in the morning. 16 Hanbury-street—Salvation Army shelter for women and children. Time of visit, 1.15—1.45 a.m., about. The conditions found at the time of the two inspections were as follows— Night inspection. Previous day inspection. Dormitory at rear of day room .. Five Jubilee stands with 4 bunks, 44 bunks. each 20 Floor bunks 3 Total 23 A few bunks were unoccupied. Dormitory for women and children 33 bunks, 24 occupied. 33 bunks. Gallery dormitory— Gallery 76 bunks 218, ALL OCCUPIED 78 BUNKS FLOOR 142 BUNKS 122 BUNKS The mission or day-room here is also used during night time for sleeping in, and at time of visit there were some 20—30 women lying on the benches and floor. The charge made for admission into this shelter is twopence. Medland Hall. Time of visit, 2.0—2.30 a.m., about. This place is somewhat altered since previous visit. The actual service area has been increased by erecting in each gallery a platform, about 6 feet above the level of the gallery floor, on which bunks can be placed. Chamber utensils have also been provided in the room in the roof, in place of an old tank which was formerly used as a urinal. The conditions found on the occasions of the night inspection and previous day visit are as follows— Night inspection. Previous day inspection. Total number admitted limited Ground floor 107 bunks, all occupied. to 300, but no definite Galleries 118 mation available as to how Top floor 50 this number was disposed in Small rooms (a) 18 the different parts of building, Small rooms (b) 7 there being at this date no bunk accommodation. 300 It will be seen that the account given in Dr. Young's report of the number of bunks, &c., in the several rooms as the result of inspection by day is not found to require material modification as the result of inspection of these premises by night. The only notable difference was found on the floor of the gallery dormitory in the women's shelter in Hanbury-street, where the number had been increased from 122 to 142. Decrease had also taken place in the dormitory at the rear of the day room, apparently as the result of the reduction of the size of this dormitory. A number of women were found lying on the benches and floors of the day room. Of the use of this room in this manner at night, there was no evidence at the time of the day inspection, although it was stated at that time by the officer in charge that occasionally when bunks were full women were admitted and allowed to sleep in their clothes in the day room. Shirley F. Murphy, Medical Officer of Health. Appendix VI. London County Council. THE SANITARY CONDITION OF ELTHAM. Report of the Medical Officer submitting Dr. Young's report on the sanitary condition and administration of the Parish of Eltham. (Printed by order of the Public Health Committee, 11th June, 1896.) I present Dr. Young's report on the sanitary condition and administration of Eltham. Dr. Young's report shows that there is need in Eltham of more active sanitary administration than in the past, and especially is there need of a more regular cleansing of cesspools. There would evidently be advantage in the re-arrangement of the duties of road foreman and sanitary inspector in the manner indicated by Dr. Young, and the district board should, I think, be asked to consider the desirability of adopting this course. There would also be advantage if the work of the sanitary inspector were to a great extent superintended or controlled by the medical officer of health. The sufficiency of the office accommodation should be considered. (Signed) Shirley F. Murphy, Medical Officer of Health. Dr. Young's Report. Eltham is one of the four parishes which together form the district under the control of the Lee Board of Works. This Board was constituted by the Metropolis Management Act, 1893. Previous to this date the four parishes of Eltham, Lee, Kidbrooke and Charlton were combined with the parish of Plumstead, and formed one district under the Plumstead Board of Works. The above-mentioned Act provided for the separation of Plumstead, which became a separate sanitary district under the Vestry of Plumstead, and the creation of a board of works as the local authority for the remaining parishes. Eltham is the largest of these parishes, having an area of 3,782 acres (including 9 acres of water), or rather more than half the extent, namely, 7,006 acres of the whole district under the jurisdiction of the Lee Board of Works. It is situated at the extreme south-eastern portion of the county; and a considerable part of its boundary on the east, south and south-west corresponds with that of the county. On the north it is bounded by the district of Plumstead and to a small extent by Woolwich, and on the west by the parishes of Kidbrooke and Lee. The populated portions of the parish may be said to consist chiefly of three aggregations of houses. One of these, at the western extremity of the parish, consists of a few cottages near Leegreen, and a row of large residences extending eastwards along the Eltham-road. A second group is formed by the village of Eltham, which consists partly of one main street with houses on either side, and with a few side roads and yards off this street containing small groups of cottages ; and partly of a large number of residences lying to the south of the village. A third group is a collection of houses situated on the boundary of the county about a mile and a half to the south-east of the village, and known as New Eltham. These three groups are separated from one another more or less by intervening fields and agricultural land, scattered throughout which are some few cottages and big residences. The parish of Eltham corresponds with the registration sub-district of that name, the population of which in 1871 was 4,064, in 1881 was 5,048, in 1891 was 5,682, and at the census taken in March, 1896, for the purposes of the Equalistion of Rates Act, was 5,911. In 1891 the population consisted of 3,183 females and 2,499 males, or 56.1 per cent. females and 43.9 per cent. males; the proportion for the whole of London being 52.7 per cent, females and 47.3 per cent, males. The population of Eltham forms about one-sixth of the total population cf the district of the Lee Board of Works. The number of inhabited houses in 1891 was 1,025, which gives an average of 5'6 persons to each house. The average for London is 7*7 inmates to each house. The houses in Eltham comprise large residential premises and small cottages occupied by the working classes. Many of the cottages are of considerable age, and a large proportion are built wholly or partially of wood. In the old village of Eltham the houses are arranged on either side of the Highstreet, and in side streets, and yards immediately behind. Most of them are but two storeys high (some having attic rooms above), and having gardens of good size in the rear they are well provided as regards light and air. Exception to this remark should be made in respect to some of the cottages situated in Sun-yard, Kirk's-yard and Scriven-alley. In the case of Sun-yard the houses are arranged in two rows, with a central block between, and some of the rooms of the houses on the west side are dark, owing to the proximity of the buildings of the middle block. Moreover, some of these cottages, as well as some in Kirk's-vard, are built back to back with other buildings, and are thus without means Sold by Edward Stanford, 26 and 27, Cockspur-street, Charing-cross, S. W. No. 303. Price Id. [3149 2 of through ventilation; in all these cases, however, the houses do not contain more than two rooms, one above the other. Scriven-alley is a narrow passageway leading off the High-street, in which there are four very old two-room cottages without back yards or proper means of through ventilation. At New Eltham the houses have been constructed at a more recent date than many in the old village, having been built within the last 30 years. They are brick buildings, two storeys high, with back additions and washhouses, are arranged in some three or four streets of good width, and have goodsized gardens at the rear. In houses of this class no drain inlets were found within doors, and waste pipes were found to be properly disconnected and to discharge over trapped gulleys in the open air. Nearly all cottages are provided with water-closets, which are situated in the garden at the rear, but a few outlying cottages have earth-closets and privies. The earth-closets which were seen were not properly attended to, and the receptacles were in a foul condition. As regards the condition of the privies, I found that at one group of cottages in Well hall-lane, were there were four privies under one roof, the cesspool had an overflow to an adjoining ditch, and this was fouled by excrement. In the case of another privy the excrement was seen soaking through the surface of ground at the back of the privy building. At another cottage, where the privy was situated within twenty feet of the back door complaint was made by the tenant that it had not been cleansed for several years. I was informed during the inquiry that there are now some forty cesspools in the parish, and that when it is necessary to cleanse any of them arrangements are made by the vestry with the Bexley Urban District Council for the execution of the work. It does not appear, however, that there is any systematic periodical cleansing, while as regards some of the privies referred to above I was informed that the cleansing of the cesspool was carried out by the tenant or the owner whenever they considered this proceeding was necessary. In most cases each house is provided with its own water-closet, but at Sun-yard, Kirk's-yard, Scrivenalley, and at a group of houses, which includes the west side of Pound-place and the adjoining houses in High-street, a number of water-closets have been erected in one or more buildings in the common yard, there being generally one water-closet to each house. It is stated that the drainage from these waterclosets as well as from yard drain inlets usually discharges into a drain common to a group of houses and not directly into a sewer, the combined drains passing out to join the sewer at the end of a row of houses, and seldom, if ever, passing underneath a dwelling. This system of drainage was constructed some twenty to thirty years ago, but no records appear to have been kept of their arrangement, so that it is not possible to obtain definite information as to the course of the drains. In some instances ventilation pipes were noticed, placed apparently at the head of a combined drain, but so far as could be ascertained intercepting traps between the drains and the sewer do not exist. It is said that the drains are laid at a considerable depth from the surface, and that complaint of nuisance arising from them is seldom made. A large proportion of the water-closets in the houses visited were unprovided with water supply or flushing apparatus, and in some instances the pans were in a dirty state. The absence of water supply appears to be due to the fact that till recently many of the cottages have obtained their water from wells, and although this condition is now being altered, and a proper supply from a public source is being provided, the alteration has not yet been completed. The condition of houses visited during the inspection varies considerably. A condition which was frequently met with was dampness of walls; this in some cases appears to be brought about by a defective state of the guttering or of the pointing of the house; in others it is apparently due to moisture rising from the ground. In the latter case this was probably contributed to by the absence or defective state of yard paving adjoining the house which was noticed in many instances. In one row of eight cottages, some of which showed marked signs of dampness, the water supply tap is fixed to the rear wall immediately outside the door leading from the kitchen to the yard, in such a way that splashing of the brickwork must occur each time that water is drawn. Generally speaking, the interior of houses were in a cleanly condition and in fair repair, but a few cottages were worn out and dilapidated, and in some rooms the walls were dirty or defective and the flooring, sometimes laid directly on the earth, without any intervening air space, was rotten and broken. The cottages in Eltham are mostly occupied by single families, and there is no evidence of overcrowding occurring to any extent. The water supply for this district is furnished by the Kent Waterworks, and except in two or three instances, each house has or is being provided with a separate tap, the water being drawn direct from the main. At one cottage complaint was made, when I visited, that the inmates had been without a supply for several months, owing to a spring which they originally depended on having been diverted by the construction of a new railway. The removal of house refuse is carried out by a contractor. It is stated that a list of premises which are to be called at is given daily to the contractor by the surveyor, and that a weekly collection is made from all houses. Houses are now in most cases furnished with movable dust receptacles, but in some there was no receptacle and accumulations were noticed in the gardens. The bakehouses visited were all situated on the ground level and in a satisfactory state. The cowsheds, slaughterhouses and milkshops were also found to be kept in compliance with the regulations. The cowsheds are all situated at a distance from dwellings, and it is not customary to provide dung receptacles. This seems to lead to the accumulation in the yard adjoining the sheds of large deposits of manure and stall refuse which are afterwards dug out and removed to the fields. This operation was taking place at one cowshed at the time of my visit, and was the cause of much nuisance in the immediate neighbourhood. The vestry have a contract with the district of Plumstead for the removal and the disinfection by steam of articles of clothing and bedding. The disinfection of rooms is carried out by the sanitary inspector, sulphur being burnt for the purpose. The subject of the erection of a mortuary for the parish is at present under consideration. Although there is a small mortuary in the district at Charlton cemetery, the distance from Eltham is too great to make it available for this part of the district. 3 Sanitary administration.—The sanitary authority for the parish of Eltham is the Lee District Board of Works, which has also jurisdiction over the parishes of Lee, Kidbrooke and Charlton. There are local committees, consisting of the members elected to the board by each vestry, which deal with matters relating to each parish. The Board of Works meets fortnightly, and the local committee for Eltham also meets at similar intervals in the week alternating with that in which the board meeting takes place. For the parish of Eltham the Board have appointed a medical officer of health and a sanitary inspector. There is in addition an inspector who carries out the duties connected with the Food and Drugs Act for the four parishes. The medical officer of health is also engaged in private practice in the neighbourhood. Until quite recently the work of sanitary inspector has been allotted to the officer who filled the post of road foreman under the surveyor of the parish. The Board have now decided to relieve him of the duties of the latter office, with a view to his devoting his whole time to those of sanitary inspector. A complaint book, incompliance with section 107 (3) of the Public Health (London) Act, is kept at the vestry office. Past entries in this book do not show in any detail the conditions found to exist in premises which have been inspected, though in this respect improvement is to be observed in the entries of the last few months. Among the entries in this book are included houses which have been visited by the inspector owing to the occurrence of infectious diseases. As a rule in few of these entries is there any record of the existence of sanitary defects having been noted at such premises. The entries on the counterfoils of the books of intimation and statutory notices also show that during the last few months the requirements in each case are set out in greater detail than formerly. The clerical work involved in filling up the notices and in keeping the complaint book appears to be carried out by a boy clerk in the vestry's office. At each meeting of the local committee the inspector reports as to whether intimation notices have been complied with or not, and in those cases for which it is necessary a resolution is passed for the service of a statutory notice, and this is then entered in the complaint book. The sanitary inspector has not in the past been under the supervision of the medical officer of health, his time appears to have been chiefly taken up with the duties of road foreman; but during the last few months more time has been given to the work of the sanitary department, and notices have been served in the case of a large number of premises for the execution of necessary works. At a large proportion of the houses visited I found work in progress in connection with waterclosets, the provision of water supply, the provision of proper traps to drain inlets, and the ventilation of drains, and in the case of others where defects were noticed, I was informed by the inspector that notices had been served on the owners with a view to remedying the existing conditions. The vestry have an office, which is shared by the surveyor of the parish with the medical officer of health and the sanitary inspector, at a house on Eltham-green. There is little doubt that there has in the past been neglect in carrying out a proper inspection of the houses in the parish, probably due to this duty having been placed upon an officer whose time was also engaged as foreman of roads, and the Board of Works have appreciated this in deciding that the duties of sanitary inspector are sufficient to engage the whole time of one officer. In view of the conditions which have been found to exist, and of the fact that the present inspector formerly was largely occupied in the work of road foreman, it would, I think, have been a better arrangement to have retained his services for that purpose, and to have appointed as sanitary inspector an officer who had been more actively engaged in sanitary work. C. W. F. Young, Assistant Medical Officer of Health. Public Health Department, Spring Gardens, S.W., 11th June, 1896. Appendix VII. london County Country. SANITARY CONDITION OF HOLBORN. Report of the Medical Officer of Health, presenting Dr. Young's report on the sanitary condition and administration of the District of Holborn. (Ordered by the Public Health Committee to be printed, 29th October, 1896.) I present Dr. Young's report on the sanitary condition and administration of Holborn. This report shows that the condition of houses and the character of the population in Holborn are such as to require an active administration. The existing staff is evidently inadequate for the purpose, and the Holborn District Board of Works should at once adopt the recommendations contained in the report as to an increase in the number of officers and should proceed more largely to regulate houses let in lodgings. The subject of dust collection in Holborn has already been considered by the Committee; Dr. Young's inspection affords confirmatory evidence of the need for the adoption of means for securing the more frequent collection of dust. The attention of the District Board should be given to the areas specially indicated by Dr. Young; the area of which Union buildings and terrace are the centre, is now under the consideration of the Council's Housing of the Working Classes Committee. The District Board should be urged to provide without delay a suitable shelter for the accommodation of poor persons during the disinfection of their rooms. Shirley F. Murphy, Medical Officer of Health. Dr. Young's Report. The sanitary district of Holborn consists of the united parishes of St. Andrew Holborn, and St. George-the-Martyr,the parish of St. Sepulchre, the Liberty of Saffron-hill, Hatton-garden, Ely's-rents and Ely-place, and the greater part of the Liberty of Glasshouse-yard. It is situated in the central part of the metropolis, and has adjoining it the following districts, namely, on the west St. Giles, on the north St. Pancras and Clerkenwell and the Liberty of the Charterhouse, and on the south St. Giles, the Strand and the City. At the eastern end the district becomes much reduced in size, forming a narrow and irregularly shaped area which is for a short extent of boundary in juxtaposition with the district of St. Luke. Within the limits of the district Gray's-inn is situated, while Lincoln's-inn, Staple-inn and Furnival's-inn form small areas on the southern boundary of the district. These, for sanitary administrative purposes, are not under the jurisdiction of the Holborn Board of Works. The soil is made up of gravel overlying the London clay, the latter coming to the surface in a narrow strip running north and south in the neighbourhood of Farringdon-road. The area of the district is 168 acres. The greater part, of the sanitary district of Holborn is included within the registration district of Holborn, but the Liberty of Glasshouse-yard, which forms the eastern extremity of the district, forms part of the registration district of London City. The number of persons per acre in Holborn in 1891 was 199, as compared with 56 per acre in London generally. When the census was taken in 1896, the average number per acre was 185. The population of the district at the 1891 census was found to be 33,485. This number compared with the two previous census returns, shows that the number of residents has been decreasing. There has also been a decrease in the number of inhabited houses. Similar changes are noticeable in the case of other centrally situated districts, and there is little doubt that the decrease is largely due to the increased use of premises for business and commercial purposes and to the removal of residents from the district. There are at the present time in the district many streets containing houses which were apparently at one time private residences, but which are now used as offices, while in other parts houses and courts, which existed when the Ordnance survey was made about thirty years ago, have disappeared, and been replaced by warehouses and factories. The census taken in March, 1896, for the purpose of the Equalisation of Rates Act shows that decrease in the population is still taking place, the population at this date being 31,208. The reduction in the population has affected, with one exception, each of the above-named subdivisions which constitute the sanitarv district of Holborn. The following figures show the changes which have been taking place— Inhabited bouses. Population. 1871. 1881. 1891. 1871. 1881. 1891. St. Andrew, Holborn, with St. George-the-Martyr 2,831 2,423 2,573 33,493 28,874 26,228 St. Sepulchre 313 278 190 2,888 2,392 1,972 Liberty of Saffron-hill, Hattongarden, Ely's-rents, Ely-place 527 453 605 5,907 3,980 4,506 Liberty of Glasshouse-yard 149 93 69 1,232 931 779 Whole district 3,820 3,247 3,437 43,520 36,177 33,485 * Dr. Bond, the medical officer of health of Holbnro, points out in his report for 1895, that the census figures include the whole population of Glasshouse-yard, although a part of this liberty, containing 71 inhabitants at the 1891 census, is under the jurisdiction of the Commissioners of Sewers, the population of Glasshouse-yard belonging to Holborn therefore shonld be 708. [9370 2 It will be observed that the number of persons has in each part of the district decreased in each decade, except in the Liberty of Saffron-hill, Hatton-garden, Ely's-rents and Ely-place, where, during the interval 1881-1891, a slight increase occurred both in the number of persons and the number of inhabited houses. This is probably accounted for by the erection of large blocks of model dwellings in the place of smaller houses and other buildings which were demolished in the construction of the main thoroughfare known as Clerkenwell-road. The population contains a fair proportion of shopkeepers, small tradesmen and a few caretakers, but is chiefly made up of artizans, labourers, and persons engaged in connection with cabyards and mews, with a small proportion of very poor persons in some of the smaller side streets. It would appear that the number of foreigners is not an inconsiderable proportion of the population, but it is not possible to give the exact number of those residing within the limits of the sanitary district. A large number of the foreigners are of Italian nationality, and these congregate to such a degree in a part of Holborn and the adjoining part of the district of Clerkenwell as to have given rise to the designation of the neighbourhood as the " Italian colony." During the decade 1881—1891 the average number of persons to each inhabited house has undergone a decrease, thus in 1881 there was an average of 11 1 persons per house, in 1891 9.7 persons per house. More definite information as to the density of the population in dwellings may be gathered from the fact that when the census was taken in 1891, more than 35 per cent, of the population were living in tenements having more than two occupants to a room. The proportion of the population so situated in Holborn is only exceeded in the metropolis by that in St. Luke 44'.4 per cent., Whitechapel 43.50 per cent., St. George-in-the-East 39.83 per cent., and Clerkenwell 38.78 per cent., the proportion in Holborn being 38.08 per cent. The population of Holborn in 1891 consisted of 16,606 males and 16,879 females or a proportion of 49.5 per cent. males and 50 5 females as compared with 47.3 per cent. males and 52.7 females in London generally The following table shows the age and sex constitution of the population in comparison with that of London at the time of the 1891 census— Age period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- Holborn— Males 5-26 4.75 4.49 5.03 4.83 8.85 6.59 4.91 2.96 1.47 0.45 Females 5.31 5.17 4.51 4.89 5.32 8.55 6.47 5.02 3.04 1.63 0.50 London— Males 5.92 5.36 4.90 4.69 4.61 7.92 5.85 4.11 2.35 1.20 0.37 Females 5.99 5.42 4.99 5.21 5.56 9.11 6.49 4.64 292 1.72 0.69 These figures bring out the fact that in Holborn there is a smaller proportion of persons under 25 years of age than in London generally. This defect being most marked at ages under 15 years. Between 25-75 years the proportion is greater than in London owing to an excess in the proportion of males. This is probably in great measure due to the population being largely made up of artizans and labourers. The following statistics as to the births and deaths do not relate to exactly the same area as that under the jurisdiction of the Holborn Board of Works, because the figures which are obtainable include births and deaths occurring in Lincoln's-inn, Gray's-inn, Staple and Furnival's-inn, and the Liberty of the Charterhouse, but do not include those occurring in the Liberty of Glasshouse-yard. The general death rates are corrected for age and sex distribution, and for comparison the London rates are also given. Birth rate per 1,000 living. General death rate per 1,000 living. Zymotic death rate per 1,000 living. Infantile death rate per 1,000 bom. Holborn. London. Holborn. London. Holborn. London. Holborn. London. 1891 27.7 31.8 33.6 21.0 4.36 23 228 153 1892 27.1 30.9 29.9 21.6 3.00 2.80 211 154 1893 26.8 30.9 29.9 22.3 3.38 3.08 214 163 1894 26.2 30.1 22.6 18.6 2.55 2.66 180 143 1895 26.2 30.6 28.1 19.5 2.87 2.62 2.12 165 * Smallpox, measles, scarlet fever, diphtheria, whooping cough, fever and diarrhoea. During these years the general death rate and the infant mortality have been much in excess of the rates prevailing in London generally. During the course of my inquiry into the sanitary condition of the district of Holborn I inspected 280 separate houses including tenements in blocks of artizans' dwellings, and in these a large number of defective conditions were found to exist. The defects noted include the following, viz.: dirty condition of walls in rooms and passages in 106 instances; dampness of walls in 20 instances; defective walls, plaster, or ceilings in 50 instances; defective roofs or floors in 53 instances; and defective stack-pipes or guttering in 17 instances. Water-closets were found defective, or supplied 3 with an inadequate flush of water, and in a foul condition in 76 cases, and 21 cisterns for the storage of drinking water were not provided with a proper cover. Yards, generally speaking, were well paved, and the drain inlets properly trapped; but notes were made as regards 44 houses where defects in these respects existed. Of frequent occurrence was the existence of unsuitable dust-bins. In the majority of premises there are fixed wooden or brick receptacles, which are difficult to cleanse properly, and in 64 instances the receptacle was found to be either unprovided with a cover or in a dilapidated condition. The majority of the houses which were visited were found to be let in tenements, consisting mostly of one or two rooms. The occupation of houses by members of more than one family exists to a large extent throughout the district; the figures obtained at the census of 1891 showing that nearly half the total population (49.78) live in tenements of one or two rooms, while 74,l per cent, live in tenements of one to four rooms. Many of these houses originally were, no doubt, not built with a view to such usage, and are frequently not well adapted for occupation by a large number of families. In most instances it was found that there was either no washhouse accommodation at all, or that it was provided in a badly-lighted and unsuitable position on the basement floor, which most of the houses in the district contain. These basements are well paved or concreted, but the dirty and neglected condition in which many of them were found, and the frequent occurrence of dilapidated staircases leading down to them, indicate that but little use is made of them by the residents for purposes of washing. They are unsuitable for occupation as living rooms, and appear to be reserved for storerooms and washhouses, but in four cases the illegal occupation of basement rooms was met with during the inspection. In a few tenemented houses the water-closet accommodation in proportion to the number of lodgers was inadequate. The defects enumerated above are chiefly of such a character as to admit readily of abatement, and in the majority of the premises visited, the conditions found to exist do not need more than the supervision necessary for maintaining them in a satisfactory condition of cleanliness and repair. In other cases, however, owing to the old age and state of decay of the premises, or the inadequate means of light and ventilation of houses or tenements, the conditions are not so readily capable of remedy. Further, there are some narrow courts and alleys as regards which, owing to the bad arrangement and closeness of the houses, little short of demolition and re-arrangement can be productive of any satisfactory result. The following are instances to which these remarks apply— Houses in Emerald-street, Falkner's-alley, Richbell-place, Boswell-court, Little Saffron-hill, Robin Hood-yard, and tenements in Leather-lane-buildings and Evelyn-buildings. Mitre-court.—A narrow court, approached by a covered archway under a house in St. John's-streetroad. Four three-storey houses. Width of court ft. Three of the houses are overshadowed by a tall building, and the rooms are very dark. The fourth has in front of it the three water-closets for use of court, and the uncovered common dustbin. The bouses are old and worn out, have no back yards, and no through ventilation. Hat and Mitre-court.—This consists of fifteen houses, two storeys high, placed in a confined space between the houses on the east side of St. John's-street-road, and the western boundary wall of the Charterhouse. With the exception of the houses in the central block, none have through ventilation, and have no back yards. There is a fair amount of open space between the buildings, and the rooms are fairly light. The houses are old, and some show signs of dampness of walls, but are otherwise maintained in a fair state of repair. There are four water-closets for the use of all the houses, one of these, a wooden structure, is situated at the end of a narrow passage immediately outside entrance of one of the houses. The remaining three, together with the common dustbin, are objectionally placed in a covered space (which originally appears to have been the ground floor of one of the houses), immediately underneath a first-floor room of No. 3, used as a sleeping-room. There are two water taps in the court for the use of the residents, one of these draws direct from the main, the other from a large and insufficiently-covered cistern. Sumner-court.—A row of four two-storey houses with one large two-storey house in centre, situated in a confined space between Back-hill, Sumner-street, and Eyre-street-hill. The houses in the row have no means of through ventilation; the ground floor of one has been converted into an open shed for barrows. The ground is not paved or concreted, and the flooring is in a rotten condition. Houses are old and worn out, and the walls of centre house bulge. There are two water-closets for the use of the five houses. Occupants chiefly Italians, and there is evidence of overcrowding. Eyre-place.—This abuts on to Sumner-court, from which it is separated by railings. It contains two houses in a shut-in position approached by a covered way from Eyre-street-hill. Houses have no back yards and no through ventilation. Eyre-court and Eyre-terrace.—A narrow shut-in court situated between the houses on west side of Eyre-street-hill and some high warehouse premises, and approached by an archway from Eyre-street-hill. It contains twelve houses, three storeys high. Some of the houses have no back yards and no through ventilation. The court is about 15 ft. wide, closed at one end by a wall, at the other by a row of three water-closets and a building which serves as the dust receptacle. The roof of the last-named buildings forms yard level of Eyre-terrace, which has a separate approach from Eyre-street-hill and contains three houses (one lately rebuilt). Many of the houses are old and worn out. Elm-place.—Three two-storey cottages, approached by a covered way from Elm-street. No back yards and no through ventilation. There is a common dustbin (cover broken), a common water-tap and a common water-closet for the use of the three cottages. Two houses are in a dirty condition, and one is overcrowded. Union buildings and terrace.—A narrow passage leading off Leather-lane, and containing three-storey houses let in tenements. At the lower end it widens out into a square space known as Union-terrace, with buildings on three sides, which on the ground floor are used as stables and a cowshed. The upper floors, reached by an external staircase and balconies, are used as dwellings, each of which consists practically of a single room which has been divided by a wooden partition into two rooms. Some of the tenements have no through ventilation, the worst have been closed. These dwellings have a large common dustbin in the yard, and the water-closets are placed together in one corner of the buildings. Dove-court.—A narrow court, approached by a covered way from Leather-lane, and communicating with Leopard-court at the other end. Houses on the north side are in the rear of houses in Union- 4 buildings, from which they are separated by small back yards. The houses apparently are old and worn out, all are unoccupied, except two, and on the north side are being pulled down and re-built. Providence-place.—This is a narrow alley, 12 feet wide, situated at the end of Verulam-street. At one end it is closed in by the cowshed and buildings in Union-terrace. It contains a row of two-storey cottages on either side, which are old and worn out, but are now in a fair state of repai:, owing to alterations which have recently been carried out under notices served by the sanitary authority. Half Moon-court.—This is a narrow court having three rows of houses, one on either side, and the third at the end, opposite to the entrance to court from Portpool-laue. This row of houses is immediately in the rear of houses on the north side of Providence-place. The court is confined by surrounding buildings, and many of the rooms are badly lighted. The houses on eastern side and all but one of end row are closed. Overcrowding of rooms was met with in 47 cases. The most marked instances of this occurred in that portion of the district known as the "Italian colony." A form of lodging prevails here which corresponds with an ordinary common lodging-house, in that the sleeping rooms are occupied in common by four or six or more male lodgers. These rooms are generally furnished with double beds, and are only used as sleeping rooms, the lodgers making use of the living room of the occupier for the purpose of meals. In these cases, however, ordinary casual lodgers are not received, the occupiers of the premises being Italians, who provide lodging for members of their own nationality at a weekly charge, and the lodgers in most cases remain in the house for long periods. Generally the sleeping rooms in these premises and the beds were found cleanly and well kept, but the rooms were much overcrowded. The following are examples, a room of about 563 cubic feet slept in by three men ; a room with three beds, which it is stated are occupied by six men, about 1,200 cubic feet; a room with three beds for the use of five men, about 1,000 cubic feet. The registered common lodging-houses in the district now number eleven, two having been closed since my inspection began. With one exception they were found in a cleanly state and well managed. Some of the premises are not in all respects well adapted for use as common lodginghouses, in one instance the house being old, but fairly well maintained, while in two cases the dayroom is badly situated and not well ventilated. I was unable to obtain any definite information as to the number of workshops in the districts. Hitherto there has been no special inspection in regard to these premises, they have only been visited on complaint or as met with in the ordinary inspection of premises, and no register of workshops is kept by the sanitary authority. During the course of this inspection 27 workshops were visited, 16 of which were either dirty or in need of repair. In 7 the water-closet accommodation was inadequate, and 5 water-closets were in a dirty condition. Overcrowding of workroom was noted in 5 instances. There are 24 bakehouses. These, with two exceptions, are situated underground. All those visited were cleanly and in good repair, but in three the means of ventilation are not well provided. The two licensed slaughterhouses in the district I found to be in accordance with the regulations, one of them, however, is badly situated owing to the fact that it abuts upon the house, a window of one room of which opens on to the slaughterhouse. There is one cowshed, which is not well lighted and ventilated, this being in great measure due to its confined and objectionable situation. The shed is the ground floor of premises, the two upper floors of which are used for human habitation. There is also a set of premises in the district occupied by a tripe boiler, which at the date of inspection was undergoing alterations and improvements. The milkshops visited were generally satisfactory, but in a few instances (where small quantities of milk are sold in the shop only) the utensils were not kept in a cleanly manner. The sanitary authority do not themselves carry out the collection and removal of house refuse and the scavenging of the streets, but have made arrangements with a contractor for these purposes. In connection with removal of house refuse a new contract was entered into in March, 1896, and by the terms of this contract it is stipulated that each house in the district shall be called at once in each week. For some parts of the district arrangements have been made for a daily collection. Inquiry is also made daily on behalf of the contractor at the Town Hall as to any complaints of non-removal of house refuse. During the inspection 25 instances were noted where undue accumulations of refuse existed, and upon inquiry it was found, as regards some of these, that the refuse had not been called for during the previous week. The cleansing of the streets is also carried out by a contractor, and the sanitary authority have an inspector (in the department of the surveyor) who supervises this work. But there does not appear to be any control as to the method in which the house refuse is collected, except such as can be exercised by the sanitary inspectors in noting the condition of the ashpits in the course of visits to premises which are engaging their attention. The disinfection of articles of clothing and bedding after the occurrence of infectious diseases is also carried out by a contractor, the authority not having provided a suitable disinfecting oven for the use of the district. Arrangements have therefore been entered into for disinfection by steam in such cases. The contractor sends on alternate days to the offices of the sanitary authority to ascertain whether any cases requiring disinfection have occurred, and he is notified of any cases occurring between his visits. The articles are removed and returned in covered vans. The disinfection of rooms is carried out by an official of the sanitary authority. A shelter for the use of persons during the period that their rooms are being disinfected has not yet been provided within the district, but arrangements have been made with the sanitary authority of Clerkenwell to share their shelter. An ill-designed mortuary containing separate chambers for the bodies of persons dying of infectious and non-infectious complaints, and a post-mortem room has been provided in the stone-yard at the rear of the Town Hall. The situation is unsuitable owing to the surroundings, and to the fact that the building has been erected against a high wall of the adjoining premises. The entrance to the non-infectious chamber is through the post-mortem room. u 5 The water supply of the district is provided by the New River Waterworks Company, and the constant supply exists in all parts. In some houses the water is drawn direct from the main, but in many storage cisterns still exist. For the sanitary administration of the district the authority has appointed the following officers, namely— A medical officer of health. Three sanitary inspectors. One sanitary clerk. In addition to these officers there is a keeper of the mortuary who also carries out, under the direction of the sanitary inspectors, the disinfection of rooms after the occurrence of cases of infectious diseases, and a messenger in the office who acts as the inspector for smoke nuisances. In the department of the surveyor there is an inspector who superintends the cleansing of streets. This officer is a certified sanitary inspector. The medical officer of health attends at the offices of the Board daily, and controls and supervises the work of the sanitary department. He also acts as medical officer of health for another metropolitan district. As regards the work of the three sanitary inspectors, one of these officers devotes his time solely to meat inspection. The remaining two have to carry out all the duties arising in the district under the Public Health Act (except those relating to smoke nuisances) and to collect samples under the Food and Drugs Act. For these purposes the district has been divided into two districts, one being allotted to each inspector. The time of the inspectors is chiefly taken up in visiting premises in reference to which complaint has been made and in which infectious disease has occurred. All drainage works carried out in the district are inspected by the sanitary inspectors before being regarded as satisfactory. In a small part of the district they have made a house-to-house inspection, and they are expected to visit houses let in lodgings at periodical intervals. The inspectors are provided with office accommodation at the Town Hall, and attend there daily in the morning and afternoon. Each inspector assists in filling up his own intimation notices, and keeps a daily journal, and enters in a report book the result following the service of intimation notices, and whether he considers it necessary that a statutory notice be served or proceedings be taken in any case. In the office there is kept by the clerk a complaint book in compliance with section 107 (3) Public Health (London) Act, 1891. This book fails to show clearly the result of action in all cases, and a new form of register which is to be kept has recently been approved by the Board. The clerk also fills up the intimation and statutory notices, and the counterfoils of these books show that the requirements are in each case comprehensive. The sanitary authority for the district of Holborn is a Board of Works, and for matters relating to the public health there is a committee of the Board which holds meetings every fortnight. The committee possesses statutory powers for carrying out the duties under the Public Health (London) Act, 1891. All cases in which there is failure to comply with the requirements of preliminary notices are reported to the committee before further action is taken, except in cases of urgency. The Board have made by-laws under the Public Health Act for the prevention of nuisances, the paving of yards, the cleansing of cisterns and the provision of water-closets with adequate water supply. Under section 96 of the Act which relates to the making of by-laws for houses let in lodgings no by-laws have yet been made as the Board possess regulations which were confirmed in 1885. These differ from the model by-laws of the Local Government Board in that the minimum amount of cubic space required in rooms used both as sleeping and day rooms is 350 feet and not 400 feet. As the result of this inquiry evidence has been obtained that much work in the abating and removal of insanitary conditions is being carried out in the district. Much activity has also been displayed in the seizure and condemnation of meat unfit for human consumption since the appointment of an inspector specially for the purpose. The appointment of this inspector has, no doubt, by relieving the other officers of the duties connected with the sale of meat in the district, resulted in more time being devoted to the condition of premises than hitherto, and house-to-house inspections have been made, but they have been limited to certain parts of the district up to the present time; however, the registration of houses let in lodgings has not been enforced to any extent by the sanitary authority, there being only some forty-three houses on the register. It has already been pointed out that a large proportion of the inhabited houses in this district are occupied by members of more than one family, the tenements consisting for the most part of one or two rooms, and there is little doubt that a much greater number than at present should be placed on the register. Much improvement in their condition would be derived from systematic inspection by the sanitary officers of many of these premises. The Board appreciating the advantages of periodic inspection of houses of this class have recently passed a resolution that all registered houses shall be visited once in each week. The need for registration of a greater number of houses let in lodgings, together with the existence at the present time of the many defects recorded in this report, and the absence of any definite information in the possession of the sanitary authority as to the workshops in the district and their condition, indicate that a systematic house-to-house inspection should be made without delay throughout the district. This will necessitate an increase to the present staff of inspectors, as the time of the existing staff is taken up by the work now carried out by the authority. Further, it is to be observed that at the present time no direct control is exercised on behalf of the sanitary authority as to the method in which the collection of house refuse is carried on in the district. It will, I think, be necessary therefore to appoint two additional officers now, but a further increase may be called for at a later date when all tenement houses needing regulation are placed on the register, if the decision of the Board as to monthly inspection is to be carried out. Reference has been made to the existence in 6 the district of houses the condition of which does not readily admit of remedy, and of badly arranged courts and alleys. For the former, application for closing orders should be made by the sanitary authority, and for the latter steps should be taken for demolition and rearrangement. In this connection it is necessary to refer to the fact that recently a representation was made to the sanitary authority by their medical officer of health as to an area near Leather-lane, including Half Moon-court, Crown-court, Providence-place, Union terrace and buildings and Dove-court, which in his opinion, owing to the many "grave sanitary structural and architectural defects," could only be satisfactorily dealt with by scheme under the Housing of the Working Classes Act, and it is pointed out in the report that the adoption of any other course would only lead to partial amelioration of the insanitary conditions existing. The Board of Works however did not adopt their medical officer's report, and decided to deal with the insanitary conditions by serving notices under the Public Health (London) Act. Work in compliance with these notices was going on at the time of inspection, but the result of this method of dealing with the conditions prevailing cannot be other than unsatisfactory. The Board should provide within the limits of the district a properly furnished shelter for the use of persons during the disinfection of their rooms. C. W. F. Young, Public Health Department, Assistant Medical Officer of Health. Spring-gardens, S.W., 29th October, 189G.