Londan Countnry Council. TENTH ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH of the ADMINISTRATIVE COUNTY OF LONDON. 1901, (Ordered by the Council to be printed.) JAS. TRUSCOTT AND SON, LTD., PRINTERS, SUFFOLK LANE, CANNON STREET, E.C. [4479 TABLE OF CONTENTS. Part I.— PAGE Population Density of population 1 Overcrowding, etc., in tenements of less than five rooms Marriages 7 Births Deaths 9 Bates of mortality in the several metropolitan boroughs 10 London mortality in 1901 compared with the mortality in the decennium 1891-1900 12 Infant mortality 14 Deaths from several classes of disease 15 Principal epidemic diseases Smallpox and vaccination 17 London vaccination returns 24 Measles 24 Scarlet fever 28 Scarlet fever and elementary schools 32 " Return cases" of scarlet fever 32 Proportion of cases in hospitals 32 Age and sex distribution 33 Diphtheria 33 Diphtheria and elementary schools 35 Proportion of cases in hospitals 36 " Return cases" of diphtheria . 36 Bacteriological examination of material from suspected cases of diphtheria 36 Supply of anti-toxin 36 Age and sex distribution 36 Whooping cough 37 Typhus 38 Enteric fever 39 Bacteriological examination of blood serum 42 Age and sex distribution 42 Diarrhoea 43 Cholera 44 Erysipelas 44 Puerperal fever 45 Influenza, bronchitis and pneumonia 45 Phthisis 46 Cancer 4S Bubonic plague 49 Meteorology 52 pabt n.— Dairies, cowsheds and milkshops 54 Offensive businesses 55 Complaints to the London County Council 56 Nuisances 56 Smoke nuisances 56 Removal of stable manure. 57 Removal of offensive trade refuse 57 By-laws as to removal of offensive matter 58 Removal of house refuse 59 Disposal of refuse 59 Nuisance from sewers 60 Nuisance from the Thames and Lea 60 Drainage By-laws 60 Housing of the Working Classes Act 60 Representation under Part I. 60 Schemes undertaken by the County Council under Part I. of the Act 61 Schemes undertaken by the County Council under Part II. of the Act 61 Schemes undertaken by district councils under Part II. of the Act, the County Council contributing towards the cost 62 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 62 Proceedings by the County Council under Part III. of the Housing of the Working Classes Act 63 Buildings opened during the year 65 Displacement of persons of the working class 65 Reference to proceedings under the Housing of the Working Classes Act by medical officers of health 65 Conference with metropolitan borough councils 68 Houses let in lodgings 69 Common lodging-houses 71 Seamen's lodging-houses 72 Customs and Inland Revenue Acts, 1890 and 1891 72 Underground rooms 72 Workshops and workplaces 72 Bakehouses 75 page Unsound food 76 Poisoning by arsenic 77 Disinfection 77 Shelters 78 Bacteriological examination 78 The cleansing of persons 79 Mortuaries 79 Water supply 80 The London Equalization of Rates Act, 1894 80 Sanitary officers 81 Medical officers of health of metropolitan boroughs in 1901 83 Appendices— I.—London Life Table. II.—Report as to certain recent local prevalences of scarlet fever in London. III.—Experiments on disinfection. . IV.—Report on the sanitary staffs of the metropolitan boroughs. LIST OF DIAGRAMS. facing page. Diagram I.—Marriages, 1851-1901 7 II.—Births, 1851-1901 7 III.—Deaths, 1841-1901 9 IV.—Smallpox, 1841-1901 ]7 V.—Measles, 1841-1901 24 „ VI.—Scarlet fever,. 1859-1901 28 „ VII.—Scarlet fever.; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 28 „ VIII.—Scarlet fever; monthly notifications and case mortality, 1891-1901 29 „ IX.—Diphtheria and croup, 1859-1901 33 ,, X.—Diphtheria; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 33 ,, XI.—Diphtheria ; monthly notifications and case mortality, 1891-1901 34 „ XII.—Whooping cough, 1841-1901 37 XIII.—Typhus, 1869-1901 38 „ XIV.—Enteric fever, 1869-1901 39 „ XV.—Diarrhoea in relation to mean temperature (summer quarter), 1841-1901 39 „ XVI.—Enteric fever ; monthly notifications and case mortality, 1891-1901 40 „ XVII.—Enteric fever; weekly notifications, 1901, and mean weekly notifications, 1890-1901 41 Chart B.—Smallpox; death rates for a series of years in London, Paris, Berlin, Vienna and St. Petersburg 18 Administrative Country of London. REPORT OF THE MEDICAL OFFICER OF HEALTH. 1 9 O 1. PART I. Population. The population of the administrative county of London, estimated to the middle of the year 1901. was 4,544,983. The population of each of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1901 is shown in the following table— Metropolitan Boroughs. Estimated population, 1901. Metropolitan Boroughs. Estimated population, 1901. Metropolitan Boroughs. Estimated population, 1901. Paddington 144,200 Stoke Newington 51,336 Bermondsey 130,650 Kensington 176,821 Hackney 219,800 Lambeth 302,533 Hammersmith 112,631 Holborn 59,231 Battersea 169,403 Fulham 138,448 Finsbury 101,266 Wandsworth 233,985 Chelsea 73,876 City of London 26,657 Camberwell 260,022 City of Westminster 182,567 Shoreditch 118,504 Deptford 110,632 St. Marylebone 133,053 Bethnal-green 129,720 Greenwich 96,217 Hampstead 82,300 Stepney 298,985 Lewisham 128,480 St. Pancras 235,369 Poplar 168,898 Woolwich 117,652 Islington 335,441 Southwark 206,306 Density of population. Tbe enumerated population and the number of persons per acre in the several metropolitan boroughs at the date of the 1901 census are shown in the following table. It will be seen that the Metropolitan Borough of Southwark had the largest number of persons per acre, viz., 182. The greatest density of population hitherto attained by any sanitary district in London since 1811 waa 241 persons per acre (St. Luke, 1861). There is no doubt that if the density of population were shown for smaller areas than those of the metropolitan boroughs it would be found that some of these areas would have a much larger number of persons per acre than the maximum number shown in the table, viz., 182; but the general tendency of the recent London Government Act has been to increase the area of the London sanitary districts, and differences of density, when the metropolitan boroughs are compared, are probably not so great as the differences which would obtain were the former sanitary districts made the subject of comparison. In this connection it may, be pointed out that although the average density of the population of Southwark was 182 persons per acre the density of population in the Borough-road registration sub-district, one of the areas comprised in the Metropolitan Borough of Southwark, was 266 persons per acre. Population, acreage and number of persons per acre in metropolitan boroughs, census, 1901. Metropolitan boroughs. Area in Btatute acres. Enumerated population, 1901. Number of persons to an acre. Paddington 1,356 143,976 106 Kensington 2,291 176,628 77 Hammersmith 2,286 112,239 49 Fulham 1,703 137,289 81 Chelsea 660 73,842 112 Westminster, City of 2,503 183,011 73 St. Marylebone 1,473 133,301 90 Hampstead 2,265 81,942 36 St. Pancras 2,694 235,317 87 Islington 3,091 334,991 108 Stoke Newington 863 51,247 59 Hackney 3,289 219,272 67 Holborn 405 59,405 147 1092 2 Metropolitan borough. A rea in statute acres. Enumerated population, 1901. Number of persons to an acre. Finsbury 589 101,463 172 London, City of 673 26,923 40 Shoreditch 658 118,637 180 Bethnal.green 759 129,680 171 Stepney 1,766 298,600 169 Poplar 2,328 168,822 73 Southwark 1,131 206,180 182 Bermondsey 1,500 130,760 87 Lambeth 4,080 301,895 74 Battersea 2,160 168,907 78 Wandsworth 9,130 232,034 25 Camberwell 4,480 259,339 58 Deptford 1,563 110,398 71 Greenwich 3,852 95,770 25 Lewisham 7,014 127,495 18 Woolwich 8,277 117,178 14 London 74,839 4 536,541 61 The census report for London, 1901, shows the number of persons occupying tenements of less than five rooms in the several metropolitan boroughs. This information enables some estimate to be formed of the character of the several populations, and the following table has been prepared for this purpose from the figures given in the census report. It will be seen from the table that in Lewisham only 3.5 per cent, of the population occupied tenements of one room, while in Holborn this percentage was 27'0, the figures for the other boroughs being ranged between these two extremes. The Borough of Finsbury had the largest proportion of the population living in two.roomed tenements, viz., 327 per cent., the proportion being lowest in Lewisham, viz., 6.2 per cent. The table also shows the proportion of the population of each borough occupying tenements of one, two, three and four rooms in which there were more than two persons to a room. Employing the term " overcrowding" to represent such usage it will be seen that the borough having the smallest proportion of the population living in overcrowded tenements of one room was that of Lewisham (0.34 per cent.), the borough having the largest proportion being that of Holborn (8'28 per cent.). In the case of overcrowded tenements of two rooms the extremes are to be found in Lewisham (0.75 per cent.) and Finsbury (16'72 per cent.). Considering tenements of under five rooms as a whole the smallest proportion of the population living more than two in a room in such tenements is to be found in Lewisham, viz., 2.67 per cent., and the largest proportion in Finsbury, viz., 35'22 per cent. It will be seen from the table that " overcrowding," as judged by this standard, is particularly marked in the districts comprised in the eastern and central groups. Overcrowding, etc., in tenements of less than five rooms. City of Loudon—Population, 26,923 ; total tenements, 5,339. Tenements with No. of tenements. Percentage of all tenements. Total occnpaDts. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No. of occupants of such tenements. Percentage of population in such tenements. 1 roam 775 145 1,421 5.3 1.88 151 563 2.09 2 rooms 1,123 210 3,776 14.0 1.68 256 1,553 5.77 3 „ 885 16.6 3,229 12.0 1.22 81 647 2.40 4 „ 524 9.8 2,199 8.2 1.05 16 158 0.59 Total 3,307 61.9 10,625 39.5 — 504 2,921 10.85 Battrksea—Population, 168,907; total tenements, 38,987. 1 room 3,413 8.8 6,342 3.8 1.86 789 2,707 1.60 2 rooms 5,887 15.1 19,172 11.4 1.63 1,159 6,666 3.95 3 7,934 20.4 30,375 18.0 1.28 728 5,600 3.32 4 „ 6,855 17.6 33,110 196 1.21 356 3,408 2.02 Total 24,089 61.9 88,999 528 — 3,032 18,381 10.89 3 Bermondsey—Population, 130,760; total tenements, 29,073. Tenements with No. of tenements. Percentage of all tenements. Total occapants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No. of occupants of such tenements. Percentage of population in such tenements. 1 room 4,258 14.6 8,706 6.7 2.04 1,189 4,213 3.22 2 rooms 6,968 24.0 24.472 18.7 1.76 1,705 9,747 745 3 „ 5,738 197 25,808 19.7 1.50 986 7,642 584 4 „ 5,100 175 27,170 20.8 1.33 427 4,124 315 Total ... 22,064 75.8 86,156 65.9 — 4,307 25,726 1966 Bethnal-green—Population, 129,680; total tenements, 28,209. 1 room 5,378 19.1 12,755 9.8 2.37 2,042 7,602 5.86 2 rooms 7,264 25.8 28,440 21.9 1.96 2,374 14,202 10.95 3 „ 6,746 23.9 32,410 25.0 1.60 1,402 11,100 8.56 4 „ 4,344 15.4 25,248 39.5 145 566 5,506 4.25 Total 23,732 84.2 98,853 76.2 — 6,384 38,410 29.62 Camberwell—Population, 259,3.39; total tenements, 56,985. 1 room 4,906 8.6 8,856 3.4 1.81 1,016 3,541 1.37 2 rooms 7,766 13.6 24,640 9.5 1.59 1,459 8,249 318 3 „ 9,899 17.4 39,642 15.3 1 .33 1,109 8,536 3.29 4 „ 9,355 16.4 44,510 17.2 1.19 489 4,686 1.81 Total ... 31,926 560 117,648 45.4 — 4,073 25,012 9.65 Chelsea—Population, 73,842; total tenements, 17,467. 1 room 3,812 21.8 6,609 90 1.73 683 2,369 3.21 2 rooms 3,736 21.4 11,831 160 1.58 749 4,399 5.96 3 „ 2,927 16.8 11,796 160 1.34 389 3,009 4.07 4 „ 1,607 9.2 7,487 101 1.16 93 882 1.19 Total 12,082 69.2 37,723 511 — 1,914 10,659 14.43 Deptford—Population, 110,398 ; total tenements, 24,615. 1 room 1,974 8.0 4,088 37 2.07 554 2,029 1.84 2 rooms 3,313 13.5 10,229 9.3 1.54 530 2,995 2.71 3 „ 3,906 15.9 14,846 134 1.27 322 2,479 2.25 4 „ 4,763 19.3 22,698 20.6 119 261 2,496 2.26 Total 13,956 ' 56'7 51,861 470 — 1,667 9,999 906 Finsbdry—Population, 101,463 ; total tenements, 24,097. 1 room 6,364 26.4 14,416 142 2.27 2,227 8,135 8.02 2 rooms 7,882 32.7 31,482 310 2.00 2,855 16,960 16.72 3 „ 4,233 17.6 21,280 210 1.68 1,058 8,349 8.23 4 „ 2,036 8.4 11,168 110 1.37 233 2,279 2.25 Total 20,515 85.1 78,346 77.2 — 6,373 35,723 35.22 Fulham—Population, 137,289; total tenements, 32,137. 1 room 2,460 7.7 4,426 32 1.80 ,512 1,735 1.26 2 rooms 4,360 13.6 13,517 98 1.55 723 4,072 2.97 3 „ 8,309 25.9 32,116 234 1.29 752 5,707 4.16 4 „ 6,552 20.4 31,305 22.8 1.19 354 3,378 2.46 Total 21,681 67.6 81,364 592 — 2,341 14,892 10.85 4 Greenwich—Population, 95,770; total tenements, 19,702. Tenements with No. of tenements. Percentage of all tenements. Total occupaDts. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No of occupants of such tenements. Perct ntage of population iD such tenements. 1 room 1,375 7.0 2,392 2.5 1.74 248 877 0.92 2 rooms 2,552 13.0 7,480 7.8 1.47 366 2,069 216 3 „ 2,990 15.2 11,812 12.3 1 32 331 2,555 2.67 4 „ 3,960 20.1 19,576 20.4 1.24 254 2,446 2.55 Total 10,877 55.3 41,260 43.0 — 1,199 7,947 8.30 Hackney—Population, 219,272; total tenements, 48,794. 1 room 4,827 9.9 8,943 4.1 1.85 1,069 3,735 1.70 2 rooms 7,211 14.8 22,606 10.3 1.57 1,264 7,270 3.32 s ,, 9,387 19.2 36,322 16.6 1.29 888 6,870 3.13 4 „ 7,664 15.7 37,005 16.9 1.21 463 4,457 2.03 Total 29,089 59.6 104,876 47.9 — 3,684 22,332 10.18 Hammersmith—Population, 112,239; total tenements, 25,810. 1 room 2,698 10.5 4,942 4.4 1.83 566 1,993 1.78 2 rooms 4,389 17.0 14,187 12.6 1.62 892 5,161 4.60 3 „ 4,919 19.1 19,273 17.2 1.31 492 3,796 3. 38 4 „ 3,499 13.6 16,857 15.0 1.20 235 2,242 2.00 Total 15,505 60.2 55,259 49.2 — 2,185 13,192 11.76 Hampstead—Population, 81,942; total tenements, 16,998. 1 room 1,096 6.4 1,819 2.2 1.66 177 614 0.75 2 rooms 2,331 13.7 7,257 8.9 1.56 423 2,465 3.01 3 „ 2,331 13.7 8,729 10.7 1.25 203 1,550 1.89 4 ,, 1,420 8.4 6,406 7.8 113 61 586 0.72 Total 7,178 42.2 24,211 29.6 — 864 5,215 6.37 Holborn—Population, 59,405; total tenements, 13,790. 1 room 3,725 27.0 8,502 14.3 2.28 1,267 4,916 8.28 2 rooms 3,834 27.8 13,787 23.2 1.80 1,126 6,747 11.36 3 „ 2,224 16.1 9,175 15.4 1.38 328 2,603 4.38 4 „ 989 7.2 4,260 7.2 108 62 609 1.03 Total 10,772 78.1 35,724 601 — 2,783 14,875 25.05 Islington—Population, 334,991; total tenements, 79,129. 1 room 12,955 16.4 25,988 7.8 2.01 3,316 11,772 3.51 2 rooms 3 „ 18,934 14,379 23.9 18.2 65,508 57,671 19.6 17.2 1.73 1.34 4,455 ] ,662 26,056 12,914 7.78 3 86 4 „ 9,533 12.0 47,256 14.1 1.24 638 6,206 1.85 Total 55,801 705 196,423 58.7 — 10,071 56,948 17.00 Kensington—Population, 176,628; total tenements, 38,349. 1 room 5,695 14.9 11,334 6.4 1.99 1,424 5,138 2.91 2 rooms 7,776 20.3 27,800 15.7 1.79 2,208 13,123 7.43 3 „ 4,757 12.4 20,210 11.4 1.42 764 5,987 3.39 4 2,887 7.5 14,081 8.0 1.22 203 1,959 1.11 Total 21,115 55.1 73,425 41.5 — 4,599 26,207 14.84 5 Lambeth—Population, 301,895; total tenements, 70,887. Tenements with No. of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No. of occupants of such tenements. Percentage of population in such tenements. 1 room 10,058 14.2 18,932 6.3 1.88 2,258 7,882 2.61 2 rooms 12,311 17.4 40,073 13.3 1.63 2,543 14,590 4.83 3 ,, 12,120 17.1 47,255 15.7 1.30 1,229 9,467 314 4 „ 10,006 14.1 46,924 15.5 1.17 518 4,965 1.64 Total 44,495 62.8 153,184 50.8 — 6,548 36,904 12.22 Lewisham—Population, 127,495; total tenements, 27,701. 1 room 970 35 1,488 1.2 1.53 130 439 0.34 2 rooms 1,720 6.2 4,582 3.6 1.33 168 960 0.75 3 „ 2,490 9.0 8,550 6.7 1.14 132 1,007 0.79 4 „ 3,381 12.2 14,308 11.2 1.06 105 1,010 079 Total . 8,561 30.9 28,928 22.7 — 535 3,416 2.67 Paddington—Population, 143,976; total tenements, 33,661. 1 room 5,035 15.0 9,233 6.4 1.83 1,035 3,694 2.57 2 rooms 6,668 19.8 22,596 15.7 1.69 1,585 9,406 6.53 3 „ 6,548 19.5 24,933 17.3 1.27 607 4,695 3.26 4 „ 3,564 10.6 16,470 11.4 116 177 1,736 1.21 Total 21,815 64.9 73,232 50.8 — 3,404 19,531 13.57 Poplar—Population, 168,822; total tenements, 35,787. 1 room 3,935 11.0 8,274 4.9 210 1,187 4,213 2.50 2 rooms 6,450 18.0 21,896 13.0 1.70 1,419 8,237 4.88 3 „ 8,270 23.1 35,499 21.0 1.43 1,173 9,116 5.40 4 „ 7,561 21.1 39,828 23.6 1.32 635 6,134 3.63 Total 26,216 73.2 105,497 62.5 — 4,414 27,700 16.41 St. Martlebohe—Population, 133,301; total tenements, 31,623. 1 room 8,312 26.3 16,408 12.3 197 2,052 7,529 5.65 2 rooms 8,246 26.1 29,507 22.1 1.79 2,319 13,861 10.40 3 „ 4,185 13.2 17,755 13.3 1'41 637 5,079 3.81 4 ,, 2,204 7.0 10,483 7.9 119 172 1,678 1.26 Total 22,947 72.6 74,153 55.6 — 5,180 28,147 21.12 St. Pancras—Population, 235,317; total tenements, 57,045. 1 room 13,417 23.5 27,464 11.7 2.05 3,578 13,103 5.57 2 rooms 16,827 29.5 61,544 26.2 1.83 4,830 28,728 12.21 9,410 16.5 39,502 16.8 1.40 1,310 10,323 4.39 4 „ 5,369 9.4 27,280 11.6 1.27 440 4,269 1.81 Total 45,023 78.9 155,790 66.3 — 10,158 56,423 23.98 Shoreditch—Population, 118,637; total tenements, 27,031. 1 room 6,705 24.8 15,093 12 .7 2.25 2,305 8,335 7.03 2 rooms 7,509 27.8 29,026 24.5 1.93 2,439 14,442 12.17 3 „ 5,102 18.9 24,902 21.0 1.63 1,114 8,782 7.40 4 „ 3,624 13.4 20,559 17.3 1.42 411 3,970 3.35 Total 22,940' 84.9 89,580 75.5 — 6,269 35,529 29.95 6 Southwakk—Population, 206,180; total tenements, 47,808. Tenements with No. of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants pe room. No. of cccupants of such tenements. Percentage of population in such tenements. 1 room 9,896 20.7 20,151 9.8 2.04 2,706 9,417 4.57 2 rooms 12,480 26.1 44,864 21.8 1.80 3,292 19,024 9.23 3 „ 10,211 21.4 45,398 22.0 1.48 1,555 12.091 5.86. 4 „ 7,025 147 37,510 18.2 1.33 580 5,541 2.69 Total 39,612 82.9 147,923 71.8 — 8,133 46,073 22.35 Stepney—Population, 298,600; total tenements, 61,113. 1 room 13,282 21.7 34,519 11 .6 2.60 5,928 22,892 7.67 2 rooms 15.690 25.7 66,250 22.2 2.11 6,331 39,367 13.18 3 „ 11,926 19.5 60.457 20.2 1.69 3,094 25,184 8.43 4 „ 8,284 13.6 47.974 16.1 1.45 1,188 11,736 3.93 Total 49,182 80.5 209,200 70.1 — 16,541 99,179 33.21 Stoke Newington—Population, 51,247; total tenements, 11,821. 1 room 894 7.6 1,456 2.8 1.63 139 463 0.90 2 rooms 1,600 13.5 4,744 7.3 1.48 235 1,354 2.64 3 „ 1,885 15.9 6,337 12 4 112 93 729 1.42 4 „ 1,434 12.1 6,074 11.9 106 30 289 0.56 Total 5,813 49.1 18,611 34.4 497 2,835 5.52 Wandsworth—Population, 232,034 ; total tenements, 49,756. 1 room 2,039 4.1 3,217 1.4 1.58 282 952 0 41 2 rooms 3,591 7.2 9,734 4.2 1.35 367 2,034 0.88 3 „ 7,458 15.0 27,212 11.7 3 .22 529 4,028 1.74 4 „ 7,964 16.0 36,166 15.6 114 347 3,323 1.43 Total 21,052 42.3 76,329 32.9 — 1,525 10,337 4.46 Westminster, City of—Population, 183,011; total tenements, 41,244. 1 room 7,546 18.3 14,008 7.7 1.86 1,599 5,787 3.16 2 rooms 9,635 23.4 30,348 16.6 1.57 1,846 10,770 5.88 3 „ 6,279 15.2 24,809 13.6 1.32 729 5,632 3.08 4 „ 3,208 7.8 14,459 7.9 113 172 1,667 0.91 Total 26,668 64.7 83,624 45.8 — 4,346 23,856 13.03 Woolwich—Population, 117,178; total tenements, 24,585. 1 room 1,724 7.0 3,092 2.6 1 .79 333 1,126 0.96 2 rooms 3,378 13.7 9,855 8.4 1.46 386 2,152 1.84 3 „ 4,094 16.7 14,918 12.7 1.21 282 2,142 1.83 4 „ 4,821 19.6 23,120 19.7 1.20 242 2,307 1.97 Total 14,017 570 50,985 43.4 — 1,243 7,727 6.60 Administrative County of London—Population, 4,536,541; total tenements, 1,019,546. 1 room 149,524 14.7 304,874 6.7 2.04 40,762 147,771 3.26 2 rooms 201,431 19.8 701,203 15.5 1.74 50,304 296,659 6.54 3 „ 181,542 17.8 752,221 16.6 1.38 23,979 187,619 4.14 4 „ 139,533 13.7 691,491 15.2 1.24 9,728 94,047 2.07 Total 672,030 66.0 2,449,789 54.0 — 124,773 726,096 16.01 7 It may be pointed out that the figures are uot yet available which would enable comparison to be made between the results shown in the preceding table and those obtaining for the corresponding areas in the census year of 1891. Owing to the changes in London sanitary areas, consequent upon the London Government Act of 1899, the figures shown in the census report for 1901 relate to the present metropolitan boroughs, while the figures shown in the previous census report for 1891 relate to the former sanitary areas. The figures for 1891 relating to the areas of the metropolitan boroughs will, however, shortly be in the possession of the Council, and it will be possible in my next annual report to compare the results obtained in the two census years referred to. The following table shows for the registration county of London the condition of the population as to " overcrowding," etc., in tenements of under five rooms at the census of 1891 ; as the total area of the administrative county of London differs but slightly from that of the registration county as it existed in 1891 the figures relating to these areas at the two periods may, for this purpose, safely be compared. Census 1891.—Registration County of London; population, 4,211,743; total tenements, 937,606. Tenements with No. of tenements? Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No. of occupiers of such tenements. Percentage of population in such tenements. 1 room 172,502 18.4 386,489 9.2 2.24 56,622 214,843 5.10 2 rooms 189,707 20.2 688,942 16.4 1.82 54,872 330,238 7.84 3 „ 153,189 16.3 664,343 15.8 1.45 24,524 192,649 4.57 4 „ 115,171 12.3 593,378 14.1 1.29 9,495 92,035 2.19 Total 630,569 67.2 2,333,152 55.5 — 145,513 829,765 19.70 On comparing this table with the figures shown in the preceding table relating to the administrative county in 1901 it will be seen that so far as conclusions can be drawn from the figures a considerable improvement is manifest in the manner in which the people of Loudon were housed in the year 1901, compared with the previous census year. Thus the total number of tenements of less than five rooms has diminished in the county generally, and the diminution is particularly marked in the case of tenements of one room, and is wholly confined to tenements of one and two rooms. The total number of persons occupying tenements of one to four rooms shows some increase in the later period, although it is evident from the figures that the population is more favourably distributed with regard to house accommodation in 1901 than iu the earlier census year. Thus the number of persons occupying tenements of one room has considerably decreased, while the number of persons occupying tenements of two rooms shows but slight increase, the main increase being confined to that portion of the population occupying three and four rooms. The average number of persons per room has declined in the case of each class of tenements; here again, the greatest decline has been manifest in the case of the one.roomed tenements. In the case of " overcrowded " tenements it will be seen that both the total number of such tenements and the total number of persons occupying such tenements show a considerable reduction in the later census year compared with the former. The percentage of the population occupying such tenements has declined from 19'70 to 16'01, the decline being manifested in each class of tenement, but more especially in the case of tenements of one and two rooms. The figures indicate, therefore, that in London as a whole " overcrowding" in the sense here referred to, has declined during the last decade both in quantity and intensity. Marriages. The number of marriages in the administrative county of London in 1901 (52 weeks) was 40,010, giving: an annual rate of persons married of 17'6 per 1,000 living'. The marriage rate in successive periods has been as follows— 1851-60 20.6 1892 17.4 1897 18.5 1861-70 20.3 1893 17.2 1898 18.8 1871-80 19.0 1894 17.0 1899 18.6 1881-90 17.5 1895 17.2 1900 18.0 1891 17.7 1896 18.0 1901 17.6 The accompanying diagram (I.) shows the marriage rate in each year since 1850 in relation to the mean marriage rate of the period 1851.1901. In the year 1901 among the males 4.4 per cent, married were under 21 years of age, and among the females 15'0 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— 8 Marriages of minors per cent, of total marriages. Period. London. England and Wales. Males. Females. Males. Females. 1851.60 2.8 11.9 5.7 18.0 1861.70 3.6 14.6 6.8 20.1 1871.80 4.7 16..9 8.0 22.0 1881.90 5.5 18.9 6.8 20.7 1891 4.9 17.4 5.9 19.0 1892 5.2 17.7 5.9 18.7 1893 4.7 16.8 5.6 18.1 1894 4.7 16.8 5.5 18.1 1895 4.4 15.9 5.2 17.4 1896 4.9 16.1 5.3 17.4 1897 4.6 16.2 5.1 17.0 1898 4.8 16.3 5.1 16.8 1899 4.5 15.8 5.0 16.5 1900 4.5 15.5 5.1 16.3 Births. The number of births registered in the administrative county of London in 1901 (52 weeks) was 131,278, giving a birth rate of 29"0 per 1,000 living per annum ; this is the lowest birth rate recorded in London since civil registration began, and it is worthy of note in connection with the diminishing birth rate in London that although at the last census the population of registration London had increased 7.7 per cent, in the ten years 1891.1901 the number of children under 10 years of age had declined 1*8 per cent., a result to which the declining birth rate has no doubt contributed. The birth rate in successive periods has been as follows— 1851.60 33.6 1892 30.9* 1897 30.1* 1861.70 35.4 1893 31.0* 1898 297* 1871.80 35.4 1894 30.1* 1899 29.7* 1881.90 33.2 1895 30.6* 1900 29.1* 1891 31.8* 1896 30.2* 1901 29.0* The corresponding figures for England and "Wales are as follows— 1851.60 34.2 1892 30.4 1897 29.5 1861.70 35.2 1893 30.7 1898 29.3 1871.80 35.5 1894 29.6 1899 29.1 1881.90 32.5 1895 30.2 1900 28.7 1891 31.4 1896 29.6 1901 28.5 The accompanying diagram (II.) shows the London birth rate in each year since 1850 in relation to the mean birth rate of the period 1851.1901. I he following table shows the birth rate in the several metropolitan boroughs in per 1,000 persons living and per 100 married females aged 15.45— Metropolitan Boroughs. Births. Birth rate per 1,000 living. Births per 100 married femalei aged 15.45. Paddington 3,360 23.4 20.4 Kensington 3,603 20.4 20.0 Hammersmith 3,022 26.9 21.5 Fulham 4,596 33.3 23.3 †Chelsea 1,631 22.1 20.6 Westminster, City of 3,232 17.8 16.9 †St. Marylebone 4,008 30.2 27.5 Hampstead 1,481 18.0 17.5 St. Pancras 6,324 26.9 21.4 Islington 9,223 27.6 21.7 Stoke Newington 1,108 21.6 18.4 Hackney 6,344 28.9 23.9 †Holborn 1,675 28.4 24.4 †Finsbury 3,803 37.7 29.5 London, Citv of 365 13.7 16.2 * The rates for these years relate to the Administrative County of London; the rates shown lor years previous to 1891 relate to the Registration County of London. † Lying.in hospitals are situated in these district 9 Metropolitan Boroughs. Births. Birth.rate per 1,000 liviDg. Births per 100 married females aged 15—45. Shoreditch 4,102 34.7 27.5 Bethnal.green 4,608 35.6 28.4 *Stepney 11,092 37.2 29.4 Poplar 5,820 34.6 28.0 Southwark 6,875 33.4 25.2 Bermondsey 4,459 34.2 27.6 *Lambeth 9,104 30.2 24.0 Battersea 5,016 29.7 22.1 Wandsworth 6,110 26.2 21.5 Camberwell 7,303 28.2 23.2 Deptford 3,397 30.8 23.8 Greenwich 2,782 29.0 24.5 Lewisham 3,299 25.7 21.2 Woolwich 3,536 30.1 22.7 London 131,278 29.0 23.6 Deaths. The number of deaths in the administrative county of London in 1901 (52 weeks) was 77,6G3, giving an annual death rate of 171 per 1,000 living. The London death rate in successive periods has been as follows— All causes—Death rates per 1,000 living. 1841.50 24.8 1892 20.31 1898 18.41 1851.60 23.7 1893 21.01 1899 19.61 1861.70 24.4 1894 17.41 1900 18.61 1871.80 22.5 1895 19.51 1901 17.11 1881.90 20.5 1896 18.21 1891. 21.01 1897 17.81 The death rate in each year since 1840 in relation to the mean death rate of the period 1841.1901 is shown in diagram III. The following table has been prepared for the purpose of comparing the death rate of London with those of other English towns having populations which exceeded 200,000 persons at the census of 1901. 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," t published by the Registrar.General in the Annual Summary for 1901. Towns. Estimated population middle of 1901. Crude death rate per 1,000 living. Death rate per 1,000 living (corrected for age and sex distribution). 1891.1900. 1901. 1891.1900. 1901. London 4,544.983 19.62 17.62 20.9 18.8 Manchester 544,923 23.9 22.1 27.1 25.0 Liverpool 686,454 24.5 22.3 26.9 24.5 Birmingham 523,391 20.8 20.5 23.0 22.7 Leeds 430,575 20.2 19.3 22.4 21.4 Sheffield 382,269 20.8 20.4 23.1 22.7 Bristol 329,990 18.3 16.0 19.0 16.6 Nottingham 240,431 18.8 18.5 20.2 19.9 Bradford 280,163 18.9 16.8 21.5 19.1 Hull 241,753 19.6 18.6 20.6 19.5 Salford 221,563 24.0 21.7 27.0 24.4 West Ham 268,963 18.5 17.9 20.0 19.3 Leicester 212,537 18.3 15.9 19.9 17.3 Newcastle 215,972 21.3 21.9 23.2 23.9 London had, therefore (comparing the corrected death rates), a lower death rate than any of these towns in 1901, except Bristol and Leicester, and in the decennium, 1891.1900, a lower death.rate than that of any, except Bristol, Nottingham, Hull, West Ham and Leicester. * Lying.in hospitals are situated in these districts. † These factors are based upon the age and sex constitution of the leepective populations at the census of 1891, as the complete results of the census of 1901 are not yet available. The correction for aee and sex must therefore be regarded as approximate only. 1 These death rates are fully corrected for institutions, i.e., by the exclusion of deaths of persona not belonging to but occurring in institutions situated within London, and by the inclusion of deaths of persons belonging to but occurring in London institutions situated outside the administrative county. 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 Board's Hospitals within Kegistration London. [2] 10 The following table enables comparison to be made of the death rates of London with the death-rates of several foreign cities1— All causes—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 19.62 17.62 St. Petersburg 28.3 24.1 Paris 20.6 18.6 Berlin 19.0 18.0 Brussels 18.7 15.8 Vienna 22.3 19.7 Amsterdam 17.9 15.2 Rome 19.8 20.0 Copenhagen 18.8 18.1 New York 21.7 20.0 Stockholm 18.4 16.8 It will be seen that in the period 1891-1900 the London death rate was lower than that of any of these towns, except Brussels, Amsterdam, Copenhagen, Stockholm and Berlin, and in 1901 was lower than that of any except Brussels, Amsterdam and Stockholm. Rates of mortality in the several metropolitan boroughs. In previous annual reports I have published a " factor for correction for differences in the age and sex constitution of the population" for each of the sanitary areas of London, based upon the age and sex constitution of the respective populations as enumerated at the census of 1891. The recent census report provides the material for re-calculating these factors on the more recent data of 1901. The method of calculation is similar to that employed by the Registrar-General in dealing with the statistics of the large towns of England and Wales, and may be briefly described as follows— Given (1) Age and sex distribution of population of district A at last census ; (2) Death rate for each sex at each age period in England and Wales in the last decennium. To find factor for correcting the crude death rate of A for differences of age and sex distribution between A and England and Wales. Applying (1) to (2) gives standard death rate for A, say x, i.e., a death rate which would be correct on the assumption that the rates of mortality at each age-period and for each sex were indentical with the mean rates in England and Wales in the last decennium. The difference between x and the death rate for England and Wales, say y, will on the above assumption be entirely due to differences in the age and sex constitution of the two populations concerned, and -j will therefore represent the factor for correcting the crude death rate of A. The new series of factors thus calculated relate to the several metropolitan boroughs, those previously used in my annual reports related to the sanitary areas of London as they existed prior to the London Government Act of 1899. It would be interesting to compare the present series of factors with those previously used, but owing to the changes in area consequent upon the operation of the new Act it is impossible to compare the factors for all the areas involved, in this manner. The following table, however, enables comparison to be made in the case of several districts, the areas of which have been but slightly altered by the Act of 1899— Area. 1891 factor. 1901 factor. Kensington 1.10184 1.06710 Hammersmith 1.06094 1.04144 Fulham 1.04817 1.04623 St. Marylebone 1.07464 1.07466 Hampstead 1.15153 1.12378 St. Pancras 1.07043 1.05350 Islington 1.06983 1.03670 Hackney 1.04645 1.03610 City of London 1.15015 1.21944 Shoreditch 1.03794 1.02042 Bethnal-green 1.04133 1.01190 Poplar 1.03569 1.01529 Lambeth 1.04989 1.03199 Battersea 1.07584 1.07403 Wandsworth 1.06804 1.04323 Camberwell 1.05801 1.03316 London 1.06626 1.05107 The table shows that the changes in the " factors for correction" have all been in the same direction with the single exception of that relating to the City of London ; in 1 All death-rates in this report relating to foreign cities are calculated upon figures published by the Registrar-General. 2 See footnote (.), page 9. 11 other words each, of the factors for 1901, with the exception mentioned, are nearer unity than the corresponding factors for 1891. The following table shows the crude death rates and the death rates corrected for differences in the age and sex constitution of the several metropolitan boroughs during the year 1901— Crude and corrected death rates1, per 1,000 persons living, in the County of London and the several metropolitan boroughs. District. Standard death rate. Factor for correction for age and sex distribution. Crude death rate, 1901. Corrected death rate, 1901. Comparative mortality figure, 1901 (London, 1,000). England and Wales 18.19 — — — — London 17.31 1.05107 17.1 18.0 1,000 Paddington 1710 1.06398 14.3 15.2 844 Kensington 17.05 1.06710 15.2 16.2 900 Hammersmith 17.47 1.04144 170 17.7 983 Fulham 17.29 104623 15.8 16.5 917 Chelsea 18.76 0.96983 16.6 161 894 Westminster, City of 15.46 1.17684 160 18.8 1,044 St. Marylebone 16.93 1.07466 16.6 17.8 989 Hampstead 1619 1.12378 10.6 11.9 661 St. Pancras 17.27 1.05350 18.3 19.3 1,072 Islington 17.55 1.03670 160 16.6 922 Stoke Newington 17.42 1.04443 13.2 13.8 767 Hackney 17.56 1.03610 15.8 164 911 Holborn 1611 1.12936 201 22.7 1,261 Finsbury 16.83 1.08105 21.4 231 1,283 City of London 14.92 1.21944 201 245 1,361 Shoreditch 17.83 1.02042 21.9 22.3 1,239 Bethnal.green 17.98 1.01190 20.3 20.5 1,139 Stepney 17.29 1.05228 20.9 220 1,222 Poplar 17.92 1.01529 20.0 20.3 1,128 Southwark 17.29 1.05228 21.5 22.6 1,256 Bermondsey 17.60 1.03375 20.9 21.6 1,200 Lambeth 17.63 1.03199 17.2 17.8 989 Battersea 16.94 1.07403 16.4 17.6 978 Wandsworth 17.44 1.04323 13.4 140 778 Camberwell 17.61 1.03316 16.5 170 944 Deptford 17.31 1.05107 16.5 17.3 961 Greenwich 17.84 1.01984 15.2 15.5 861 Lewisham 17.64 1.03141 130 13.4 744 Woolwich 1700 1.07024 14.6 15.6 867 It will be observed on comparing the " factors for correction" that the most marked differences of age and sex distribution occur between the population of Chelsea* (factor "96983) and that of the City of London (factor 1'21944). The following table shows the constitution of these two populations as regards age and sex— Population at each age.period and for each sex, per cent, of total population. Area. Sex. All ages. 0. 5. 10. 15. 20. 25. 35. 45. 55. 65. 75 & up. Chelsea M 44.5 4.2 3.8 4.1 3.8 4.3 7.5 6.0 4.5 3.4 2.1 0.8 F 55.5 4.2 3.8 3.7 4.7 6.6 11.7 7.9 5.7 3.8 2.3 1.1 City of London M 51.4 2.9 2.8 4.8 7.7 8.5 9.0 6.4 4.9 2.9 1.2 0.3 F 48.6 2.7 30 3.4 5.4 7.0 9.2 6.7 5.0 3.4 2.0 0.8 1 All death.rates in tbis report relating to Metropolitan Boroughs are fully corrected for institutions (see footnote ('), page 9. * The somewhat abnormal age.constitution of the Chelsea population is largely accounted for by the fact that it includes the population of St. George, Hanover.square Union Workhouse and Infirmary, the inmates of which, excluding the officials and their families, numbered 2,214 at the census of 1901. For the purpose of calculating a factor for age and sex correction, this population should be deducted from the total Chelsea population, as the inmates of these institutions are drawn from the population included in the St. George, Hanover.square Union, which does not include any portion of the borough of Chelsea. At a later date, when I hope to be in possession of the figures showing the age and sex distribution of the 2,214 persons residing in the institutions in question, I shall be able to publiih a corrected factor for Chelsea. 12 The following table shows the number of deaths1 occurring at several ages in each of the metropolitan boroughs of the administrative county during the year 1901 (365 days)— Age.period. 0. 1. 2. 3. 4. Under 5. 5. 10. 15. 20. 25. 35. 45. 55. 65. 75. 85. All ages. Paddington 458 90 47 31 25 651 36 25 24 37 118 174 203 258 269 188 85 2,068 Kensington 586 156 63 45 27 882 41 29 41 53 149 237 281 334 304 264 73 2,688 Hammersmith 513 123 40 26 28 735 59 23 32 43 104 142 183 181 208 171 48 1,920 Fulham 706 157 51 43 26 983 71 35 36 46 129 175 190 180 183 143 23 2,194 Chelsea 233 71 15 15 5 339 21 7 14 21 76 110 133 157 194 147 37 1,256 Westminster, City of 445 132 52 29 17 675 40 22 38 80 190 330 394 410 404 288 63 2,934 St. Marylebone 429 107 37 31 19 623 28 23 38 52 144 204 264 299 279 203 54 2,211 Hampstead 154 46 23 7 5 235 21 21 14 37 56 62 89 111 100 108 36 890 St. Pancras 972 245 104 70 58 1,449 102 51 83 91 2.29 401 470 493 495 348 92 4,304 Islington 1,300 324 158 95 63 1,940 123 55 92 122 317 452 514 634 604 448 103 5,404 Stoke Newington 127 36 11 9 2 185 16 10 15 15 38 52 61 79 89 85 27 672 Hsckney 862 201 90 72 49 1,274 91 41 67 86 187 248 327 391 370 316 79 3,477 Holborn 2u8 60 13 22 9 312 21 16 20 25 82 152 164 148 144 78 22 1,184 Finsbury 539 176 60 37 21 833 46 23 38 45 126 199 221 223 226 139 31 2,150 London, City of 65 17 7 4 6 99 8 4 15 11 31 61 67 84 84 58 11 533 Shoreditch 810 225 81 38 •25 1,179 45 29 41 52 140 184 248 261 238 167 20 2,607 Bethnal.green 702 227 86 53 35 1,103 65 25 41 62 143 196 264 245 261 189 41 2,635 Stepney 1,819 524 171 117 59 2,690 124 80 102 132 336 571 613 576 58S 362 79 6,251 Poplar ... 968 270 114 57 37 1.446 84 60 43 87 180 259 296 336 346 216 39 3,392 South wark 1,150 361 140 86 55 1,792 101 51 69 9*2 260 400 447 498 409 235 61 4,415 Bermondsey ... 751 237 82 53 38 1,161 72 35 43 64 154 230 221 280 231 182 35 2,708 Lambeth 1,268 317 127 87 50 1,849 116 56 88 112 335 439 476 600 606 423 119 5,219 Battersea 823 2.28 84 52 34 1,2.21 63 32 44 64 164 229 231 293 253 155 34 *2,783 Wandsworth 812 196 70 46 32 1,156 70 36 50 70 181 255 279 323 353 295 92 3,160 Camberwell 1,025 283 157 90 57 1,612 156 60 82 89 217 33.2 400 413 491 350 95 4,297 Deptford 493 131 55 20 25 7*29 52 27 25 4*2 85 127 18.2 193 19.2 134 34 1,822 Greenwich 367 98 48 31 12 556 39 25 25 24 91 |102 121 160 151 135 38 1,467 Lewisham 433 96 39 15 13 596 44 17 29 4t 79 118 156 159 237 164 40 1,683 Woolwich 462 81 18 21 12 594 37 22 36 52 14.2 171 164 181 185 116 25 1,725 London 19485 5,220 2,018 1,302 814 28,899 1,792 940 1,283 1,750 1.483 6,612 7.659 8,500 3,492 6.107 1,536 78.058 London mortality in 1901 compared with the mortality in, the decennium 1891.1900. The following table shows the mean death rates obtaining in London at the several age. periods and for each sex in the ten years 1891.1900 and in the year 1901. The figures for the year 1901 are fully corrected for institution deaths (see footnote (*)» page 9), and the rates for the period 1891.1900 are based upon figures which have been corrected for institution deaths on the basis of the experience of the four years 1897.1900 ; a fuller discussion of this point will be found in the appen'ded London Life Table (see appendix I., page 2).* Age.period. Males. Females. Mean death rate 1891.1909, Mean death rate 1901. Difference per cent. Mean death rate 1891.1900. Mean death rate 1901. Difference per cent. 0 71.97 62.50 132 61.99 53.90 13.1 5 4.97 4.03 18.9 5.17 4.05 21.7 10 2.46 2.19 11.0 2.48 2.28 8.1 15 3.47 3.12 10.1 2.94 2.72 7.5 20 4.59 4.53 1.3 3.46 2.92 15.6 25 7.36 6.40 13.0 5.65 4.79 15.2 35 14.22 12.84 9.7 10.68 9.65 9.6 45 23.14 21.53 7.0 17.12 15.76 7.9 55 40.68 37.94 6.7 31.01 28.23 9.0 65 77.78 71.55 8.0 63.44 58.38 8.0 75 154.13 144.38 6.3 134.56 121.97 9.4 85 and upwards 284*10 278.51 2.0 265.77 256.16 3.6 All ages. 20.88 18.69 10.5 17.88 15.81 11.6 This table shows that the rate of mortality in 1901 was considerably lower than that of the period 1891.1900 at each age.period of life and for each sex. It appears probable from an examination of the figures shown for 1901 that the death rate among males aged 20.25 is somewhat overstated; the explanation of this may probably be found in the fact that a considerable number of healthy young men at these ages were serving with the army in South Africa at the date of the last census. It will be seen from the table that the death rate in 1901 among males * This life.table is based on t're population of London as enumerated in 1891 and 1901, and the deaths occurring in the decennium 1891.1P00. It has been calculated by the method of " finite differences," and the series used for interpolation (R?e page 7) are those which Dr. Hayward, medical officer of health of Haydock, in a paper published in the Journal of the Royal Statistical Society (Vol. LXII., Parts III. and IV.), recommended as giving the most consistent results. 1 See footnote (') page 9. 13 aged 20.25 more nearly approaches the death rate obtaining in the period 1891.1900 than does the death rate among females at the same age.period. 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," the method adopted being similar to that employed by Dr. Tatham in a report on the health of greater Manchester for the period 1891.3. The advantages of this method and the formula used are set out in some detail in the appended London life table previously referred to (pages 18 and 19). It will be seen from the description therein contained that in order to apply this method of comparison it is necessary in the first place to ascertain from the "life table" the mean future lifetime of males and females in groups of ages corresponding to those age.groups to which the deaths relate. The following table shows the results thus obtained from the London life table, 1891.1900— Table I. Mean future lifetime of males and. females in groups of ages (calculated from London life tables, 1891.1900). Age.groups. Males. Females. Age groups. Males. Females. Years. Years. Years. Years. 0- 50.16 53.66 35— 23.98 26.89 5— 49.89 53.48 45— 17.75 20.04 10— 45.61 49.30 55— 12.35 13.93 15— 41.26 44.94 65— 7.98 8.90 20— 37.05 40.62 75— 4.91 5.37 25— 31.05 34.39 85 and upwards 3.02 3.19 In the following table the number of deaths occurring in the year 1901 at each age.period and for each sex is compared with the number of deaths which would have occurred had the death rates of the period 1891.1900 been maintained in the year 1901. The number of lives gained in the latter period is also shown, and the figures in the last column of the table express this gain in terms of " life capital," these being obtained by applying the mean future lifetime figures given in Table I. to the number of lives gained at each age.group. Table II. Age.groups. Deaths calculated according to mean rates of 1891.1900. Deaths occurring in the year 1901. Gain (+) or loss (—) of lives in the year 1901 by fluctuations of mortality. Gain (+) or loss (—) of " life capital" in the year 1901 by fluctuations of mortality. Males. 0— 17,875 15,523 + 2,352 + 117,976 5— 1,097 890 + 207 + 10,327 10— 512 456 + 56 + 2,554 15— 726 654 + 72 + 2,971 20— 999 987 + 12 + 445 25— 2,739 2,381 + 358 + 11,116 35— 3,999 3,611 + 388 + 9,304 45— 4,526 4,212 + 314 + 5,573 55— 4,838 4,513 + 325 + 4,014 65— 4,286 3,943 + 343 + 2,737 75— 2,630 2,464 + 166 + 815 85 and upwards 496 486 + 10 + 30 "All ages" 44,723 40,120 + 4,603 + 167,862 Females. 0— 15,383 13,376 + 2,007 + 107,696 5— 1,152 902 + 250 + 13,370 10— 526 484 + 42 + 2,071 15— 686 634 + 52 + 2,337 20— 903 763 + 140 + 5,687 25— 2,478 2,102 + 376 + 12,931 35— 3,321 3,001 + 320 + 8,605 45— 3,744 3,447 + 297 + 5,952 55— 4,380 3,987 + 393 + 5,474 65— 4,943 4,549 + 394 + 3,507 75— 4,019 3,643 + 376 + 2,019 85 and upwards 1,089 1,050 + 39 + 124 " All ages" . 42,624 37,938 + 4,686 + 169,773 Total 87,347 78,058 + 9,289 +337,635 During the year 1901, therefore, compared with the average annual mortality of the decennium 1891.1900, there has been a saving of 9,289 lives, representing a gain to the community of 337,635 years of " life capital." 14 Infant mortality. The deaths of children under one. year of age in the administrative county of London during 1901 (52 weeks) numbered 19,412, being in the proportion of 148 per 1,000 births. The proportion in each year since 1890 has been as follows— Year. Deaths under one year per 1,000 births. 1891 1531 1892 1541 1893 1631 1894 1431 1895 1651 1896 1601 1897 1581 1898 1661 1899 1661 1900 1581 1901 1481 The following table enables comparison to be made of the infant mortality in London and other large English towns— Deaths under one year of age per 1,000 births. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 1602 1492 Nottingham 183 193 Manchester 190 199 Bradford 171 168 Liverpool 191 188 Hull 179 175 Birmingham 187 187 Salford 204 204 Leeds 179 188 West Ham 167 171 Sheffield 185 2 Leicester 195 175 Bristol 147 131 Newcastle 174 178 London had therefore, in the period 1891-1900 and in 1901, a lower infant mortality than anv of these towns excent Bristol. The following table shows the deaths under one year of age and the number of these deaths per 1,000 births in each of the metropolitan boroughs— Metropolitan boroughs. Deaths under one year of pge, 1901. Deaths under one year of age per 1,000 births, 1901. Paddington 457 136 Kensington 587 163 Hammersmith 507 168 Fulham 700 152 Chelsea 225 138 Westminster, City ot 435 135 St. Marylebone 427 107 Hampstead 154 104 St. Pancras 973 154 Islington 1,291 140 Stoke Newington 127 115 Hackney 855 135 Holborn 208 124 Finsbury 539 142 London, City of 64 175 Shoreditch 810 197 Bethnal-green 704 153 Stepney 1,811 163 Poplar 959 165 Southwark 1,153 168 Bermondsey 754 169 Lambeth 1,268 139 Battersea 817 163 Wandsworth 809 132 Camberwell 1,036 142 Deptford 496 146 Greenwich 362 130 Lewisham 427 129 Woolwich 457 129 London 19,412 1481 1 See footnote (1), page 9. 2 See footnote (2), page 9. 15 The infant mortality in London during the first quarter of the year 1901 was 126, during the second quarter 112, during the third quarter 203, and during the fourth quarter 152. Of the several metropolitan boroughs Shoreditch had the highest (197), and Hampstead the lowest infant mortality (104). During the year the infant mortality was highest in the eastern group of districts (167) and lowest in the northern group (134). Deaths from several classes of disease. Deaths from the several classes of disease registered in the county of London (including the lunatic asylums and hospitals for infectious disease belonging to the county) are given by the Registrar-General in the Annual Summary of Births, Deaths and Causes of Deaith, and the following table has been prepared from the figures contained in the summary relating to the year 1901— Causes of death. Corrected annual average 1891-1900. 1901. Zymotic diseases 14,950 11,805 Parasitic „ 59 45 Dietetic „ 679 750 Constitutional diseases 17,152 16,361 Developmental „ 5,821 5,963 Nervous „ 8,874 7,872 Diseases of organs of special sense 185 175 Diseases of the circulatory system 7,232 7,361 Respiratory diseases 17,869 14,892 Diseases of the Digestive system 5,513 5,148 ,, ,, Lymphatic „ 117 148 „ „ Urinary 2,420 2,558 ,, ,, Generative „ 547 471 „ „ Locomotive „ 273 204 „ „ Integumentary system 324 345 Violence ("accident) 3,000 2,834 Violence (other than accident) 536 585 Other causes 2,919 2,407 All Causes 88,470 79,9241 The following table gives more detailed information concerning the principal diseases included in the constitutional, nervous, and respiratory groups— Causes of death. Corrected annual average 1891-1900. 1901. Rheumatic fever, rheumatism of heart 396 366 Rheumatism 105 88 Gout 154 126 Rickets 277 224 Cancer 3,843 4,203 Tabes mesenterica 1,124 818 Tubercular meningitis 1,223 1,113 Phthisis 8,291 7,735 Scrofula, tuberculosis 1,033 948 Other constitutional diseases 706 740 Apoplexy 2,249 2,278 Epilepsy 384 364 Convulsions 1,978 1,536 Other diseases of the brain and nervous system 4,263 3,694 Croup 166 39 Bronchitis 9,679 7,317 Pneumonia 6,342 6,121 Pleurisy 310 285 Other diseases of the respiratory system 1,372 1,130 More exact comparison can be made of certain causes of death in London sanitary districts by reference to the following table. The death rates shown in the table are fully corrected for deaths in institutions (see footnote (1), page 9), but are uncorrected for differences in age and sex distribution. In my next annual report it will be possible to publish the death rates for some of these diseases corrected for differences in the age and sex constitution of the populations of the several metropolitan boroughs. 1 See footnote (2), page 9. 16 Death.rates1 per 100,000 living, from all causes and from various causes in each of the Metropolitan Boroughs, 1901 (365 days). Metropolitan Boroughs. Measles. Rheumatic fever. Cancer. Tabes mesenterica. Tubercular meningitis. Phthisis. Other tubercular diseases. Pneumonia. Other respiratory diseases. All other causes. All causes. Paddington 5 6 103 12 23 110 16 97 177 885 1,434 Kensington 42 6 112 11 19 137 10 100 177 906 1,520 Hammersmith 38 12 84 16 27 140 16 101 194 1,085 1,713 Fulham 27 5 88 14 20 137 20 136 173 965 1,585 Chelsea 14 8 91 11 23 168 12 131 240 1,003 1,701 Westminster, City of 33 10 83 10 16 187 13 118 220 917 1,607 St. Marylebone 7 5 104 8 22 182 23 12U 217 974 1,662 Hampstead 1 4 96 13 24 94 13 66 84 686 1,081 St. Pannras 29 11 88 14 25 184 14 153 179 1,132 1,829 Islington 48 4 91 16 18 152 17 116 179 970 1,611 Stoke Newine'ton 18 12 92 12 29 134 14 82 158 758 1,309 ...... . o Hackney 45 8 80 25 24 148 27 98 148 979 1,582 Holborn 37 3 100 15 25 277 12 157 279 1,094 1,999 Finsbury 49 4 78 18 30 223 22 185 281 1,233 2,123 London, City of 4 15 128 11 45 210 15 173 218 1,180 1,999 Shoreditch 63 9 81 32 36 215 30 180 291 1,263 2,200 Bethnal . green 68 12 86 17 28 216 21 183 254 1,146 2,031 Stepney 55 7 73 24 27 210 31 188 239 1,237 2,091 Poplar 52 7 73 28 25 180 19 142 258 1,224 2,008 Son th wark 79 11 86 24 24 248 28 199 245 1,196 2,140 Bermondsey Lambeth 60 40 8 11 67 99 27 21 31 22 176 166 33 21 237 139 226 193 1,208 1,013 2,073 1,725 Battersea 78 8 81 15 20 147 26 145 178 945 1,643 Wandsworth 28 10 89 15 20 115 16 95 112 851 1,351 Camberwell 58 8 97 18 18 146 18 109 178 1,003 1,653 Deptford Greenwich 46 8 81 17 25 119 19 111 189 1,032 1,647 57 6 70 19 21 116 22 103 135 976 1,525 Lewisham 25 9 95 13 12 90 14 76 110 866 1,310 Woolwich 19 7 71 14 14 175 21 84 129 932 1,466 London 43 8 88 18 23 165 20 133 193 1,026 1,717 Principal Epidemic Diseases. The number of deaths in the administrative county of London from the principal epidemic diseases, viz., smallpox, measles, scarlet fever, diphtheria, typhus, enteric and ill.defined fevers and diarrhoea, during 1901 (52 weeks) was 10,107, giving an annual death rate of 2.22 per 1.000 livinc. The death rates in each year since 1890 have been as follows— Year. Death rate from principal epidemic diseases.###] 1891 2.271 1892 2.801 1893 3.041 1894 2.651 1895 2.621 1896 3.111 1897 2.581 1898 2.801 1899 2.491 1900 2.231 1901 2.221 It will be seen from the following table that London, in the period 1891.1900 had a lower death rate from these diseases than any of the undermentioned towns, except Leeds, Bristol, Nottingham, Bradford and Newcastle, and 'in 1901 a lower death rate than any, except Bristol and Bradford. Principal epidemic diseases—Death rates per 1,000 living. Towns. 1891.1900. 1901. Towns. 1891.1900. 1901.###] London 2. 712 2.252 Nottingham 2.56 2.86 Manchester 3.38 3.43 Bradford 2.22 1.86 Liverpool 3.32 3.66 Hull 3.02 3.24 Birmingham 2.89 3.16 Salford 4.30 4.28 Leeds 2.71 3.14 West Ham 3.31 4.11 Sheffield 3.33 4.10 Leicester 3.20 2.58 Bristol 1.96 1.67 Newcastle 2 32 2150 1 See footnote (1), page 9. 1 See footnote (2), page 9. Diagram iv Smallpox. 17 The following table shows that the London death rate from the first six of these principal epidemic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping cough and fever was, in 1891-1900, higher than that of any of these towns except St. Petersburg, and in 1901 was higher than that of any except St. Petersburg and New York. Six principal epidemic diseases—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 1.932 1382 St. Petersburg 3.35 3.14 Paris 10.7 0.94 Berlin 1.30 1.12 Brussels 0.97 0.60 Vienna 1.54 0.92 Amsterdam 0.87 0.58 Rome 1.25 0.78 Copenhagen 1.28 1.26 New York 1.66 1.45 Stockholm 1.73 0.98 The death rates from the principal epidemic diseases in the several metropolitan boroughs in 1901 are shown in the following table— Metropolitan borough. Deaths in 1901. Death rate per 1,000 living. Metropolitan borough. Deaths in 1901. Death rate per 1,000 living. Paddington 249 1.73 Shoreditch 354 2.99 Kensington 321 1.83 Bethnal-green 372 2.88 Hammersmith 323 2.86 Stepney 761 2.54 Fulham 389 2.81 Poplar 514 3.04 Chelsea 97 1.31 Southwark 620 3.02 Westminster, City of 245 1.34 Bermondsey 377 2.90 St. Marylebone 219 1.65 Lambeth 649 2.15 Hampstead 81 1.02 Battersea 465 2.76 St. Pancras 563 2.39 Wandsworth 362 1.55 Islingtou 662 1.97 Camberwell 631 2.44 Stoke Newington 65 1.28 Deptford 274 2.48 Hackney 471 2.15 Greenwich 209 2.17 Holborn 135 2.28 Lewisham 211 1.65 Finsbury 279 2.78 Woolwich 178 1.51 London, City of 28 1.06 London 10,107 2.221 The eastern group of districts had the highest mortality from the principal epidemic diseases in 1901, viz., 2.82 per 1,000 living, and the northern groups the lowest (1.95). Among the metropolitan boroughs, Poplar had the highest death rate (3.04) and Hampstead the lowest (1.02). Smallpox and Vaccination. The deaths from smallpox in the administrative county of London numbered 229 in 1901, and 4 deaths were attributed to cownox and effects of 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 1895 0.0121 1861-70 0.28 1896 0.0021 1871-80 0.46 1897 0.0041 1881-90 0.14 1898 o.ooo1 1891 — 1899 o.oo11 1892 0.0071 1900 o.oo11 1893 0.0401 1901 0.0511 1894 0.0201 In this table where — is inserted no deaths occurred. 1 See footnote (1), page 9. * See footnote 2'), page 9. [3] 18 The smallpox death rate in each year since 1840 in relation to the mean smallpox deulh rate of the period 1841-1901 is shown in diagram IV. During the complete years 111 which the notification of infectious diseases has been obligatory, the number of cases of smallpox notified to the medical officers of health in the various sanitary districts comprised in the administrative county has been as follows— Year. Cases notified. Case rate per 1,000 living. 1890 6O 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 1897 104 0.023 1898 33 0.007 1899 29 0.006 1900 86 0.019 1901 1,700 0.375 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 1891-1900 the London rate was exceeded by the death rate of Birmingham, Bristol, Bradford, Hull and West Ham, while in 1901 the London death rate was considerably higher than those of Liverpool, West Ham and Newcastle; no deaths from this disease being registered in any of the other towns shown in the table. Smallpox death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.011 0.051 Nottingham 0.00 - Manchester 001 — Bradford 0.07 — Liverpool 001 0.01 Hull 0.08 — Birmingham 005 — Salford 0.01 — Leeds 001 — West Ham 0.05 0.01 Sheffield 000 — Leicester 0.01 — Bristol 002 - Newcastle 0.00 0.00 In this table 0 00 indicates that the deaths were too few to give a rate of 0.005 ; where no dea'.h occurred — is inserted. If the London smallpox death rate be compared with the death rates of the following large foreign towns it will be seen that in the period 1891-1900 the London rate was exceeded by the rates of Paris, Brussels, St. Petersburg, Vienna and New York, and in 1901 by the rates of Paris and New York. Smallpox death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.011 0.051 St. Petersburg 0.12 0.04 Paris 0.03 0.16 Berlin 0.00 0.00 Brussels 0.08 0.00 Vienna 0.03 0.00 Amsterdam o.oo — Rome 0.00 0.00 Copenhagen 0.00 — New York 0.02 0.12 Stockholm 0.00 — In this table O.OO indicates that the deaths were too few to give a rate of 0'005; where U3 death occurred — is inserted. By the courtesy of the President of the Imperial Board of Health of Germany, I have been permitted to reproduce diagrams (see Chart B) showing the death rates from smallpox for a series of years in several of the European towns mentioned in the above table. These diagrams were originally published in a work entitled " Blattern und Schutznockenimpfung" Berlin. 1900. ihe tollowing table shows the death rate irom smallpox in 1901 and the case rates for 1901 and the decennium 1891-1900 in the several metropolitan boroughs included in the administrative county— 1 See footnote (2), page 9. Diagram shewing mortality from Smallpox in principal Towns of Europe. VIENNA. 19 Metropolitan borough. Cases, 1901. Case-rate per 1,000 living. Deaths, 1901. Death-rate per 1,000 living. 1901. 1891-1900. 1901. Paddington 21 0.1 0.1 Kensington 14 0.1 0.1 1 0.01 Hammersmith 45 0.0 0.4 15 0.13 Fulham 16 0.1 0.1 3 0.02 Chelsea 5 0.1 0.1 1 0.01 Westminster, City of 100 0.1 0.5 16 0.09 St. Marylebone 79 0.4 0.6 7 0.05 Hampstead 7 0.0 0.1 2 0.02 St. Pancras 256 0.1 1.1 41 0.17 Islington 62 0.1 0.2 8 0.02 Stoke Newington 19 0.1 0.4 3 0.06 Hackney 41 0.1 0.2 5 0.02 Holborn 216 0.3 3.7 30 0.51 Finsbury 93 0.1 0.9 7 0.07 London, City of 8 0.1 0.3 2 0.08 Shoreditch 18 0.1 0.2 5 0.04 Bethnal-green 32 0.2 0.2 2 0.02 Stepney 161 0.2 0.5 22 0.07 Poplar 71 0.2 0.4 10 0.06 Southwark 89 0.1 0.4 14 0.07 Bermondsey 107 0.2 0.8 14 0.11 Lambeth 50 0.1 0.2 4 0.01 Battersea 53 0.1 0.3 2 0.01 Wandsworth 32 0.0 0.1 3 0.01 Camberwell 54 0.1 0.2 7 0.03 Deptford 4 0.1 0.0 1 0.01 Greenwich 11 0.2 0.1 3 0.03 Lewisham 12 0.0 0.1 — — Woolwich 23 0.2 0.2 1 0.01 Port of London 1 — — — — London 1,700 0.1 0.4 229 0.051 In this table where — is inserted no death occurred. The central group of districts had the highest mortality from smallpox during the year 1901, viz., 1.21 per 1,000 living, and the southern group the lowest (0 03). Among the metropolitan boroughs Holborn had the highest death rate (0'51), no deaths from this disease being registered in Lewisham and Paddington. During the first quarter of the year no deaths from this disease were registered in London; during the second quarter of the year the deaths were too few to give a death rate of 0.005 per 1,000 living; during the third quarter of the year the death rate was 0 03 per 1,000 living, and during the fourth quarter the death rate rose to 0.17. The number of cases of smallpox notified in each week of the year 1901 in London will be seen on reference to the following table— Smallpox—Notified cases, 1901. Week ended No. of cases notified. Week ended No. of cases notified. Week ended No. of cases notified. January 5 May 11 1 September 7 27 ,, 12 — ,, 18 — „ 14 53 ,, 19 — ,, 25 — „ 21 37 ,, 26 3 June 1 1 „ 28 39 February 2 1 ,, 8 — October 5 44 ,, 9 — „ 15 1 ,, 12 28 ,,16 2 ,, 22 1 ,, 19 48 ,, 23 — „ 29 2 ,, 26 54 March 2 — July 6 5 November 2 173 ,, 9 — ,, 13 5 ,, 9 64 ,, 16 — ,, 20 8 ,, 16 104 ,, 23 — ,, 27 1 „ 23 140 ,, 30 1 August 3 3 „ 30 105 April 6 — „ 10 5 December 7 163 ,, 13 — „ 17 7 „ 14 117 ,, 20 — „ 24 22 „ 21 161 ,, 27 — „ 31 60 ,, 28 213 May 4 1 The foregoing table includes every case of illness notified as "smallpox." The annual report of the Statistical Committee of the Metropolitan Asylums Board states that of the total number of cases originally certified in London as "smallpox" and removed to the wharves the cases incorrectly diagnosed amounted to 13"3 per cent, of the total. 1 See foo jtnote (1) page 9. 20 In my last aniiual report I gave account of the occurrences of smallpox in London in 1900, the last cases (two domestic servants) occurring in Chelsea and Fulham in November of that year, and being traceable to the illness of their master who suffered from "blood-poisoning two days after his return from Paris. It is not yet possible to discuss in any complete manner the whole of the outbreak which extended into the summer of 1902, but the manner in which the disease became diffused in London, causing some 1,700 cases in the year, may at once be stated. From November, 1900, no cases of smallpox are known to have occurred in London until the week ending the 26th January, 1901, and the following history, for which I am largely indebted to the reports of medical officers of health and weekly memoranda of the Metropolitan Asylums Board, contains particulars of the cases up to the time when the disease became general in Loudon. In that week there were notified two cases, one that of a girl having a Polish name, resident in Stepney; the other a patient in Kensington, who was incubating the disease at the time of his return from Paris. No further cases occurred until the week ending the 16th February, when a case was reported in Wandsworth, that of a steward from a ship on which two cases of smallpox had occurred during the voyage. Smallpox was not known to have occurred again in London until the week ending the 30th March, when a woman was attacked in Fulham. Mr. Jackson states that her husband three weeks before had suffered from smallpox, but that the nature of his malady had not been recognised. The source of his infection could not be ascertained. The next case was notified in Bethnal-green in the week ending the 11th May, a domestic servant who had not left her home for six weeks. Dr. Bate, who saw the patient, regarded the diagnosis of smallpox as doubtful. No case was subsequently heard of in London until the week ending the 1st June, when a lady who had just arrived in Islington from Egypt, developed smallpox. The next case was a child aged three years, in Stepney, whose illness was notified in the week ending the 15th June; then a nurse in St. Marylebone, notified in the week ending 22nd June, who appears to have been infected by a young American returning from Paris, and the nature of whose illness was not at the time recognised. In the next week ending 29th June, a case was notified in Hackney, a carman who fetched linen from the customers of a laundry. Up to this date there had been no known extension of the disease from any of the cases of notified smallpox, but the carman infected three persons in his own family, and a woman who sorted the linen and who was also attacked, infected two members of her family. The same week the Hackney carman's case was notified, four cases were notified in Wandsworth. Dr. Caldwell Smith, having been informed that a Mrs. B., who had been staying in Streatham, had developed smallpox, instituted inquiry as to the circumstances of this case in London. He found that she had been infected by a Mr. W., who, after arrival from Paris, had died of unrecognised smallpox in the house in which she had been staying, and that Mr. W.'s wife had suffered from "influenza." Another visitor was then removed from the house suffering from smallpox and a third visitor was found to have suffered near Loughborough from what was called malignant chicken-pox, and finally two girls who worked in the laundry to which the linen of this house was sent suffered from smallpox in their homes, together with a third girl who was infected by one of them. The completeness of the measures taken prevented any further extension of the disease. In addition to cases belonging to the Hackney and Wandsworth groups mentioned above, one case was notified in St. Marylebone. The St. Marylebone case was that of a clerk who, with a servant whose ilness was notified the following week, was associated with a case in Paddington notified in the week ending the 20th July. Another case in Paddington notified in the week ending the 20th July was a woman who had arrived from Texas on the 27th June and who was erroneously thought for some time to be suffering from enteric fever. In the week ending 27th July there was notified in Hammersmith a woman employed at the premises of a disinfector at whose works infected articles are disinfected for the sanitary authorities of Kensington and Chiswick. The inmates of this patient's house were offered but declined vaccination, and her daughter was attacked the following week and her son a week later. In the same week as the son's attack (week ending the 3rd August) a woman living in Westminster, whose husband was a tailor, suffered from smallpox. The source of infection could not be ascertained. There was also attacked a man in Hackney whose sister lived next door to the workers at the laundry who were attacked in July. In the following week (ending the 10th August) a young man was removed from a hotel in St. Marylebone, and a young man in Wandsworth, who had been infected in Paris. The history of cases of smallpox in London gave no reason for thinking that up to this time the steps which had been taken in the several metropolitan boroughs to prevent the general extension of the disease had not proved sufficient for the purpose, but the occurrence of certain cases of smallpox in St. Pancras at this time was followed by rapid diffusion of the disease. Three cases of smallpox were notified in that district on 2nd August. Two of them were those of women living in a house in Tottenham-street. Their illness, which was recognised at the Middlesex Hospital to be smallpox, had been preceded by the illness of their sister a fortnight before, her malady having been thought to be chicken-pox; she was a girl 17 years of age, a sorter of dirty linen at a laundry received from hotels and boarding-houses in the W.C. district. A case was also notified in Huntley-street on the 9th August. In the same week the case of a man living in Portpool-lane, Holborn, was notified. He was believed to have contracted his disease at a working men's club near the Holborn Town Hall. There were also notified thd case of a boy in Hackney, who visited on the 28th July the man in Hackney referred to above; the case of this man's sister and that of a barman in Exeter-street, Strand; also those of a printer in Finsbury and a printer in Southwark, members of the club in Holborn; also a caretaker in Hampstead, whose disease was contracted outside the borough, but the source of whose infection Vas not known. In the following week (ending the 24th August) the number of cases notified in 21 London was as many as 22, 18 of which occurred iu St. Paneras. One of these occurred in the house in Tottenham-street originally invaded. Four cases occurred in the house next door (No. 44); their illness had been preceded by the death, on the 11th August, of a child from chicken-pox, in the house in which they lived, this child having been fondled by the two sisters who were removed from No. 40. The child's sister- lived in fciandwich-street, .and she was removed on the 19th, and on the 23rd a man in the same house was also removed. He was brother to one of the four cases removed from Tottenham-street on the 22nd; a child was also removed on the 23rd from the same house in Sandwich-street. Of the remaining 10 cases in St. Paneras, two were removed from other houses in Tottenham-street, one, a boy, who was removed from William-street, knew boys in Tottenham-street, another from Gresse-street, who played with children in Tottenham-street, another in Pitt-street, a porter who was employed in a neighbouring restaurant, another a woman in Seaton-street, who worked in a laundry in Tottenham-street, another a lad, who lived in the neighbouring Whitfield-street, and another a man living in the neighbouring Charlotte-street. In the same week there were removed from Foley-street and Little Marylebone-street, both iu St. Marylebone, two cases, the former a child who had friends in Tottenham-street, the latter a man who worked with the father of two cases who were removed from Tottenham-street and Sandwich-street respectively. Other cases were a man in Stoke Newington who worked with a man in Hackney removed on the 2nd August, and a man who was removed from the St. Marylebone Workhouse on the 24th August. This man had been living in Barking, and after infection, had been in a common lodging-house in St. Paneras and subsequently in the Salvation Army Shelter, Bume-street, Marylebone, in both of which he was resident while in an infectious condition. In the following week (ending the 31st August) there was an outbreak of 25 cases in St. Paneras, and 16 cases (the diagnosis of 4 of which was incorrect) occurred in St. Marylebone. The cases in St. Paneras were apparently all associated with the outbreak already referred to, and those in St. Marylebone were probably also associated; they lived in a locality abutting on that in St. Paneras which was invaded, and in several instances they were acquainted with the invaded families in St. Paneras. Mr. Wynter Blyth, the medical officer of health of St. Marylebone, writes that his district had been "free from smallpox for 18 days, but on the 24th August up to the present date [3rd October] a series of notifications of smallpox have been received, the infection apparently for the most part being derived from a group of cases which occurred in the neighbouring district of St. Paneras." Dr. Sykes, the medical officer of health of St. Paneras, referring to the St. Marylebone cases speaks of them as "not apparently infected from the same source." The same week two cases, a man and wife, were notified in Islington, infection being received iu Tottenham-street, and a third case, the source of infection of which is not known. There were also notified a child in Stoke Newington whose aunt lived in Tuttenhaiji-street and a man in Holborn who kept a butcher's stall in Goodgestreet, Tottenham-court-road. The infection of a woman in Holborn who shopped in the infected neighbourhood, of a man in Finsbury who worked near there, and of a man in Wandsworth who also worked in that neighbourhood, were also probably due to the same centre of infection. It is unnecessary for the purposes of this report to continue to show the progress of the disease from caso to case. In the week in question cases of smallpox occurred in nine of the London boroughs, and gradually spread throughout the county, no single district escaping. The circumstances of smallpox among the poorest class of the population may, however, be more fully stated. In September the disease appeared among hop-pickers on a farm near Bodiam, in Sussex, who were no doubt, from the evidence, infected by a girl from Tliomas-street, Finsbury, who developed her illness on the farm, but the nature of whose malady was not recognised at the time. A family among the hop-pickers apparently infected by this girl returned to London suftering from an eruption on the skin. They were taken to the lloyal Free Hospital, where their illness was recognised to be smallpox, and the whole circumstances of the outbreak were promptly investigated by Dr. Newman, the medical officer of health of Finsbury. He found that several of the hop-pickers had been attacked on the farm with what had been thought to be chicken-pox, and that several hundreds of persons thus engaged were returning to London. Steps were at once taken for the inspection of these people as they arrived in the railway stations by the officers of the County Council and the Finsbury Borough Council, and for the taking of the addresses of persons coming from the infected farm. Five cases of smallpox were thus detected and removed direct to hospital from the Cannon-street Station. In other cases the disease appeared after their return home to London, Dr. Newman stating that in and near Tliomas-street some twenty cases were removed. Until this time the inmates of common lodging-houses were remarkably free from attack by smallpox. On the 23rd August, however, a man had been removed from a Salvation Army Shelter in Bcthnal-green, and on the 8th September another man from the same shelter. Daily inspections were made of the inmates in consequence. On the 24th August a man was removed from the Burne-street shelter; on the 19th September a man was attacked who stated he had slept in casual wards and various common lodging-houses, and on the 3rd October, a man who had slept in various shelters. In the middle of October this class of the population became more seriously involved. On the 19th October a man was removed from the St. Marylebone casual ward who had frequently been in the Burne-street shelter. Mr. Wynter Blyth reported that this man had walked the streets in the neighbourhood of Covent-garden on the night of the 18th October while probably delirious, and had passed the day on one of the seats in Regent's-park. Close watch was, therefore, kept on the inmates of the Burne-street shelter, and on the night of the 1st November the County Council's medical officers inspected 369 persons who occupied bunks in the shelter, but no case of smallpox was discovered. On the 22nd October a hop-picker from Barnet was removed from a shelter in Stepney. The first considerable outbreak affecting the occupants of common lodging-houses occurred ill Holborn. A woman, who had been engaged in selling walnuts in Covent-garden, had the 22 eruption of smallpox on 13th October. She was taken to the Endell-street Infirmary on the 15th, where her disease was recognised, but she escaped before the ambulance arrived. Search was made for her, and watch maintained in the neighbouring common lodging-houses by the Council's officers, which were visited in the early hours of the morning by Mr. Wynter 131yth and the Council's medical officer. On the 17th she was encountered by the keeper of a common lodginghouse, who handed her over to a police constable, but she again escaped, and it was not until the 18th inst., when she entered a common lodging-house in Parker-street, that she was secured and removed to hospital. She was thus, while suffering from smallpox, a source of considerable risk to other persons during a period of four days, and after the lapse of time corresponding with the incubation period of smallpox, ten women, who were inmates of common lodging-houses in Parker-street, Kennedy-court, Stanhope-street and Whitehorse-yard, were attacked. At all these houses she was well known. At the same time three men in the neighbouring common lodging-houses in Yere-street and Greville-street were attacked, and two men in Harmood-street, St. Paneras, were also attacked. Following these, and no doubt dependent on them, a series of cases occurred in common lodging-houses in Fulwood's-rents and in Greville-street, Holborn, and a case in a common lodging-house in Queen-street, Drury-lane. A series of cases also occurred in the Hanbury-street shelter and other common lodging-houses in Whitechapel. In November and December a series of cases occurred in Rowton House, Hammersmith, and in November a series occurred among ihe inmates of common lodging-houses for women in Southwark. The appearance of cases in the common lodging-liouse population of Holborn led to two courses of action being taken by the County Council. The occurrence of four cases among the inmates of the Parker-street common lodging-house, as already stated, made it appear probable that other inmates of the house were incubating the disease, and inasmuch as at this time the common lodging-house population had not been largely involved, the Public Health Committee determined to take every possible step to limit its spread amongst people of this class. Arrangements were therefore made with the keeper that the Council should rent all the beds in the house, and should make a small allowance for food for all the inmates who consented to remain in the house. To this house, moreover, were removed certain inmates of other common lodging-houses in the neighbourhood who had been especially exposed to smallpox. This system of quarantine was maintained for three weeks, the lodgers, with rare exceptions, consenting willingly to the conditions imposed. It was only at a later date, however, that the disease reappeared in this house. The other course of action which was at once adopted and maintained during the outbreak, was the daily inspection of the inmates of invaded houses by the Council's inspectors, with a view to ascertaining whether any of the inmates were manifesting signs of illness, in which case one of the Council's medical officers was immediately sent for. Further, when smallpox occurred in a common lodging-house, every effort was made to ensure that those exposed to infection should continue to reside in the same house until the period of incubation had elapsed, and the privilege of a free bed, and, in a number of instances, small sums for food, were offered in cases in which, without such inducement, it would have been impossible to retain particular lodgers under observation. As a result, in numerous instances it was found possible to separate persons who were beginning to sicken with smallpox from the other inmates, and retain them in a different room from those occupied by the other lodgers until the circumstances warranted their removal to hospital. The history of smallpox occurrences during the latter part of the year pointed to the frequency with which there was mistake in the diagnosis of smallpox. Cases of this disease were in a number of instances due to infection from persons whose illness had been regarded as chicken-pox, and hence chicken-pox was in 1901 added to the list of diseases required to be notified in St. Paneras, Hampstead, Holborn, Bethnal-green and Greenwich. The London County Council at the beginning of 1902 made an Order which required the notification of chicken-pox throughout the whole of London, and also made arrangements by which the services of medical men familiar with smallpox were made available for the purposes of diagnosis. On the 25th September the Local Government Board addressed a circular letter to the metropolitan borough councils, calling attention to the increase of smallpox in London, and stating that the Board attached very great importance to the most energetic measures being taken in connection with the cases which were occurring, with the view to preventing the spread of infection, and asking that the medical officer of health should be instructed to visit every house in which the disease had broken out, and at the earliest possible moment to take such measures as might be necessary to secure, as far as practicable, the isolation of the patient, the vaccination of any persons who may have been exposed to infection, and the disinfection of the premises, and any further action which the circumstances would admit of for the purpose of checking the extension of the disease. The Board enclosed copies of a memorandum on the steps specially requisite to be taken in places in which smallpox was prevalent. At the same time the Local Government Board addressed a circular letter to Boards of Guardians, asking that the attention of the Boards of Guardians should be at once specially given to the state of vaccination of all children or other persons who may not have been vaccinated, and to the promotion of revaccination among adolescents and adults. The attention of the boards of guardians were directed to the Article of the Vaccination Order of 1898, requiring them to ascertain that the vaccination officer was performing the duties imposed upon him and that he should, on hearing of importation of smallpox, immediately make inquiries (if need be from house to house) as to vaccination throughout the locality, and that in addition to seeing that children illegally unvaccinated are vaccinated he should impress on the parents of all unvaccinated children the extreme danger of delaying vaccination. The Board promised their immediate attention to any 23 proposal they may make as to assistance to public vaccinators and vaccination officers. Copies of the memorandum referred to were enclosed. On the 23rd September, 1901, the London School Board resolved— That facilities be given to the public vaccination officers of the metropolis, on the application of the proper local authority, to enter the schools of the Board, in infected areas, for the purpose of examining the arms of the children, with a view to advising the parents to allow their children to be vaccinated, provided that the School Board issue a circular to the parents asking if they have any objection to this examination, and in case of such objection in any particular case, that such examination shall not take place; and that the Local Government Board and the public vaccination officers be informed accordingly. A number of the reports of medical officers of health show the steps taken in their districts to limit the spread of smallpox. In some districts these included an inspection of children in schools with a view to ascertaining whether they had been vaccinated. Thus the annual reports show that children in schools were inspected in Kensington, Chelsea, Hackney, Holborn, Finsbury, City, Greenwich, and Woolwich. Some of the reports show the proportion of children whose parents refused to allow them to be inspected and the proportion of children examined who were found to be unvaccinated. Thus, in Hackney 12,890 children were inspected and 28 per cent, found to be unvaccinated; while the parents of 48 per cent, of the children attending the schools refused to allow tlieni to be inspected. In Holborn 2,657 children were inspected, of whom 21.4 per cent, were found to be unvaccinated. In Finsbury children in 16 schools were examined. The number of children on the rolls of these schools was 15,652, and 16.7 per cent. of the children examined were found to be unvaccinated. In the City 1,809 children in the ward and parochial schools were inspected, and 16.6 per cent. found to be unvaccinated; in the Board schools 1,341 children were examined, and 7 per cent. found "unprotected"; the number of refusals of the parents of children in the Board schools being 600. In Greenwich 7,761 children were inspected, and 9.2 per cent. presented no evidence of vaccination; the number of refusals being 5,139. The medical officer of health of Woolwich states that 525 children in the Board schools were without satisfactory marks of vaccination. In Islington children in schools were inspected in like manner. The effect of the examination of school children is stated in a few reports. In Holborn, of the 568 children found unvaccinated 398 were successfully vaccinated. Of the unvaccinated children in the ward and parochial schools 354 were vaccinated. In Woolwich the majority of the children found without satisfactory marks of vaccination were vaccinated. In Islington 1,866 children were vaccinated as the result of these inspections. Throughout London generally there was considerable resort to vaccination, and large numbers of people were vaccinated or revaccinated. In Westminster Dr. Allan reports, 9,557 persons were revaccinated in 1901 by the public vaccinators. The measures taken in the several districts were generally those usually adopted for the limitation of smallpox prevalence and included in large degree the keeping under observation of persons exposed to infection. The use of shelters for the temporary accommodation of persons who had to leave their homes while their premises were being disinfected was also largely resorted to, and in some districts accommodation for this purpose was specially provided. The supply of food to persons thus accommodated was regarded by the Local Government Board as one upon which it was competent for the sanitary authority to spend money. Returns were issued by the Metropolitan Asylums Board showing the connection between cases of the disease and indicating the probable source of infection, and in the early part of 1902 the Public Health Committee of the County Council, at the request of the metropolitan branch of the Society of Medical Officers of Health, arranged for the daily communicating to all London medical officers of health of particulars concerning the cases of smallpox which each sent to the Council for that purpose. In respect of hospital provision the report of the Statistical Committee of the Metropolitan Asylums Board states that "For this disease the managers possessed, at the end of 1901, 250 beds at the hospital ships and 1,074 at Gore Farm. To meet the expected demands of the smallpox epidemic, buildings were in course of erection at the end of the year which would increase the total number of beds to 3,238, exclusive of 940 beds in the permanent Joyce-green Hospital fin course of construction') and 464 beds in wooden (Hawkins') huts." lhe same report includes the following table showing the condition as to vaccination and the fatality of cases of smallpox admitted into the hospitals of the Metropolitan Asylums Board— Admissions. Deaths. Mortality per cent. (A) Vaccinated class— (A1) Half and upwards of half square inch total area of cicatrices 939 69 7.35 (A2) One-third, but less than half ditto 172 28 16.28 (A3) Less than one-third ditto 159 23 14.47 (A4) Area not recorded 12 7 58.34 Totals of vaccinated class 1,282 127 9.91 (B) Doubtful class 89 46 51.69 (C) Unvaccinated class 372 119 31.99 Grand Totals 1,743 292 16.75 24 The report states—"Under 10 there were only 20 Vaccinated Cases Bud ho death; 4 doubt ful cases, of whom 1 died; and 192 unvaccinated cases, of whom 65 died—a percentage of 33.85. Under 20 there were 264 vaccinated cases, of whom 3 died—a percentage of 114; 14 doubtful cases, of whom 3 died—a percentage of 21.43; and 309 unvaccinated cases, of whom 95 died—a percentage of 30.74. The diminution after the age of 20 years in the protective power afforded by infant vaccination is shown in the rise in the death rate [fatality] from 6.67 iu vaccinated cases between 20 and 25 years of age to 18.31 in cases between 35 and 40." In previous reports I have referred to the increasing proportion of children born in London who appear in the vaccination returns as "not finally accounted for." The proportion in successive years has been as follows. The figures for the years subsequent to 1899 are not yet available. London vaccination returns. Year. Children not finally accounted for (including cases postponed) per cent, of total births. Year. Children not finally accounted for (including cases postponed) per cent, of total births. 1872 8.8 1886 7.8 1873 8.7 1887 9.0 1874 8.8 1888 10.3 1875 9.3 1889 11.6 1876 6.5 1890 13.9 1877 7.1 1891 16.4 1878 7.1 1892 18.4 1879 7.8 1893 18.2 1880 7.0 1894 20.6 1881 5.7 1895 24.9 1882 6.6 1896 26.4 1883 6.5 1897 29.1 1884 6.8 1898 33.0 1885 7.0 1899 27.7 The number of children in respect of whom certificates of "conscientious objection were received numbered 226 in 1897, 1,814 in 1898 and 1,362 in 1899, these numbers representing less than one per cent, of the total births in the three years. Measles. The deaths from measles in the administrative county of London during 1901 (52 weeks) numbered 1,952, as compared with 1,930 in 1900. The death rates from this disease per 1,000 living in 1901 and preceding periods have been as follows— Measles—Death rates per 1,000 living. 1851-60 0.53 1895 0.601 1861-70 0.58 1896 0.821 1871-80 0.51 1897 0.431 1881-90 0.64 1898 0.691 1891 0.431 1899 0.481 1892 0.791 1900 0.431 1893 0.381 1901 0.431 1894 0.761 The death rate in each year since 1840 in relation to the mean death rate of the period 1841-1901 is shown in diagram V. If the London measles death rate be compared with the death rates of the following large English towns it will be seen that in the period 1891-1900 the London death rate exceeded the death rates of all except Manchester, Salford, West Ham and Newcastle, while in 1901, the London death rate was lower than any except Bristol, Nottingham, Bradford, Leicester and Newcastle. Measles—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.582 0.432 Nottingham 0.41 0.41 Manchester 0.77 0.54 Bradford 0.36 0.06 Liverpool 0.54 0.68 Hnll 0.50 0.51 Birmingham 0.44 0.59 Salford 0.96 0.52 Leeds 0.52 0.58 West Ham 0.62 0.65 Sheffield 0.55 0.56 Leicester 0.44 0.08 Bristol 0.48 0.02 Newcastle 0.59 0.33 1 See footnote (1), page 9. 2 See footnote (2), page 9. Diagram V Measles. 25 The following table shows that the measles death rate in London was higher than that of any of the undermentioned foreign towns in the period 1891.1900, and in the year 1901 was higher than that of any except St. Petersburg. Measles—Death rates per 1,000 living. Towns. 1891.1900. 1901. Towns. 1891.1900. 1901. London 0 581 0 431 St. Petersburg 0.57 056 Paris 034 0.20 Berlin 019 023 Brussels 034 0.12 Vienna 055 038 Amsterdam 0.22 013 Rome 036 003 Copenhagen 0.21 0.37 New York ... 0.27 012 Stockholm 0.34 015 The following table shows the deaths and death rates from measles in 1901 iu each of the metropolitan boroughs included in the administrative county— Metropolitan borough. Deaths in 1901. Death.rate per 1,000 living, 1901. Metropolitan borough. Deaths in 1901. Death.rate per 1,000 living, 1901. Paddington 9 0.06 Shoreditch 75 0.63 Kensington 76 0.43 Bethnal-green 88 0.68 Hammersmith 47 0.42 Stepney 180 0.60 Fulham 38 0.28 Poplar 89 0.53 Chelsea 9 0.12 Southwark 161 0.78 Westminster, City of 59 0.32 Bermondsey 81 0.62 St. Marylebone 9 0.07 Lambeth 122 0.40 Hampstead 1 0.01 Battersea 132 0.78 St. Paneras 68 0.29 Wandsworth 65 0.28 Islington 157 0.47 Camberwell 152 0.59 Stoke Newington 8 0.16 Deptford 53 0.48 Hackney 94 0.43 Greenwich 55 0.57 Holborn 23 0.39 Lewisham 3] 0.24 Finsbury 48 0.48 Woolwich 21 0.18 London, City of 1 0.04 London 1,952 0.432 In the distribution of measles mortality in London throughout the year 1901 the eastern group of districts had the highest death rate (0.61), and the western group the lowest (0.29). Among the several metropolitan boroughs Southwark and Battersea had the highest death rate (0.78), and Hampstead the lowest (0.01). The measles death rates in London in the four quarters of the year were as follows: first quarter, 0.37; second quarter, 0.48; third quarter, 0.39, and fourth quarter, 0.48 per 1,000 living. The following table shows the number of deaths from measles at several age periods in each of the metropolitan boroughs. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the deceased had Dreviouslv resided. Age.period. 0— 1— 2— 3— 4— under 5 5— 10— 15 and upwards. All ages. Paddington — 5 2 — — 7 — — — 7 Kensington 14 35 10 5 5 69 4 — 1 74 Hammersmith 10 20 4 1 2 37 6 — — 43 Fulham 3 18 3 4 1 29 9 — — 38 Chelsea 1 4 — 3 1 9 1 — — 10 Westminster, City of 10 26 10 6 6 58 3 — — 61 St. Marylebone 1 2 3 2 — 8 — — I 9 Hampstead 1 — — — — 1 — — — 1 St. Paneras 16 21 13 10 4 64 4 — — 68 Islington 38 59 33 18 6 154 5 — 1 160 Stoke Newington 2 5 1 — — 8 1 — — 9 Hackney 20 33 23 12 6 94 5 — — 99 Holborn 8 8 1 2 2 21 1 — — 22 Finsbury 7 28 4 5 3 47 3 — — 50 London, City of — — — — — — 1 — — 1 See footnote (2), page 9. See footnote (1), page 9. [4] 26 Age.period. 0— 1— 2— 3— 4— under 5 5— i L0. 15 and upwards. All ages. Shoreditch 12 42 10 5 3 72 3 — — 75 Bethnal.green 16 37 15 9 5 82 5 1 — 88 Stepney 45 65 28 21 2 161 3 — — 164 Poplar 18 37 18 7 6 86 2 — — 88 Southwark 35 74 30 12 6 157 5 — — 162 Bermondsey 13 37 14 9 6 79 — — — 79 Lambeth 24 46 20 13 7 110 11 — — 121 Battersea 27 53 31 9 9 129 3 — — 132 Wandsworth 15 28 8 7 3 61 4 — — 65 Camberwell 30 51 37 16 10 144 6 — — 150 Deptford 8 26 12 1 3 50 1 — — 51 Greenwich 14 17 14 4 2 51 3 — 1 55 Lewisham 10 10 5 2 1 28 4 — — 32 Woolwich 4 8 2 4 2 20 2 — — 22 London 402 795 351 187 101 1,836 95 1 4 1,936 In this table where — is inserted no death occurred. Iu any comparison of the distribution of measles mortality in different parts of London due regard should be paid to the fact that the mortality from this disease is almost wholly confined to children under five years of age. Thus, in the year 1901, in London, out of 1,936 deaths from this disease at "all ages," 1,836 deaths, or 94.8 per cent. occurred among children aged 0.5 years. It will be seen, therefore, that the measles death rate among children of this age affords a much more reliable indication of the relative mortality from this disease, when the rates obtaining in the metropolitan boroughs are compared, than does the measles death rate at "all ages," owing to the considerable variations in the proportion of young children, which exist in different parts of the London population. Having regard to this fact, the following table showing the measles death rates among children under five years of age in the several metropolitan boroughs is of interest— Measles—Death.rate per 1,000 children living, aged 0—5. Metropolitan Boroughs. Death rate ages 0.5. Metropolitan Boroughs. Death rate ages 0.5. Metropolitan Boroughs. Death rate ages 0.5. Paddington 0.55 Stoke Newington 1.69 Bermondsey 4.71 Kensington 4.88 Hackney 3.88 Lambeth 3.39 Hammersmith 3.05 Holborn 4.38 Battersea 6.34 Fulham 1.63 Finsbury 3.83 Wandsworth 2.49 Chelsea 1.44 City of London — Camberwell 4.88 Westminster, City of 4.53 Shoreditch 4.84 Deptford 3.75 St. Marylebone 0.72 Bethnal.green 4.64 Greenwich 4.62 Hampstead 0.16 Stepney 4.04 Lewisham 2.07 St. Paneras 2.65 Poplar 4.00 Woolwich 1.45 Islington 4.28 Southwark 6.19 London 3.70 In view of what has been already stated in reference to the variations in the proportion of children aged 0.5 in the several metropolitan boroughs, it is interesting to compare the relative positions occupied by these boroughs in respect of measles mortality, (a) when the death rates at "all ages" are compared, and (b) when the death rates at asres 0.5 are made the subject of comparison. parison. This will be seen from the following table— Ages 0.5. " All ages." Order. Metropolitan Borough. Measles death rate. Order. Metropolitan Borough. Measles death rate. 1 Battersea 6.34 1 Battersea 0.78 2 Southwark 6.19 2 Southward 0.78 3 Kensington 4.88 3 Bethnal-green 0.68 4 Camberwell 4.88 4 Shoreditch 0.63 5 Shoreditch 4.84 5 Bermondsey 0.62 6 Bermondsey 4.71 6 Stepney 0.60 7 Bethnal.green 4.64 7 Camberwell 0.59 8 Greenwich 462 8 Greenwich 0.57 9 Westminster, City of 4.53 9 Poplar 0.53 10 Holborn 4.38 10 Deptford 0.48 11 Islington 4.28 11 Finsbury 0.48 12 Stepney 4.04 12 Islington 0.47 27 Ages 0-5. "All ages." Order. Metropolitan Borough. Measles death rate. Order. Metropolitan Borough. Measles death rate. 13 Poplar 4.00 London 0.43 14 Hackney 3.88 13 Kensington 0.43 15 Finsbury 3.83 14 Hackney 0.43 16 Deptford 3.75 15 Hammersmith 0.42 London 3.70 16 Lambeth 0.40 17 Lambeth 3.39 17 Holborn 0.39 18 Hammersmith 3.05 18 Westminster, City of 0.32 19 St. Paneras 2-65 19 St. Paneras 0.29 20 Wandsworth 249 20 Fulham 0.28 21 Lewisham 2.07 21 Wandsworth 0.28 22 Stoke Newington 1.69 22 Lewisham 0.24 23 Fulham 1.63 23 Woolwich 0.18 24 Woolwich 1.45 24 Stoke Newington 0.16 25 Chelsea 1.44 25 Chelsea . 0.12 26 St. Marylebone 0.72 26 St. Marylebone 0.07 27 Paddington 0.55 27 Paddington 0.06 28 Hampstead 0.16 28 City of London 0.04 29 City of London — 29 Hampstead 0.01 In thia table where — is inserted no death occurred. The order of the boroughs, therefore, in relation to measles mortality at "all ages" is considerably altered if the mortality at ages 0.5 be adopted for purposes of comparison. Thus Kensington, which is 13th in order among the boroughs in the "all ages" comparison, takes 3rd place in the "0.5 ages" column. Bethnal-green, Stepney and Deptford, which occupy the 3rd, Gth, and 10th places, respectively, in the "all ages" column, are more favourably situated in the 0.5 age column, their respective places being 7th, 12th and lGth. Again, it will be seen that the measles death rates at "all ages" of Holborn and Westminster are below the London average, while the death rates for these districts at ages 0.5 are considerably above the London average. Generally speaking, the age constitution of the poorer and more overcrowded boroughs tends to place them in a less favourable position when the measles death rates at '' all ages " are compared than when the death rates at ages 0.5 alone are considered. The subject of measles is, as a rule, only dealt with statistically in many of the reports of medical officers of health relating to the year 1901. Referring to the letter of the London County Council of the 1st December, 1900, asking the several sanitary authorities whether they were in favour of extending to measles the provisions of the Public Health (London) Act other than notification relating to dangerous diseases, the medical officer of health of Kensington states that in the early part of 1901 the borough council intimated to the County Council that they were in favour of the sections of the Public Health (London) Act which prohibit the exposure in public places of persons suffering from an infectious disease being made applicable to measles. The medical officer of Westminster states that the medical officers of health of the constituent districts of the borough reported in favour of the extension to measles of the several provisions other than notification. The medical officer of health of Finsbury reported in the same sense and his report was adopted by his committee. A similar report was presented by the medical officer of health of Lambeth. The medical officer of health of Camberwell held a different opinion. He states that he thinks that if measles be added to the list of dangerous infectious diseases there should be no partial application, but that notification should be included, and this he did not recommend. Dr. McCleary, the medical officer of health of Battersea, refers to the frequency with wbich serious pulmonary affections complicate the disease, particularly in persons who are not carefully nursed, and he adds that it is much to be regretted that there are no hospitals provided to which children suffering from measles could be removed from overcrowded and insanitary houses. It is noteworthy that of nearly 2,000 deaths from this disease in London during 1901 onlv 226 occurred in public institutions. If severe cases which cannot be properly cared for in their own homes were treated in hospital there is reason for thinking that better results would be obtained than at present. Hospital provision for measles should no doubt be thought of as relating to the treatment of such cases, and not to the isolation of infectious persons with a view to controlling the prevalence of the disease. Medical officers of health are, in the main, dependent upon the teachers in the elementary schools for information concerning the incidence of measles. The London School Board requires its teachers to give such information, and this instruction appears to be more fully acted upon than before. Thus the medical officer of health of Islington states that in 1901 he learnt from this source of 2,772 cases of measles, and he reports that the measures he is able to adept have a decided effect in preventing its spread in the schools. In Hammersmith 193 cases became known to the medical officer of health, but 50 cases were unknown to him until after death. In Westminster 230 cases were reported in the north-eastern part of the city, and Dr. Alk.n states the disease was probably prevalent in the south-western district, but the system of notification was not fully adopted at the time. In Shoreditch 326 oases were reported. In Ifolborn the borough council invited the managers of all voluntary schools to forward lists of all children absent or excluded on account of measles. In several districts handbills were distributed explaining the precautions which should be taken to prevent extension of the disease. 28 In Southwark all houses known to be invaded were visited by the women inspectors, and advice given by them to those in charge of the patients. Dr. Millson states that this work has been appreciated by the inhabitants. In Bermondsey it was decided by the borough council to disinfect in houses in which a death from measles occurred. In a number of instances schools were closed on account of prevalence of measles among the scholars. The reports of medical officers of health show that in fulham, in December, the infants' departments of the Munster-road and Kingwood-road Board Schools were closed for three weeks, and in Westminster" one school was closed on July 3rd until the end of the month, when the holidays began; one infant school in October for fourteen days, two in November for three weeks, and one mixed school for fourteen days from the 22nd November (the infant department of the same school having been closed a week earlier); the closing, especially just before the usual holiday period, was accompanied in most instances by a cessation of the outbreak." In Islington the class-rooms were closed in the infants' departments of the following Board schools—Gillespie-road, Montem-street, Ecclesbourne-road, Hungerford-road, Blackstock-road, Yerbury-road, Upper Hornsey-road, Queen's Head-street, York-road, Forster-road, Duncomberoad, Westbourne-road and Buckingham-street, and in the following church schools—St. Paul's, St. Philip's, St. Matthew's, St. Mark's, St. Mary Magdalene and St. James'. In some instances class-rooms were closed in the same school more than once in the year. In Holborn, the infants' department of the St. George-the-Martyr Schools was closed for 28 days, at the time of closure only 100 out of a roll of 259 being present; at the re-opening of the infant department very few children were absent on account of measles. In Poplar the infants' department of the Newby-place Church Schools was closed in March for three weeks, and members of the families of these children were excluded for two weeks from the boys' department, National School, Highstreet, and from the girls' department, Bow-lane School. In April one of the class-rooms of the Smeed-road Board School, Bow, was closed for three weeks. In July the infants' department of the Knapp-road Board School was closed, also, in December, the infants' department of the Glengall-road Board School was closed, and during the Christmas holidays the infants' department of the British-street Board School, Millwall, was disinfected on account of measles prevalence among the children. The medical officer of health of Bermondsey reports that in March, Trinity Schools, in Rotherhithe, were closed, and later, in April, the infants' department of Silwood-street and Medway-place Schools; other schools, the attendance of which was affected by prevalence of measles among the scholars, were Clarence-street, from February to May; St. Paul's, in March and April; and St. Mary's School, in June and July. The schools closed in Lambeth were the infants' department, St. Stephen's School, Dorset-road, for four weeks in March, average attendance 200 scholars, 68 of these or 34 per cent, being absent; in St. Mary-the-Less, Princes-road Infants' School, the Easter holiday was extended, 30 per cent, being absent before the holiday began: a class-room in the infants' department, Jessop-street Board School, was closed for three weeks, and the infants' department of the Woodland-road Board School for three weeks at the end of November. In five other schools there was prevalence of measles among the scholars, but it was found either that the prevalence was diminishing or that a holiday period was approaching, rendering no other action necessary than the exclusion of affected scholars or children living in the same house with tliein. Dr. Priestley states that the result of the action taken was in all cases satisfactory. In Battersea the infants' departments of the following schools were partially closed—Bolingbroke-road, Latchmere-street, Shillington-street and Raywood-street Board Schools. In Wandsworth the following schools were closed or partially closed—St. Ann's, Merton-road, Warple-wav and All Saints'. In Woolwich, class-rooms of the infants' departments of the following schools were closed—Bloomfield-road, St. Thomas', St. Michael's, Wood-street, Slade, High-street and Eglinton-road. Scarlet Fever. The cases of scarlet fever notified in the administrative county of London during 1901 numbered 18,381, compared with 13,892 in 1900. The number of deaths registered from this cause in 1901 was 584, compared with 361 in 1900. The London rates in 1901 and preceding: 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 1897 0.17! 5.1 3.0 1898 0.131 3.8 3.4 1899 0.091 4.1 2.2 1900 0.081 3.1 2.6 1901 0.131 4.1 3.2 1 See footnote (1), page 9. * The Infectious Disrate (Notification) Act came into force in 1889. Qiagram.VI Scarlet Fever DiagramVIII. Scarlet Fever. 29 The death rate in each year since 1858 in relation to the mean death rate of the period 1859-1901 will be seen on reference to diagram VI., and the monthly case rate and case mortality in each of the years 1891-1901 in relation to the mean of the whole period is shown in diagram VIII. This diagram shows slight increase of prevalence and slight increase in the case mortality of the disease in 1901 compared with the preceding year, but both prevalence and case mortality are markedly below those of the years 1892 and 1893. It will be seen from the following table that in the period 1891-1900 the London scarlet fever death rate was lower than that of any of the undermentioned towns, except Birmingham, Leeds, Bristol, Hull, West Ham and Newcastle, and in 1901 was lower than that of any except Bristol, Nottingham, Bradford, Hull, West Ham and Leicester— Scarlet fever—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.19 0.13 Nottingham 0.21 0.05 Manchester 0.23 0.23 Bradford 0.26 0.13 Liverpool 0.29 0.27 Hull 0.17 0.07 Birmingham 0.17 0.30 Salford 0.36 0.48 Leeds 0.17 0.19 West Ham 0.18 0.12 Sheffield 0.21 0.15 Leicester 0.22 0.03 Bristol 0.12 0.11 Newcastle 0.13 0.20 ihe tollowing table shows that the .London scarlet lever death rate, in the period 18911900, was lower than that of any of the undermentioned foreign towns, except Paris, Brussels, Amsterdam and Borne, and in 1901 was lower than that of any, except Paris, Brussels, Amsterdam, Conenliajren and Home— Scarlet fever—Death rates per 1,000 living. [####]Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.19 0.13 St. Petersburg 0.62 0.60 Paris 0.06 0.04 Berlin 0.26 0.26 Brussels 0.04 0.03 Vienna 0.20 0.22 Amsterdam 0.03 0.01 Rome 0.02 0.00 Copenhagen 0.21 0.08 New York 0.27 0.33 Stockholm 0.37 0.21 The following table shows the death rate from scarlet fever in 1901 and the case rates ii 1901 and the deceunium 1891-1901 in the several metropolitan boroughs— Metropolitan Borough. Cases, 1901. Case-rate per 1,000 living. Deaths, 1901. Death-rate per 1,000 living. 1901. 1891-1900. 1901. Paddington 505 39 3.5 11 0.08 Kensington. 475 3.5 2.7 15 0.09 Hammersmith 346 4.1 3.1 14 0.12 Fulham 600 5.2 4.3 20 0.14 Chelsea 190 4.3 2.6 5 0.07 Westminster, City of 478 3.5 2.6 11 0.06 St. Marylebone 397 3.8 3.0 18 0.14 Hampstead 218 3.7 2.7 4 0.05 St. Pancras 991 4.8 4.2 33 0.14 Islington 1,290 5.0 3.9 30 0.09 Stoke Newington 172 4.7 3.4 4 0.08 Hackney 933 5.8 4.3 26 0.12 Holborn 259 4.4 4.4 3 0.05 Finsbury 502 5.3 5.0 18 0.18 London, City of 110 4.3 4.1 4 0.15 Shoreditch 556 4.7 4.7 20 0.17 Bethnal-green 841 5.8 6.5 44 0.34 Stepney 1,177 5.6 3.9 42 0.14 Poplar 560 5.5 3.3 14 0.08 Southwark 1,301 5.2 6.3 54 0.26 Bermondsey 932 5.3 7.2 44 0.34 Lambeth 1,037 4.6 3.4 38 0.13 Battersea 602 6.1 3.6 10 0.06 Wandsworth 689 4.3 3.0 17 0.07 Camberwell 1,472 4.6 5.7 47 0.18 Deptford 549 6.1 5.0 17 0.15 Greenwich 419 4.9 4.4 5 0.05 Lewisham 465 3.7 3.6 11 0.09 Woolwich 310 6.0 2.6 5 0.04 Port of London 5 — — - - London 18,381 4.8 4.1 584 0.132 ' See footnote ('), page 9. * See footnote ('), page 9. 30 Tlie eastern group of districts had the highest scarlet fever death rate during the year 1901, viz., 0-11 per 1,000 living, and the western group of districts the lowest (0-09^. Among the several metropolitan boroughs Bethnal Green and Bermondsey had the highest death rate (0 34) and Woolwich the lowest (0'04). The scarlet fever death rates in London in the four quarters of the year 1901 were as follows: first quarter, 0*08 ; second quarter, 014; third quarter, 015, and fourth quarter, 014 per 1,000 living. Of special outbreaks of scarlet fever in Loudon during the year the most notable was one commencing in April and extending into May, and in which some 300 persons were attacked. The cause was an infective milk supply, the milk being received originally from a farm in Staffordshire. This milk was distributed by a wholesale milk vendor along with other milk to numerous retail vendors, for the most part in Shoreditch, Bethnal-green and Finsbury, in which districts the majority of the persons affected resided, a few cases occurring also in St. Pancras, Isbngton, and Hackney. Information was first brought to the knowledge of the County Council's Public Health department by Dr. Bryett, the medical officer of health of Shoreditch, who had observed that the persons in his district who were attacked had been mostly supplied with milk by two retail vendors, one in Shoreditch, the other in Bethnal-green, and he further stated that the Shoreditch vendor derived his supply from two middlemen, and that he haid ascertained from Dr. Bate, the medical officer of health of Bethnal-green, that there had been a similar occurrence of scarlet fever in his district among the customers of the local vendor in that district, who also derived his supply from one of the middlemen mentioned. The locatiou of the farm from which the infective milk was supplied was at once investigated by the County Council's officers, who received continuously information from the medical officers of the districts concerned. The inquiry was rendered much more difficult by the fact that the middleman whose milk was under suspicion derived his supplies from nearly forty farms, and by the absence of records as to the localities in which the several milk supplies had been distributed. As a result of continuous inquiry by all the officers concerned the farm from which the infective milk supply was received was, in less than three days from the time when Dr. Bryett first reported the outbreak, sufficiently identified for the middleman to be advised to stop the supply of milk from this source. Upon this farm cases of srarlet fever were found in the farmer's family. The details of this outbreak will be found in a report presented to the Public Health Committee, which is appended (see appendix II.), and the matter was also the subject of the following report of the committee to the Council on the 21st May, 1901, in which the insufficiency of the law for limiting the distribution of an infective milk supply in London is discussed. The medical officer has brought under our notice the position of the law in London in relation to the subject of limiting the spread of dangerous infectious disease by milk. Medical officers of health in London possess powers for this purpose under section 71 of the Public Health (London) Act. On finding evidence that any person in his district is suffering from dangerous infectious disease attributable to milk supplied from any dairy situated either within or without his district, or that the consumption of milk from such dairy is likely to cause such infectious disease, the medical officer of health, if authorised by an order of a justice having jurisdiction in the place where the dairy is situated, may inspect the dairy, and if accompanied by a veterinary surgeon may inspect the animals therein. If, on such inspection, he is of opinion that any such infectious disease is caused by the consumption of the milk supplied from such dairy, he is required to report thereon to his authority, and his report must be accompanied by any report furnished to him by the veterinary surgeon. The sanitary authority is then empowered to serve on the dairyman notice to appear before them within not less than 24 hours, and, if he fails to show cause why an order should not be made, they may make an order requiring him not to supply any milk from the dairy within their district. " This procedure, if strictly followed, involves considerable delay. In the outbreak which has recently been investigated, a considerable number of persons were daily infected during the period in which the infective milk was being supplied, and, had the supply of this milk been continued pending the carrying out of the procedure above indicated, numerous cases which ought to and might have been prevented would have occurred. Moreover, when milk from a particular source has been found to be producing disease in one district, and even when it transpires that cases traceable to the same supply of milk are occurring in other districts, it would be necessary for the medical officer of each .of these other districts separately to inspect the particular dairy from which the milk was supplied, and comply with the other requirements of the section before the implicated milk could be excluded from his district. It seems obvious that when disease has been traced to a particular milk supply the sale of such milk should be altogether stopped, and not merely that it should be excluded from the district in which the outbreak has occurred. The County Council has no power to exclude from London even a particular milk known to be the cause of disease. Moreover, when a sanitary authority in London excludes fiom its district the milk from a particular farm, notice is required to be given to the council of the county in which the farm is situated, but we know of no power of the County Council to stop the sale of the milkIn the recent outbreak the milk supplied in the districts affected was procured through a middleman who obtained the milk from a number of farms in various parts of the country and distributed it to'the local vendors direct from the railway stations to which it was sent by the farmers It does not appear to be a general practice in the milk trade to keep such a record as would enable the origin of the milk supplied to particular local vendors to be readily traced. We think such a record should be kept, and that a medical officer of health should be able to procure information as to the sources of supply of milk distributed in his district. _ , . . We may point out that authorities in Scotland have much wider powers and duties in this connection than those of authorities in London. Thus, under section 60 (2) of the Public Health ("Scotland) Act, 1897, if the medical officer of any district has evidence that any person in the district is suffering from an infectious disease attributable to milk from any dairy without the district or that the milk from any such dairy is likely to cause any such disease to any person residinq; in the district such medical officer shall forthwith intimate the-same to the local authority of the district in which such dairy is situate, and such other local authority shall be bound, forthwith, by its medical officer to examine the dairy and the persons aforesaid, and by a veterinary surgeon to examine the animals therein, previous notice of the time of such examination having been given to the local 31 authority of the tirst-mentioned district, in order that its medical officer or veterinary surgeon may, if they so desire, be present at the examinations referred to, and the medical officer of the secondmentioned local authority shall forthwith report the results of his examination, accompanied by the report of the veterinary surgeon, if any, to that local authority. Sub-section 3 of the same section requires the local authority of the district in which the dairy is situate to meet forthwith and consider the reports and any other evidence by parties concerned, and either to make an order requiring the dairyman not to supply any milk from the dairy until the order has been withdrawn by the local authority, or to resolve that no such order is necessary. Under sub-section 5 the local authority may, if the dairy is within the district, require the dairyman not to supply milk either within or without the district, and shall give notice of the fact to the local authority of any district within which they believe milk to be supplied from such dairy. Provision is made in sub-section 7 for appeal to a sheriff by any local authority or dairyman aggrieved, and for the order to remain in force pending the disposal of such appeal. Section 61 enables the local authority in cases where infectious disease is attributable to milk supplied by any dairyman, whether wholesale or retail, or to milk supplied by one or other of several such dairymen, whether wholesale or retail, to require such dairyman, whether within or without its district, to furnish a full and complete list of the names and addresses of all his customers within the district on payment at the rate of 6d. for every 25 names, and also a full and complete list of the farmers, dairymen, or other parties from whom, during a period to be specified, the milk or any part of the milk which they sell or distribute was obtained, and if required to produce and exhibit to the medical officer or person deputed by him, all invoices, pass-books, accounts or contracts connected with the consignment or purchase of milk during such period. We think there would be great advantage if these or similar powers were given to authorities in England and Wales, and that there is urgent need for legislation on the subject. So far as London is concerned we have instructed the officers to report as to the form of the legislation necessary, with a view to the Council, if possible, introducing a bill on the subject. In the meantime we think the attention of the Local Government Board should be called to the matter, and we recommend— That the Local Government Board be informed of the facts set forth in the foregoing report as illustrating the need for an amendment of the law with regard to infectious diseases attributed to milk. The committee further reported to the Council on this subject on the 18th June, 1901, to the following effect— On 21st May last we reported to the Council the circumstances of a serious outbreak of scarlet fever, mainly in the east of London, and we pointed out that they illustrated the unsatisfactory position of the law with regard to infectious diseases attributed to milk. We stated that so far as London was concerned we had instructed the officers to report as to the form of legislation required, with a view to the Council, if possible, introducing a bill on the subject. In the meantime we recommended the Council to call the attention of the Local Government Board to the facts as evidence of the necessity for an amendment of the law. The Council adopted our recommendation, and a letter was accordingly addressed to the Local Government Board. We have now received reports from the officers, and after carefully considering them we are of opinion that the following powers are urgently required, viz.— 1. Power to require a dairyman to supply to the medical officer of the district a list of his customers on payment of a small sum for the service. 2. Power to require a dairyman to furnish to the medical officer of the district a list of the sources of his supply. 3. Power to the sanitary authority to compensate a milk vendor whose milk supply is stopped at the request of the authority on account of suspicion that it is infective, and whose milk is as the result of further inquiry subsequently determined not to have been infective. As to (1) provision should be made for the requirement to apply (a) to the supply to retail vendors by wholesale vendors, (6) to the supply to consumers by retail vendors. As to (2) it would be requisite to provide machinery by which milk distributed to consumers could, if necessary, be traced to the farm from which the milk is received. It would probably suffice, in cases in which the retail vendor receives milk through a middleman, for the middleman to keep a register of the sources from which he supplies the retail vendor. In the same way, one vendor selling to another should be required to keep a record of such transactions and the source from which the supply is derived. As already pointed out, there is no power to exclude an infective milk supply from London as a whole, inasmuch as the Council has no power in the matter, and each of the 29 sanitary authorities can only exclude the milk from its own district, and that after adopting a procedure involving considerable loss of time. Such power should be given to the County Council, and along with it the necessary powers of inspection of dairies and cattle outside as well as inside London. The Council should also be enabled to exercise the powers numbered 1, 2 and 3, should it find it necessary to do so for the purpose of dealing with some widespread prevalence of disease involving more than one district. The necessity for the sanitary authority to obtain a magistrate's order before making an inspection of a dairy and of cows ought to be obviated ; at any rate, it might be provided that this should be unnecessary unless demanded by the dairyman. The loss of time in obtaining an order may mean loss of life among the consumers. Again, the procedure provided in section 71 of the Public Health (London) Act, by which a meeting of the sanitary authority is needed before the supply of milk within its district from a particular dairy can be stopped, may lead to serious loss of time. The procedure adopted in connection with the closure of a school under the Education Code, by which any two members can act on the advice of the medical officer of health, is much more convenient. It might be well to provide for appeal. Loss of time in connection with the settlement of an appeal as to money is of small moment as compared with loss of time in stopping the distribution of an infective milk supply. A few other prevalences of scarlet fever a.re referred to in the reports of medical officers of health. The medical officer of health of Paddington comments on excessive prevalences of the disease in the Hall Park district and in the neighbourhood of Clarendon-street. In the former the evidence suggested personal communication as the cause, the disease being probably contracted by children playing together in the street ; later the association of children in a board school appeared also to have had some influence in the same direction. In the latter there was less evidence of direct personal infection, and there was no evidence that attendance at school was operative as a cause. The medical officer of health of St. Pancras reports the occurrence of eight cases in a private school, and also an outbreak involving 30 cases in the Regent's-park Barracks, probably ilue to the existence of an unrecognised case of the disease. The medical officer of health of Hackney reports a small outbreak in a home in Clapton, 17 persons being attacked. The disease was due to the introduction into the home of an inmate who was not known at the 32 time to be suffering from scarlet fever. Dr. Reginald Dudfield, in an analysis of the cases of scarlet fever occurring in Paddington, states tliat of 503 cases notified in the district, in 328 instances but 1 case occurred in each house, 52 houses had 2 cases, 13 houses had 3 cases, 1 house had 4, 4 houses had 5, and 1 house had 8 cases. In the houses which had 2 cases he found the interval between them was under 7 days in 18 instances, over 7 days and less than 28 days in 1G instances, and over 2 months in 18 instances. Scarlet fever and elementary schools. The influence of schools upon scarlet fever prevalence is referred to in a few reports. This subject, in relation to a Board school in Paddington, has been already mentioned. Dr. Parkes stales that in Chelsea the fall in notified cases following the closing of the schools (board schools on the 24th July) was well marked. Dr. Allan writes that in Westminster, after the usual fall in numbers during the school holiday period, the succeeding rise was small, and did not continue. Dr. Kenwood mentions that school attendance was ascribed as the origin of infection in 17 cases. Dr. Bond writes that in Holborn the greatest incidence of the disease occurred in the four weeks prior to the closure of the schools for the summer holiday, when 48 cases were notified, and that during the holiday scarlet fever much diminished, only 17 notifications being received during the four weeks ending the 31st August. During the period of greatest incidence the schools most affected were Tower-street and St. George, Bloomsbury. Dr. Davies mentions that tl>ree schools were most affected, being attended by 1G, 18 and 28 of the children between 5 and 15 years of age who suffered from scarlet fever in Woolwich. The medical officers of health of Fulham and Woolwich show in tabular form the number of cases of scarlet fever known to be present among the attendants at each school in their districts. In previous annual reports I have commented on the decline in scarlet fever prevalence during the summer holiday period of the London Board Schools, and it will be seen from the following table that the year 1901 presents no exceptional features in this respect. The summer holiday of the London School Board schools began in 1901 on Thursday, the 25th July, i.e., the latter part of the 30th week, and the schools re-opened on Mondav, the 2Gth August, i.e., at the beginning of the 35th week. If the number of cases notified in the four weeks, which would be most subject to holiday influence, be compared with the number of cases notified in the four preceding and four subsequent weeks, the results shown in the followiug table are obtained. It will be seen that the decrease during the period of holiday influence is most marked at ages 3—13, and the increase subsequent to the period of holiday influence is particularly marked at the school age. Scarlet fever—Notified cases, 1901 Notified cases—Ages. Increase or decrease per cent. Period. 0-3 3-13 13 and upward-. 0-3 3-13 13 and upwards. Four weeks preceding weeks of holiday influence (28th to 31st) 184 1,141 352 — — — Four weeks of holiday influence (32nd to 35th) 169 890 281 — 8.2 — 220 — 20.2 Four weeks following weeks of holiday influence (36th to 39th) 193 1,391 382 + 14.2 + 563 + 35.9 Return cases of scarlet fever. " Return cases," i.e., cases occurring at a short interval after the return home from hospital of a previous case, are mentioned in several reports. In Pulham there were 34 such cases occuring within 10 days of the return of the previous case, in Stoke Newington 2 return cases, in Bermondsey 21 return cases, or 3 per cent, of the cases removed, in Wandsworth 19, and iu Woolwich 7. Proportion of cases in hospitals. It will be seen on reference to diagram (VII.) that there was in 1901 a slight increase in the proportion of the notified cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board compared with the proportion in the preceding year. In the report of the Statistical Committee of the Metropolitan Asylums Board for the year 1901 it is pointed out that the proportion of scarlet fever admissions to notifications has risen from 42'82 per cent, in 1890 to 78'89 in 1901, and that the low figures of 1893 and the falling off in the admission rate of the year 1895 were due to inadequacy of hospital accommodation in those years. Owing to the allotment of the Gore Hospital for cases of smallpox, the medical officer of Poplar states there was for some time difficulty in securing the removal of cases of scarlet fever, and' the medical officer of health of Battersea mentions the same subject. Diagram IX. — Diphtheria. 33 Scarlet fever—Age and sex distribution. The following table shows the case rates, death rates, and fatality of scarlet fever during the year 1901. It will he seen that the case rate, death rate and fatality were higher among males at " all ages " than among females. In the age-groups adopted for the purposes of the table the greatest incidence of attack was upon both males and females of four years of age. The greatest incidence of death was upon males and females of two years of age. The fatality was greatest among males under one year of age, and also among females under one year of age if the age group 55 years and upwards be excepted on the ground of the smallness of the figures at these asres. Scarlet fever,* 1901. 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. 8,830 323 3.7 412 15 9,545 272 2.8 398 11 0— 144 22 15.3 261 40 104 13 12.5 190 24 1— 351 43 12.3 719 88 299 33 11.0 612 68 2— 645 63 9.8 1,307 128 595 56 9.4 1,211 114 3— 796 52 6.5 1,657 108 832 51 6.1 1,711 105 4— 889 27 3.0 1,891 57 922 25 2.7 1,970 53 5— 3,279 83 2.5 1,486 38 3,634 47 1.3 1,631 21 10— 1,399 10 0.7 672 5 1,594 21 1.3 751 10 15— 669 11 1.6 320 5 677 9 1.3 290 4 20— 358 5 1.4 164 2 441 8 1.8 170 3 25— 225 3 1.3 60 1 337 4 1.2 77 1 35— 59 3 5.1 21 1 73 2 2.7 23 1 45— 17 1 5.9 9 1 28 2 71 13 1 55 and upwards. 5 — — 3 — 6 1 16.7 2 0 Diphtheria. The cases of diphtheria notified in the administrative county of London in 1901 numbered 12,156, compared with 12,023 in 1900. The number of deaths registered from this cause in 1901 was 1.330. comnared with 1.540 in 1900. The diphtheria case rates and death rates in 1901 and preceding periods are shown in following table— 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 20 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 1897 0.501 3.0 17.0 1898 0.391 2.7 14.8 1899 0.431 3.1 14.2 1900 0.341 2.7 12.8 1901 0.291 2.7 10.9 The death rate in each year since 1858, in relation to the mean death rate of the period 1859-1901, is shown for diphtheria and for diphtheria and croup combined in diagram IX. The monthly case rate and case mortality in each of the years 1891-1901 in relation to the mean of the whole period is shown in diagram XI. This diagram shows that while there is no marked diminution in the prevalence of the disease the case mortality continues to decline. If the London diphtheria death rate be compared with the death rate of the following large English towns it will be seen that in the period 1891-1900 the London rate exceeded the rates of all these towns, except West Ham, and in 1901 exceeded the rates of till except Leeds, Sheffield, Bristol, Salford, West Ham and Leicester. * In the preparation of this table, the question whether the persons, who were attacked and who died, belonged to London is disregarded, the pereen'age being calculated on the number of cases notified in London, and the number of deaths occurring in London and the institutions belonging to London. f The Infectious Direase (Notification) Act came into force in 1889. See footnote ('), page 9. . [5] 34 Diphtheria—Death-rates per 1.000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.501 0.301 Nottingham 0.09 0.12 Manchester 0.19 0.24 Bradford 0.09 0.12 Liverpool 0.20 0.27 Hull 0.12 0.18 Birmingham 0.24 0.16 Salford 0.28 0.63 Leeds 0.29 0.41 West Ham 0.60 0.65 Sheffield 0.39 0.63 Leicester 0.43 0.73 Bristol 0.17 0.38 Newcastle 0.18 0.16 It will be seen from the following table that the London diphtheria death rate in the period 1891-1900 was higher than that of any of the undermentioned foreign towns, except Stockholm, St. Petersburg, Berlin, Vienna and New York, and in 1901 was higher than that of any, except Stockholm, St. Petersburg and New York. The inclusion of deaths from croup, however, in the case of several of these towns makes comparisons of the death rates of little value.t Diphtheria—Death-rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.50' 0.301 St. Petersburg 0.92 0.94 Paris 0.29* 0.27* Berlin 0.51 0.25 Brussels 0.13* 0.13* Vienna 0.61* 0.23* Amsterdam 0.20* 0.11 Rome 0.18 0.09 Copenhagen 0.43 0.09 New York 0.71* 0.08* Stockholm 0.73* 0.45* The case rate of each of the metropolitan boroughs in 1891-1900 and in 1901, and the deaths and death rate in 1901 are shown in the following table— Metropolitan borough. Cases, 1901. Case-rate per 1,000 living. Deaths, 1901. Death-rate per 1,000 living, 1901. 1891-1900. 1901. Paddington 340 2.1 2.4 46 0.32 Kensington 251 1.7 1.4 38 0.22 Hammersmith 226 2.2 2.0 36 0.32 Fulham 644 3.2 4.7 48 0.35 Chelsea 107 2.9 1.5 9 0.12 Westminster, City of 255 1.6 1.4 21 0.12 St. Marylebone 259 1.8 2.0 33 0.25 Hampstead 153 1.8 1.9 20 0.24 St. Pancras 941 2.2 4.0 109 0.46 Islington 915 2.3 2.7 132 0.39 Stoke Newington 144 2.0 2.8 14 0.27 Hackney 979 3.1 4.5 97 0.44 Holborn 167 2.0 2.8 15 0.25 Finsbury 297 3.0 2.9 36 0.36 London, City of 68 1.8 2.6 8 0.30 Shoreditch 326 2.6 2.8 29 0.25 Bethnal-green 463 3.7 8.6 63 0.49 Stepney 845 3.2 2.8 76 0.25 Poplar 619 3.9 3.7 83 0.49 Southwark 558 3.2 2.7 53 0.26 Bermondsey 329 2.8 2.5 37 0.28 Lambeth 527 2.5 1.7 51 0.17 Battersea 267 3.2 1.6 20 0.12 Wandsworth 478 2.1 2.0 41 0.18 Camberwell 867 3.3 3.3 112 0.43 Deptford 427 3.3 3.9 37 0.34 Greenwich 188 2.7 2.0 22 0.23 Lewisham 299 2.6 2.3 24 0.19 Woolwich 217 2.2 1.8 20 0.17 Port of London — — — — London 12,156 2.6 2.7 1,330 0.292 The northern group of districts had the highest diphtheria death rate during the year 1901, viz., 0'38 per 1,000 living, and the western and southern groups the lowest (0'24). Among . Including deaths from croup. t The death.rate in London from diphtheria, including deaths from croup, was 0 53 in 1891 1900, and 0 31 in 1901. 1 See footnote (2) page 9. 2 See footnote (') page 9. Diagram XI Diphtheria. 35 the several metropolitan boroughs Bethnal Green and Poplar had the highest death rate (0'49), and Chelsea, Westminster and Battersea the lowest (0.12). The diphtheria death rates in London in the four quarters of the year 1901 were as follows: first quarter, 0'26 ; second quarter, 0'20 ; third quarter, 0.31 ; and fourth quarter 0.40 per 1,000 living. To enable the variations in diphtheria prevalence in the several metropolitan boroughs to be more clearly appreciated the following table has been prepared. This table shows the comparative case rates of each borough in each of the years 1891-1901 inclusive, i.e., the case rates of each borough are shown in relation to the London case rate of the same year, the London rate being taken as 100. Diphtheria. Comparative case rates (London taken as 100). Metropolitan borough. Comparative case rates (London case rates taken as 100). 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901. Paddington 104 77 73 117 74 66 91 98 68 44 89 Kensington 78 60 68 63 86 70 67 49 51 74 52 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 Fnlham 61 58 78 126 139 99 109 145 135 178 174 Chelsea 138 110 83 107 143 184 107 79 61 74 56 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 Hampstead 105 96 73 53 61 84 47 65 48 74 70 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 Islington 152 119 86 103 70 106 73 60 68 70 100 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 Hackney 131 147 135 108 93 89 122 152 106 107 167 Holborn 52 89 79 61 66 61 104 102 46 70 104 Pinsbnry 118 82 130 81 86 112 170 163 93 74 107 City of London 59 130 60 49 51 74 71 60 68 89 96 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 Bethnal-green 154 230 181 168 143 114 144 100 89 115 133 Stepney 106 132 112 123 157 150 128 93 89 107 104 Poplar 191 148 214 159 179 133 141 105 83 141 137 South wark 71 72 116 113 86 106 102 151 207 141 100 Bermondscy 68 60 84 126 80 99 97 90 177 133 93 Lambeth 88 97 91 83 88 74 83 103 121 104 63 Battersea 144 123 132 122 97 81 125 178 116 70 59 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 Camberwell 69 65 67 112 140 180 154 102 156 130 122 Deptford 72 68 86 153 225 113 141 132 121 111 144 Greenwich 60 43 84 85 137 189 82 105 122 89 74 Lewisham 48 74 82 70 57 122 85 127 170 126 85 Woolwich 32 68 66 66 81 96 91 86 100 115 67 London 100 100 100 100 100 100 100 100 100 100 100 Diphtheria and elementary schools. The reports of medical officers of health show the following prevalences of diphtheria among children attending particular schools. The medical officer of Chelsea mentions the occurrence of four cases among the scholars of St. Simon's School, Milner-street, and five cases among those of Christchurch School, both of which were closed and disinfected. In Islington " an undue number of cases (57) occurred among the pupils of the Queen's Head-street Board School, the cases being distributed throughout the year." It was not found necessary to adopt any special measures in connection with the outbreak. In Stoke Newington in 14 cases, or 10.2 per cent, of the total cases, school attendance was alleged by the parents or surmised by the medical officer of health to be responsible for the attack. In Lambeth a private school of 52 scholars was closed in March on account of a pupil teacher contracting the disease. In several reports a tabular statement is supplied showing the number of scholars attending each of the elementary schools attacked with diphtheria. Reference has been made in previous annual reports to the decline in diphtheria prevalence which occurs during the holiday period of the schools of the London School Board. The following table shows that the figures for the year 1901 are not exceptional in this respect The summer holiday of the schools of the London School Board began on Thursday, the 25th July, i.e., the latter part of the 30th week, and the schools reopened on Monday, the 26th August, i.e., the beginning of the 35th week. If the number of cases in the four weeks preceding and four weeks subsequent to the weeks most subject to holiday influence be compared, the following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. It will be observed that the decrease in the number of cases notified during the period of holiday influence, and the increase in the subsequent period is most marked at the school age. 36 Diphtheria—Notified cases, 1901. 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) 158 657 231 - - - Four weeks of holiday influence (32nd to 35th) 157 530 211 — 0.6 —19.3 — 8.7 Four weeks following weeks of holiday influence (36th to 39th) 177 826 290 + 12.7 + 55.8 + 37.4 Diphtheria—Proportion of cases in hospitals. It will be seen on reference to diagram X. that there was in 1901 a slight decrease in the proportion of the notified cases of diphtheria admitted to the hospitals of the Metropolitan Asylums Board compared with the proportion in the preceding year. In the report of the Statisticail Committee of the Metropolitan Asylums Board for 1901 it is pointed out that the proportion of diphtheria admissions to notifications has risen from 17.87 in 1890 to 74'85 in 1901, and that the low figures of 1893 were due to the fact that scarlet fever and diphtheria were unusually prevalent in that year and the Board's hospital accommodation quite inadequate. " Return cases " of diphtheria. " Return cases " are mentioned in a few of the reports, and particulars are given by the medical officer of health of Wandsworth of three cases resulting in one instance, and eight cases resulting in another from exposure to a child who had been discharged from hospital where it had been admitted on account of suffering from diphtheria. Bacteriological examination of material from suspected cases of diphtheria. In Westminster it was decided to extend to the whole city the arrangements which previously existed in some of the constituent districts for the bacteriological examination at the Jenner Institute of material from the throats of persons suspected to be suffering from diphtheria. Of 52 specimens thus examined, in 16 the bacillus was found, in 34 it was not found and in 2 the pseudo-diphtheria bacillus was found. In St. Pancras, where similar examination is made, in 99 cases the bacillus was found, in 144 it was not found and in 3 it was doubtful. In Islington 170 specimens were examined, 80 of which " resulted in a positive diagnosis of the disease." In Stoke Newington 28 specimens were examined at the Jenner Institute, in 12 of which the bacillus was found, in 13 it was not found and in 3 the pseudodiphtheria bacillus was found. In Hackney, in 35 instances material was sent to the Jenner Institute for examination. In Finsbury, material from 98 cases was examined, the results being that the diphtheria bacillus was found in 29 cases, the pseudo-diphtheria bacillus in 7 cases, the results being negative in 62 cases. In Poplar, material was sent to the Jenner Institute in 84 instances. The diphtheria bacillus was isolated in 36 and the pseudo-diphtheria bacillus in 7 instances. At the end of the year a laboratory was provided in Bermondsey for the examination of pathological matter. In Lambeth, 233 samples were examined, the KlebsLceffter bacillus being found in 48 and the pseudo-bacillus in 1 sample. In Deptford arrangements were made with the Clinical Research Association for the examination of material, and every medical practitioner supplied with the necessary apparatus for sending it for examination. In Aloolwich, material from 26 cases was sent to the Jenner Institute. The diphtheria bacillus was isolated in 6 cases and the pseudo-diphtheria bacillus in 1 case. Supply of antitoxin. In Stoke Newington many applications were made to the medical officer of health for antitoxin, which he stores for the convenience of local practitioners. In Hackney 30 bottles of antitoxin were supplied by the medical officer of health. In Finsbury arrangements have been made for the supply to medical men free of charge of one dose of antitoxin for each notification received, and also doses of antitoxin to any medical practitioner who desires to use it for prophylactic purposes. In Lambeth antitoxin is distributed gratuitously as a remedy and a prophylactic, and during 1901 75 vials were thus distributed. In Greenwich 66,000 units were distributed. Diplitheria—Age and sex distribution. The following table shows the cases, deaths, case rates, death rates and fatality of diphtheria at the several ages, and for each sex in London during the year 1901. As in preceding years the incidence of attack at " all ages" was greater on females than on males, but the death rate and fatality were higher among males than among females. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon males and females of four years Diagram JIl Whooping Cough. 37 of age, and the greatest incidence of death was upon males of two years of age and females of three years of age. The fatality was greatest among males and females under one year of age. Diphtheria—* 1901. 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. Death». All ages. 5,657 685 121 264 32 6,499 670 103 271 28 0— 132 43 32.6 239 78 94 36 383 172 66 1— 418 107 25.6 856 219 352 111 31.5 721 227 2 566 126 22.3 1,147 255 464 101 21.8 944 206 3— 612 96 15.7 1,274 200 646 111 17.2 1,328 228 4— 693 106 15.3 1,474 225 688 69 10.0 1,470 147 5— 1,757 166 9.4 796 75 2,075 202 9.7 931 91 10— 616 25 4.1 296 12 804 24 3.0 379 11 15— 324 8 2.5 155 4 394 1 0.3 169 0 20— 200 2 10 92 1 336 1 0.3 129 0 25— 213 4 1.9 57 1 439 4 0.9 100 1 35— 96 — — 34 — 131 4 31 42 1 45— 18 1 56 9 1 55 3 5.5 25 1 55 and upwards. 12 1 8.3 6 1 21 3 14.3 8 1 Whooping Cough. The deaths from whooping cough in the administrative county of London in 1901 numbered 1,604, compared with 1,948 in 1900. lhe death rates from this disease in 1901 and preceding periods have been as follows— Whooping covgh. Period. Death-rate per 1,000 living. Period. Death-rate per 1,000 living. 1851-60 0.88 1895 0.34' 1861-70 0.88 1896 0.651 1871-80 0.81 1897 0.421 1881-90 0.69 1898 0.481 1891 0.681 1899 0.38' 1892 0.581 1900 0.43l 1893 0.541 1901 0.351 1894 0.491 The death rate in each year in relation to the mean death rate of the period 1841-1901 is shown in diagram XII. It will be seen from the following table that the London whooping cough death rate exceeded the death rates of all the undermentioned towns, except Manchester, Liverpool, Birmingham, Salford and West Ham in the period 1891-1900, and in 1901 was lower than that of any except Liverpool, Leeds, Sheffield and Leicester. Whooping cough—Death-rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0 .502 0.35' Nottngham 0.39 0.42 Manchester 0.59 0.41 Bradford 0.37 0.45 Liverpool 0.59 0.24 Hull 0.37 0.41 Birmingham 0.52 0.42 Salford 0.71 0.41 Leeds 0.39 0.33 West Ham 0.53 0.41 Sheffield 0.49 0.34 Leicester 0.38 0.33 Bristol 0.40 0.59 Newcastle 0.49 0.50 The following table shows that the London whooping cough death rate exceeded the death rates of all the undermentioned foreign towns in the period 1891-1900, and in the year 1901 exceeded the death rates of all except Copenhagen— * See footnote (*) page 33. 1 See footnote ('), [ age 9. * See footnote (*), page 9. 38 Whooping-cough—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.5C1 0.351 St. Petersburg 0.24 0.16 Paris 0.14 0.14 Berlin 0.28 0.33 Brussels 0.16 0.16 Vienna 0.09 0.05 Amsterdam 0.32 0.25 Rome 0.06 0.08 Copenhagen 0.34 0.50 New York 0.20 0.09 Stockholm 0.20 0.13 The following table shows the deaths and death rate from whooping cough in 1901 in each of the metropolitan boroughs— Metropolitan borough. Deaths in 1901. Death-rate per 1,000 living. Metropolitan borough. Deaths in 1901. Death-rate per 1,000 living. Paddington 52 0.36 Shoreditch 60 0.51 Kensington 62 0.35 Bethnal-green 38 0.29 Hammersmith 80 0.71 Stepney 98 0.33 Pulham 77 0.56 Poplar 79 0.47 Chelsea 29 0.39 South wark 98 0.48 Westminster, City of 48 0.26 Bermondsey 57 0.44 St. Marylebone 40 0.30 Lambeth 115 0.38 Hampstead 24 0.29 Battersea 81 0.48 St. Pancras 87 0.37 Wandsworth 62 0.27 Islington 90 0.27 Camberwell 81 0.32 Stoke Newington 6 0.12 Deptford 50 0.45 Hackney 50 0.23 Greenwich 39 0.41 Holborn 10 0.17 Lewisham 28 0.22 Finsbury 38 0.38 Woolwich 20 0.17 London, City of 2 0.08 London 1,604 0. 352 The western group of districts had the highest whooping cough death rate during the year 1901, viz., 0-42 per 1,000 living, and the central group of districts the lowest (0"27). Among the several metropolitan boroughs Hammersmith had the highest death rate (0'71), and the City the lowest (0 08). The whooping cough death rates in London in the four quarters of the year 1901 were as follows: first quarter, 0-51 ; second quarter, 0 53 ; third quarter, 0'2l ; and fourth quarter, 015 per 1,000 living. Typhus. The deaths from typhus in the administrative county of London during the year 1901 numbered 4. The death rates from this disease in 1901 and previous periods were as follows— Typhus. Period. Death-rate per 1,000 living. Period. Death-rate per 1,000 living. 1871-80 .055 1896 .0012 1881-90 .008 1897 .0002 1891 .0022 1898 .001s 1892 .0032 1899 .0002 1893 .0012 1900 .0002 1894 .0012 1901 .0012 1895 .0012 Iii this table '000 indicates that the deaths were too few to give a rate of *0005. The death rate in each year since 1868 in relation to the mean death rate of the period 1869-1901 is shown in diagram XIII. Twenty persons were certified during the year to be suffering from typhus. The circumstances of the cases in which the diagnosis could not at once be stated to be inaccurate are as follows—■ Nine persons, all members of the same family, living in Addey-street, Deptford, suffered in January from this disease. The father of the family was an asphalt© road worker, and the familyb had been living in this house for three or four years. The first person in this group to be attacked was a boy aged 13 years. He was a pupil at the Regent-street Board School, and used to run messages for his mother, but had not been out of his own neighbourhood. It is not known how he became infected, but there is no reason for doubting that he infected the other members of the family, although it was not until his mother, who was the fifth case, was attacked that the disease was recognised as typhus. 1 Fee footnote (5) page 9. 2 See footnote (') page 9. Diagram Xlll — Typhus Fever.— DiagramXIV. - Enteric Fever. — Diarrhoea. — Dia&ramXV. 39 In March, a house-breaker living in Rothsay-street, Bermondsey-new-road was attacked. The source of his infection was unknown. He had for a fortnight before his illness been employeed in the demolition of houses in Catherine-street, Strand. In April a man employed as a flower-seller was attacked. He lived in an extremely dirty room in St. Katherine's-road, Kensington. The source of his infection was unknown. In May his wife, who visited him in hospital, contracted the disease. In June a man living in Caledonia-street was certified to have typhus, but the disease was probably pneumonia in a man of drunken habits. In the same month a woman living in Whitehorse-lane, Stepney, was attacked. She was engaged in nursing her invalid mother, and the source of her infection was unknown. In August a grocer's assistant living in Prince's-street, Stepney-green was attacked. The source of infection was unknown. In September a man living in New Compton-street, W.C., was certified to have typhus. He had just returned from Hamburg and the probabilities are that he did not suffer from this disease. In October a man living in Kneller-road, Brockley, was certified to have typhus. He was a railway porter and had been living in lodgings in Portsmouth for some days previous to his illness. Before removal, it had been thought desirable that he should be seen by Mr. Cantlie, the County Council's plague expert, as his symptoms were indefinite and he had some glandular enlargement. He was, therefore, examined by Mr. Cantlie, by Dr. Harris the medical officer of health of the district and by the Council's medical officer. It was concluded that he was suffering from typhus. The source of his infection was not discovered. Enteric Fever. The number of cases of enteric fever notified in the administrative county of London during 1901 (52 weeks) was 3,194 compared with 4,317 in 1900; the number of deaths from this disease belonging to the administrative county was 497 compared with 717 in 1900. Ihe rates per 1,000 living in 1901 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 0.10l 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 0.131 0.7 17.6 1897 0.131 0.7 18.0 1898 0.121 0.7 18.3 1899 0.171 1.0 17.0 1900 0.161 1.0 16.6 1901 0.111 0.7 15.6 Ihe death rate in each year since 1868 in relation to the mean death rate of the period 18G9-1901 is shown in diagram XIV., and the monthly case rate and case mortality in each of the years 1891-1901 in relation to the mean of the whole period is shown in diagram XVI. This diagram shows that the autumnal prevalence of 1901 was less marked than those of the two preceding years. The decline in case mortality, so conspicuous in recent years in the case of scarlet fever and diphtheria, is not manifest in the case of enteric fever. The following table shows the death rate from enteric fever in 1901 and the case rates in 1901 and the decennium 1891-1900 obtaining in each of the metropolitan boroughs— Metropolitan borough. Cases, 1901. Case rate per 1,000 living. Deaths, 1901. Death rate per 1,000 living, 1901. 1891-1900. 1901. Paddington 92 0.5 0.6 15 0.10 Kensington 99 0.6 0.6 11 0.06 Hammersmith 77 0.7 0.7 16 0.14 Fulham 133 0.6 1.0 20 0.14 Chelsea 41 0.7 0.6 6 0.08 Westminster, City of 105 0.6 0.6 20 0.11 St. Marylebone 82 0.7 0.6 8 0.06 Hampstead 50 0.6 0.6 7 0.09 St. Pancras 186 0.9 0.8 30 0.13 Islington 281 0.8 0.8 47 0.14 Stoke Newington 26 0.7 0.5 5 0.10 Hackney 193 1.1 0.9 20 0.09 * The Infectious Disease (Notification) Act came into force in 1889 1 See footnote (') page 9. 40 Metropolitan borough. Cases, 1901. Case rate per 1,000 living. Deaths, 1901. Death rate per 1,000 living, 1901. 1891-1900. 1901. Holborn 39 0.9 0.7 12 0.20 Finsbury 68 0.9 0.7 11 0.11 London, City of 21 1.0 0.8 3 0.11 Shoreditch 97 0.9 0.8 10 0.08 Bethnal-green 108 1.0 0.8 19 0.15 Stepney 267 0.9 0.9 44 0.15 Poplar 172 1.3 1.0 26 0.15 Southwark 135 0.7 0.7 18 0.09 Bermondsey 150 0.9 1.2 22 0.17 Lambeth 144 0.7 0.5 23 0.08 Battersea 91 0.3 0.5 18 0.11 Wandsworth 99 0.6 0.4 16 0.07 Camberwell 154 0.6 0.6 25 0.10 Deptford 63 1.1 0.6 10 0.09 Greenwich 68 0.9 0.7 10 o.io Lewisham 61 0.5 0.5 13 0.10 Woolwich 69 0.7 0.6 12 0.10 Port of London 23 — - London 3,194 0'8 0.7 497 0.111 The eastern anil central groups of districts had the highest enteric fever death rate during the year 1901, viz., 0"14 per 1,000 living, and the southern group of districts the lowest (0-10). Among the several metropolitan boroughs the death rate was highest in Holborn (0-20) and lowest in Kensington and St. Marylebone (0 06). The enteric fever death rates in London in the four quarters of the year 1901 were as follows—First quarter, 012; second quarter, 0*06; third quarter, 014 ; and fourth quarter, 013 per 1,000 living. Information as to the possible causes of enteric fever is contained in a number of the reports of the medical officers of health. Dr. Reginald Dudfield in an analysis of the cases occurring in Paddington states that 92 cases were reported, of which 21 contracted the disease outside the borough, in 2 infection was contracted while nursing cases of this disease, and in G there was error in diagnosis. Among the remaining G3, 12 persons habitually had meals beyond the borough, 4 admitted having eaten oysters, 5 admitted having eaten mussels or cockles, or both, an'd 5 had had ice-creams. In one street he found cases in three houses adjacent to each other, and in another in two houses, but with considerable intervals between the dates of attack. Dr. T. Orme Dudfield gives account of eight cases occurring in three houses in Kensington. The inmates of two of the houses were related to each other, and one of these houses was frequently visited by the inmate of the third house (situated in another street), who was himself attacked. Mr. -Jackson writes that there was an especial prevalence of the disease in Fulham during the last week of July and the first three weeks of August, 43 cases being notified in that period. He adds— " Careful inquiries were made into the cases, especially as to the possibility of the infection having been connected with the food supply, but no explanation was forthcoming of the outbreak, which occurred before the usual autumnal increase of the disease was established. The localised prevalence of the disease was, of course, strongly against the supposition that it could have been connected with the water supply, but it may be mentioned that Drs. Crookes and Dewar reported that between the 6th and 15th July, which was about the period when the bulk of the cases were infected, the disease being in many instances not notified until a week or two after the commencement of the illness, nearly the whole of the filtered water of the different companies derived from the Thames and Lea showed an excessive number of microbes per cubic centimetre, far above the variations permissible as showing the difference between good and bad filtration." In the following table will be seen the number of notified cases of enteric fever in London at this period of the year as shown in the weekly notification lists of the Metropolitan Asylums Board. These cases have been distributed according to the water supply of the houses in which they occurre'd— No. of week. Week ending. Grand June! ion. Weft Middlesex. Chelsea. New River. Eact London. Southwark and Vanxhall. Lambetli. Kent. . 25 22nd June 4 3 2 11 14 5 4 1 44 26 29th „ 3 7 2 12 11 4 7 2 48 27 6th July 4 4 2 6 5 3 4 2 30 28 13th „ 2 6 2 17 12 6 4 7 56 29 20th „ 7 6 4 15 14 11 5 2 64 30 27th „ 3 6 7 11 10 5 2 3 47 31 3rd Aug. 5 13 6 20 18 8 4 4 78 32 10th „ 4 13 6 11 14 12 8 9 77 33 17th „ 1 14 6 24 16 7 8 6 82 34 24th „ 4 7 6 16 10 8 7 8 66 35 31st ,, 5 8 5 22 31 17 9 12 109 1 See footnote ('). page 9. Enteric Fever. Diagram XVI Diagram XVII. Enteric Fever. 41 Enteric fever in London manifested increase in the 31st, 32nd and 33rd weeks, decrease in the 34th, and then rose in the 35th week, after which the usual autumnal increase was maintained. A comparison of the mean weekly cases of enteric fever notified in the years 18901901, see diagram XVII., shows a slight and gradual increase from the 30th week, the cases being below the average until the 34th week. In 1901 the average was exceeded in the 31st week. The increase in the 31st, 32nd and 33rd weeks of 1901 upon preceding weeks was most conspicuous in the West Middlesex area, but the increase in that area is in great part due to the increase in Fulham, of which Mr. Jackson gives account. In 14 cases among those occurring in Fulham Mr. Jackson found the disease was apparently communicated by personal infection from a previous case in the same house. In Westminster, Dr. Allan states that of 102 actual cases of the disease it was found that 24 persons "came into the city suffering from the complaint which they had contracted, some in South Africa, some in France, and a number at other places in this country." Of the 78 remaining cases 7 were due to infection from a previous case, and 5 to eating shellfish. Of five cases treated in King's College Hospital, it had been observed that "four of the patients had some slight gastric ailment before the proper symptoms appeared, which might probably suggest infection through food; three of these suffered from extremely toxic symptoms." He thus reports concerning another case, that of a girl, aged 12 years, living in a block of buildings in which there were no sanitary defects— She was very fond of cockles, and frequently bought some at a certain shop on Saturdays, on which day they arrived from Leigh-on-Sea. On 11th May she ate some; she felt ill the next day, and was seen by a medical man on the 15th, who treated her for congestion of the bowels. From this attack she recovered, but a week afterwards again became ill, and on the 26th May the doctor certified that she had typhoid fever. The fishmonger who sold the cockles gave all the information he had with reference to the source; in order to obtain the best quality he paid a little more than the market price for the cockles. The Public Health Committee, deeming the matter one of peculiar importance, gave instructions that a bacteriological examination be made of some cockles as supplied by this fish merchant (which was done), and that a special report be made on the subject, which is incorporated herewith. The Jenner Institute subsequently reported that "the cockles were examined by culture methods; the typical bacillus, coli communis, was isolated. A bacillus was isolated, which in all its characters resembled the typhoid bacillus. It was an actively motile, non-liquefying bacillus, producing no gas, and growing on culture media like the typhoid bacillus. Its colonies in the Eisner medium were typical typhoid-like. It was agglutinated by typhoid blood, whereas normal blood did not produce agglutination." Dr. Allan quotes a report to the Local Government Board in 189G, in which Dr. H. Timbrell Bulstrode wrote "that the cockles laid down to 'clean' in the bed of Leigh Creek are liable to pollution, must, I think, be admitted, since they are often placed near one or other of the Leigh sewage outfalls," and Dr. Allan states that Dr. Bulstrode's description still applies, though some improvements have been made, and that there is no doubt as to the possibility of sewage obtaining access to the cockles, as they lie on the side of the creek. He mentions, moreover, that the cooking process to which the cockles are submitted can scarcely be called '"boiling" them; "it consists rather of dipping a cage containing the cockles into a copper of boiling water, the process only taking 1 or 1½ minutes, the object being to kill the 'fish,' and enable it to be separated from the shell." Dr. Allan points out that this process cannot be relied upon to kill the typhoid bacillus if it be inside the cockle, as was the case in those examined by the Jenner Institute. Experiments by Dr. Klein, of which account is given in the report of the Medical Officer of the Local Government Board, 1900-01, tend to confirm this view and further show that "mussels and cockles that have sojourned for 24 hours in typhoid-infected sea water, did not, after a further sojourn for 48 hours in clean sea water, become free of the typhoid bacilli they had taken up," and indeed the bacilli appear to have "actually increased in number within the bodies of the cockles." In a special report on the outbreak of typhoid fever in Southend during June and July, 1902, which has just been published, Dr. Nash, the medical officer of health, found, as a result of inquiry, that 54 per cent. of the cases of typhoid fever occurred among the 5 per cent. of the population which, he estimated, eat cockles. In Stoke Newington 20 cases were notified, in 5 of which the disease was contracted outside London during the summer and autumn holiday. "The evidence pointed strongly to the infection having been derived from the eating of mussels in one instance and to the consumption of tinned salmon in another instance." In Hackney, 8 cases of 183 cases of actual enteric fever had been infected outside the borough. In Finsbury, Dr. Newman says, there is some evidence to show that enteric fever was caused in 3 instances by drain nuisances in the house, in 8 instances by eating shellfish, in 4 instances by personal contact with previous cases, in 2 instances by personal contact with unrecognised cases, in 5 instances by eating ice-cream, in 4 instances by eating watercress. In the remainder of 65 cases notified it had not been possible, even approximately, to discover the source of infection. One, however, appeared to be connected with a ragshop anil another with a visit to the hop-gardens in Kent, while another was that of an ambulance porter, and may have contracted the disease in the discharge of his duties. In Southwark, the cause of one case is attributed by Dr. Millson to contact with clothes which two years before had been worn by a man who had died of enteric fever. In Bermondsey a group of 14 cases occurred in Irwell-place between the 23rd September and the 28th October. Inquiry by Dr. Brown, as to milk and food supply, threw no light on the occurrence, but defective water service pipes were found in connection with the invaded houses. In Lambeth, Dr. Priestley states, no rase could be traced to infected water, milk, oysters or other shellfish, or to ice-creams. In Battersea Dr. McCleary found reason to suspect shellfish in two cases, while in the remaining cases, "where a history of infection was obtained, the source was to be found in personal infection." In 8 cases the disease was imported from outside the borough. In Wandsworth, Dr. [6] 42 Caldwell Smith reports, in only 2 cases could oysters be said to have been the cause, while in 11 instances the disease was contracted outside of the borough, in 2 instances in Paris. In Greenwich, Dr. Annis states, "ice-cream was alleged to have been the infecting agent in one or two of the cases, but no definite proof of this point was obtainable, although a knowledge of the conditions under which this delicacy is prepared always allows quite legitimate grounds for suspicion, if no more." Dr. Sidney Davies states that 8 of the 68 notifications of enteric fever in Woolwich were not actual cases of the disease. Of the actual cases, 4 were due to infection from previous cases, 13 had partaken of shellfish within four weeks of the commencement of the illness, 4 of celery or watercress, and 3 of ice-creams. One was attributed to working on a blocked drainage manhole, and in one case a wife contracted the disease several months after her husband had it. Dr. Davies discusses the occurrence of 11 cases at Eltham which occurred in July, August, September and October. Of a series of 9 cases, the first was a milk carrier, but none of the later cases received milk from this source. Of the remaining 8, 6 had their milk from one dairy, the milk of which was widely distributed. The cases were, however, on one round, and the man who served this round had been in good health. A man who served another round was a friend of the milk carrier, the first of the series. He was of unclean habits, and was dismissed for this reason, and there was a cessation of cases shortly after his dismissal. Dr. Davies states, "it is possible that this man may have had some dealings with milk cans belonging to the affected round, but the fact remains that no cases occurred on his own round." Other food supplies could be excluded as possible sources of infection. Bacteriological examination of blood serum. The annual reports in several instances show that the blood of persons suspected to be suffering from enteric fever was examined for the "Widal reaction"; thus, in Paddington, the reaction was obtained in 22 out of 37 cases, in Fulham in 33 out of 44 cases. In Westminster, of 10 cases examined, the reaction was strong in 5 and feeble in 1. In St. Pancras, of 92 cases examined the reaction was obtained in 47. In Islington, 112 specimens were examined, and the reaction obtained with 66. In Stoke Newington the reaction was obtained with 2 out of 6 specimens. In Hackney, blood from 9 cases was sent to the Jenner Institute for examination. In Finsbury, in 23 cases blood was examined, in 17 of which there were positive results. In Shoreditch the blood was examined in 9 instances, in 4 the results were positive. In Poplar, the blood was examined in 52 instances, the reaction being obtained in 28. In Lambeth, 98 samples of blood were examined, the reaction being obtained in 50. In Wandsworth, the blood was examined in 7 cases, in 3 the result being positive. In Deptford, arrangements have been made for the examination of blood from doubtful cases of enteric fever. In Woolwich, an examination was made in 27 cases, and in 15 a positive result obtained. Enteric fever—Age and sex distribution. The following table shows the cases, deaths, case rates, death rates and fatality of enteric fever during the year 1901 in London. The case rate at "all ages" was greater among males than among females, as were also the death rate and fatality. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon males aged 15-20 and females aged 10-15. The greatest incidence of death was upon males aged 20-25 and females aged 10-15. The fatality was greatest among males aged 55 and upwards and females aged 45-55. Enteric fever*, 1901. 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. 1,714 317 18.5 80 15 1,480 223 15.1 62 9 0— 6 1 7.7 37 3 3 1 15.2 32 5 1— 8 — 4 1 2— 18 3 13 4 3— 29 3 28 5 4— 30 — 31 1 5— 178 11 6.2 81 5 194 12 6.2 87 5 10— 258 20 7.8 124 10 234 28 12.0 110 13 15— 288 45 15.6 138 21 227 29 12.8 97 12 20— 254 56 22.0 117 26 213 26 12.2 82 10 25— 348 90 25.9 94 24 283 45 15.9 65 10 35— 187 55 29.4 66 20 155 35 22.6 50 11 45— 79 20 25.3 40 10 64 25 38.1 29 11 55 and upwards. 31 13 41.9 16 7 31 11 35.5 12 4 * See footnote (*), page 33. 43 Diarrhœa. The deaths in the administrative county of London attributed to diarrhoea and dysentery in the year 1901 numbered 3,900, compared with 3,537 in the year 1900. The death rates in 1901 and preceding periods are shown in the following table— Diarrhoea—Death rate per 1,000 living. Period. Death rate per 1,000 living. Period. Death rate per 1,000 living. 1851-60 1.03 1895 0.821 1861-70 1.04 1896 0.711 1871-80 0.95 1897 0.921 1881-90 0.75 1898 0.981 1891 0.571 1899 0.931 1892 0.601 1900 0.781 1893 0.801 1901 0.861 1894 0.411 The diarrhoea 'death rate in each year since 1840 in relation to the mean death rate of the period 1841-1901 is shown in diagram XV. The mean temperature of the summer quarter of each year in relation to the mean of the period of 1841-1901 is also shown. The age distribution of the deaths 2 from this disease in London in the year 1901 was as follows— Under 1 year. 1-5 5-20 20-40 40-60 60-80 80 and upwards. 3,176 425 10 32 50 137 58 It will thus be seen that over 81 per cent. of the total deaths occurred among children under 1 year of age, and over 92 per cent. among children under 5 years of age. It will be seen from the following table that the London diarrhoea death rate was lower than that of any of the undermentioned towns except Bristol, in the year 1901, and in the period 1891-1900 was lower than that of any except Bristol and Newcastle— Diarrhœa—Death rates per 1,000 living. Towns. 1891-1900. 1901. Towns. 1891-1900. 1901. London 0.782 0872 Nottingham 1.17 1.51 Manchester 1.37 1.85 Bradford 0.90 0.89 Liverpool 1.36 1.95 Hull 1.53 1.80 Birmingham 1.27 1.47 Salford 1.61 1.91 Leeds 1.13 1.44 West Ham 1.09 1.95 Sheffield 1.40 2.11 Leicester 1.54 1.32 Bristol 0.66 0.45 Newcastle 0.77 1.24 The deaths and death rates per 1,000 living in the year 1901 in each of the metropolitan boroughs are shown in the following table— Metropolitan Borough. Deaths, 1901. Death rate per 1,000 living, 1901. Metropolitan Borough. Deaths, 1901. Death rate per 1,000 living, 1901. Paddington 116 0.81 Bethnal-green 117 0.90 Kensington 117 0.66 Stepney 298 1.00 Hammersmith 115 1.02 Poplar 213 1.26 Fulham 181 1.31 Southwark 222 1.08 Chelsea 38 0.52 Bermondsey 122 0.94 Westminster, City of 70 0.38 Lambeth 293 0.97 St. Marylebone 104 0.78 Battersea 202 1.20 Hampstead 26 0.32 Wandsworth 157 0.67 St. Pancras 195 0.83 Camberwell 204 0.79 Islington 198 0.59 Deptford 104 0.94 Stoke Newington 25 0.49 Greenwich 75 0.78 Hackney 179 0.82 Lewisham 104 0.81 Holborn 42 0.71 Woolwich 99 0.84 Finsbury 121 1.20 Port of London — — London, City of 8 0.30 London 3,900 0.86l Shoreditch 155 1.31 ' See footnote ('), page 0, ' See footnote (*), page 9, 44 The eastern group of districts had the highest diarrhoea death rate during the year, viz.: 1.10 per 1,000 living, and the northern group the lowest (0.69). Among the several metropolitan boroughs Fulham and Shoreditch had the highest death rate (1.31) and the City the lowest (0.30). The diarrhœa death rates in London in the four quarters of the year 1901 were as follows—first quarter, 0.16; second quarter, 0.19; third quarter, 2.77; and fourth quarter 0.32 per 1,000 living. It needs to be stated that the above figures and diagram relate only to deaths which are classified by the Registrar-General under the heading "diarrhoea." There is no question that alteration in nomenclature is largely affecting the number of deaths in London classified under this heading, the increasing use of the terms "enteritis" and "gastro-enteritis," as shown by the reports of the Registrar-General, leading to the registration of deaths under these headings which in earlier years would have been classified with " diarrhoea." Cholera. During the year 1901 three persons were certified to be suffering from cholera, one in Fulham, one in Hackney and one in Lambeth. Inquiry into each of these cases showed that none of them could be regarded as cases of Asiatic cholera. The number of deaths attributed to cholera and choleraic diarrhoea was 43, of these deaths, 29 occurred among children under one year of age. Erysipelas. The deaths from erysipelas registered in the administrative county of London during 1901 (52 weeks) numbered 171; the corrected annual average of the preceding ten years was 235. The number of cases notified and the number of deaths registered from this disease since 1890 have been as follows— Erysipelas. 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 1897 5,794 1.31 184 .04 1898 5,169 1.16 165 .04 1899 5,606 1.25 213 .05 1900 4,762 1.06 182 .04 1901 4,604 1.02 171 .04 The number of cases of erysipelas notified and the case rate of the year 1901, together with the case rate of the decennium 1891-1900 for each of the metropolitan boroughs are shown in the following table— Metropolitan borough. Cases, 1901. Case-rate per 1,000 living. Metropolitan borough. Cases, 1901. Case-rate per 1,000 living. 1891- 1900. 1901. 18911900. 1901. Paddington 141 1.1 1.0 Bethnal-green 211 2.4 1.6 Kensington 171 1.3 1.0 Stepney 372 1.7 1.2 Hammersmith 116 1.0 1.0 Poplar 187 1.8 1.1 Fulham 132 1.1 1.0 Southwark 241 1.5 1.2 Chelsea 47 1.4 0.6 Bermondsey 155 1.6 1.2 Westminster, City of 117 0.8 0.6 Lambeth 238 1.2 0.8 St. Marylebone 183 1.7 1.4 Battersea 126 1.6 0.7 Hampstead 48 0.7 0.6 Wandsworth 225 1.3 1.0 St. Pancras 253 1.7 1.1 Camberwell 228 1.2 0.9 Islington 287 1.2 0.9 Deptford 111 1.4 1.0 Stoke Newington 41 0.8 0.8 Greenwich 110 1.4 1.1 Hackney 326 1.4 1.5 Lewisham 86 0.9 0.7 Holborn 89 2.1 1.5 Woolwich 70 0.9 0.6 Finsbury 135 1.9 1.3 Port of London 3 - - London, City of 13 1.0 0.5 London 4,604 1.4 1.0 Shoreditch 142 1.8 1.2 1 See footnote (2), page 9. 45 The following table shows the age and sex distribution of the notified cases of erysipelas in 1901— Age period. All ages. 0- 5- 10- 15- 20- 25- 35- 45- 65- 65- 75 and upwards. Males 1,993 145 89 80 92 119 272 375 377 235 150 59 Females 2,611 190 81 124 152 163 346 444 469 323 220 99 Persons 4,604 335 170 204 244 282 618 819 846 558 370 158 The table shows that the incidence of this disease is greatest upon the later ages of life, and that the number of females attacked considerably exceeds the number of males attacked. Puerperal Fever. The deaths in the administrative county of London in 1901 attributed to puerperal fever numbered 184, the corrected annual average of the preceding ten years being 238. The number of cases notified and the number of deaths registered from this cause since the year 1890 have been as follows— Puerperal fever. Year. Notified cases. Deaths.1 1891 221 222 1892 337 313 1893 397 352 1894 253 210 1895 236 208 1896 277 225 1897 264 215 1898 247 184 1899 326 209 1900 237 169 1901 253 184 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 1897 .06 1.98 .05 1.61 1898 .05 1.86 .04 1.39 1899 .07 2.45 .05 1.57 1900 .05 1.81 .04 1.29 1901 .06 1.93 .04 1.40 Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1900 numbered 1,950, fell to 664 in 1901, the corrected annual average for the preceding ten years being 1,573. The deaths attributed to bronchitis in 1901 numbered 7,317, being 2,362 below the corrected annual average for the preceding ten years; the deaths from pneumonia numbered 6,121 in the year 1901, being 221 below the corrected annual average of the preceding ten years. 1 See footnote (2), page 9. 46 The deaths from these diseases since 1889 have been as follows— Year. 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 5,996.0 1897 671 1,069.0 7,408 10,754.0 5,053 5,962.0 1898 1,283 1,138.0 7,779 10,446.0 5,440 5,988.0 1899 1,817 1,272.0 9,195 10,203.0 6,666 6,069.0 1900 1,950 1,462.0 8,699 10,226.0 7,189 6,341.0 1901 664 1,573.0 7,317 9,679.0 6,121 6,342.0 The following table is of interest as showing the rapidity with which influenza may increase from small to epidemic proportions, and the fact that the mortality from the disease has usually attained its maximum in the late autumn or winter months. Influenza—Deaths1 registered in London in four-weekly periods, 1890-1901. Number of weeks. 1890. 1891. 1882. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. Weeks 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 „ 5-8 167 7 637 96 96 164 58 55 368 259 298 75 „ 9-12 75 8 119 162 69 1,343 61 94 193 430 130 134 „ 13-16 39 29 42 180 56 257 50 121 140 302 172 102 „ 17-20 13 770 33 125 32 106 50 96 61 121 105 81 „ 21-24 5 1,044 22 72 27 35 33 54 51 82 57 30 „ 25-28 6 242 15 49 19 28 17 26 25 42 16 21 „ 29-32 6 51 7 23 17 14 15 18 27 27 12 18 „ 33-36 3 32 9 23 20 17 10 13 10 11 11 11 „ 37-40 6 13 6 18 14 15 12 19 17 19 15 12 „ 41-44 5 15 20 28 29 22 27 29 46 55 17 23 „ 45-48 13 35 18 152 41 47 56 35 49 61 55 44 „ 49—52* 6 81 28 546 58 49 56 71 52 342 46 56 PnTinsis. The deaths from phthisis in the administrative county of London during 1901 (52 weeks) numbered 7,514. The death rates from this disease per 1,000 living iu successive periods have been as follows— Phthisis. 1851-60 2.861 1895 1.831 1861-70 2.841 1896 1.731 1871-80 2.511 1897 1.781 1881-90 2.09' 1898 1.791 1891 2.021 1899 1.901 1892 1.891 1900 1.791 1893 1.911 1901 1.71* 1894 1.741 The Registrar-General, in the annual summaries relating to London and other large towns, since the year 1893, 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 (2 ) in the several groups ot districts since 1893 have been as follows— 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. Central group 2.58 2.65 2.53 2.69 2.66 2.75 2.90 2.40 East ,, 2.00 2.05 1.89 2.03 2.06 2.19 2.04 2.06 South „ 1.54 1.70 1.60 1.62 1.66 1.74 1.63 l.55 North „ 1.60 1.63 1.58 1.55 1.54 1.64 1.61 1.59 West „ 1.55 1.55 1.54 1.53 1.52 1.65 1.50 1.47 * The deaths occurring in the 53rd week of the years 1890 and 1806 are excluded from these figures, 1 See footnote (2), page 0, ' See footnote ('), page 9. 47 The following table shows the deaths and the death rate per 1,000 living in 1901, for each of the metropolitan boroughs— Metropolitan borough. Deaths, 1901. Death-rate per 1,000 living, 1901. Metropolitan borough. Deaths, 1901. Death-rate per 1,000 living, 1901. Paddington 158 1.10 Shoreditch 264 2.23 Kensington 241 1.37 Bethnal-green 279 2.16 Hammersmith 160 1.42 Stepney 623 2.09 Fulham 189 1.37 Poplar 302 1.79 Chelsea 124 1.68 Southwark 516 2.51 Westminster, City of 344 1.89 Bermondsey 233 1.79 St. Marylebone 251 1.89 Lambeth 499 1.65 Hampstead 75 0.91 Battersea 246 1.46 St. Pancras 439 1.87 Wandsworth 267 1.14 Islington 504 1.51 Camberwell 384 1.48 Stoke Newington 69 1.35 Deptford 131 1.19 Hackney 336 1.53 Greenwich 111 1.16 Holborn 166 2.81 Lewisham 115 0.90 Finsbury 221 2.19 Woolwich 206 1.76 London, City of 61 2.29 London 7,514 1.661 The central group of districts had the highest phthisis death rate during the year 1901, viz., 2.40 per 1,000 living, and the western group of districts the lowest (l.47). Among the several metropolitan boroughs the death rate was highest in Holborn (2.81), and the lowest in Lewisham (0.90). The phthisis death rates in London in the four quarters of the year 1901 were as follows: First quarter, 1.78; second quarter, 1.57; third quarter, 1.47, and fourth quarter, 1.77 per 1,000 living. The following table shows the number of deaths from phthisis at several age periods in each of the metropolitan boroughs. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the deceased had previously resided. (See footnote (1), page 9.) Phthisis (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddington 4 2 2 1 13 40 35 33 14 7 2 159 Kensington 6 3 3 7 19 59 63 45 24 11 2 1 243 Hammersmith 8 4 3 12 13 37 32 26 18 4 1 _ 158 Fulham 5 3 5 15 22 36 43 37 18 6 - - 190 Chelsea 5 1 2 4 4 25 37 26 16 4 - - 124 Westminster, City of 4 3 6 10 27 60 96 73 45 14 4 - 342 St. Marylebone 4 2 3 10 12 54 65 57 22 10 3 - 242 Hampstead 1 - 2 4 15 17 15 17 4 1 1 - 77 St. Pancras 18 2 3 16 29 80 123 87 46 23 6 - 433 Islington 10 4 2 22 42 128 136 106 44 15 1 - 510 Stoke Newington 1 2 1 4 9 15 14 14 6 2 1 - 69 Hackney 16 6 4 20 28 78 70 51 39 12 1 - 325 Holborn — 1 2 5 10 26 62 37 15 4 2 - 164 Finsbury 7 4 3 7 9 46 67 56 21 5 1 - 226 London, City of 1 - - 2 3 10 16 13 6 3 2 - 56 Shoreditch 14 1 5 13 17 51 74 61 14 4 1 - 255 Bethnal-green 5 2 2 16 25 65 66 48 30 18 3 - 280 Stepney 16 6 4 21 43 129 197 126 63 22 - 1 628 Poplar 13 5 7 13 30 65 81 44 30 15 1 - 304 Southwark 13 5 6 19 40 103 133 108 56 22 5 1 511 Bermondsey 6 5 2 5 23 66 55 38 23 6 1 - 230 Lambeth 18 2 4 21 45 124 120 95 53 19 2 - 503 Battersea 13 7 5 14 25 60 54 42 26 3 - - 249 Wandsworth 9 4 2 20 26 57 68 41 27 12 3 - 269 Camberwell 13 4 3 18 33 90 114 69 29 6 - - 379 Deptford 4 4 1 6 16 25 33 27 12 4 - - 132 Greenwich 2 5 3 8 6 32 23 22 9 1 - 1 112 Lewisham 4 1 — 6 16 23 37 12 8 6 2 115 Woolwich 2 3 2 14 20 53 59 24 18 9 2 206 London 222 91 87 339 620 1.654 1988 1,435 736 268 47 4 7,491 The discovery of the fact that tubercular disease is caused by a bacillus has inevitably led to endeavour to apply to this disease measures which have been employed for the limitation of maladies which have long been recognised to be communicable from person to person. Before this discovery, however, it was known that amelioration of the conditions of life, and especially the improvement of the air space within the dwelling, tended to reduce mortality from phthisis. 1 See footnote (1), page 9. 48 Thus, in the absence of such measures as those which have been specially advocated in the last few years there has been a fall in the death rate from this disease, so much so that the phthisis death rate of London in the decennium 1891-1900 was 35 per cent. below that of the decennium 1861-1870. It is now proposed to go further and to adopt measures held to be necessary in view of the belief that a phthisical person may be, unless precautions be taken, a source of risk to others. In so far as this can be done without prejudice to the sufferer there is reason for believing that good will result. In any step taken in this direction it is, however, necessary to recollect that the disease is often one of considerable duration and that many of those who are subjects of phthisis are supporting themselves and others who are dependent upon them. It is therefore very important that while having in view the public interest that of the sufferer should be carefully safeguarded. The measures which are being adopted in this and some other countries are briefly— (a) Measures for obtaining knowledge of cases with a view to medical supervision. (b) The observance of care in dealing with the sputum so as to prevent it being a cause of disease to others. (c) The maintenance of cleanliness in the rooms occupied by the phthisical person and their disinfection on the removal of the patient when necessary. (d) The treatment of the sick person in a sanatorium in which he is given opportunity for recovery, but which also serves at the same time to relieve the home, often the crowded tenement, of his presence. In large degree what is required is the education of the sick person in the precautions which should be taken, a matter in which the medical man, in whose care he is, is able to exercise a useful influence. The provision of sanatoria is matter in which public aid is needed, and it may be that even after the discharge from the sanatorium of the patient, who has apparently recovered, further public action will be necessary which will tend to ensure that he is living under conditions that will not lead to recrudescence of his disease. The problem for London is a vast one. Some idea of its extent may be gained by consideration of the number of London inhabitants who die annually from this disease. In the year 1901 this number exceeded 7,500, and when it is recollected that the average duration of the disease is several years it is seen that many thousands of persons in London are now suffering from this malady. In an address delivered by Dr. Koch to the Congress on Tuberculosis, held in London in 1901, he stated that he estimated the extent of infection by the milk and flesh of tubercular cattle, and the butter made of their milk, as hardly greater than that of hereditary transmission, and, therefore, he did not deem it advisable to take any measures against it. As the result of this statement a Royal Commission was appointed to further consider the identity of human and bovine tuberculosis and the transmissibility of bovine tuberculosis to the human subject. The Local Government Board recommended sanitary authorities that, pending the report of the Royal Commission, there should be no relaxation on their part, or on that of their officers, in the taking of proper measures for dealing with milk from tuberculous cows and with tuberculous meat which may be intended for the food of man. The resolutions adopted at the Congress were as follows— 1. That tuberculous sputum is the main agent for the conveyance of the virus of tuberculosis from man to man; and that indiscriminate spitting should therefore be suppressed. 2. That it is the opinion of this Congress that all public hospitals and dispensaries should present every patient suffering from phthisis with a leaflet containing instructions with regard to the prevention of consumption, and should supply and insist on the proper use of a pocket spittoon. 3. That the voluntary notification of cases of phthisis attended with tuberculous expectoration, and the increased preventive action which it has rendered practicable, has been attended by a promising measure of success, and that the extension of notification should be encouraged in all districts in which efficient sanitary administration renders it possible to adopt the consequential measures. 4. That the provision of sanatoria is an indispensable part of the measures necessary for the diminution of tuberculosis. 5 That in the opinion of this Congress and in the light of the work that has been presented at its sittings, medical officers of health should continue to use all the powers at their disposal, and relax no effort to prevent the spread of tuberculosis by milk and meat. 6. That, in view of the doubts thrown on the identity of human and bovine tuberculosis, it is expedient that the Government be approached and requested to institute an immediate inquiry into this question, which is of vital importance to the public health and of great consequence to the agricultural industry. 7. That the educational work of the great national societies for the prevention of tuberculosis is deserving of every encouragement and support. It is through their agency that a rational public opinion may be formed, the duties of public health officers made easier of performance, and such local and State legislation as may be requisite called into existence. 8. That this Congress is of opinion that a permanent international committee should be appointed (a) to collect evidence and report on the measures that have been adopted for the prevention of tuberculosis in different countries; (b) to publish a popular statement of these measures; (c) to keep and publish periodically a record of scientific research in relation to tuberculosis; (d) to consider and recommend measures of prevention. This Congress is further of opinion that all international and great national societies, whose object is the prevention of tuberculosis, should be invited to co-operate. 9. That in the opinion of this Congress, overcrowding, defective ventilation, damp and general insanitary conditions in the houses of the working classes diminish the chance of curing consumption, and aid in predisposing to and spreading the disease. 10. That the following question be submitted for the consideration of the next congress on tuberculosis. The constitutional conditions of the individual which predispose to tuberculosis, and the means by which they may be modified. 11. That while recognising the great importance of sanatoria in combating tuberculosis in all countries, the attention of Government should be directed to informing charitable and philanthropic individuals and societies of the necessity for anti-tubercular dispensaries as the best means of checking tubercular disease among the industrial and indigent classes. Cancer. The deaths from cancer in the administrative county of London during 1901 (52 weeks) numbered 4,203, the corrected annual average for the preceding ten years being 3,843. 49 The death rates of this disease per 1,000 living in successive periods have been as follows— Cancer. 1851-60 .42 1895 .83 1861-70 .48 1896 .86 1871-80 .55 1897 .88 1881-90 .68 1898 .92 1891 .78 1899 .95 1892 .75 1900 .95 1893 ..0 1901 .93 1894 79 The following table shows the number of deaths from cancer at several age-periods in each of the metropolitan boroughs included in the administrative county. For the purposes of this table, deaths occurring in public institutions belonging to London have been distributed to the areas in which the deceased had previously resided. (See footnote (1), page 9.) Cancer (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddington 1 1 1 5 20 36 42 26 15 2 149 Kensington - - - 2 - 6 14 41 53 46 35 1 198 Hammersmith - - - - 1 4 6 23 26 26 9 - 95 Fulham 1 — - — 2 4 8 23 32 24 24 4 122 Chelsea - - - - - 2 4 16 17 18 7 3 67 Westminster, City of - - - — 1 3 17 46 41 25 18 - 151 St. Marylebone - 1 - 1 — 2 7 26 48 34 16 3 138 Hampstead - - - - - 3 2 18 23 20 10 3 79 St. Pancras 1 - - 2 2 1 22 49 69 43 17 1 207 Islington 2 1 — 1 - 11 36 64 80 80 27 4 306 Stoke Newington - - 1 - - 1 6 11 14 10 4 - 47 Hackney - 1 2 - - 5 15 42 54 42 13 2 176 Holborn 2 — — 2 — 3 5 13 19 11 3 1 59 Finsbury 1 - - 2 - 6 11 19 17 14 8 1 79 London, City of - - 1 - - - 2 6 7 13 4 1 34 Shoreditch - - - 1 2 3 13 29 24 19 5 - 96 Bethnal-green 1 - - 1 2 4 13 34 26 24 6 - 111 Stepney 1 - 3 - 1 9 23 49 59 55 18 1 219 Poplar - - 1 2 — 2 17 25 49 16 11 — 123 Southwark 2 1 - - - 11 23 38 56 34 12 1 178 Bermondsey - - - - - 4 9 24 19 22 10 - 88 Lambeth - 1 2 2 2 6 27 73 83 67 34 3 300 Battersea — 1 1 1 - 4 16 17 43 40 13 1 137 Wandsworth - 1 - 1 — 8 20 49 62 44 21 3 209 Camberwell 5 - 1 2 — 1 23 47 68 80 21 4 252 Deptford 1 - - 2 6 10 21 21 21 7 1 90 Greenwich - - - 1 3 11 12 19 12 9 - 67 Lewisham 2 1 - 1 1 4 6 20 31 42 11 3 122 Woolwich - - - - - 3 12 20 22 20 6 - 83 London 19 8 13 22 18 124 398 891 1,124 928 394 43 3,982 Bubonic Plague. The occurrences of plague in this country during 1901 showed that there was risk of the disease being introduced into London and emphasised the need for the maintenance of the provision the Council had made in the event of the disease being introduced into London. In January a man died of plague in Cardiff. lie had been working at some grain stores in the West Bute Bock. An unusual mortality was observed among the rats in the neighbourhood of the stores, and in one of two rats found dead Br. W. G. Savage found plague bacilli in large numbers. In the same month eight cases of plague occurred in connection with the ss. " Friary," in Hull, which had arrived in that port from Alexandria with the body of a man who had died 12 hours before arrival from an illness regarded as " influenza." The disease was of tho pneumonic form, and the cases comprised (including the man who died before arrival) seven of the crew, a watchman, and the medical man who had attended the first two sailors who sickened while the vessel was in Hull. Among the nine there were eight deaths. In March a Lascar from the " Simla," which had arrived from South Africa, was admitted into the South Hants Hospital for treatment of an abscess in his groin. Plague bacilli were found in the pus. At the end of August and in September five cases of plague occurred in Glasgow. The first person to be attacked was a man who worked on the third floor of a building, on the ground floor of which lived a man and two children, who were attacked, and lastly, the attendant at the reception house, who bathed them, suffered from plague. The three adults and one of the children died. A plague-infected rat was later discovered in an adjoining yard. The locality in which these cases occurred was 1 See footnote (2), page 9. [7] 50 in the neighbourhood of the first outbreak of plague in Glasgow, and of which account is given in my report for the year 1900. At the latter part of October five cases of plague occurred among the servants of the Central Hotel, Glasgow, and the plague bacillus was recovered from the bodies of rats found dead beneath the floor. About the same time two children in Liverpool were reported to be suffering from typhus. When the ambulance arrived one was dying, and another had become ill; eventually both died. There being some doubt as to the nature of the illness, inquiry was made in the neighbourhood by Dr. Hope, the medical officer of health, and a young woman found whose condition was indicative of plague. It was then ascertained that her mother and sister had died shortly before, after a brief illness, and one at least of them, it was alleged, had complained of tenderness in the armpits. It was also ascertained that the woman who hod assisted in washing and laying out the body of the mother had died suddenly. Two other children and their mother were subsequently attacked, and one of the children died of plague. Moreover, bacteriological examination showed that the first-mentioned children had plague. The source of infection was not discovered, and rats were not found to be infected. Dr. Hope, from whose report these details are taken, states that some of the adults were the employees of leading firms in the millinery business, and the cases were entirely dissociated from the squalor and filth with which plague is commonly connected. The medical officer of the Port of London reports that during the year there have been three suspicious cases brought by three vessels into the Port of London, but in no case was the plague bacillus found ; all necessary steps were taken in each case. On the occurrence of the Cardiff case the London County Council communicated with the London sanitary officers, expressing the opinion that it was desirable that systematic inquiry should be made in London as to mortality among rats in the docks, wharves or sewers, so that if unusual mortality were found to have occurred the bodies of the rats might be examined by a bacteriologist. The Council invited the sanitary authorities to make such inquiries, and to inform the county medical officer of the results. No evidence of such mortality was, however, brought to the knowledge of the Council. In seven instances during 1901 the services of one of the Council's plague experts was sought to determine whether a resident in London was suffering from plague and had died of that disease. These cases were as follows— On the 12th February Dr. Davies, the medical officer of health of Woolwich, asked that Mr. Cantlie should visit a man residing at Bamfield-road, Plumstead, who was suffering from general glandular enlargement. Mr. Cantlie visited him with the Council's medical officer. Dr. Klein, to whom blood and gland fluid was sent, reported that this was distinctly a case of splenic leuchæmia. On the 9th April the opinion of Mr. Cantlie was sought in respect to a boy named B., who had been admitted two days before into St. Bartholomew's Hospital from a house in Grahamstreet, City-road, Islington, suffering from fever and glandular enlargement with a sore on the foot. Mr. Cantlie visited him with the Council's medical officer the same day. This boy, who was aged 10, was the child of a woman who dealt in second-hand clothes and nursed and washed for women in their confinement. He himself went to school and was otherwise employed in selling newspapers in the neighbourhood of the Holborn Town Hall. On the 23rd March he complained of headache and pains in the limbs, and on the 1st April he was too unwell to go to school. The patient's blood and gland juice were examined by Dr. Klein, and on the 12th instant the cultivations raised suspicion of plague, but later this opinion was negatived. The suspicion which for the moment existed made it desirable that the inmates of the house where the boy lived should be removed to one of the Council's shelters, and they were accordingly admitted into that situated in the Gray's-inn-road. The boy was removed to the South Eastern Hospital. With the medical officer of health of Islington the Council's medical officer made inquiry into the circumstances of the case, and watch was kept over all persons who had been in contact with him. The house and its contents were disinfected by the staff of the Borough Council of Islington and the clothes and bedding destroyed. Inquiry was also made in the neighbouring houses by the medical officer of health of Islington as to whether other similar cases had occurred in them. No such cases were found, and the inmates of the Gray's-inn-road shelter remained well, with the exception that the mother of the boy suffered from a swollen face, the result of a decayed tooth. Further examination by Dr. Klein led to the conclusion that the disease from which the boy suffered was not plague. On the 5th June the medical officer of health of Islington reported that he had been informed that a man named R., living in Caledonia-street, Islington, had died the previous day from a disease which was suspected to be plague or typhus. The man was employed as a carman by a firm of ice merchants. He was taken ill on the 3rd June and came home at 7 p.m. complaining of pains in the back and left side; the following day he became worse and died at 12.30 p.m. Mr. Cantlie examined the body on the 5th June in the Islington mortuary with the Council's medical officer and took material which was sent to Dr. Klein. On the 6th June a post-mortem examination was made, Drs. Klein, Hamer and the Council's medical officer being present. The post-mortem showed that there was pneumonia of the upper part of the lower lobe of the left lung, and that the liver was fatty, and bacteriological examination by Dr. Klein gave no evidence of plague. On the 22nd October Dr. Parker, of Brockley, asked that Mr. Cantlie should examine a young man named K., living in Kneller-road, Brockley. This man was a railway porter and he had been travelling to different places on the railway. For some days before his illness he had been living in lodgings in Portsmouth. He had been taken ill on the 17th with pains about his body, and in the evening he had a temperature of 103°. On the 18th he had pain in his chest, was breathing rapidly and was delirious and sick. On the 19th his temperature was 103° and his nose 51 bled. On the 20th he continued sick, complained of headache and was delirious. On the 21st his temperature was 100°, and a swelling appeared over the sternum and an eruption was found over his chest, abdomen and upper part of his thighs. On the 22nd, when he was seen by Mr. Cantlie, the medical officer of health of Lewisham and the Council's medical officer, his morning temperature was normal, his tongue white and moist and the eruption was fading. He had a swelling over the sternum. Mr. Cantlie was of opinion that the illness was a mild attack of typhus and that it was unnecessary to send material to Dr. Klein. The source of infection could not be discovered. On the 2nd November the medical officer of health of Wandsworth reported that he had been informed that a young man named L., living in Hobertson-street, Clapham, was suffering from illness with glandular enlargement, and asked that Mr. Cantlie should visit the patient. Mr. Cantlie, with the Council's medical officer, saw him the same day and found him suffering from orchitis. Mr. Cantlie did not think bacteriological examination was necessary. On the 11th November Mr. Cantlie called on the Council's medical officer and stated that he had been informed that a man named M., a patient in the West London Hospital, Hammersmith, but usually living at Barrett's-cottages, Strou'd-green, was suspected to be suffering from plague. This man had been employed on a tug which towed lighters down from Brentford Gas Works and up from Beckton Gas Works, and lighters loaded with timber and boards from the Surrey Commercial and Millwall Docks up to Brentford. Three weeks before this date he had fallen and struck his back on an iron casing. He subsequently suffered from headache, pain above the hip joint and in the axilla. Since the 6th November he had been worse, and when seen by Mr. Cantlie and the Council's medical officer on the night of the 11th November, he had a temperature of 101°, with swelling of the inguinal glands of both sides. Bacteriological examination by Dr. Klein of gland juice and of blood taken from this case proved entirely negative. On the 9th December Sir Hugh Beevor supplied information that a nurse had died at St. John's House, Norfolk-street, Strand. She had been engaged in nursing a case of acute rheumatism at a restaurant in the Strand, and the house was infested with rats. She became ill on the 4th; on the 5th she felt sick and had headache; on the 6th was no better and thought she had influenza; on the 7th was considerably worse, and had a faint rash on the upper part of the chest; on the 8th was evidently going to die, the skin of the chest and abdomen had become darker, and she died next day. The body was removed to the mortuary and a postmortem examination made at 4 p.m. on the 9th, Drs. Klein, Hamer, Young, and Allan, the medical officer of health of Westminster, being present. The body was found to be covered with a purpuric eruption, which was especially marked in a triangular area included between a transverse line drawn through the umbilicus and bounded below by two lines drawn across the front of the thighs parallel to and a few inches below Poupart's ligament. There were haemorrhages in the conjunctivæ and petechiæ in the pericardium, the pericardial sac containing several ounces of blood. The appearances were consistent with those of hæmorrhagic smallpox. There had been a number of cases of smallpox in the neighbourhood, and she had been in contact with other nurses who had been on the smallpox hospital ships. Bacteriological examination by Dr. Klein proved negative, so far as plague was concerned. Thus, in each of the above cases, examination led to the conclusion that the patient had not suffered from plague. In my last report I stated that under the arrangements made in London for dealing with any cases of plague which might occur in London the duty of providing for actual cases of this disease devolved upon the Metropolitan Asylums Board, that of providing for persons in contact with cases of plague upon the London County Council. In the first instance it was arranged that the Council should receive into their shelters persons who presented symptoms of plague for such time as was necessary to determine the nature of the malady from which they were actually suffering, but later it was agreed that the Metropolitan Asylums Board should receive suspected cases of plague. In February the Public Health Committee presented to the Council an estimate for providing accommodation for 1,000 persons in 200 families. This accommodation was divided into three classes (a) that which should be ready at the moment when required, (b) that which could be got ready in a few hours, and (c) that which could be got ready in a few weeks. The first would make provision for 212 persons, the second for 200 and the third for 600. The estimate for this provision was £50,000, but it was only proposed to expend some portion of this immediately in repairs to and furnishing of buildings already in possession of the Council, in the acquisition of certain buildings, including a laundry, and in preliminary expenses for foundations, water supply and drainage of further buildings on land belonging to the Council, and in provision of clothing for the persons removed to the shelters. Steps were taken to repair and furnish the buildings in possession of the Council and to provide clothing, but it was not found necessary to proceed further with this scheme, the Committee having ascertained that various premises in London could be obtained if necessary in consideration of the payment of a small annual retaining fee to the proprietors. These houses would accommodate 670 persons, and the retaining fee was £200 per annum, the total rent payable if all this accommodation was required at the same time being less than £200 per week. The Council on the recommendation of the Committee decided that arrangements should be made with the proprietors for this purpose. In April the Public Health Committee reported to the Council the steps which would be taken in the event of any person in London presenting symptoms which raised suspicion of plague. The report was as follows— We reported to the Council on the 2nd instant the result of a conference with representatives of the Metropolitan Asylums Board on the subject of the method of dealing with suspected cases of plague in London, and the Council passed the following resolution— That the Local Government Board be informed that the Council is willing that the Metropolitan 52 Asylums Board should make provision for dealing with all suspected cases of plague in London, if the Local Government Board think fit to transfer this duty from the Council to the Asylums Board, and that the Asylums Board be informed of the Council's resolution in the matter; and, further, that the Public Health Committee be instructed to report upon the control and treatment of " contact" cases. Letters were accordingly addressed to the Local Government Board and the Metropolitan Asylums Board, and on the 11th instant the Local Government Board intimated that after consideration of all the circumstances they had asked the Metropolitan Asylums Board to undertake the duty of dealing with suspected cases. With regard to the Council's instruction to us to report as to the control and treatment of "contact" cases, we may point out that the duty of dealing with these cases was undertaken by the Council in October last at the suggestion of the Local Government Board, that a number of premises in different parts of London have already been prepared for the isolation of these cases, and that the Council has authorised us to expend, if necessary, a sum not exceeding £50,000 upon these and other precautionary measures. The object of isolating all persons who come in contact with plague cases is to enable them to be kept under medical observation until the period of incubation has passed. They are healthy persons and do not therefore require nursing or special treatment, and it is not proposed that they should be prevented from following their usual occupations. All that is desired is that they shall live in the isolation homes and be medically examined each morning and evening, in order that should symptoms of plague develop they may be at once detected and removal to hospital effected without delay. Experience has shown the extreme importance of the early isolation of these "contacts," and the recent epidemic in Glasgow was stamped out by the adoption of this and other precautionary measures. The Council has no power to compel the isolation of persons who may have been in contact with plague cases, but in Glasgow little difficulty was found in inducing such persons to use the isolation homes. We propose that food shall be provided, that the clothes of the inmates of the homes shall be washed in a laundry to be purchased by the Council for the purpose, and that, while this is being done, clothing shall be lent them by the Council. We think that the Council is the proper authority to make provision for these people, and that, as they are not sick persons, they do not come within the sphere of operations of the Metropolitan Asylums Board. Moreover, we have no reason to believe that the Board desire to deal with these "contacts" as they will, in the event of any serious outbreak of plague, have sufficient work to do in treating actual and suspected cases. The following statement shows in detail the procedure which will be adopted in conjunction with the Metropolitan Asylums Board on cases raising suspicion of plague becoming known— On receipt by the London County Council of intimation from any medical man that any person in London is suffering from a malady raising suspicion of plague, the Council's plague expert will be requested immediately to visit the patient. He will decide whether the patient should be removed to one of the hospitals of the Metropolitan Asylums Board— (а) As a suspected case of plague. (b) As an actual case of plague. If he is of opinion that the patient should be removed, he will communicate with the Metropolitan Asylums Board with this object in the manner provided by the regulations of the managers, stating whether the patient is to be deemed a suspected or an actual case of plague. He will write a certificate as to the nature of the case and leave it in a closed envelope with the patient's friends, to be given to the ambulance driver when he comes to fetch the patient. In the case of every patient to be removed to hospital, either as a suspected or actual case of plague, he will take material for bacteriological examination and send it immediately to the County Council's bacteriologist. In all other cases he will use his discretion as to whether he shall take and send such material. He will at once report to the county medical officer of health as to every case and the course he has taken. The County Council's bacteriologist will report the results of his examination to the county medical officer of health, who will at once inform the medical officer of the Local Government Board, the clerk of the Metropolitan Asylums Board, and the medical officer of health of the district of these results. In the event of a case of actual plague occuring, if the removal of "contacts" to one of the Council's shelters is desired, arrangements will be at once made by the county medical officer of health for this purpose. Persons in contact with suspected plague will, pending decision as to the nature of the case, not be removed to a shelter unless the circumstances of the case are altogether exceptional. The Metropolitan Asylums Board will not remove any suspected or actual case of plague except on the certificate of the County Council's plague expert. The certificate of the Council's bacteriologist is to be accepted for this purpose. The certificate may be signed by the expert only, or by any medical practitioner and countersigned by the expert. The Council approved the arrangements made by the Committee. Buildings iu the possession of the Council were prepared for occupation, furniture and clothes being provided for this purpose. There was, however, only one occasion on which any of the Council's shelters were used. This occasion was in the month of April, and the circumstances of the case will be found among those of others which were inquired into during the year. Meteorology. The tables published in the Annual Summary of the Registrar General, prepared by Mr. J. Glaisher, F.R.S., from observations at Greenwich, show that the mean temperature of the air in 1901 was 49 2° Fahrenheit, or 0 3° above the average of the 130 years 1771-1900. The rainfall during the year amounted to 20'28 inches and was 4.52 inches below the mean of 86 years. The temperature and rainfall in each month of 1901 are shown in the following table— 53 Month. Temperature of the air. Departure from average of 130 years, 1771-1900. 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 54.1 21.0 38.7 + 1.9 11 0.76 February 52.3 20.4 35.7 — 3.1 11 0.86 March 54.1 24.2 39.0 — 2.1 16 2.17 April 76.6 30.3 48.2 + 2.0 13 1.81 May 83.2 35.3 53.2 + 0.6 5 1.79 June 79.7 42.7 58.8 + 0.4 9 1.49 July 87.9 46.2 64.8 + 3.0 8 1.72 August 84.2 44.5 62.3 + 1.3 10 2.03 September 76.9 39.6 57.9 + 1.3 6 1.35 October 75.3 29.9 50.5 + 1.0 11 2.60 November 54.8 20.6 41.3 — 2.4 8 0.67 December 55.4 24.8 39.9 + 0.1 15 3.03 54 PART II. Dairies, Cowsheds and Milkshops. Under the London Government Act, 1899, the duty of registering dairies and the enforcement of the regulations made under the Dairies, Cowsheds and Milkshops Order devolved upon the several London sanitary authorities. Some of the reports of medical officers of health give particulars of the work done in their districts. Thus in Kensington 274 milk premises were on the register during the year. In Westminster it was resolved to register restaurants in which milk was consumed on the premises. In St. Pancras there were 285 inspections of milk premises, and proceedings were instituted in one instance. In Islington there were 589 milk premsies on the register; the medical officer of health points out the need for the duty of inspection to devolve on a special inspector. In Holborn the number of premises on the register was 156. In Finsbury the number was 267; restaurants were not registered, but a list was kept. In the City 448 premises in which milk was sold were dealt with; of these 368 were registered, 64 unregistered, and 16 were closed or demolished. In Shoreditch 319 premises were on the register, and 27 notices were served; milk purveyors were recommended to protect the vessels containing milk from flies and dust by covering them with fine linen. In Poplar there were 407 premises on the register; they were kept under observation. In Bethnal-green there were 331 premises on the register, and 1,217 visits were paid to them. In Southwark 426 premises were on the register, concerning which there were 617 inspections and 2 prosecutions. In Bermondsey 243 premises were on the register and they were regularly inspected. In Lambeth 458 premises were on the register; all the drains were chemically tested and various structural improvements effected. In Battersea 259 premises were on the register; they were systematically inspected and any defects found remedied. In Wandsworth 274 premises were on the register. In Camberwell, restaurants were registered. In Deptford the milk premises were regularly inspected and notices served where necessary. In Woolwich 185 premises were on the register; they were all inspected and were found generally in satisfactory condition, and no proceedings were instituted. The administration of the provisions of the Order, other than that relating to registration, remains with the County Council, and in 146 instances inquiries were made concerning infectious disease on milk premises. During the year the Council received applications for the licensing of 303 cowshed premises. and licences were granted in resnect of 295. During the year, Mr. W. F. Shaw, the Council's veterinary inspector completed four inspections of all the cows in London cowsheds. The results of his inspections were as follows— 3rd report. 4th report. 5th report. 6th report. Number of cows examined 4,317 4,352 4,086 4,164 Affected with disease or defects of the udder 356 255 292 258 Clinically affected with tubercular disease of the udder 6 4 6 4 Suspected cases of tubercular disease of the udder 10 8 4 3 Subjects of acute mastitis ... 52 41 37 23 Affected with chronic induration of the udder 18 17 14 5 Atrophy of one or more quarters 137 99 139 154 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 50 26 57 42 Hypertrophied udders without induration 1 2 2 1 Giving milk of poor quality, dried-off cows 35 59 9 14 Recovered or removed from premises 47 27 24 12 These inspections were completed in January, June, September and November, and were the third, fourth, fifth and sixth inspections made by Mr. Shaw. In every case of a cow certified by Mr. Shaw to be suffering from tubercular disease of the udder the owner was at once informed of the fact, and the sale of the milk from the cow was prohibited. In numerous other cases in which Mr. Shaw was of opinion that the milk should not be used for human food the owner was informed of this opinion. Mr. Shaw, in his third report, states that in nearly every case of the sixteen cows suffering from, or suspected to be suffering from, tubercular disease of the udder, the animal was removed for slaughter. A second examination was made of a few cows remaining, and suspected to be suffering from tubercular disease of the udder, and fluid from the udder sent to Dr. Klein for bacteriological examination. The tubercle bacillus was not found in the material sent. In his report Mr. Shaw states that the condition of cows' udders in London cowsheds had much improved, the udders being kept cleaner by the cowman, who now reports to his employer when any cow under his charge exhibits the least imperfection. In his fourth report he states that the four cows suffering from tubercular disease of the udder were removed for slaughter. The eight cows suspected to be suffering from this disease were kept under observation, and as far as could be ascertained the milk of these cows was not again used for human food. One of these cows died in the shed and the udder was found, on post-mortem examination, to be affected with tubercular disease. Cows affected with mastitis, 41 in number, were periodically examined until the udders recovered or the affected quarters atrophied. He comments on the 55 decrease in the number of cows having defects of the udder, and attributes it in part to greater care taken in the purchase of the cows. In his fifth report he states that the 6 cows affected with tubercular disease of the udder were removed for slaughter. Samples of milk from the 4 cows suspected to be so suffering were sent to Dr. Klein for bacteriological examination. Two cows were affected with tubercular disease of the lungs, one which had lesions of the udder was removed for slaughter, the other was retained in the shed for a few weeks and kept under constant inspection. Both these cows were followed to the slaughterhouse, the carcase of one was totally condemned and the fore-quarters of the other. In this report he states that the number of cases of vesicular eruption in the teats has increased. Fifty-seven affected cows were kept under observation until the teats had healed, and in the worst cases the milk was scalded before being sold for human food. Thirty-seven cows were affected with mastitis and were periodically examined until they recovered or were removed for slaughter. In his sixth report Mr. Shaw states that in each instance in which the cow was certified to be suffering from tubercular disease of the udder the cow was removed for slaughter. In two of these cases the carcases were condemned as unfit for human food. Three cows suspected to be suffering from this disease were kept under observation until removed for slaughter. In no case, he states, was the milk used while the animal remained in possession of the dairyman. Twenty-three cows affected with mastitis were periodically examined until they recovered or were removed for slaughter. In June the Public Health Committee reported on the need for obtaining power to prevent the importation into London of milk from cows suffering from tubercular disease of the udder The committee referred to their report of the preceding year on the results of examination of 97 samples of milk, 7 of which were found to contain tubercle bacilli. The Council on that occasion sent a copy of the report to the Local Government Board and Board of Agriculture, expressing the hope that some steps would be taken to render the periodical inspection of cattle by veterinary surgeons obligatory throughout the country. No bill having been introduced, the committee now pointed out that powers had been obtained by a number of municipal authorities, the committee reporting as follows— Samples of milk are examined, and, if found to contain tubercle bacilli, the medical officer of health is authorised, after obtaining a magistrate's order, to inspect the farm from which the milk comes, and, if accompanied by a veterinary surgeon, to inspect the cattle. The local authority is then empowered to exclude from its district the milk from such farm if it finds it necessary to do so. We think if this power were possessed by the London County Council, the owners of cows and the authorities of districts outside London might possibly be led to institute a periodical examination of cows, and thus, by the early exclusion from the milk supply of the milk of a particular cow suffering from tubercular disease of the udder, to obviate the risk of the whole milk supply of the farm being prohibited from coming into London. Some of the special Acts referred to contain other provisions which would be useful in this connection. Thus, the Dairies, Cowsheds and Milkshops Order of 1899, which is in London enforced by the County Council, makes it illegal to sell milk from a cow having a tubercular udder only after that disease has been certified by a veterinary surgeon. In Manchester, however, a dairyman is liable to a penalty if he knowingly sells milk from a cow which is suffering from this disease, and if he does not properly isolate such cow, irrespective of whether the disease has been certified. Further, dairymen are required under the Manchester Act to notify to the medical officer of health any cow affected with, or suspected of, or exhibiting signs of, tuberculosis of the udder. In connection with the administration of the Dairies, Cowsheds and Milkshops Order of 1899 in London, additional power is needed by the Council, viz., that of seizing cows which the veterinary inspector is of opinion are suffering from tubercular disease of the udder, and of requiring such cows to be at once slaughtered. The Royal Commission on Tuberculosis recommended that, if the veterinary surgeon's opinion is found to be incorrect, the owner should receive the full value of the animal; but that, if the veterinary surgeon's opinion is found to be correct, then the owner should receive the value of the carcase only. In this view we concur. Under the terms of the standing order we have consulted the solicitor, who thinks that, though the question is not free from doubt, upon the whole the Council has power to spend money in promoting legislation in the direction indicated. If the Council adopts our recommendation the Parliamentary Committee will no doubt carefully consider whether any or all of the powers desired can be obtained by a clause in one of the Council's bills or whether a public bill would be necessary to give effect to any or all of our proposals. The matter is in our opinion one of great moment as affecting the health of the consumers of milk in London, and in which it is desirable to proceed without delay. It is necessary under the standing order for proposals for legislation next session to be brought before the Council at its first meeting in June. We accordingly now submit our proposals, but we have not yet had time to consult the borough councils with regard to them. We hope to enlist the sympathy and support of these bodies, and accordingly suggest that a copy of this report be sent to each, with an intimation that any suggestions they may make will be considered. On the recommendation of the committee the Council decided to seek legislation in the next session to give effect to the proposals in the report. Later in the year the committee reported to the Council that a cow which had been certified by the Council's veterinary inspector to be suffering from tubercular disease of the udder, was removed from a shed in London and sent to Romford, where it was sold in the market. The purchaser could not be traced. Offensive Businesses. The duty of administering the by-laws of the London County Council regulating noxious trades now devolves on the sanitary authorities. Few references are made to this subject in the reports of medical officers of health. In Shoreditch, in one instance, the drains of a tripe boiler were reconstructed. In Southwark, the several premises were proved on inspection to be clean and in a proper sanitary condition, except that in one instance it was necessary to provide proper vessels for receiving garbage. In Lambeth, the scraping of gut on a butcher's premises led to the licence for the slaughterhouse being granted on condition, inter alia, that this work should be abandoned. In Bermondsey only one complaint was received, and that was as to nuisance from the keeping of scutch on the premises of a glue manufacturer. 56 The London County Council received 384 applications for licences for slaughterhouses, and 381 licences were granted. Five licences for knackers' premises were also granted. The number of applications and the number of licences for slaughterhouses granted in recent years is shown in the following table— Year. No. of applications received. No. of licences granted. Year. No. of applications received. No. of licences granted. 1891 656 651 1897 460 456 1892 547 537 1898 442 429 1893 542 529 1899 419 411 1894 518 506 1900 405 393 1895 497 485 1901 384 381 1896 478 470 Complaints to the London County Council. During 1901 the Council received 800 applications for assistance in securing the removal of insanitary conditions. In cases in which representation had not already been made to the sanitary authority, the applicants were advised to make such representation. In other cases the sanitary authorities were communicated with. In all cases the matter was kept under observation until the conditions complained of were remedied. In connection with these applications, 835 inspections were made by the Council's inspectors, the number of premises visited being 1,463. Nuisances Smoke nuisance. The annual reports of medical officers of health show the following proceedings in connection with smoke nuisance— In Paddington, proceedings were instituted concerning smoke nuisance from a brewery in Queen's-road and from an electric lighting generating-station in Amberley-road, an abatement order being made in the first instance and the summons being adjourned with consent in the other, costs being allowed in each instance. In Kensington, complaints were received as to smoke nuisance from the generating station of an electric railway company in Shepherd's-bush. Proceedings instituted by the Borough Council of Hammersmith led to the company being fined £60 and costs. The same company was on another occasion fined £25 and costs, on a third occasion £10 and costs, and on a/ fourth occasion £60 and costs, the proceedings being instituted by the Hammersmith Borough Council. The same authority also obtained the conviction of the proprietor of a brewery for the same offence. In Fulham eight notices were served, and one offender was fined £4 and costs. In Chelsea smoke nuisance was abated in three instances. In Westminster 1,370 observations were made by two inspectors appointed for this purpose; eight prcsecutions were instituted, and penalties amounting to £63 and costs were recovered. In one case an appeal was taken to the High Court, and was heard by the Lord Chief Justice, Mr. Justice Darling and Mr. Justice Channel. In this case the Queen Anne Residential Chambers and Hotel Company having been convicted by the magistrate, the company appealed, contending that the chimney was that of a private dwelling. " The Court dismissed the appeal with costs, looking at the fact that there were 300 flats, with five boilers in the basement for electric lighting, cooking, warming and other purposes for the benefit of the residents in these flats, and that, in truth, a large trade establishment was carried on, the decision of the magistrate was right." In St. Marylebone, the medical officer of health states, the number of nuisances from smoke showed a marked decrease as compared with last year. In Hampstead, 8 complaints of smoke nuisance were received. In St. Pancras, 102 chimney shafts are entered in the register, 125 complaints were received, 206 observations made, 21 notices served, and 1 summons issued, resulting in an abatement and prohibition order. In Islington, 863 observations were made, 36 notices served, and 2 summonses issued. In Hackney, 1,754 observations were made and 78 notices served. In Holborn, 12 notices were served. In Finsbury, in 3 instances a summons was taken out, in 2 an abatement order was made, and in the third the summons was withdrawn on payment of costs, the defendant having removed the furnace. In Shoreditch the various chimneys and shafts were kept under observation by the inspector charged with this duty ; among the complaints were 45 from the County Council, referring to shafts and chimneys on 15 premises; notices were served; the medical officer of health notes an improvement with respect to smoke nuisance in the borough. In Bethnal-green, 48 intimations and 16 notices were served, and 1 summons issued, a penalty of £40 being inflicted. In Stepney, 70 smoke nuisances were abated, in 3 cases summonses being taken out and magistrates' orders obtained. In Poplar, 251 smoke nuisances were dealt with. Two summonses were taken out in respect of one set of premises, and two penalties, each of £5, inflicted. In Southwark, 32 complaints were received, 75 observations were made and 12 notices served. In Bermondsey 159 observations were made, and 6 summonses were taken out. In Lambeth the special smoke inspector made 620 observations, and 98 notices served. In 29 instances information as to smoke nuisance was received from the County Council; a decision was given by the Lord Chief Justice upon an appeal by an electric supply company from the decision of a magistrate who had fined the company on account of black smoke issuing from a destructor belonging to the company ; the question at issue was whether for the purpose of conviction it was necessary to prove that nuisance to some one resulted from the issue of black smoke; the appeal was dismissed, it being held that nuisance to anyone need not be 57 proved. In Wandsworth 47 smoke nuisances were dealt with; in 3 cases legal proceedings were instituted, in 2 cases penalties of £10 each were recovered and in the other the summons was withdrawn. In Camberwell 33 instances of smoke nuisance were abated. In Deptford 52 observations were made, and notices served in 6 instances. In Greenwich 136 observations were made, and when necessary, notices served. In Woolwich 148 observations were made and legal proceedings instituted in 21 cases, in 17 of which convictions were obtained and fines inflicted from 5 guineas downwards ; the remaining 4 cases were withdrawn at the magistrates' suggestion. A table contained in the report of the chief officer of the Public Control Department for the year ended March, 1902, shows that 819 reports of smoke nuisance were sent by the County Council to the borough councils during that period. Removal of stable manure. In previous reports I have referred to the increasing difficulty in securing the removal of stable manure, and especially to the owners of small quantities. At the present time the sanitary authority can only undertake the removal of manure when the owners are in agreement with them or in the case of a particular collection when it is in such a condition that the sanitary inspector is of opinion that it ought to be removed. The conference of London sanitary authorities held in the County Hall in 1900 expressed the opinion that the sanitary authority should be empowered to employ, if they thought fit, a sufficient number of scavengers or contract with any scavengers, whether a company or individuals, for collecting and removing the manure and other refuse matter from any stables and cow-houses within their district, at a charge to be fixed by the local authority, or in the event of dispute by a police magistrate. The medical officer of health of Kensington, in discussing this subject, cites the following observations of the borough engineer in a report dealing with the utilisation of the borough council's land at the Wood-lane depot, adjoining the West London Railway at Shepherd's-bush— "Great and increasing difficulty is experienced in getting stable manure regularly removed. On the one hand sanitary officials are pressing and prosecuting for more frequent removal, and on the other hand the occupiers of stables have the greatest difficulty in getting market gardeners and others to send for the manure. Take the Council's case, relative to their own stud of (about) 125 horses—a few years ago market gardeners were contracting to clear the manure regularly twice a week and pay £100 per annum for it; now it costs the Council a small sum per annum to get rid of the said manure, with a good deal of attendant bother to ensure regularity of removal. Stable manure should, in my opinion, be regularly collected by the Council and should become their property, in the same way as the statutes deal with house refuse, and steps should be taken to get the law amended accordingly." The engineer's report was considered by a special committee, who, without proposing to deal with the merits of the case as stated by the engineer, recommended that "provision should be made for the necessary sidings which would allow of the Council, should they think fit at any time in the future to do so, to undertake the removal of manure from the stables in the borough." This recommendation was adopted by the borough council. Dr. Dudfield expresses the opinion that the recommendation of the conference does not go far enough, and that the only useful amendment would be "to make it the duty of the sanitary authority to remove the refuse at the reasonable cost of the owner." Steps were taken in a number of districts in connection with nuisance from manure. In Westminster, 155 notices were served regarding accumulations of manure, 64 for the provision of proper dung receptacles, and 49 for the removal of dung-pits which did not comply with the County Council's by-law. 104 stables were re-drained, 97 paved and 58 cleansed. In St. Pancras, proceedings were instituted in one case and a penalty recovered. In Lambeth, nuisance was complained of in connection with stables in the Hackford-road, resulting from the disturbance of peat moss manure at the time of renewal; Dr. Priestley points out that when the manure is placed in at van directly from the stables, and without intervening deposit, nuisance at the time of removal from the premises can be obviated. Dr. Caldwell Smith refers to the increasing difficulty experienced by small tradesmen in Wandsworth in getting rid of their manure regularly and in a satisfactory manner. Removal of offensive trade refuse. At the conference of London sanitary authorities held at the County Hall in 1900 a resolution was adopted " that in the opinion of the conference the sanitary authority should be empowered to employ, if they think fit, a sufficient number of scavengers, or contract with any scavengers, whether a company or individuals, for collecting and removing trade refuse of an offensive or noxious nature from any premises within their district, at a charge to be fixed by the local authority, or, in the event of dispute, by a police magistrate. The subject of removal of offensive trade refuse was also considered by a committee of the London County Council, and in January, 1901, the committee presented the Council with a report containing the following recommendation—" That the Local Government Board be also informed that in the opinion of the Council the best solution of the difficulty with regard to the removal of fish offal and other offensive refuse in London would be for its removal to be effected by the various sanitary authorities at the expense of the occupiers." This recommendation was adopted. The report of Dr. Davies as to the removal of trade refuse in Woolwich deserves to be stated somewhat fully, inasmuch as the sanitary authority itself undertakes the collection. His report contains the following extract from the report of Chief Inspector Duck— "Trade refuse was formerly collected in the parish of Woolwich free of cost. The borough council resolved that a charge should be made for collection as follows—1s. 6d. per load, or 2d. per bushel, for the removal and disposal of inoffensive trade refuse; 3d. per receptacle for the removal and disposal of offensive refuse. Subsequently it was arranged to charge 6d. for the use by tradesmen of the destructor as a shoot for a load of inoffensive refuse, such amount to be prepaid. The contractors for Plumstead and Eltham remove inoffensive trade refuse at 1s. 6d. per load. During the period from [8] 58 27th April to 28th December, 1901, there have been 5,187 receptacles of offensive trade refuse removed, amount paid £64 16s. 9d.; 633 loads of inoffensive trade refuse, amount paid £47 9s. 6d.; and 283 bushels of inoffensive trade refuse, amount paid £2 7s. 2d. In connection with these removals there are 126 trademen's names in the books. The collection of offensive refuse is in regular operation at 57 tradesmen's premises. The 663 inoffensive accumulations came from 63 different premises, and this collection is intermittent, and a separate application is made for each accumulation required to be removed. The 283 bushels of inoffensive refuse came from six separate tradesmen. The collector hands a form filled in to the tradesman, with details of the accumulation removed, and obtains his signature to the counterfoil. The accounts are rendered quarterly. The system was some little time getting into order, but can now be regarded as working very satisfactorily. In connection with the removal of offensive refuse, galvanised iron air-tight receptacles are supplied by the Council for the use of tradesmen, an empty receptacle being left when the full one is removed." In seven instances proceedings before the magistrate were instituted in Paddington for the removal of offensive refuse during prohibited hours, and penalties were recovered in each case. In Chelsea there were proceedings before the magistrate in four instances for similar offences, fines were inflicted in three instances and the summons dismissed in one. In Westminster, proceedings were instituted in four instances and penalties inflicted in each. In St. Pancras, proceedings were instituted in one instance for conveyance of offensive matter by canal in an improperly constructed carriage, and in another instance for removal during prohibited hours, fines being recovered in each instance. In Holborn there was one prosecution for breach of by-law and a penalty inflicted. Dr. Collingridge reports that some amount of nuisance was caused in the City by the late removal of refuse and offal, and the irregularity of removal of fat, bones, etc., by the contractor, and it was arranged with the Superintendent of Cleansing to collect in the Corporation vans all refuse matter before 9 a.m., disinfecting the same as it was placed in the carts, and to water the road regularly with a disinfectant solution whenever necessary. Dr. Annis reports that in Greenwich, complaints as to offensive smells occasioned by the process of collecting fish offal have been somewhat frequent, but the by-laws were not found to be infringed. He writes, "The nuisance is doubtless often intensified by the habit which some fishmongers have of themselves storing up their refuse for several days, and not permitting the contractor to remove the same as often as he desires." By-laws as to removal of offensive matter. In my last report I stated that the committee had had under consideration the amendment of the by-law relating to the removal of offensive matter. The existing by-law required offensive matter to be removed in a suitable carriage or vessel, properly constructed and furnished with a sufficient covering so as to prevent the escape of any matter or liquid therefrom, and so as to prevent any nuisance arising therefrom. The by-law further prohibited the removal of such matters, except during the following periods, viz., between 4 o'clock and 10 o'clock in the forenoon during the months of March, April, May, June, July, August, September and October, and between 6 o'clock in the forenoon and 12 o'clock at noon during the months of November, December, January and February. From the requirements of this by-law the carriage of horsedung manure was exempt. The Public Health Committee having had under consideration the fact that serious nuisance was caused by the removal of manure consisting of horsedung and peat moss litter and the request for more extended hours during which offensive matter might be removed, had in 1890 proposed to limit the extension relating to horsedung manure to " horsedung manure with a sufficient proportion of straw to render it inoffensive," and to extend the hours of removal to periods between 5 o'clock a.m. and 10 o'clock a.m., and from two hours before sunset to one hour after sunset in the months of March, April, May, June, July, August, September and October, and between G o'clock a.m. and 11 o'clock a.m., and from two hours before sunset to one hour after sunset in the months of November, December, January and February. A firm, acting on behalf of soap makers, tallow melters and bone boilers in London, raised objection to these hours, and later the committee received a deputation from these trades, after which it was proposed that the hours of removal should be between 7 a.m. to 4 p.m. all the year round. The Council referred this proposal back to the committee, and in January, 1901, the committee recommended that the hours of removal should extend from 7 a.m. to 2 p.m. all the year round. The Local Government Board having agreed to these hours, a copy of the proposed by-law as amended was communicated to each of the London sanitary authorities. In July, the committee reported that the majority of the sanitary authorities objected to these hours, and the committee therefore recommended that the Local Government Board should be asked to agree to the alteration of tho by-law being limited to the modification with respect to horsedung manure, the hours of removal remaining the same as in the existing by-law. The Local Government Board having intimated their approval of the adoption of this course, the by-law as amended was confirmed. The by-law now in force in London is, therefore, as follows— Every person who shall remove or carry, or cause to be removed or carried, by road or water in or through London any fecal or offensive or noxious matter or liquid, whether such matter or liquid shall be in course of removal or carriage from within or without or through London, shall use or cause to be used therefor a suitable carriage or vessel properly constructed and furnished with a sufficient covering so as to prevent the escape of any matter or liquid therefrom, and so as to prevent any nuisance arising therefrom. Shall person shall not remove or carry, or cause to be removed or carried, such matter or liquid by road in or through London, except during the following periods, viz.— Between 4 o'clock a.m. and 10 o'clock a.m. in any day during the months of March, April, May, June, July, August, September, and October. Between 6 o'clock a.m. and 12 o'clock at noon in any day during the months of November, December, January, and February. This by-law shall not apply to any person removing or carrying manure, consisting only of horse dung with a sufficient proportion of straw to render it inoffensive, and shall not apply to any person removing or carrying in a suitable carriage or vessel as aforesaid manure consisting of horse dung and litter other than straw. 59 Removal of house refuse. Only a few references are made in the annual reports of medical officers of health to the collection of house refuse. Dr. T. Orme Dudfield states that in Kensington a call is made for this purpose once a week. In Islington, where the same course is adopted, Mr. Harris reports that the number of applications by householders for the removal of their house refuse was only 157 in 1891, showing that the wants of the householders had been well anticipated by this system. Again, in Hackney, the number of applications was only 158. Dr. Caldwell Smith reports that in the eastern district of the Borough of Wandsworth there is a weekly collection, but, at the discretion of the surveyor, certain premises, including flats, are cleared two or three times a week. The same course is adopted in the western district, the more frequent collection being from flats and public institutions. Referring to the rapid erection of residential flats in the borough, especially in Clapham, Balham and Putney, he says that the removal of dust from them is a question often of serious and increasing difficulty. In many no adequate provision has been made for the storage of dust for one week. In some, shoots had been constructed, but they were soon found to be a source of serious nuisance, and other means had to be adopted, and nothing short of daily removal will remove the nuisance. Dr. Davies reports favourably of the dust collection in Woolwich parish by the borough council. In Plumstead and Eltham the work is done by two contractors. With regard to Plumstead, he states that "the collection of the dust continues to be slovenly; the carts are not adapted for this work, and are not sufficiently covered ; spilling of contents is of frequent occurrence." One of the resolutions adopted at the conference of London sanitary authorities, which was held at the County Hall in 1900, was that, in the opinion of the conference, house refuse should be removed daily when practicable. In May, 1902, the Public Health Committee proposed to the County Council that the Council's by-law requiring the removal at least once a week should be amended so as to require the removal to be effected at least twice a week. The Council having adopted this recommendation, a draft by-law amended in this way was communicated to the several sanitary authorities for their observations. Disposal of refuse. Dr. Reginald Dudfield states that in Paddington, since the closure of the wharf, No. 20, North Wharf-road, there have been no complaints of nuisance from any of the wharves. The old Paddington Act has been repealed, and accumulations on the wharves can now only be dealt with under section 16 (2) of the Public Health (London) Act, 1891. Dr. T. Orme Dudfield states that a part of the refuse of Kensington, from the northern part, is conveyed out of London on the Grand Junction Canal, the refuse from the southern district being taken down the Thames. He writes that, "The time when the refuse will be cremated at the council's land at Wood-lane, Hammersmith, would appear to be at hand." Dr. Sykes states that the refuse of St. Pancras is deposited in the destructor yard in Georgiana-street, and in the yards or wharves of the railway companies, but it does not remain there more than 24 hours, and is not manipulated. Dr. Priestley describes the dust wharves in Lambeth, which are as follows— Three dust depots in Commercial-road belonging to three sanitary authorities —(1) Lett's Wharf (City of London), (2) Shot Tower Wharf (City of Westminster), (3) Phoenix Wharf (Borough of Finsbury). In Belvedere-road are (1) the wharf depot (Borough of Lambeth), (2) Gabriel's Wharf (private contractor), and (3) Canterbury Wharf (private contractor dealing with refuse from the Borough of Holborn). On the Albert-embankment is Cookson's Wharf, and near to, in Tin worth-street, Cookson's Yard (private contractor dealing with refuse from the Borough of Holborn), and also in Tinworth-street, Clarkson's Yard (private contractor dealing with part of the refuse of the Borough of Lambeth), and Boyce's Yard (private contractor dealing with manure and road or slop sweepings). A siding at Herne-hill Station is used as a temporary manure depot by the Chatham and South Eastern Railway Company in connection with the removal of offensive matter from various parts of London. A siding at Tulse-hill Station is used by the London, Brighton and South Coast Railway for loading house refuse, etc. At times offensive matters are left for a longer time than is necessary or desirable, and nuisances thus arose in 1891 in connection with the depots belonging to the City Corporation, the City of Westminster and the Finsbury Borough Council. Summonses were taken out but the nuisances were abated, and no further action was necessary. No nuisance has been experienced since. Nuisance was complained of in connection with Canterbury Wharf, Belvedere-road, and in consequence the shoots were ordered to be covered with canvas to prevent dust, paper, etc., flying about. Boyce's Yard, Tinworth-street, was complained of on several occasions. Nuisance also occurred at stables in Hackford-road at the time of removal of manure, and at the Herne-hill siding of the Chatham and South Eastern Railway. Destructors have been erected in connection with Lett's Wharf, Shot Tower Wharf, Phoenix Wharf, and Clarkson's Wharf. In a special report dated the 15th July, 1901, Dr. Priestley describes the Horsfall destructor erected by the late Strand District Board of Works at Shot Tower Wharf, Commercial-road, Lambeth. He states that his observations, which commenced in November, 1900, satisfied him that the destructor caused nuisance, and alterations in the destructor were made, and in a further report, dated the 20th February, 1902, he states that he is in a position to certify that "the destructor, as amended and improved, is capable of carrying out the work required of it without nuisance to the surrounding neighbourhood, if properly attended to." The refuse of Wandsworth, Dr. Caldwell Smith reports, is collected by a contractor, and in Putney by the employees of the council, and is deposited into barges at the parish yards in Wandsworth and Putney, and taken down the river to some brickfields in Kent. The refuse from Clapham, Balham, Streatham and Tooting is burnt at the council's destructor at Tooting. 60 155 accumulations of manure were removed, and 45 notices were served for the removal to be carried out every 48 hours. The house refuse of "Woolwich parish, Dr. Davies states, is disposed of at the dust destructor near St. Mary's Church, that of Plumstead is disposed of on the levels at a sufficient distance from houses, that of Eltham on a brickfield at a considerable distance from any houses, except two occupied by the contractor and his assistant. He writes, "No complaints were received as to nuisance from the shoots." Dr. Davies also states that the Plumstead shoot was well attended to, paper and other organic matter being burnt, and nuisances kept at a minimum. The completion, he says, of the Plumstead destructor will, however, be a great gain. In Poplar, the proprietor of a wharf in Bloomfield-street was fined for having a very large accumulation of refuse on his premises, in contravention of the by-law. Nuisance from sewers. The medical officer of health of Kensington states that complaints as to offensive smells from the Counter's-creek sewer were received during the year, and that certain ameliorative works were carried out. Complaints were also received concerning nuisance from a sewer in the Warwick-road between the railway bridge and the south end of Philbeach-gardens, and certain works were carried out with a view to improvement. The medical officer of health of Hackney states that on the 27th July, as the result of a heavy fall of rain, a number of houses, chiefly in Clapton Park and Hackney Wick, were flooded with sewage, and as many as 206 houses were afterwards cleansed by the sanitary authority. The medical officer of health of Popular states that complaints were received as to nuisance from sewers in the neighbourhood of the Smeed-road. The County Council had desired to erect shafts against neighbouring buildings, but had met with opposition from the owners. The medical officer was satisfied that chemicals were being illegally discharged into the sewers in Hackney Wick, and he was of opinion that the owners of factories should afford every assistance to the County Council to erect shafts against buildings. He reported on this subject in July, and subsequently, during a storm, a disastrous and fatal explosion took place in the neghbourhood of White Post-lane. The number of houses rendered temporarily unfit for habitation was 71, and the water gaining access to the underground tanks of mineral oil works, the oil was washed into the streets and became ignited, leading to damage of houses and deaths. The medical officer of health of Wandsworth reports that flooding of sewers after heavy rainfall occurred in a number of streets in Clapham, giving rise, in some cases, to nuisance of a serious nature. He states that the flooding was due to the fact that the Heath-road sewer was insufficient to carry off the water during heavy storms. In Wandsworth parish flooding occurred from the same cause, and in Streatham. The medical officer of health of Greenwich states that complaints were received as to nuisance from the manholes and entrances to the main sewers in various parts of the borough, particularly in connection with a portion of an old and practically disused sewer which runs along a portion of the Greenwichroad up to the neighbourhood of St. Alphege Church. On each occasion steps have been taken to at once temporarily remedy the matter. The medical officer further reports that serious nuisance was caused by the storm overflow of the main sewer which opens into the river near to the entrance to Deptford-creek. The medical officer of health of Woolwich states that houses in Harden's Manorway frequently had their drains stopped through irregularity of the level of the sewer. It was decided that the sewer and its branch should be relaid for a length of 1,050 feet, and this appears to have provided a remedy. Nuisance from the Thames and Lea. The medical officer of health of Woolwich states that repeated complaints of the nuisance caused by the foul state of the river Thames were received from July to October. "After lasting several weeks the nuisance was abated." The medical officer of health of Hackney includes in his report the results of analyses of samples of Lea water made during the summer of 1901, which he says show the continued and increasing pollution the water is receiving. Drainage By-laws. At the end of 1900 the Couucil made by-laws, under section 202 of the Metropolis Local Management Act of 1855 for regulating the dimensions, form and mode of construction, and the keeping, cleansing and repairing of the pipes, drains and other means of communicating with sewers, and the traps and apparatus connected therewith; These by-laws were confirmed by the Local Government Board in June, 1901. Housing of the Working Classes Act. Representation under Part 1. On the 29th October the Council resolved that an improvement scheme under Part I. of the Housing of the Working Classes Act should be carried out in an area known as the Providenceplace area, Poplar, which had been represented by the medical officer of health of the borough. In a report which the Housing of the Working Classes Committee presented to the Council on the 22nd October the area was thus described— The Providence-place area is nearly an acre in extent, and the houses are for the most part twostorey cottages situated in ill-arranged courts. Providence-place itself is a narrow court of about ten feet in width, leading from Woolmore-street to Wright's place, which leads out of Cotton-street. Providence-place contains 21 houses, 17 of which comprise four rooms each, the remaining four having an extra set of two rooms in a basement. The houses are old and in bad repair, and the first floor is approached by a staircase leading from the back room. The ground floors are generally on a level with or just below the level of the pavement. In Wright's-place the houses are generally three storeys in height with only one room on each floor, but 61 with back-addition washhouses. They are in a slightly better condition than those in Providence-place. Union-place contains five small two-storeyed cottages, which, however, have no back yards at all. Their w.c.'s are in their forecourts. Osborn-place, is only six feet wide; the ground floors of the houses are below the level of the pavement, and the houses are in a very bad state of repair. Dickerson'splace is a cul-de-sac about ten feet wide. The houses are on one side only, and are of two storeys with yards only about six feet deep. These yards contain a washhouse. Union-street contains houses of a somewhat better character on the west side, but on the east side the yards are very confined, and in most cases the third room is over the washhouse on the ground floor. Union-court comprises also two-storeyed cottages. Three have no back yards, and the yards to the other two are very small. The water-closets for the use of the inmates are in the court. The houses in Ashton-street and Woolmore-street are of a somewhat better character than those on the area generally, but they are all old and in indifferent repair. The population of the represented area, as above described, amounts to 411 persons, and the mean death-rate from all causes in the period 1895-99 works out at 33 6 per 1,000, as compared with 21'3 for the Poplar district, and 18'7 for the whole of London. The chief defect of the area, however, is its arrangement. Having regard, therefore, to the whole of the circumstances, we have come to the conclusion that it is an area such as can only be satisfactorily dealt with by way of a scheme. We have had such a scheme prepared and we now submit it for the approval of the Council. The scheme, prepared by the officers, omits from the area to be dealt with the houses in Union-street and Ashton-street, and, after full consideration, we have decided that this course is justified. The scheme therefore includes on the east of Union-street only the five houses in Union-court. On the west of Union-street, however, it is desirable to include as neighbouring lands three more houses, Nos. 2, 3 and 4, Union-street. By this means a more convenient site will be secured for the erection of dwellings. The number of persons of the working class who will be displaced is 277, and accommodation can be provided on the cleared land for about 400 persons. It will therefore be possible to comply with the Council's resolution of 29th November, 1898, without acquiring any additional land. The scheme also provides for the carrying of Union-street through to Woolmore-street, and for its widening for a portion of its length on its west side. It is hoped that it may ultimately be possible to make arrangements by which it can be widened to 40 feet throughout. The estimated gross cost of acquiring the property proposed to be taken amounts to £17,000 ; the cost of paving works is estimated at £l, 600; while the estimated housing value of the cleared land is £1,500; leaving the net cost £17,000. We have forwarded a gross estimate of £18,000 to the Finance Committee, who will submit the same in due course. A small area in King-street, Poplar, consisting of two small courts and the houses frontiug King-street between them, had also been represented by the medical officer of health of Poplar. The committee were of opinion that the borough council should deal with this area under Part II. of the Act. Schemes undertaken by the County Council under Part 1. of the Act. On the 12th February the Council authorised an advertisement for tenders for the erection of dwellings on the Duke's-court site, Drury-lane, for the accommodation of 610 persons, to be displaced by the carrying out of the Clare Market (Strand) scheme, and on the 26th March the Council accepted a tender amounting to £23,600 for the erection of Sheridan, Beaumont and Fletcher Buildings, the dwellings to consist of three blocks of five storey buildings, providing accommodation for 610 persons in 130 tenements, 10 of one room, 75 of two rooms, 35 of three rooms, and 10 of four rooms, 120 of these tenements to be self-contained, and the remaining 10 to have private water-closets, but sculleries common to two tenements. In February the erection of Wellesley-buildings on the Churchway (St. Pancras) area, providing accommodation for 360 persons in 60 two-room and 20 three-room tenements, was completed. On the 25th June the Council approved the working drawings, specifications and bills of quantities and the architect's estimate of £22,567 10s. 2d., in respect of Seymour and Somerset-buildings, to be erected on this area, and referred them to the manager of the Works department to be carried out by the Council without the intervention of a contractor. The buildings are to be five storeys in height, and will provide accommodation for 472 persons in 2 tenements of one room, 64 tenements of two rooms, 30 tenements of three rooms, and 4 tenements of four rooms. Schemes undertaken by the County Council under Part II. of the Act. On the 18th June the Council resolved to issue an advertisement inviting tenders for the erection of Sydney and Melbourne buildings to be erected on the Ann-street, Poplar, area. These buildings will provide accommodation far 440 persons, in 65 tenements of two rooms and 30 tenements of three rooms. The Council on the 30th July accepted a tender for the erection of these buildings at a cost of £15,674 12s. 4d. On the 17th December the Council approved the working drawings, specification, bills of quantities and the architect's estimate of £51,500 for the erection of a lodging-house on the Mill-lane site by the Council, without the intervention of a contractor, and referred them to the manager of the Works department for that purpose. This lodging-house will provide accommodation for 804 lodgers. The following account of the plan is contained in the report of the Housing of the Working Classes Committee to the Council: "The entrance is central and gives access to the dining-room on the right and to the smoking and reading rooms on the left. The office commands the entrance for lodgers and for the staff and is arranged close to the superintendent's quarters. The dining-room is planned with a long hot-plate chamber in the centre, with lodgers' sculleries. It is well lighted from side and roof. The hot-plate chamber is ventilated by two fans driven by electricity, and this arrangement helps the ventilation of the dining-room. Immediately adjoining the dining-Toom is the lodgers' crockery room. The shop for sale of hot and cold viands is placed in a convenient position with a direct servery thereto, and with easy communication to the kitchen in the rear. The smoking-room is arranged on the Mill-lane frontage. It is well lighted and has good ventilation. The reading-room is approached from two of the main corridors; it is of a suitable shape and is well lighted by side and top lights. This room also will have cross-ventilation." The superficial area in square 62 feet in the dining, reading and smoking rooms is as follows: Dining-room 6,067, including 475 round hot-plate, reading-room 3,057, and smoking-room 2,031, providing per lodger respectively 7.54, 3.80 and 2.53. "With regard to the sleeping accommodation, two principal staircases leading to the dormitories, and one emergency staircase axe provided. It will therefore be impossible for all egress from the house to be blocked in the event of fire. Each cubicle is 4 ft. 10½ inches wide and 7 ft. 4½ inches long (internal dimensions), and is provided with a window so that ample means of through ventilation are secured. Two cubicles on each floor will be occupied by the resident male staff. The dormitory corridors are 4 ft. 6 in. wide, and four water-closets and two sinks for urgent use are provided on each of the five dormitory floors. The lodgers' promenade is provided over the reading-room and part of the dining-room, and is approached by means of the south-west staircase." Schemes undertaken by District Councils under Part II. of the Act, the County Council contributing towards the cost. On the 26th November the County Council had under consideration a proposal by the Metropolitan Borough Council of Shoreditch for the modification of the Moira-place and Plumber's-place scheme. This scheme originally provided for the displacement of 533 persons of the working class and the rehousing of 400 upon part of the areas cleared. In 1897 the scheme was modified to enable the local authority itself to erect the necessary buildings, and in the following year the approval of the County Council was given to a proposal that the borough council should build dwellings for an additional 72 persons on land which it was formerly proposed to devote to commercial purposes. There were three remaining pieces of land on which the borough council had proposed to build, under Part III. of the Act, shops with dwellings over for 48 persons. In view of the opinion of the Local Government Board that there is no power under Part III. which authorises the erection of shops, the approval of the County Council was sought to the work being carried out under Part II. On the recommendation of the Housing of the Working Classes Committee the Council assented to the necessary modification of the scheme for this purpose. On the 17th December the County Council approved the plans of buildings (with some modification to be erected on these plots). On the 3rd December the Countv Council approved plans for the erection of a block of buildings on the Queen Catherine-court, Limehouse, area. The building will be five storeys in height, of the balcony type, and will provide accommodation for 130 persons in 11 tenements of two rooms and 14 tenements of three rooms. Proceedings in respect of houses represented under Part II. of the Act 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, 1901— Local Authority. Total number of houses concerning which the Council has received information that representations have been made from the 1/1/01 to the 31/12/01. Number of houses dealt with 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 represented but subsequently dealt with under Public Health (London) Act, 1891. Still closed. Demolished. Improved. Total. Still closed. Demolished. Improved. Total. Battersea _ _ Bermondsey - - - - - - - - - - - Bethnal-green 16 — — 7 7 — — 9 9 — _ Camberwell - - - - - - - - - _ _ Chelsea - - - - - - - - - - _ Deptford - - - - - - - - - - - Finsbury - - - - - - - - - - - Fulham 11 5 — 6 11 — - — - _ _ Greenwich 2 - 2 - 2 - - - - — Hackney - - - - - - - - - - - Hammersmith - - - - - - - — - — - Hampstead - - - - - - - - - - - Holborn 6 6 - - 6 - - - - - — Islington - - - - - - - - - - — Kensington - - - - - - - - - - — Lambeth 17 — 4 13 17 — - — — — _ Lewisham 4 4 - - 4 - - - - — _ Paddington - - - - - - - - - - - Poplar - - - - - - - - - - - St. Marylebone* - - - - - - - - - - - St. Pancras - — — - - - — - - - Shoreditch - - - - - - - - - - _ Southwark - - - - - - - - - _ _ Stepney - - - - - - - - - - - Stoke Newington - - - - - - - - - - - Wandsworth - - — — — - - — — - _ Westminster 11 - - - - 11 - - 11 — Woolwich 28 1 - - 1 2 - - 2 - 25 Total 95 16 6 26 48 13 - 9 22 - 25 * The houses on the Devonshire-place area, represented to the Borough Council of St. Marylebone under Part 2 of the Act and afterwards reported to the London County Council under Part 1, have not been included in the above return. 63 Proceedings by the County Council under Part III. of the Housing of the Working Classes Act. On the 29th January the Council resolved to purchase the site of the Royal Caledonian Asylum in Caledonian-road, Islington, for the purpose of erection of artisans' dwellings under Part III. of the Housing of the Working Classes Act. The site is about two acres in extent, and has a frontage of 248 feet ; the cost Is about £8,000 per acre. It was proposed to provide accommodation for about 1,400 persons in 10 one-room tenements, 196 two-room tenements, 96 three-room tenements, and 4 four-room tenements, the whole of the tenements to be self-contained, and the average size of the living and bedrooms to be respectively 147 square feet and 104 square feel. During the year progress was made with the development of the Totterdown-fields Estate, Tooting. On the 26th February the Housing of the Working Classes Committee thus reported on this subject— Three lateral streets run eastwards from Tooting High-road straight through to Church-lane. The middle one of these three will be 45 feet wide and the other two 40 feet wide. A short 40 feet street connects the southern of these lateral streets with the middle one, and from this short transverse street a fourth lateral street, also 40 feet wide, runs straight through to Church-lane. Three main 45-feet streets divide the estate transversely, and are so arranged as to provide for their continuation on the development of the adjoining land. All the 45-feet streets will be lined with plane trees, which will be planted just inside the forecourts of the cottages abutting upon them. The forecourts abutting on the 45-feet street will be 14 feet in depth, and the forecourts abutting on the 40-feet streets will average 5 feet in depth. The arrangement of roads outlined above enables the whole estate to be divided into 1,244 plots for the erection of cottages of four different kinds. The average sizes of the plots will be as follows— Area in square feet. Frontage. Depth. ft. in. ft. in. First-class cottage plot 2,494 33 8 74 0 Second-class cottage plot Third-class cottage plot 1,164 799 16 0 13 2 72 9 60 6 Fourth-class cottage plot 1,210 18 5 66 0 The minimum distance between the streets will be 103 feet and the maximum will be 158 feet. The distance between the backs of the houses will vary from 38 feet to 90 feet. The cottages will be arranged in terraces of about 18 cottages to each terrace ; and between these terraces will be a space of about 15 feet. None of the cottages will have back additions, and the free circulation of air will therefore be unimpeded. The accommodation provided will be according to the following schedule— Cottages. No. No. of rooms. No. of persons provided for. Average size of Living room. 1st bedroom. 2nd bedroom. 3rd bedroom. sq. ft. sq. ft. sq. ft. sq. ft. 1st class 29 5 and scullery 290 150* 104 101 96 2nd class 100 4 and kitchen 800 158† 115 98 96 109 3 and kitchen 654 3rd class 818 3 and scullery 4,908 144 96 96 — 4th class 188 3 and scullery 1,128 130 96 96 — 2 and kitchen 752 144‡ 101 — — Totals 1,244 — 8,532 — — — — It will thus be seen that it is proposed to put 8,532 persons on an estate of about 38¾ acres. This is an average of about 221 persons per acre. This may at first sight appear a high average when compared with the whole of London (57), but it must be borne in mind that the latter number of persons per acre is arrived at by including in the acreage land covered not with dwelling houses alone but with factories, warehouses and commercial property generally as well as all open spaces. The only fair comparison would be between the estate as proposed to be developed and an area of similar acreage exclusively covered with dwelling houses. It will be seen that the proposed arrangement of the estate provides only two-storey buildings, with gardens in the rear, abutting on 45 and 40 feet streets, and 45° angle of light to all windows is in all cases more than provided for, the maximum height of the cottages being only 17 feet to eaves, and the minimum space at the back and front being 38 and 50 feet respectively. From these facts the Council will understand that the scheme which we have adopted for the development of the Totterdown-fields estate is one which can be thoroughly recommended on sanitary grounds. We have given instructions for the preparation of working drawings to be proceeded with for the portion—about one-third—of the estate nearest to Tooting High-road. On the 23rd July the Council approved an estimate of £30,000 for the formation of roads and construction of sewers on this estate, and on the 30th July approved the working drawings, specifications and bills of quantities in respect of three representative rows of cottages of four classes, to be erected on section A, and the estimate of £74,093 in respect of the erection. The cottages to be built on this section include 11 of the first class, 66 of the second class, 167 of the third class and 32 of the fourth class, or a total of 276 cottages for 1,888 persons, and authorised * Parlour, 99 sq. feet. †Kitchen, 79 sq. feet. ‡Kitchen, 60 sq. feet. 64 tenders to be invited. On the 8th October the committee reported that a tender of £7,2G9 had been accepted for construction of the first part of the roads and sewers on section A, and that the work was in progress, and on the 22nd October the Council accepted a tender of £11,184 12s. 9d. for three rows of cottages, subject to the contractors undertaking the erection of the remaining cottages on section A at the same schedule of prices. White Hart-lane estate.—On the 2Gth February the Housing of the Working Classes Committee presented to the Council a report on as estate at Tottenham, situated about G miles from London. This estate consists of two portions, the larger of 179 acres fronting Lordship-lane, and the smaller of about 46 acres is approached by a narrow road from White Hart-lane. The Committee proposed that the Council should purchase this estate at a cost of £400 per acre, and tentatively reported as follows— We have considered the means to be adopted for the development of the estate, and have had exhaustive reports from the officers on this point. As we have already stated, the owners of the estate are prepared to accept a low figure for the land, subject to the Council acquiring the whole estate. After careful consideration it appears to us that the northern site, which is less suitable for immediate development than the southern site, should not be dealt with until the southern site has been developed. The architect informs us that it could be developed to accommodate 2,460 persons in 1,029 cottages. The valuer also states that every house built and occupied on the southern site will tend to render the northern site not only more suitable for development but also more valuable. The scheme of development, therefore, which we have had before us deals only with the southern site, comprising 179 acres. This scheme is only tentatively submitted in order that the Council may come to a conclusion as to the practicability generally of developing the land for the purpose of cottage dwellings, and it should be understood that it will probably be necessary to deviate from it somewhat in the future. Full particulars of any alteration will be given in due course. The particulars of the present scheme are as follows— Accommodation for 33,000 persons will be provided in 4,750 self-contained two-storey cottages, and 2,000 more will be provided for in tenements over shops. The cottages will be of various classes, and each cottage will have its own garden. The number of persons to be placed on the site will not crowd the land unduly. The depths of the various cottage plots will be generally greater than the by-laws of the local authorities require, and forecourts will in all cases be provided. The frontages to the main roads are very suitable for shops, and about 10½ acres of land will be given up to this purpose, upon which about 250 shops will be erected, and from these a considerable income could probably be obtained should the Council decide itself to build the shops. It will be necessary to widen Lordship-lane for the construction of the proposed tramway, and the shop plots have been made of sufficient depth to allow of this being done. Access to the site will be given by eight roads leading from Lordship-lane, Snakes-lane and Hatherley-road on the south, three from Church-lane on the east, eight from White Hart-lane on the north, and provision will be made upon the other boundaries for future continuation of the roads should opportunity arise. The principal roads providing thoroughfares over the site, both east and west, and north and south, are 50 feet wide, with trees on each side, and the majority of the remaining roads are 40 feet wide, with the exception of those within the district of Wood-green, which are in all cases 50 feet wide as required by the Urban District Council. It is proposed to take advantage of the river Moselle which runs through the eastern portion of the estate and some slightly rising ground upon its bank, which is difficult to build on, to arrange a public garden of about two acres and a quarter, with the river flowing through it. Four other smaller gardens will be arranged on other parts of the site, which will help to preserve the healthiness of the estate. The parish church at Tottenham and the churchyard are very picturesque, and effective use will therefore be made of them in laying out the estate. The total accommodation that can be provided on both sites is 42,500 persons in 5,779 cottages. The estimated cost of erecting the cottages on the south side only, providing the roads, gardens sewers, diversion of the river Moselle, etc., and provision of shops is £1,530,858. On the other hand the estimated sum available after allowing for the cost of the land, interest and sinking fund charges and all outgoings is £1,521,800, or a deficiency of £9,058. The difference represents only three-fifths per cent. on the total estimate. We may point out that two per cent. of the estimated gross rental has been set aside in the estimate under the heading of contingencies, and a very small saving under this heading will convert the deficiency into a surplus. The standing order No. 336 (1)—(4) requiring that there shall be no charge on the county rate in respect of the erection of working-class dwellings applies only to schemes or areas dealt with under Parts I. and II. of the Housing of the Working Classes Act, 1890, and does not affect schemes under Part III. of the Act, but standing order No. 336 (5) relates to Part III. and only requires that the Finance Committee shall simultaneously report with us on the estimated financial effect of a Part III. scheme, and this will be done in the present instance. It may be mentioned that on 6th December, 1898, the Council by resolution approved of action being taken under Part III. of the Act, provided that no charge be placed on the county rate thereby. The amount of the estimate, which has been forwarded to the Finance Committee, and which the Council will be asked to approve, is £91,500. This includes the value of the land, the agent's fee, and all expenses connected with the sale and purchase of the land. The sale of the estate is subject to the condition that the Council shall take over the land subject to the existing tenancies and tithe. The gross rental received from the agricultural tenants on the estate is stated to be £500 per annum. The tithe and tithe rent charge amount to £65 17s. 11d. per annum normal, the value in 1899 being £43 19s. per annum. The Council decided to purchase this estate, and an estimate of £91,500 was approved for this purpose. Reid's Brewery site.—Progress was made in the development of the Reid's Brewery site, which had been purchased to provide accommodation for persons of the working class displaced in connection with the Holborn to Strand street improvement scheme. In February the Housing of the Working Classes Committee reported as follows on the way in which it was proposed to utilise the site— We have had under consideration plans for the development of the Reid's Brewery site, Clerkenwell, which was acquired by the Council for the provision of accommodation for persons to be displaced by the formation of the new street from Holborn to the Strand. The site has frontages to Clerkenwell-road, Leather-lane, Portpool-lane and Gray's Inn-road. The plan which we have approved and which has also received the approval of the Secretary of State provides for the erection of fivestorey block dwellings all round the site except on the frontage to Gray's Inn-road, where the existing buildings will remain for the present. These dwellings will be pierced with six archways up to the 65 second floor, giving access to the interior of the site. There are also two existing archways from Gray's Inn-road. The main interior of the site will be occupied by five 5-storey transverse blocks of dwellings divided by yards and gardens. The narrow end of the site next Grays Inn-road will contain another short block of five-storey dwellings, and the remainder of the site between this block and Gray's Innroad frontages will be laid out as a playground and garden. An estate office and twenty-three shops will be provided on the ground floor of the dwellings facing Clerkenwell-road and Leather-lane. The accommodation will consist of 551 tenements, of which only 13 will be associated and the remainder self-contained. The 13 associated tenements all consist of one room ; there will be 361 two-roomed tenements, 136 three-roomed tenements, and 41 four-roomed tenements. Accommodation will be provided in all for 2,614 persons exclusive of the shops. In July the Council approved the working drawings, specification and bills of quantities in respect of the foundations of two of the blocks of buildings, together with an estimate of £15,000 in respect of the foundations of all the blocks of buildings on the site except those facing Clerkenwell-road and Leather-lane, and resolved that if the manager of the Works department was prepared to undertake the work of constructing the foundation of two of the blocks at the architect's estimate, and the foundation of the remaining blocks at the same schedule of prices, that the drawings, specification, quantities and estimate be referred to him for that purpose. In October the Council resolved to invite tenders for the erection of the superstructure of blocks A, B, and C on the site, and the committee reported that the manager of the Works department should have the opportunity of erecting blocks D, E and F at the amount of the architect's estimate. In December the Council approved the working drawings, bills of quantities and specifications in respect of the superstructure of blocks C and D, and the estimate of £62,135 in respect of the superstructure of blocks A to F, and in the same month accepted a tender of £10,026 for block C, the erection of the superstructure of blocks A and B to be undertaken at the same schedule of prices. The Council also resolved that the superstructure of blocks D, E and F should be erected by the manager of the Works department, and referred the working drawings, specifications, bills of quantities and architect's estimate relating to block D to him for this purpose on the understanding that the superstructure of blocks E and F shall be undertaken at the same schedule of prices. liotherhithe Tunnel displacement.—The Council also accepted a tender of £8,122 in September for the erection on a site in Swan-lane, a block of dwellings consisting of 20 two-room and 20 three-room tenements, providing accommodation for 200 persons displaced by the construction of the Rotherhithe Tunnel. Millbank estate.—The erection of artisan dwellings on this site was continued during the year. In March, the Housing of the Working Classes Committee reported that Ruskin-buildings was completed. This block is divided into four houses containing 85 tenements and 215 rooms, giving accommodation for 430 persons. In April Rossetti-buildings was practically completed. This block is divided into three houses containing 60 tenements and 145 rooms, accommodating 290 persons. In October one block of Reynolds-buildings was nearly completed. The block contains 20 tenements of two rooms and 20 tenements of three rooms, and provides accommodation for 200 persons. A remaining block, the completion of which was delayed by a fire, was finished in November. It contains 19 tenements of two rooms, 19 tenements of three rooms, and provides accommodation for 190 persons. It also contains an estate office and a four-room tenement for the superintendent. In the same month Mulready-buildings was completed. It provides accommodation for 230 persons in 20 tenements of two rooms and 25 tenements of three rooms. Buildings opened during the year. The following buildings erected by the Council were opened during 1901—Ruskin-buildings Millbank-estate, providing accommodation for 430 persons; Wellesley-buildings, Churchway, St. Pancras, for 360 persons; Rossetti-buildings, Millbank-estate, for 290 persons; Reynoldsbuildings, for 200 persons; Lowood and Chancery buildings, Cable-street, Shadwell, for 276 persons; Hardy-cottages, Trafalgar-road, Greenwich, for 306 persons; Toronto and Montreal buildings, Ann-street, Poplar, for 190 persons; Battersea-bridge-buildings, for 286 persons. Displacement of persons of the working class. On the 23rd October, 1900, the Council resolved that the Building Act Committee should inform the Housing of the Working Classes Committee of all applications under the Building Act which were made to them, and which involved displacement of persons of the working class. A report of the latter Committee, dated the 27th November, 1901, showed that to that time the applications involved the removal of 517 houses thus occupied and the erection of 141. The number of persons displaced was 4,393, the number of persons proposed to be rehoused was 1,692, leaving 2,701 persons unprovided for. Reference to proceedings under the Housing of the Working Classes Act by Medical Officers of Health. The annual reports of medical officers of health supply the following information as to the action taken in their districts in connection with this Act. The medical officer of health of Paddington presented two reports, a preliminary report containing statistics of the approximate housing conditions, sickness and mortality rates in three special areas, viz., North Wharf-road area, Hall-park area and Clarendon-street area, and later, a second and more complete report as to the last-named area. The Borough Council of Kensington had before them a Teport by their medical officer of health on overcrowding in the borough, with the result that the council adopted Part III. of the Act. He further recommended that the Public Health Committee and the Law and General Purposes Committee should consider and report as to the Council adopting the provisions of the Small Dwellings Acquisition Act. The question was referred to the Law and General Purposes Committee, who reported in favour of adopting the Act. This report was adopted by the borough council but no further action taken up [9] 66 to April, 1902. In his special report, Dr. Dudfield states that after inquiry he found few cases of overcrowding in Kensington, judged by the standard of the by-laws. With respect to rents, he says that "cases could be cited of houses worth, perhaps, twelve to fifteen shillings a week unfurnished, let in 'furnished' rooms so as to bring in thirty, forty, and in a few cases, fifty shillings a week. The rent per tenement of a single room ranges from 3s. to 7s. 6d. per week; for two rooms, from 7s. 6d. to 10s. 6d. The 'furniture' for the most part is meagre in quantity, in quality wretched, and hardly deserving the name. With few exceptions the furnished rooms are found in the 'special area'; in which district the unfurnished tenements of one room fetch from 1s. 6d. to 4s., the two-room tenements from 4s. 6d. to 7s., the three-room tenements from 5s. 6d. to 10s. per week, according to size and position. A tenemented house let in unfurnished rooms by the middleman consequently realises double the amount of the weekly rent paid to the landlord." Dr. Parkes reports that the Borough Council of Chelsea acquired, under Part III. of the Act, the reversionary interest of the freeholder in Onslow-dwellings, Pond-place, at a cost of £13,350, to include law and incidental charges. Onslow-dwellings consist of four blocks of three-storey brick buildings containing 63 three-room tenements let at 5s. 6d. per week and 45 two-room tenements let at 4s. 6d. per week. There are also a club-room and mission hall attached. The buildings house a population of about 450 persons. The lease expires at Christmas, 1909. Dr. Allan's report relating to Westminster contains particulars of population, occupation and rents paid by the inhabitants of Chadwick-street, Great Peter-street, Laundry-yard, Monckstreet, Monck-court, Blue-anchor-court, St. Matthew-street, St. Ann's-court, Medway-street and Arneway-street. He came to the conclusion that provision should be made for at least 500 persons at an early date, and he thought that provision for another 500 or 750 persons within the next five years would not prove excessive. The Council purchased a piece of land 64,000 square feet in area abutting on Regency-street, Page-street and Vincent-street. "It has been cleared of houses, and it is proposed to erect upon it dwellings similar to those recently erected by the Guinness Trust in Hammersmith, which have been visited by the Housing Committee. Several schemes for providing additional accommodation in the northern part of the city have been considered, but have not as yet assumed a practical shape." Mr. Wynter Blyth states that a report relating to an area in St. Marylebone was made during 1901 under Part II. of the Act, but at the request of the borough the report was afterwards made under Part I. to the London County Council. He adds that "no action as yet has been taken by the London County Council, but the matter is still under their consideration." The Borough Council resolved to purchase an area of 9,000 square feet abutting on John-street for the sum of £7,000. On this site artisans' dwellings will be erected. Dr. Littlejohn reports that in Hampstead the Borough Council adopted Part III. of the Act, and instructed the Public Health Committee to investigate the nature and extent of overcrowding in the borough, for which purpose seven inspectors were temporarily engaged, the results of their inquiries being embodied in a special report by the late medical officer of health. Later, a Housing Committee was constituted who instructed Dr. Littlejohn to report further upon the death-rate and incidence of zymotic disease in various districts. Dr. Sykes gives particulars as to the areas in St. Pancras which have been subject to a decision of the Home Secretary. With regard to the Churchway area he says that the Borough Council is in negotiation for the purpose of acquiring the houses Nos. 146 to 150 (even), Euston-road, the freehold having been already acquired, for the purpose of opening the new thoroughfare into Euston-road. With respect to the areas being dealt with under Part II. of the Act for that part of the area west of Chalton-street and north of Drummond-street, no scheme is being carried out, the houses having been dealt with individually some years since. In the pair, of the area east of Chalton-street the Borough Council has passed resolutions for the amendment of the Chapel-grove scheme by the acquisition of Nos. 13, 15 and 17, Chapel-street, and for the amendment of the Eastnor-place scheme by the acquisition of Nos. 10, 14, 16 and 18, Phœnix-street, and the construction of a block of dwellings down the centre of the cleared area. The Borough Council also passed a resolution that dwellings for the working classes should be erected on the Great College-street, on the Brantome-place and North Crescent-mews, and on the Prospect-terrace and Derry-street sites when cleared under Part II. of the Housing of the Working Classes Act. The plans, etc., for the buildings on the last two sites were approved by the Borough Council in November and forwarded for the approval of the Local Government Board and the County Council. In September it was reported to the Borough Council that the Local Government Board and County Council had approved the plans, etc., of the buildings to be erected on the Great College-street (supplemental) site. The modified and supplemental schemes were included in one order which was sealed by the Local Government Board on the 7th December. In a special report Dr. Warry discusses the need for accommodation for the working classes in Hackney. He found, as a result of inquiries, that in the houses let in lodgings, in Hackney which had been registered, the rooms used for sleeping and living were not of a size that permitted more than two persons in a room without infringement of the by-law as to overcrowding, and that "eight per cent. may be regarded as a fairly reliable estimate of the overcrowding of tenement dwellings at the present time." His report contains numerous instances of considerable increase in the rent paid by the working classes amounting to over 33 per cent. in recent years, and shows that the cost of building has largely increased; he recommends the provision of a municipal lodging-house for the poorest class, the conversion of large houses in Hackney into tenement dwellings and the erection of suitable dwellings both within and without the borough, the latter in the suburbs. Dr. Bond describes the area in Holborn occupied by the Italian colony. This area contains houses in Eyre-court, Eyre-terrace, Eyre-place, Summer-court, Fleet-row, Eyre-street-hill, Little Bath-street, Summer-street, Warner-street and Back-hill. He states that the houses generally are old and worn, and many are dangerously dilapidated. Many of The houses have no through ventilation 67 and many have no back areas. Notices were served in respect of each, of the premises to abate the nuisances and remedy the sanitary defects that existed. These have all been complied with, except some of the structural defects that could only be remedied by an improvement scheme. His report contains a list of houses closed voluntarily, demolished, re-built, etc., as well as of houses he represented under Part II. of the Housing of the Working Classes Act. Dr. Newman describes three groups of areas in Finsbury. The first group includes five areas, viz., Aylesbury-place area, Roby-street area, Garden-row area, Baltic-street area and Hondurasstreet area, containing 264 houses with an approximate population of 1,704, which the County Council has decided shall be improved by scheme under Part I. of the Act. The purchase of the property by the County Council is now proceeding. The second group includes six comparatively small areas in the parish of St. Luke, represented by Dr. Yarrow when medical officer of health of that district. These the County Council left to be dealt with by the district authority; they contain 110 houses and an approximate population of 859. "The third group," Dr. Newman writes, "are properties in the western division of the borough which are similar to those in the second group and demand improvement schemes at an early date. They have not yet been represented. Concerning the areas mentioned in the second and third groups, it may be said that they are now receiving attention. In more than one instance the owner of the property is himself undertaking its demolition, and in this way justly and fully meeting his responsibilities. In other cases it will be necessary to proceed with a considerable degree of legal strictness." Dr. Newman states that a large part of the borough is covered by warehouses, factories, workshops, or small shops, in immediate proximity to, and often crowded together with, dwelling houses. The majority of the dwelling houses are of two or three storeys, the former situated in narrow streets and alleys off main thoroughfares. Many of them are small, old cottages showing signs of decay, the majority consisting of two rooms. These are generally occupied by a single family. The three-storey houses are generally in the larger thoroughfares. They were originally constructed for one family, and are now occupied by more than one family, for which they are not adapted. The most satisfactory immediate treatment for much of this kind of house property is registration under the by-laws for houses let in lodgings. Dr. Newman comments on the fact that building has taken place on the yard space at the rear of houses, practically converting them into back-to-back houses. "Finsbury," he says, "is at present in the transition stage of a radical change from a residential into a non-residential commercial district comparable to the City of London. Such a transition acts prejudicially for a long series of years on dwelling house property and overcrowding," and he adds tnat one of the most essential requirements in Finsbury at the present time is sanitary supervision of existing houses, which will deal with house structure and sanitary maintenance, and with overcrowding of persons. Dr. Collingridge states in his report on the City that two houses in Sandys-row, Middlesex-street, four houses in Heneage-lane, Aldgate, represented in February, 1900, and three houses in Three Herring-court, Redcross-street, represented in July, 1901, have been demolished, also that two houses in Beech-street, Barbican, and three houses in Fann-street were pulled down by the owners, who adopted this course rather than carry out the extensive repairs required by the sanitary committee. Dr. Bryett gives account of 31 houses in Shoreditch which were closcd to enable the necessary improvements to be effected. Dr. Bate gives particulars of a small area in the east district of Bethnal-green, which he examined "with a view to submit a report, under Part I. of the Housing Act, to the London County Council." The area comprises all the houses in Digby-street, Digby-walk, Baker-street and Lansdellplace, i.e., 96 houses, occupied by 640 persons. Of the 96 houses, 54 are more or less dilapidated and dirty, and the houses on the south side of Digby-walk are back to back with those in Digby-street. The average mortality of the area for the past three years is 34.2 per 1,000 population, that of the whole of Bethnal-green being 18"7 per 1,000. Dr. Thomas, in referring to overcrowding in Stepney, points out that the number of immigrants annually arriving in the borough adds to the difficulty caused by want of house accommodation. Mr. Alexander states that he made a representation to the London County Council under Part I. of the Housing of the Working Classes Act, of "an unhealthy area in Poplar, comprising Providence-cottages, certain houses in Emmett-street and Arnold's-buildings, in all, 122 dwelling houses if Arnold's-buildings be considered as 110 tenements." Dr. Priestley states that the Ecclesiastical Commissioners have a large building scheme in Lambeth. It is proposed to demolish a number of old and worn-out buildings situated on an area which is bounded by the south side of New-cut on the north, Short-street on the east, Uffordstreet on the south, and the east side of Webber-street on the west, and including Mitre and Caffyn-streets. There will be erected on the area 38 three-storey tenement houses and 24 two-storey cottages, together with business premises facing the New-cut and some dwelling houses with shops—accommodation for about 250 tenants in all. Dr. Priestley says there will eventually be a total displacement of 643 persons, excluding children. About half an acre will be devoted to open space. He also mentions that the Loudon and South Western Railway Company are erecting blocks of artisans' dwellings on three sites, viz., Boniface-street (Upper Marsh), 55 tenements, 145 rooms ; South Lambeth-road site (Miles-street), 190 tenements, 450 rooms ; Maudslay's site (Westminster-bridge-road), 300 tenements, 730 rooms. In a special report he calls attention to the rebuilding or alteration of existing houses into separate flats, which has taken place in a number of streets, fifteen of which he mentions, and he says that, "There are in Lambeth plenty of houses that would readily lend themselves to a similar conversion." He is of opinion that in the inner wards tenement blocks might be erected by the Borough Council on vacant (or occupied) land to be acquired compulsorily for the purpose, and in the absence of sites at a suitable price, he suggests existing houses could be converted in the manner mentioned 68 above. He suggests, moreover, the erection of cottages on land at Tooting, adjoining the burial ground, and at present under the control of the Baths and Cemetery Committee. The Lambeth Borough Council adopted Part III. of the Housing of the Working Classes Act in April, 1901. Referring to the Borough of Wandsworth, Dr. Caldwell Smith states that after receiving reports from the several medical officers of health who were formerly in the service of the W andsworth District Board, and after considering other evidence, the Public Health Committee, of the council reported that the borough was at present free from overcrowding, although it is commencing in Clapham. In November, 1901, the committee further reported on the subject, and stated that the question of overcrowding and high rents might arise in the near future, and recommended the building of blocks of tenements similar to those erected by the Guinness Trust. Three sites, one in Clapham, one in Wandsworth, and one in Putney, were regarded as suitable for such buildings. Dr. Caldwell Smith adds that the council have under consideration the reports of the architects as to sites in Rectory-grove, Clapham, and Hill syard, Wandsworth. Dr. Sidney Davies, the medical officer of health of Woolwich, states that he represented an area comprising Salutation-alley and 1 to 5, Beresford-street, containing 16 houses, as a proper area to be dealt with under section 39 of the Housing of the Working Classes Act, on account of the bad arrangement and condition of the buildings and the want of light and ventilation. He also reports that plans have been prepared for building 25 houses in North Woolwich, and that a large scheme for building 1,000 houses at Eltham is at present in abeyance. Conference with metropolitan borough councils. On the 29th April a conference of representatives of the metropolitan borough councils, convened by the Metropolitan Borough Council of Islington, was held at the Islington Town Hall at which the following resolution was passed— "That inasmuch as the adoption of Part III. of the Housing of the Working Classes Act, 1890, by the metropolitan borough councils will lead to dual control and possibly to overlapping expenditure, it is desirable that some arrangement should be come to with the London County Council as to the respective spheres of action of the County Council on the One hand and the borough councils on the other." The Mayor of Islington was requested to communicate with the London County Council with a view to effect being given to the resolution. A conference was accordingly held at the County Hall on the 14th May at which members of the Housing of the Working Classes Committee of the County Council and representatives of the metropolitan borough councils were present. The following resolutions were passed, the members of the Housing of the Working Classes Committee, according to usual practice, not voting— (i.) That it is desirable, with a view to avoiding dual control and overlapping expenditure, that no scheme for the housing of the working classes in any metropolitan borough should be promoted by either the London County Council or the council of any metropolitan borough pursuant to Part III. of the Housing of the Working Classes Act, 1890, except after due consultation between the two councils (a) as to the desirableness of the scheme, and (b) with a view to ascertaining whether the cost of such scheme can be fairly apportioned between the county and the particular borough. (ii.) That in order to ascertain the immediate responsibility or requirements of each borough council, a simultaneous special inquiry be made by each council as to the number of the working class that it may be necessary, by the conditions and circumstances of their employment, to house within the area of each borough. (iii.) That reasonable modifications of the existing building laws and regulations are essential in order to facilitate the further erection of industrial buildings. (iv.) That the conference do stand adjourned to a date to be fixed in the following autumn. Upon these resolutions the Housing of the Working Classes Committee reported as follows— Following the method adopted in regard to resolutions passed at the various assessment conferences which have been held from time to time by the Council, we have considered the above resolutions with a view to ascertaining how far they should be acted upon by the Council. With regard to resolution (i.) (a) we are of opinion that some consultation should take place between two authorities having concurrent jurisdiction so that all danger of conflict may be avoided. The negotiations, however, involved in the purchase of sites for the erection of working-class dwellings under Part III. of the Housing of the Working Classes Act, are of such a delicate nature that we think the carrying on of consultations must be safeguarded in every possible way. Such consultations should we think, be of an entirely private and confidential character, and it is our desire and intention to arrange consultations of this kind whenever it is possible to do so. In fact, we may mention that a consultation of this character has already taken place in at least one case with mutual advantage. The second part of resolution (i.) as to the apportionment of the cost of building schemes between borough councils and the County Council, however, is of quite a different character. We are advised that there is no legal provision for any such apportionment as is suggested. Moreover, were we to say that we agreed with its object, we should be committed to the approval of an alteration in the Council's standing orders of doubtful expediency. All dwellings erected by the Council in the independent exercise of the powers of Part III. of the Act are only sanctioned on a self-supporting basis, and we are strongly of opinion that this principle should be maintained. The proposal in resolution (i.) (6) from the County Council's point of view therefore does not appear to be necessary, and we cannot recommend the Council to pledge itself to assist borough councils in building schemes which would involve a contribution from the rates. With regard to resolution (ii.) we are in communication with the several metropolitan borough councils, and propose to report further when we shall have received their views. Resolution (iii.) is one which raises a question of considerable executive importance, and would involve an amendment of the London Building Acts. Before expressing any definite opinion upon it we propose to have detailed reports from the Council's officers on the subject. Resolution (iv.) merely provides for the continuance of the sitting of the conference. We are of opinion that a further conference of this kind will do good, and we therefore propose to summon the conference at a later date. We will report as to this after the summer recess. 69 Houses let in lodgings. The history of the year in respect of the administration of by-laws under section 94 of the Public Health (London) Act for houses let in lodgings, shows, on the whole, some improvement. In some districts new by-laws have been made and confirmed, the by-laws in two instances placing the duty of annual cleansing on the owner, i.e., the person receiving the rack rent instead of the person who actually lets the several rooms of the house to the lodgers. This, it may be presumed, will provide a remedy for the difficulty which it is said has been found in some districts, due to the inability of the person actually letting the lodgings to bear the expense such measures entail. In some districts, moreover, the work of inspection of houses let in lodgings has been made to devolve upon one or more special inspectors, an arrangement without which this duty is more likely to be neglected than when its importance is thus recognised and definite provision is made for it to be carried out. The information on this subject supplied by the reports of medical officers of health is to the following effect— Paddington.—The enforcement of the by-laws was almost entirely in abeyance during the year. No houses were added to the register, but those houses already registered were inspected, and the annual white-washing enforced as far as possible. Kensington.—Dr. Dudfield's report contains a list of streets in which are situated 1,703 registered houses. It was proposed to register an additional 377 houses, but the question was postponed until the Local Government Board had confirmed the proposed new by-laws. The need for better control of overcrowding and of maintenance of the bedding and furniture of furnished rooms free from noxious insects is referred to, and Dr. Dudfield states that the late vestry applied to the Local Government Board to sanction the following by-laws— "If any lodger in a registered house cause or suffer any room under his control to be occupied by a greater number of persons than is allowed by this by-law, it shall be the duty of the keeper of the registered house, upon his becoming aware of the fact, to notify such fact to the medical officer." " The landlord or keeper of a registered house in which rooms are let in furnished lodgings shall cause the bedding and other articles in such rooms to be at all times maintained in a clean and wholesome condition and free from noxious insects." The final views of the Local Government Board had not yet been received. During the year two inspectors were (successively) employed in measuring rooms in the registered houses, and 1,768 houses were visited for this purpose. As to the advantages of registration, Dr. Dudfield writes, "Whilst facilitating the work of the public health department, registration of houses let in lodgings has given rise to none of the evils feared by the owners and occupiers of houses proposed to be registered; and practically there has been little objection by any of the parties affected by them. The extension of the operation of by-laws to all tenemented houses, and other houses occupied in lodgings by the poorer classes, would be an unmixed benefit from the public health point of view, by enabling the sanitary authority to maintain the conditions necessary to secure healthy houses for the people who, in regard to such matters, have little power to help themselves." Hammersmith.—Directions were given for the registration of 373 houses during the year, making a total of 1,030 premises on the register. Owing to more pressing work it was not found possible to regularly inspect the houses, but a special inspector has now been appointed for this duty. Fulham.—In consequence of difficulties experienced in connection with the definition of the term "landlord" in the existing by-laws, new by-laws were framed by the late vestry and submitted to the Local Government Board who, after certain amendments, intimated that they were prepared to sanction them. The public health committee recommended the Borough Council to adopt the amended by-laws and to apply to the Local Government Board for their confirmation, but the Council refused. "In the existing by-laws the 'landlord' is the person by whom the house is let in lodgings, and, as such, is responsible for the necessary repairs and annual cleansing of the premises, but it has been found that very frequently he was but a weekly tenant, and was not in such a financial position as to be able to comply with the requirements of the council. In the proposed by-laws as approved by the public health committee and the Local Government Board these duties were imposed upon the 'owner,' i.e., the person in receipt of the rack rent of the premises." Westminsler.—" Forty houses were placed on the register, making a total of 1,678 so registered. Some of these require visiting only once a year, while others, need to be visited every week, or oftener, on account of the dirty habits of the tenants. These visits are productive of much good, and an improved standard of cleanliness is being attained." Proceedings were instituted in nine instances. In view of the fact that the by-laws governing all parts of the city are not the same, new by-laws have been adopted, to which the Local Government Board had not as yet given their consent. St. Marylebone.—There were 972 inspections of registered houses in 1901. Hampstead.—There are 908 houses registered, of which 200 were cleansed, and in 8 overcrowding was abated. St. Pancras.—The number of houses measured and registered in 1901 was 832. At the end cf the year there were 1,006 houses registered, at all of which inspections were made, and 1.673 re-inspections after the service of notices. Islington.—The number of houses on the register at the end of 1901 was 453, and the number at the end of 1900 was 459. There were 2,006 inspections of houses on the register and 6,635 subsequent calls to watch the progress of works ordered for the abatement of nuisances. The total number of improvements effected was 1,723. The medical officer of health comments on the want of progress in registering houses; he states that "one reason is that neither the " council nor the late vestry have made it a habit to place houses on the register simply because 70 "they were found to be overcrowded, but only when the owner was negligent as to their sanitary state. In fact, registration has been held in terrorem over negligent property-owners. The "overcrowding. ding, when met with, has been usually dealt with by formal notice, although latterly "it has not been so urgent as formerly, owing to the fact that property-owners, in Islington, "at all events, will not let their tenements to persons who have several, and in some cases, any, "children. This was the great cause of the small increase in population between 1891 and 1900." Stoke Newington.—By the end of the year 219 houses were on the register. Holborn.—The number of houses on the register was 596. All were inspected from time to time and the regulations enforced. Finsbury.—When the borough was formed the number of houses on the register was 333. New by-laws were framed and confirmed by the Local Government Board in November, 1901. During the first three months of 1902, 92 houses were registered. "There can be little doubt that the sanitation of the borough will be greatly advanced by placing upon the register under these by-laws a large number of tenement houses." City of London.—The number of houses on the register was 403; they comprised 1,283 tenements, and contained 3,056 lodgers. "The houses in question are frequently inspected, and in April of each year their owners called upon to undertake a thorough cleansing of them." The number of notices served was 673. Shoreditch.—The number of houses registered in the year was 28, making a total of 184 on the register. Bethnal-green.—Dr. Bate states that the Borough Council had appointed a special inspector, and set him to work to inspect a number of houses let out in tenements with a view of registering them. Referring to the decision in the case of Weatheritt v. Cantley, he writes, "Almost at once our right to demand the particulars necessary for registration was challenged. The legal point was referred to the Town Clerk; his report was carefully considered by the Public Health Committee, and it was decided that it would be futile to attempt to enforce registration in the present state of the law as to the definition of a house." He adds, "There are not more than 20 houses (within the meaning of the judge's definition of a house) let out in lodgings, in the borough, to which the regulations could be made to apply, and these particular premises: are not by any means the worst of their kind." It was felt that the special inspector's appointment was, at any rate for the present, superfluous. Stepney.—There are two inspectors appointed to register and enforce the by-laws for houses let iu lodgings. Poplar.—In October an inspector was appointed for 12 months to measure up the rooms of houses on the register and to enter such measurements in the new register. The number of bouses placed on the register was 120. In 20 overcrowding was abated. Southwark.—For the supervision of houses let in lodgings the borough was divided into three districts. Three women inspectors were appointed, inter alia, for obtaining information for registration and inspection of houses let iu lodgings. At the beginning of the year there were 702 houses on the register, and 170 additional houses were registered during 1901. Bermondsey.—The number of houses on the register was 289, to which must be added Wolseley and Javen's buildings. They have been systematically inspected. More houses would have been registered but the sanction of the Local Government Board to new by-laws was awaited. This was received in December, 1901. Lambeth.—At the end of 1901 there were 371 registered houses, containing 2,117 rooms and 3,644 persons, of whom 2,294 were over 10 years of age. Dr. Priestley refers to difficulty arising from the definition of the term "landlord," who, not being the owner, often has no money to expend on annual cleansing. Battersea.—The number of houses on the register is 49. These are regularly inspected, and the by-laws strictly enforced. Dr. McCleary writes: "Some time has elapsed since the last houses were registered, but the health' committee have lately decided to place upon the register such houses as appear to stand in need of a proper administration of the by-laws. This decision will, I am convinced, prove of much benefit to the borough. There is a very large number of houses in Battersea which come within the definition of 'houses let in lodgings,' but in the case of many, perhaps most, of them, nothing would be gained, for obvious reasons, by placing them on the register. But there are many houses, particularly in the north-western sub-district, where a judicious administration of the by-laws would be productive of much good in promoting cleanliness and preventing overcrowding." Wandsworth.—The number of houses on the register at the end of the year was 67. They are frequently inspected, and the statutory cleansing has in every case been carried out at the proper time. As necessity arises, other premises will be placed on the register. Camberwell.—Dr. Stevens reports that the Local Government Board has assented to the responsibility for the annual cleansing, etc., being imposed "on the superior landlord instead of the man who holds the house on a weekly tenancy." He states, "The change is most beneficial, and coupled with the raising of the rent limit, should do much to render these by-laws more workable, and to bring a larger number of houses under their scope." Deptford.—The medical officer of health states that "houses let in lodgings or occupied by members of more than one family, under the provisions of the Public Health (London) Act, 1891, have received constant supervision, thereby avoiding overcrowding, and ensuring cleanliness and proper ventilation." Lewisham.—The annual report contains a list of 24 houses registered, to which periodical visits have been made. Woolwich.—At the beginning of the year there were 88 houses on the register. Dr. Davies recommended the registration of 49 additional houses, of which 17 were registered. He st ates, "These houses were regularly inspected every three or six months, according to the 71 conditions found to exist in each case. . . . Every tenant was supplied with a card giving an abstract of the by-laws, the dimensions of the rooms occupied, and the number of persons allowed to occupy them. The result of being under definite regulations as to cleansing and overcrowding, together with frequent inspection, has undoubtedly led to these houses being kept clean and free from overcrowding to a far greater extent than was possible without the by-laws." Proceedings were instituted in respect of four houses, and fines inflicted of from 5s. to 40s. in each case. Common Lodging Houses. The duty of administering the Common Lodging Houses Acts devolved upon the Council in November, 1894. The following table shows the number of houses on the register, the authorised number of lodgers, the number of convictions, penalties, and notices in each year since 1894— Year. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties. No. of notices. No. of deaths. Cases of infectious disease. £ s. d. 1895 626 29,574 — — 16 12 37 6 — — 51 99 1896 596 29,140 28,331 — 31 30 112 16 — 334 65 71 1897 581 28,718 26,121 — 31 30 92 11 — 261 59 48 1898 560 28,332 27,658 — 29 29 167 3 — 264 S7 44 1899 544 28,448 28,229 1,162 25 22 183 9 — 238 96 54 1900 528 28,311 28,428 668 16 13 102 15 — 240 91 40 1901 514 *28,037½ 35,225 2,133 16 15 96 3 — 241 102 166 In the year 1901, proceedings before the magistrate were instituted in 16 cases, resulting in 15 convictions, fines being inflicted amounting to £86 and £10 3s. costs. The remaining summons was dismissed. The number of cases of infectious disease reported in common lodging-houses was as follows—Smallpox, 135; erysipelas, 17; diphtheria, 6; enteric fever, 5; scarlet fever, 2; measles, 1; Total, 166. In addition to the number of inspections mentioned in the table, there were 4,241 day visits and 55 night visits to unregistered houses, including 3,185 visits to seamen's lodginghouses. The number of new houses placed on the register in 1901 was 9. The following table shows the number of common lodging-houses, the authorised number of lodgers in such houses at the end of 1901, and the number of houses registered in each district during the year. Common lodging-houses. Sanitary district. Total number of houses. Authorised number of lodgers. Number of houses registered during the year 1901. Battersea 7 255 1 Bermondsey 5 789 — Bethnal-green 16 506 1 Camberwell 9 609 — Chelsea 10 522 —__ Deptford 10 552 — Finsbury 9 546 — Fulham 1 51 — Greenwich 6 202 — Hackney 9 431 — Hammersmith 9 550 — Hampstead 1 35 — Holborn 43 2,408 1 Islington 44 1,360 1 Kensington 33 1,019 — Lambeth 10 696 1 Lewisham 1 30 — Marylebone 19 904 — Paddington 9 304 — Poplar 13 948 — St. Pancras 16 1,020 1 Shoreditch 14 779 — Southwark 54 3,588 — Stepney 92 6,744 3 Stoke Newington 1 37 — Wandsworth 10 231 — Westminster 29 2,096 — Woolwich 34 825½* — Total 514 28,0371½* 9 * ½ = 1 child. 72 A marked improvement in the standard of cleanliness maintained in common lodginghouses in London is observable. Much attention has been devoted by the Council's officers to the maintenance of these houses in a condition free from noxious insects; particularly may be mentioned the use of the plumber's blow-pipe, the flame of which is able to penetrate the interstices of iron bedsteads and of woodwork. Seamen's Lodging-houses. During the year, 3,185 visits were made by the Council's inspectors to seamen's lodginghouses. The new by-laws made by the Council under the Merchant Shipping Act, 1894, came into force on the 1st Octobcr. A circular letter enclosing a copy of the by-laws was sent to the keeper3 of all the known seamen's lodging-houses on the 23rd October. Customs and Inland Revenue Acts, 1890 and 1891. Several of the annual reports of the medical officers of health show the number of applications for certificates of exemption from inhabited house duty, and also the number which were granted. In Fulham, applications were made in respect of 458 houses, of which 190 were refused, and the others received certificates, some only on completion of certain specified works. In Westminster 295 certificates were granted and 90 were refused. In Hackney, 5 certificates were granted. In Shoreditch, 62 applications were received in respect of tenements, 12 of which belonged to the Borough Council; they all received certificates. In Bethnal-green the medical officer of health refused all the applications, as in some cases the buildings did not comply with the requirements of the Act, in others the sanitary condition was unsatisfactory. In Lambeth, 360 applications were received, of these 12 were refused, 329 were given certificates unconditionally and 19 conditionally on certain sanitary works being carried out. In Battersea the medical officer of health inspected 64 houses before granting certificates and refused 32 of the applications owing to the existence of sanitary defects. In Wandsworth, 5 certificates were granted. In Greenwich, 1 application was received, but as the sanitary condition did not appear satisfactory the certificate was refused. Underground Rooms. The annual reports relating to the following districts show that underground rooms (illegally occupied) were dealt with— Paddington, 38; Chelsea, 8; Westminster, 25 were vacated during the year and 21 were "to be dealt with as circumstances arise;" St. Marylebone, 470 inspections were made; Hampstead, 2; St. Pancras, 36; Islington, 57; Holborn, 27; Finsbury, 42; Bethnal-green, 3; Stepney, 86 ; Lambeth, 79; Battersea, 15; Greenwich, 1; Woolwich, 3. Workshops and Workplaces. In 1901 the law relating to factories and workshops was consolidated and amended. Under the previous law the occupier of every factory and workshop was required to keep lists showing the names and addresses of out-workers employed by him (with the place of employment) in such classes of work as may be specified by Special Order of the Secretary of State, in addition he is now required, on or before the 1st of February and the 1st of August of each year to send a copy of the list to the district council in which the factory or workshop is situated (in London to the Court of Common Council or the Metropolitan Borough Council). Each district council is to furnish the name and address of every out-worker included in the list, whose place of employment is outside their district, to the council of the district in which it is situated. The district council may prohibit the giving out of work relating to clothes to any persons living in a house in which there is infectious disease. The district council may also prohibit the giving out of certain classes of work, specified by Order, to be done in a place which is dangerous and injurious to the health of the persons employed in it, the prohibition coming into force a month after notice has been served. The district council is required to keep a register of workshops. A card must be exhibited showing the number of persons who may occupy a workroom. All rooms in factories and workshops must be provided with means of ventilation and sufficient ventilation must be maintained, and the Secretary of State may prescribe a standard of ventilation in any class of factories or workshops. Means must be taken to secure a reasonable temperature, which must not interfere with the purity of the air. Where any process is carried on which renders the floors liable to be wet adequate means must be provided for draining the floor so far as practicable. Certain exceptions to these requirements are made in the case of domestic workshops. With respect to underground bakehouses the new law prohibits the continued existence of an underground bakehouse after the 1st January, 1904, unless it is certified by the district council to be suitable as regards construction, light, ventilation, and in all other respects. An underground bakehouse is defined as any baking room which is so situate that the surface of the floor is more than 3 feet below the surface of the footway of the adjoining street or of the ground adjoining or nearest to the room. Medical officers of health are required in their annual reports to their authorities to report specifically upon the administration of the Factory Act in workshops and workplaces, and to send a copy of the report to the Secretary of State. The annual reports of medical officers of health generally show that the supervision of workshops and workplaces is being performed in a more systematic way, and that in a number 73 of districts special inspectors are employed in this duty. Where this is done there is evidence of better administration than where the inspection of workshops only forms one of numerous other duties of the inspector. The appointment of female inspectors for the inspection of places where women are employed is increasing, and where such appointments have been made a considerable amount of work is being done in connection with such premises. The annual report for 1900 contained reference to a decision of Mr. Justice Grantham and Mr. Justice Channel that a stable-yard is a "workplace." In a memorandum on the Factory and Workshop Act of 1901, issued by the Home Office, reference is made to this case, and it is stated that the Secretary of State has been advised that the kitchens of restaurants, etc., though they are not workshops, come within the meaning of the term "workplace." In several annual reports it is stated that such places have been inspected. The following information as to the action taken under the Factory and Workshop Act in the following districts is supplied by the annual reports of medical officers of health— Paddington.—The number of workshops inspected was 456, and 158 workrooms were measured. In view of the passing of the Factory and Workshop Act, 1901, special recommendations as to the increase of the staff were submitted by the Public Health Committee to the Borough Council, and adopted by them. Kensington.—A list of outworkers was compiled, and the names and addresses of all working within the borough, but not residing therein, was forwarded to the medical officers of health of the districts in which they resided. Corresponding information was received from other medical officers of health. The duties of occupiers of workshops as to outworkers were advertised, and with a print of the "'Home Work Order" sent to upwards of 1,000 persons. At the beginning of the year there were 818 workshops, etc., in which women were employed on the register. During the year 167 premises were added and 9 removed. Among the workplaces registered were kitchens of restaurants and dining-rooms, typewriting offices, etc. At the end of January, 1902, 1,013 premises were on the register. The rooms which were measured in the 167 premises newly registered in 1901 numbered 297. The kitchens of workmen's dining-rooms and coffee-houses were as a rule found to be cleaner and better kept than those of higher class restaurants. At a number of restaurants, chiefly those kept by foreigners, no lavatory accommodation for customers had been provided. Overcrowding was found in 62 rooms; dirty or defective water-closets in 118 instances; defective staircases were repaired in several instances; rooms insufficiently warmed, or in such a manner, by open gas jets, as to impair the purity of the air were found in 91 dressmaking workrooms, and other rooms were found without the means of warming; ventilation was found to be defective in a number of rooms, and in others gas iron-heaters were without ventilation. The female inspector states, "It is "unfortunately the case that the local authority has now no power to enforce the law regarding 'reasonable temperature' of a workroom, this being tne duty of the factory inspector, the ventilation merely being under the control of the local authority." Hammersmith.—During the year 236 notices were served and 235 notices were complied with. During the previous year 148 notices were served and as many complied with. The increase is due to the fact that a special inspector was appointed for this duty. Westminster.—The addresses of outworkers living in other districts were communicated to the several medical officers of health. At the end of 1901 there were 1,183 outworkers on the register. These were engaged in making various kinds of wearing apparel. It had not been found possible to make any systematic inspection of their houses, but in 1902 the Act requires this to be done. At the end of 1901 a copy of the register of workshops kept at the Home Office was made, which, together with those already on the list of the borough council, amounted to 2,065 workshops, and to this list many more were added. A register showing particulars of the various workshops was prepared; 643 were occupied by tailors, 522 by dressmakers, 251 by milliners. Particular attention has been given to workplaces generally, and especially those in which wearing apparel was made. In many of the tailors' and dressmakers' workrooms gas stoves for heating irons are used, and the fumes pass into the room. Instructions have been given to the inspectors to secure efficient means of ventilation for such stoves. During the year inquiry was made by the Home Office as to the nature and the extent of, and conditions of women's employment in West London. One inspector made 344 visits to dressmakers' and milliners' premises in Westminster, and conditions of overcrowding, defective ventilation and heating, dirtiness of workshops were found and remedied, but regular supervision is required. In 206 instances notice of defects was sent to the sanitary authority. The absence of separate water-closet accommodation for women occurred mostly in tenement houses used by different occupiers. This can often be remedied, but in some cases persons had to vacate the premises. The number of workshops inspected by the officers of the borough council was 1,115, and in these any sanitary defects found were remedied; 199 workrooms were measured and cards issued showing the amount of cubic space and number of persons allowable. St. Marylebone.—There are 129 registered workrooms which are exclusively occupied by men. The principal trades are tailoring and outfitting. These workrooms have been measured and certain drainage works carried out. The number of visits to such workshops and workrooms was 156. There were on the register at the end of the year, 1,874 workshops and laundries in which women and girls are employed, 556 having been added during the year. They were registered to accommodate about 15,000 workers. These are employed in 914 businesses, of which 40 are laundries and the rest principally millinery and tailoring businesses. To these premises the female inspector made 379 first visits and 1,895 visits of re-inspection, as well as 635 calls on miscellaneous business, leaving workroom cards, making inquiries, etc. A separate register of outworkers is kept, of these there are 255. Their premises have been duly inspected. The addresses of 159 women employed by persons in the borough but resident elsewhere have been [10] 74 sent to the other borough councils, but information of only 30 women living in St. Marylebone has been received from other borough councils. Cleansing of walls and ceilings, additional water-closet accommodation, improvements in ventilation, in drainage and in respect of overcrowding have been effected. Hampstead.—There were 251 workshops on the register, all of which were periodically inspected, and in 40 instances notices served and complied with. St. Pancras.—There were 250 factories on the register. Several were inspected, some upon complaint and for drainage works, and notices served where necessary. There were 484 workshops on the register (a small part only of the workshops and workplaces in the borough). Several were inspected and found satisfactory, others were inspected as to drainage or as to other matters on complaint, and notices served where necessary. Islington.—Two inspectors, male and female, to specially inspect factories and workshops had been appointed in 1895. In 1901 there were 1,612 workshops, etc., on the register, of which 382, containing 490 rooms, were used for dressmaking, etc., and 513, containing 513 rooms, were used as laundries. During the year, 7,371 visits were made by the two inspectors, 387 dirty premises were cleansed. In 14 instances the workrooms (all occupied by women) were found overcrowded. In 51 cases the ventilation was defective. The provisions as to outworkers are being actively enforced, and 69 additional water-closets had to be provided and 717 other defects remedied. Restaurants to the number of 25 were also inspected. The addresses of outworkers were sent to and received from other borough councils. Stoke Newington.—The report contains an abstract of the new provisions in the Factory and Workshop Act. Hackney.—The workshops registered during the year were 99, of which 9 were workshops where men were employed and 90 where women were employed. The total number of workshops on the register was 1,727, and is increasing every year. " If these are to be inspected once or more during the year an increase in the inspectorial staff will be necessary if other important work has not to be neglected." Of the 99 premises registered in 1901, 28 were on notice from H.M. inspector. Of these workshops, 6 were found overcrowded, 5 with improper water-closet accommodation, 2 with no separate conveniences for the two sexes, and 46 had other nuisances. Any nuisances found were abated. The female inspector paid 139 first visits and 1,833 visits of re-inspection to workshops. She states, "I am sure that a careful examination of the borough would reveal the fact that there are many other occupiers of workshops who up to the present have evaded inspection of their premises. But at present, owing to the press of other work, it is almost impossible for me to undertake such an investigation. I cannot feel, however, that the work of inspection of the district is thoroughly done until I have been able to devote some time to this purpose." In 1901, 465 outworkers were registered as against 1,630 in 1900. The female inspector made 262 visits of inspection of outworkers' premises. The number of intimation notices served was 253, and of statutory notices 19. In 3 instances summonses were taken out. Holborn.—The number of workshops inspected was 551, the number of notices served was 82; 53 dirty and 4 overcrowded workshops, together with 12 instances of insufficiency of waterclosets, among other faulty conditions, were dealt with; 67 kitchens of restaurants were inspected, and 17 notices served; among these were found 9 dirty kitchens, one insufficient water-closet, and one kitchen used for sleeping. Finsbury.—The number of premises registered at the end of 1901 was 1,356. The number of inspections made was 200, and 80 defects were remedied. Workshops notified by H.M. inspector of factories were inspected and measured up. In 70 workshops insufficient water-closet accommodation was found. In 1901 there was considerable increase in the amount of attention paid to the sanitation of workplaces, and in 1902 it has been found possible to set apart an inspector for this work. City of London.—Registers of workshops have been prepared. The appointment of a female sanitary inspector was sanctioned. In September a systematic inspection of workshops and workplaces was begun, and 745 workrooms were measured up. In 73 instances works of cleansing were required, and numerous structural works ordered. The report contains particulars of factories and workshops reported by H.M. inspector and the action taken. Account is given of a case of want of separate provision of water-closet accommodation for women ; an arrangement by which the owner paid for the use of a public lavatory was accepted with the approval of the Home Office. In two instances the requirement of separate water-closet accommodation led to female employees being dismissed. Shoreditch.—The number of intimations from the factory inspector respecting the establishment of workshops was 38; of these, 24 were found in a satisfactory condition and in the others the attention of the sanitary officers was required. In addition, 94 intimations were received from the factory inspector of faulty conditions, and these were dealt with. In addition to these numbers of other workshops, factories and workplaces received attention during the year. Bethnal-green.—The report contains a summary of the law relating to factories and workshops. The chief inspector reports that for the first time it has been possible to deal with outworkers; 89 factories were visited and lists of outworkers obtained and registered; 24 outworkers' houses were inspected and the necessary notices served. Stepney.—The numbers of workshops inspected and nuisances abated were respectively 767 and 434. Poplar.—In Poplar the report of the female inspector shows that the number of workshops, etc., on the register was 343, containing 665 workrooms, in connection with which there were 935 inspections and 569 re-inspections. The number of workrooms measured was 67 and 139 written instructions and 66 statutory notices were served. In 11 instances workrooms were 75 found overcrowded, And in 8 cases additional water-closet accommodation was required to be provided. In 4 cases the employers discharged their female employees in preference to making the necessary alterations; 135 rooms were cleansed, the ventilation of 4 rooms was improved and various nuisances were abated. Southwark.—During the year there were 299 inspections and 188 re-inspections of workshops. Lambeth.—When Lambeth became a metropolitan borough there were on the register 721 workshops containing 1,258 workrooms. During 1901, 69 additional workshops containing 133 workrooms were registered. The Borough Council received 32 notices of occupation of workshops from H.M. factory inspector and 17 notices of contravention of the provisions of the Public Health Act. The nuisances were abated. In 4 of the 69 workshops the ventilation was unsatisfactory, in 16 the workrooms were dirty, in 15 the drains were defective, in 17 the sanitary fittings and appliances were bad, and in 4 cases separate water-closets for the two sexes were wanting. In two of the 133 workrooms there was overcrowding. In one of these, 17 women were employed in a space only sufficient for 8. In October, 1901, a female sanitary inspector was employed. Battersea.—The number of workshops registered in 1901 was 48, making a total of 457. Statutory notices to provide additional water-closets were served in 30 instances, and 10 notices to remedy other defects. In 6 instances complaints from H.M. inspector were received and attended to. In January, 1902, the Borough Council decided to appoint a male and a female inspector of workshops. Wandsworth.—The number of workshops inspected was 497 and the number re-inspected 134. The number of workrooms inspected was 1,055. The newly-registered workshops numbered 28, and in 3 of these the workrooms were measured. One workroom was found to be overcrowded and 30 were dirty. Various defects were remedied and 58 notices served. During the last six months of the year the kitchens of all eating-houses and coffee-shops were inspected and with few exceptions were found in a clean condition. Camberwell.—A female sanitary inspector was appointed early in 1901. The time spent in preparing a register of workshops has rendered the inspections less numerous than they otherwise would have been. This inspector made 1,175 inspections and re-inspections and 16 complaints were dealt with, 120 intimation notices were served and 2 statutory notices. Cleansing was effected in 130 instances and water-closets were improved in 56 instances. In 3 cases the watercloset accommodation was insufficient; the ventilation was defective in 7 instances and there was slight overcrowding in 18 and decided overcrowding in 8 instances. Other defects were also dealt with. Deptford.—The report states that workshops have received constant supervision. Greemwich.—There were 85 inspections of workshops, but the matter has not been dealt with in any thorough and systematic manner, as up to the present a complete register of these premises has not been kept. Steps are being now taken to complete a register when periodical and systematic inspection will be carried out. Lewisham.—The report contains a table showing the nature of the work carried out in the 290 workshops on the register. Woolwich.—Owing to there being no special workshop inspector and to the ordinary inspector's time being fully occupied, it was not found possible to inspect factories and workshops as much as is desirable. A considerable amount of work was, however, done. Five large factories were inspected as to the provision of sanitary conveniences. These were completely reconstructed in one and improved in another. The medical officer inspected 15 of the larger workshops and found overcrowding in 3, improper or insufficient water-closet accommodation in 8, and dirty conditions in 6. The sanitary inspectors inspected 27 workshops, in 4 of which there was defective ventilation and in 18 overcrowding. The defects were remedied. The kitchens of 13 restaurants and hotels were inspected ; dirty conditions were found in 13 instances and the necessary steps taken. The names and addresses of 99 outworkers were obtained and their homes visited. Nuisances were found in 24 houses and were abated. Bakehouses. In the reports of medical officers of health account is given of the number of bakehouses, and, in some of the reports, the number which are underground is stated. In Paddington there were 63 bakehouses. In Kensington there were 114; all of which were periodically inspected. In Hammersmith, 64, of which 43 were underground; notices were served in respect of 15 which were not in a sanitary condition. In Fulham the bakehouses were regularly inspected and proceedings instituted in one case. In Chelsea there were 47 bakehouses, of which 40 were below ground; in Westminster there were 129,9 of which were closed, 5 for street improvements and 4 which were underground and were not in occupation at the time of the passing of the Act of 1895. In St. Marylebone there were 92 bakehouses in regular use and 10 houses in which baking is only done occasionally; these received 291 visits from the inspector. In St. Pancras there were 182 bakehouses and 3 which are non-textile factories, motive power being employed in the process of manufacture; they were regularly inspected twice in the year, a second visit being necessary in most cases; 38 notices were served; a diagram in the report shows that all but some 40 are underground bakehouses. In Hampstead there were 37 bakehouses. In Islington there were 233 bakehouses of which 165 were underground; the inspector made 505 visits to them, and various defects were remedied. In Hackney there were 119 bakehouses; 32 notices were served. In Holborn there were 40 bakehouses, all but 4 of which were underground; all were inspected and notices served where necessary. In Finsbury there were 78 bakehouses, of which 46 were underground; about a dozen notices were served. In the City there were 41 bakehouses, 34 of which were 76 underground; the medical officer of health writes, "Additions may have to be made to the list, as the new Act includes the manufacture of biscuits, confectionery, etc., as well as bread"; the bakehouses were regularly inspected. In Shoreditch the bakehouses numbered 86, of which 53 were underground, 16 required attention. In Bethnal-green 103 bakehouses were periodically inspected. In Stepney 314 bakehouses were inspected and 176 cleansed. In Poplar 113 premises were used as bakehouses, notices were served where necessary. The number of bakehouses in Southwark was 126, and towards the end of the year the medical officer of health made a special report on every bakehouse in the borough, showing the position and condition of the premises; in 64 instances defects required to be remedied. In Bermondsey there were 110 bakehouses, of which 46 were underground; all were inspected twice. In Lambeth there were 222 bakehouses, of which 84 were underground; the necessary periodical cleansing was carried out. In Battersea the bakehouses numbered 94, and of these there were 57 wholly or partially underground; in 21 instances notices were served. The medical officer of health of Wandsworth gives in his report, in tabular form, the number of bakehouses in the district; these numbered 153; those above ground 97, underground 48, semi-basement 8; the report states that there are several where it will be difficult to grant certificates unless alterations are carried out; all these bakehouses were inspected and the necessarv cleansing carried out. In Camberwell there were 395 inspections of bakehouses. In Deptford there were 145 bakehouse inspections; action was taken where necessary. In Greenwich there were 76 bakehouses, of which 29 were underground; 221 visits of inspection were made and various improvements effected. In Woolwich the bakehouses numbered 73, of which 35 were underground. They were inspected twice, 13 were unsatisfactory as regards cleanliness, and several defective as to ventilation and light; cleansing was effected in all cases, but in view of the probable closing of some bakehouses, improvements involving much expense were not insisted on. In Lewisham 89 bakehouses were visited. Unsound Food. The report of Dr. Collingridge shows that the general supply of meat to the Corporation Markets, Smithfield, was in 1901 equal to 415,510 tons, and that the amount seized was 1,271 tons. In streets situated on the borders of the City and included in the Metropolitan Borough of Finsbuiy since the passing of the London Government Act a considerable meat trade is carried on and a special meat inspector is employed; in this district the amount of meat seized is much greater than in other districts, except the City. The report of Dr. Newman shows that 7,282 lbs. of diseased meat and 60,533 lbs. of decomposed meat was seized during the year. In Islington a special meat inspector was employed during the first six months of the year, but on his being subsequently appointed an inspector in the Deptford Cattle Market much difficulty was experienced in finding a competent officer to succeed him, and the inspections of the Islington slaughterhouses devolved upon the district inspectors. Later, a special inspector was appointed. The medical officer reports that during the third and fourth quarters of the year no serious work of meat inspection was undertaken. The total weight of food condemned was 3 tons 7 cwt. 3 qrs. and 4 lbs., the whole or part of 243 carcases having been destroyed in the first six months of the year. Seizures of meat are also recorded in the annual reports relating to Paddington, Hammersmith, Westminster, St. Pancras, Hackney, Shoreditch, Bethnal-green., Stepney, Poplar, Southwark, Lambeth, Battersea, Greenwich and Woolwich. Seizures of other articles of food are recorded in the reports relating to a number of districts. These include seizures of fish, poultry, rabbits, tinned food, fruit, vegetables, eggs, and sweetmeats. In the City 252 cartloads of unsound vegetables, fruit, tinned food, etc., were surrendered. Large quantities of frozen rabbits were seized on the wharves and in the central markets, and 888 tons of fish were condemned in Billingsgate Market. The reports as to other districts show that fowls and rabbits were seized in Holborn; fish in Paddington; fruit in Chelsea; fish, caviare, rabbits and fruit in Westminster; fruit, vegetables, rabbits and fish in St. Pancras; fish, fruit, vegetables, and tinned food in Hackney; fruit and fowls in Finsbury; fish, fruit, vegetables, rabbits and fowls in Shoreditch; fruit, eggs and fish in Bethnal-green; fish rabbits, vegetables, fruit and tinned food in Stepney; eels, rabbits, fruit and eggs in Southwark, one large seizure of 2,441 frozen rabbits having been made on the wharf; in Bermondsey tinned food and fruit, etc., were seized; in Lambeth fruit pulp; in Battersea mussels and fruit; in Wandsworth fish, vegetables and fruit were surrendered; in Deptford fish, eggs and lemons were seized; in Greenwich fish and toffy apples, and in Woolwich fowls, rabbits, and fruit. In several reports mention is made of prosecutions of persons selling unsound food. In the City there were nine convictions, and penalties to the amount of £195 were recovered, one person being sentenced to two months' imprisonment with hard labour. In Paddington there was 1 conviction; in St. Pancras 11; in Hackney 2; in Finsbury 27 prosecutions, in 2 cases the vendors being sentenced to six months' imprisonment; in Bethnal-green there were 11 convictions; in Stepney 15; in Southwark 3; in Lambeth 1; in Battersea 7; and in Woolwich 3. In Westminster a merchant in Russian produce was sentenced to two months' imprisonment for using the contents of two casks of caviare which had been returned to him as bad for placing at the bottom of tins which were subsequently filled up with good caviare. Twenty-five gross of tins which had been sent to South Africa were recovered and destroyed, the contents of the whole of them being in a putrid condition. A series of occurrences of poisoning from the eating of cheese was observed during the year, of which account is given in the annual reports of the medical officers of health of the City, Finsbury and Poplar. On the 21st October Dr. Newman, the medical officer of health of Finsbury, was informed by Dr. Bate, the medical officer of health of Bethnal-green, that certain cases of illness had occurred in Bethnal-green which were supposed to be due to the eating of Dutch cheese obtained from a local vendor who had been supplied by a wholesale firm in Finsbury. 77 Dr. Newman himself ate an ounce or two of the cheese, and four or five hours afterwards suffered acutely from symptoms similar to those from which other people had suffered. The next day he informed the head of the Finsbury firm of what had occurred and he in turn ate some of the cheese and suffered in a like way. This firm had received the cheese from a large wholesale firm in the City. On the 28th October four cases of poisoning in Finsbury, attributed to the same cheese, were reported to Dr. Newman. Thirteen cases also occurred in Bermondsey, with eight later cases in the same district, the cheese having been obtained from a firm in the City. Four cases also occurred in Deptford. The symptoms were epigastric pain, rigors, vomiting, diarrhoea, prostration and some fever. No death appears to have occurred, and in general the symptoms passed off in the course of 48 hours. The shipper was traced and also the maker of the cheese in Holland, who came to London to give to and obtain from Dr. Collingridge any information possible. Of four samples of the cheese forwarded by Dr. Newman to the publio analyst of Finsbury (Mr. Kear Colwell), in two samples tyro-toxicon was found to be present, but not uniformly distributed through the cheese. Samples of the cheese were also examined by Dr. Pakes, of Guy's Hospital, but no ptomaine was discovered. The cheese was also examined by Dr. Klein, and four mice, three white rats, two guinea-pigs and two rabbits were fed upon it and one rat and one mouse died. In the winter of 1887 a similar outbreak of illness among the staff and patients of a hospital in central London, and the evidence then pointed strongly to the consumption of butter as the cause. Similar outbreaks were at the time taking place in other parts of London and, indeed, of England. The symptoms noted were diarrhoea, in the majority abdominal pains, vomiting, cramps in the limbs, great depression and high temperature.* The occurrence of alleged poisoning in Camberwell from the eating of chocolate drops was investigated by Dr. Stevens, the medical officer of health, who came to the conclusion that it was impossible to say "that in any case there was clear proof that the sweets were the sole cause." Chemical analysis of the chocolate drops showed that there was 1.79 per cent. of mineral oil present. Poisoning by arsenic. In my last report it was stated that in November, 1900, a number of persons had been found in Manchester and some other places to be suffering from peripheral-neuritis due to the presence of arsenic in the beer they had consumed. Under the instructions of the Public Health Committtee the Council's chemist examined during the latter part of 1900 and during 1901 numerous samples of beer and other articles taken in all parts of London, many of the samples of beer being drawn from brewery taps. Altogether he examined 586 samples of beer and ale, 5 of hops, 25 of glucose and saccharine, 31 of jams and marmalade, 91 of sweetmeats, syrup and honey, and 22 of condensed milk; 760 samples in all. In only 2 was arsenic detected. These were samples of syrup. They were labelled alike and were purchased at the same shop, but on different dates. A large quantity of the syrup was taken and by careful manipulation the amount of arsenic present was found to be less than one part in five million parts. Disinfection. The medical officer of health of Kensington reports that the Borough Council of Kensington has resolved to provide a disinfecting station at the depot, Wood-lane, Shepherd's-bush, instead of as heretofore relying upon the services of a contractor. It was stated in the last annual report that the new disinfecting station in Fulham was completed; the medical officer of health states that the provision of a well-equipped laundry enables articles to be washed, which was not done when the work was carried out by a. contractor. The provision of a central disinfecting station for Westminster instead of those already in existence was under consideration, and the medical officer of health expresses the opinion that this should be situated in the south of the borough; the London County Council is required, under the Improvements Act of 1899, to provide a station in place of that in Denzell-street, required to be demolished for the purposes of the new street from Holborn to the Strand. The Lambeth Borough Council resolved to purchase a new disinfecting machine and to place it at the Wanless-road disinfecting station. The new disinfecting station which the sanitary authority of Battersea decided to provide was in course of erection in 1901 and was completed in March, 1902; the medical officer of health states that the station is well designed, but that the provision for chemical disinfection is not adequate and that steps are being taken to remedy this defect. In Wandsworth the medical officer of health reports, in the first six months of the year the disinfection by steam of the bedding, etc., from infected houses in the sub-districts of Putney and Clapham was done by a contractor, while that from houses in Wandsworth, Streatham and Tooting was done at the disinfecting station in Wandsworth; during the last six months the disinfection of infected articles from all parts of the borough was done at the Wandsworth station; the apparatus at this station has proved most efficient, but at no distant date additional accommodation and apparatus will have to be provided. In Camberwell the Borough Council resolved to. purchase a second disinfecting apparatus for use during the temporary disablement of the existing apparatus. The disinfection of infected articles from Paddington is still carried out by a contractor; the medical officer of health expresses the opinion that it might prove advantageous for the Council themselves to disinfect and to contract for the subsequent cleansing. In reference to the methods of disinfection of rooms which were adopted, it is reported that in Paddington spraying with formaldehyde solution has gradually replaced the use of * Transactions of the Society of Medical Officers of Health, session 1886-7, page 1.35. 78 sulphur; the medical officer says that apart from the greater efficiency of the former method it is on the whole cheaper and has the advantage of not keeping the occupants out of their houses. In Finsbury formalin gaseous disinfection has been employed followed by wet spraying of the surfaces with chloride of lime (1.2 per cent.). In Westminster the walls are sprayed with a solution of formic aldehyde. Burning sulphur or generating formic aldehyde gas is still resorted to in certain cases. In Southwark the surfaces are sprayed with a solution of formalin and afterwards exposed to sulphur fumigation. In Woolwich infected rooms were fumigated for the most part with formalin, and school-rooms were disinfected with sulphur. In Battersea in most cases sulphur di-oxide gas was used, but where it appeared that this agent would do damage formic aldehyde was employed. In the year 1900 the County Council, on the recommendation of the Public Health Committee, authorised arrangements to be made with Drs. Klein, Houston and Gordon to make experiments with the object of ascertaining the value of various disinfectants under the ordinary conditions of their use in dwelling-houses. The report containing the result of these investigations was in due course presented to the committee and is appended. (See appendix III.) Shelters. The use of shelters was greater during 1901 than heretofore, especially in districts in which smallpox was prevalent. The number of families occupying the shelter in Paddington was 24 during the year, 99 persons having been accommodated. No shelter has yet been provided in Kensington; the need for this provision has been repeatedly pointed out by the medical officer of health. In connection with the subject of smallpox the medical officer of health of Fulham states that three families were received from houses infected with this disease. In Westminster two of the shelters (those in Commercial-road and Little Chapel-street) have been closed, and those in Horseferry-road and Dufours-place retained; thirteen persons were admitted during the year. The St. Marylebone shelter was used 27 times and accommodated 67 persons. In St. Pancras the shelter was used 24 times and accommodated 70 persons. The number of persons admitted into the Islington shelter was 11. In Hackney accommodation was paid for by the sanitary authority in one case; a shelter has now been provided. In Holborn an empty house belonging to the Borough Council was utilised for persons from houses invaded by smallpox, and 111 persons accommodated. In Finsbury are two shelters, one in Macclesfieldstreet, the other in Northampton-road; a case of smallpox having occurred in the former house, an empty house lent by the County Council was utilised as a shelter; the number of families accommodated was 72, comprising 310 persons. In the City shelter 17 families were accommodated. In Shoreditch the shelter was used 13 times, the number of persons received being 52. No shelter had been provided in Poplar, but a house at the Bromley depot was fitted up for the reception of persons from houses invaded by smallpox. In Southwark 211 families, comprising 814 persons, were admitted into the shelter in 1901; in the first six months of 1902 267 families, comprising 686 persons, were received; the medical officer of health refers to the great value of the shelter, especially in connection with smallpox. There are two shelters in Lambeth, one on the wharf, Belvedere-road, the other at Wanless-road, Loughborough; they were used on three occasions, the number of persons accommodated being 7. There is no shelter in Battersea, and the need of such provision was much felt during the smallpox prevalence of 1901; in one instance three persons had to spend the night in a washhouse; it has been decided to erect a shelter. The shelter in Woolwich is the only one now maintained, that in Plumstead parish having been abandoned; the Woolwich shelter was used by 4 families, comprising 11 persons. Bacteriological Examination. Information recently supplied by medical officers of health shows that the sanitary authorities of the following districts have made arrangements with the Jenner Institute for the bacteriological examination of pathological material—Paddington, Kensington, Fulham, Chelsea, Westminster, St. Marylebone, St. Pancras, Islington, Stoke Newington, Hackney, Poplar, Wandsworth, Wolwich. Similar arrangements have been made with the Clinical Research Association by the sanitary authorities of Greenwich, Deptford and Bethnal-green; with the laboratory of the Royal Colleges of Physicians and Surgeons by the sanitary authority of Holborn; with the bacteriologists at the Middlesex Hospital by the sanitary authority of Finsbury, at the London Hospital by the sanitary authorities of Shoreditch and Stepney, at Guy's Hospital by the sanitary authority of Southwark. Lambeth has provided a laboratory, Camberwell has appointed a bacteriologist, Bermondsey has provided a laboratory, the medical officer of health doing the work himself; Hampstead, Battersea and Lewisham appear to have made no special arrangements. The material generally examined is from suspected cases of diphtheria and enteric fever, and in some districts of phthisis. Anti-toxic serum is stored by the sanitary authority and supplied in the following districts— Fulham, Stoke Newington, Hackney, Greenwich, Lewisham, Camberwell, Lambeth and Finsbury. In Islington arrangements have been made with the Great Northern Central Hospital by which a supply is available to practitioners at cost price. In Woolwich it is supplied when, owing to want of hospital accommodation, the immediate removal of the patient to hospital cannot be effected. In some districts no charge is made, in others the cost price is charged. In Finsbury the medical officer states that the serum is supplied for prophylactic as well as therapeutic purposes. In St. Pancras it was found that the serum could be obtained from the various druggists in the district. In the other districts serum was not supplied by the sanitary authority. 79 The Cleansing of Persons. In very few instances is reference made in the annual reports of medical officers of health to the arrangements made, under The Cleansing of Persons Act, 1897, for enabling dirty and verminous persons to be cleansed free of charge. In St. Marylebone special provision has been made by the sanitary authority not far from the Salvation Army shelter in Burne-street, and 3,967 males and 135 females were cleansed in the year, their clothes being disinfected at the same time. This number includes persons who had been in contact with cases of infectious disease and who desired to be cleansed, a use of the baths which has been encouraged. In Westminster, since the passing of the Act, free accommodation has been provided by the Strand Board of Guardians, but during three months in 1901 the borough council paid 2s. 6d. for each person cleansed, the number of persons cleansed in this period being 473. The guardians having declined to reduce their charge the arrangement came to an end. Dr. Allan writes: "It appears that during the 12 months about 1,700 persons availed themselves of the guardians' offer, about half of them giving addresses in the city, generally common lodging-houses. It is, therefore, a boon which is largely appreciated, and it is suggested that at the new central disinfecting station proper accommodation be provided for this purpose; meanwhile, instructions have been given to utilise the bath and disinfecting apparatus at Denzell-street, and 60 sets of verminous clothing and bedding have been treated, in addition to which 10 rooms have been fumigated." Dr. T. Orme Dudfield states that in Kensington "nominal effect was given to the Act soon after it passed by an arrangement whereby cleansing and disinfecting apparatus at the able-bodied workhouse, Maryplace, in the Potteries, was made available on payment of a small fee by the late vestry— an arrangement still in force. But little use has been made of the apparatus owing possibly to ignorance of the arrangement on the part of the poor intended to be benefitted and probably, to some extent, owing to the locality and ownership of the apparatus. . . . The question of providing a place for the purposes of the Act is engaging the attention of the Public Health Committee. Information which has recently been supplied by medical officers of health shows that no provision has been made in Paddington, Hampstead, Stepney, Bermondsey, Lambeth, Battersea, Wandsworth, Camberwell, Lewisham and Woolwich. The position of St. Marylebone, Westminster and Kensington in respect of this subject has already been mentioned. In Fulham the work could be done at the disinfecting station. In Chelsea there is a bath-room for casuals and tramps at the disinfecting station, and it is proposed to take some action in the matter. In St. Pancras an arrangement has been made, but re-arrangement is under consideration. In Islington arrangements have been made by the sanitary authority. Iu Stoke Newington bedding and clothing with vermin are disinfected, but there are no baths. In Hackney two baths have been provided at the disinfecting station. In Holborn the baths at the casual wards are available, the clothes are taken to the disinfecting station, the guardians supplying the clothes to be worn in the meantime. In Finsbury arrangements have been made with the Board of Guardians. In Shoreditch clothes are disinfected at the disinfecting station. In Bethnal-green arrangements have been made. In Poplar there are baths in connection with the disinfecting station. In Southwark arrangements have been made by the sanitary authority. In Greenwich cleansing is done at the shelter. In Deptford the Borough Council disinfects and the Board of Guardians provides opportunity for bathing. It is obvious that in many districts of London no provision has been made for this purpose. The subject is, however, one that well deserves the attention of sanitary authorities for it is of the greatest importance that persons in the condition for which the Act proposes a remedy should be encouraged in every way to avail themselves of the opportunity of cleansing themselves. The improved condition of common lodging-houses has already been referred to, but the maintenance of personal cleanliness must depend upon the desire of the individual and the opportunity which is afforded him for this purpose. The experience already gained in St. Marylebone and Westminster shows that where this opportunity exists and is known, it is well appreciated. It must obviously be suitable in character and in a position where it is readily accessible and known to those for whom it is intended. In connection with the subject of personal cleanliness may be mentioned the efforts which are being made in some countries to inculcate in the young the habit of bathing. As stated in the annual report for the year 1897, a visit to Norway, Denmark and Germany showed that spray baths had been provided in connection with certain schools in which practically all the children were bathed once a week. No compulsion whatever was exercised, but the children and parents readily acquiesced in the proposals of the teachers and excellent results attended the practice. Mortuaries. In a few districts additional mortuary accommodation was being provided or alterations made in view of the rearrangement of the former sanitary areas under the London Government Act. The following information is supplied by the annual reports of medical officers of health— In Paddington the mortuary in Paddington-green was being enlarged and reconstructed, and when complete there will be a coroners' mortuary (view room, post-mortem room, microscope room, lavatories and exhibition case), a mortuary for infectious cases and a mortuary chapel, each being a separate building; the medical officer of health suggests that the mortuary in Kensalroad should be used also for North Kensington. In Westminster there were seven mortuaries; it was resolved to close those at Dean-street, Ebury-bridge and St. Martin's Church; the remaining mortuaries are situated in Denzell-street, Dufours-place, Mount-street and Horseferry-road; 80 the medical officer of health states that the increased use of the last mortuary will necessitate some re-arrangement. In Lambeth there are now two mortuaries, inquest rooms and coroners' courts, one at Wanless-road, Loughborough, and the other in High-street, Lambeth. In 1896 a site for an additional mortuary near to Norwood Cemetery was approved, but owing to some difficulty the purchase was not completed. In 1901 it was decided to obtain a site in Norwood Ward; the medical officer states that only a small mortuary is needed with accommodation for infectious cases and other dead bodies, and that this would provide for the wants of Tulse-hill and Norwood Wards, the Wanless-road mortuary for Brixton, Herne-hill and Stockwell wards, and the High-street mortuary would provide for Marsh, Bishop's, Prince's and Vauxhall Wards. The new mortuary in Sheepcote-lane, Battersea, was opened in April, 1902. In the Borough of Wandsworth there are five mortuaries, one having been in the past provided for each parish. In Clapham parish there are both a mortuary and coroner's court; in Streatham there is a mortuary, and inquests are held at the Streatham Hall and other public buildings; in Putney there is a mortuary and inquests are held at the parish offices, but these offices are to be disposed of; in Tooting there is a mortuary which is of an unsatisfactory kind, and in Wandsworth there is a mortuary which is unsuitable. A conference was held with the County Council and it was resolved that a central coroner's court and mortuary should be provided in Wandsworth for the last three parishes. In Deptford the borough council were negotiating for a site for a mortuary and coroner's court. The medical officer of health of Greenwich states that there is great need of modern mortuary accommodation in the district, the existing mortuaries being unsuitable. Water supply. In his report to the Local Government Board the Water Examiner, under the Metropolis Water Act, refers to the recommendation of the Royal Commission, presided over by Lord Llandaff, that it should be made obligatory on the companies to pass water drawn from the river into a storage reservoir before letting it on to the filter-beds, and he states that at present some of the companies which have large storage reservoirs take water direct from the river or merely run it through some of their smaller reservoirs before passing it on to the filter-beds. With reference to the provision of storage reservoirs from which water can be drawn when the river is in bad condition, Dr. Thorpe states that of the Thames companies, the Chelsea, West Middlesex and Southwark Companies having from 13.4 to 18.7 days' storage, delivered the best water during the six winter months of 1901, the Grand Junction Company with less than three days' storage delivered water containing most organic impurity, whilst the Lambeth Company supplied water of slightly better quality than the former company. Referring to diagrams in his report showing variations in the proportions of organic elements in the filtered waters of the companies, and to the storage capacity of the different companies' reservoirs, he comments on the fact that the diagrams show that " the Chelsea and West Middlesex water, as delivered in London, is not affected (as indicated by rise in organic matter) by unfavourable condition of the river until about 10 or 12 days after the Grand Junction and Lambeth Companies' supplies exhibit marked evidence of increased organic pollution." It is interesting to recollect that in 1894, when increase of enteric fever in London followed the exceptional river floods in the winter of that year, the increase of cases of this disease noted occurred in the area of the company then having subsidence reservoirs with the smallest storage capacity (1.5 days' supply) a week before it became conspicuous in the areas supplied by the companies having reservoirs with larger storage capacity, and the same difference was noticeable in the record of the amount of " oxygen consumed." 1 he report of the water examiner shows the capacity of the subsidence reservoirs belonging to the several companies and the average monthly mean and maximum rate of filtration in 1901. Capacity of subsidence reservoirs. Monthly rate of filtration per square foot ver hour. Name of company. No. of days' supply. Mean monthly averages. Gallons. Maximum monthly averages. Gallons. Chelsea 14.5 1.78 2.13 East London 29.3 1.13 1.48 Grand Junction 2.9 1.20 1.47 Lambeth 4.6 2.27 2.71 New River 4.2 2.30 2.59 Southwark and Vauxhall 13.7 1.45 1.89 West Middlesex 17.8 1.26 1.41 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 the parish is less than the grant due, the 81 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 each 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 has 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 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 of the parish. The following table shows the population in 1901 and the amount of excess of contribution over grant, or of grant over contribution in respect of each district for the year ended 31st March, 1902— Population, 1901. Equalisation charge being excess of contribution over grant. Net grant being excess of grant over contribution. £ s. d. £ 8. d. Paddington 143,976 4,599 9 9 — Kensington 176,628 16,698 18 3 — Hammersmith 112,239 — 7,930 12 2 Fulham 137,289 — 11,616 3 7 Chelsea 73,842 3,802 10 6 — Westminster, City of 183,011 95,881 13 9 — St. Marylebone 133,301 12,775 6 2 — Hampstead 81,942 5,504 15 4 — St. Pancras 235,317 — 6,611 9 1 Islington 334,981 — 25,764 — — Stoke Newington 51,247 — 2,683 19 11 , Hackney 219.272 — 19,062 18 3 Holborn 59,425 9,772 7 5 — Finsbury 101,463 1,561 14 8 — London, City of 26,689 114,755 3 7 — Shoreditch 118,668 — 6,792 14 10 Bethnal-green 129,680 — 15,464 5 5 Stepney 298,600 — 30,311 7 7 Poplar 168,822 — 17,449 13 3 Southwark 206,160 — 13,809 17 8 Bermondsey 130,730 — 6,135 3 5 Lambeth 301,895 — 19,706 11 8 Battersea 168,909 — 12,022 14 4 Wandsworth 232,024 — 12,758 8 11 Camberwell 259,339 — 25,458 19 6 Deptford 110,388 — 9,189 7 1 Greenwich 95,780 — 6,502 8 11 Lewisham 127,495 — 6,953 16 11 Woolwich 117,178 — 10,087 0 7 Inner Temple 127 600 17 — — Middle Temple 107 358 16 8 — Sanitary Officers. Appended to this report (see appendix IV.) will be found a return which was prepared under the instruction of the Public Health Committee, showing particulars as to the sanitary officers in the service of the several sanitary authorities of London in 1901. The number of sanitary inspectors employed in London at the time of the return was 275. The reports of medical officers of health supply additional information. At the end of the year an increase in the staff of officers was decided upon by the Paddington Borough Council. The appointment of an additional inspector in Hammersmith enabled an increased number of notices to be served in respect of workshops. The medical officer of health of Westminster shows how the several duties are distributed among the inspectors, and he adds that the extra duties [11] 82 imposed by the Factory and Workshops Act will render the staff inadequate for efficient administration. He discusses the question of the appointment of a female sanitary inspector and of an assistant medical officer of health. The medical officer of health of Stoke Newington mentions the recent decision of the borough council to appoint a third sanitary inspector. The medical officer of health of Hackney states that if the workshops on the register are to be inspected once or more during the year an increase in the staff will be necessary. The medical officer of health of Finsbury reports that during 1901 there had been no factory inspector, but in March, 1902, the borough council decided to appoint an additional inspector whose services will be devoted to the inspection of factories and workshops. In Bermondsey the borough council appointed two additional inspectors in December, 1901.. In Lambeth a female sanitary inspector was appointed. In Battersea it was decided to appoint a male and a female inspector of workshops. In Wandsworth the appointment of a female inspector of workshops was decided on. The medical officer of health of Camberwell calls attention to the need for a larger staff in the following paragraph extracted from his report— In my report for the year 1900 is inserted a statement that I had made on the question of the necessity of the re-organisation of the sanitary staff, with the additions which were, in my opinion, necessary for the proper equipment of the office. It was adjourned from the old vestry to be dealt with by the council, and early in the year 1901 some members of the committee personally inspected the working of the department, and the matter was also gone into by the combined Drainage Sub-Committee as a whole. The result of their deliberations was that no increase was necessary, except that a female sanitary inspector was to be appointed. The matter, therefore, so far as I am concerned, is at an end ; but I still repeat the opinion that the department has neither a proper number of inspectors nor of clerks on its staff, and that the only way that I can see out of the difficulty is to carry out the previous suggestions and additions advised in that report. Books and records of inspections, which, for purposes of supervision imperatively demand careful indexing, are crowded out of the daily work by the other duties of the clerical staff, and unless a broader view be taken of the necessities of this department, the present unsatisfactory state of things must continue. The new duties in connection with the proper recording of the inspection of milkshops, etc., which were cast upon the local authorities by the London Government Act, almost require a clerk to themselves. In Deptford the Borough Council decided to appoint two additional inspectors. The medical officer of health of Woolwich states that factories and workshops could not be inspected as much as is desirable owing to the fact that there was no special inspectors for this purpose and that the ordinary inspectors' time was fully occupied with other duties. The following table shows the month in which the annual reports of the medical officers of health of metropolitan boroughs, relating to the year 1901, were received by the Council— February, 1902 1 July, 1902 10 March „ 1 August ,, 8 May „ 3 Sept. „ 3 June „ 1 Oct. „ 2 To the London County Council. Shirley F. Murphy, Medical Officer of Health. December, 1902. 83 Medical Officers of Health of Metropolitan Boroughs in 1901. Metropolitan boroughs. Medical officers of health. Battersea G. F. McCleary, M.D. Bermondsey R. K. Brown, M.D. Bethnal-green G. P. Bate, M.D. Camberwell F. J. Stevens, M.R.C.S. Chelsea L. C. Parkes, M.D. City of London W. Collingridge, M.D. Deptford H. W. Roberts, M.R.C.S. Finsbury G. Newman, M.D. Fulham J. C.-Jackson, L.R.C.P. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead H. Littlejohn, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. O. Dudfield, M.D. Lambeth J. Priestley, M.D. Lewisham A. W. Harris, M.D. Paddington R. Dudfield, M.B. Poplar F. W. Alexander. L.R.C.P. St. Marylebone A. W. Blyth, M.R.C.S. St. Pancras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D. Southwark G. Millson, L.R.C.P. Stepney D. L. Thomas, M.D. Stoke Newington H. R. Kenwood, M.B. Wandsworth P. C. Smith, M.D. Westminster, City of F. J. Allan, M.D. Woolwich S. Davies, M.D. Appendix I. D/A GRAM 1. Diagram showing the interpolated population and death numbers at each year of age . London county council. THE LONDON LIFE TABLE, 1891-1900. (Printed by order of the Public Health Committee, 24th April, 1902.) Public Health Department, 8, St. Martin's-place, W.C. Introduction. The form of the life table" was invented in the 18th century by Halley, the astronomer, although the mode of construction of Halley's table, calculated on the deaths in the city of Breslau, differed materially from that adopted in life tables of more recent date. The celebrated Carlisle table, calculated by Mr. Milne on two enumerations of the population of Carlisle and its environs made by Dr. Heysham in 1779 and 1787 and the deaths in nine years, was, according to Dr. Farr, the first correct representation of the vitality of any portion of the English population, and reference may also be made to a table of mortality calculated from observations made in connection with the population of Glasgow in the years, 1821-27. The latter table has been used for comparative purposes by Dr. Chalmers, who recently published an extended life table for the Glasgow population based on the experience of the decade 1881—90. Since the publication of the Carlisle table of mortality the importance of life tables has been increasingly manifest, and many improvements in life table construction have been made. The institution of civil registration in England has given opportunity for the construction of national life tables, and such tables have from time to time been published in the reports of the Registrar-General. Extended life tables, which are invaluable for comparative purposes, have also been calculated for Manchester (Dr. Tatham), Glasgow (Dr. Chalmers) and Brighton (Dr. Newsholme) on the experience of the decennium 1881-90, and, in view of the increasing attention devoted to sanitary progress, it is to be anticipated that local life tables for a large number of sanitary areas will be calculated when the results of the most recent census are published. A life table shows the viability of the population at each age of life and for each sex under the conditions to which they are exposed during some limited period, in other words, it follows the history of a million children throughout the whole of their lives, on the assumption that the conditions to which they are exposed during the limited period in question and which influence their longevity are maintained from their birth until the last of them has disappeared from the earth. It shows from the beginning of life and at each age of life the number dying and the number surviving, the probability which each has of living one year of life beyond the age he or she has attained, the total number of years which the survivors at any particular age may be expected to live, and lastly the mean expectation of life at each age and for each sex. A life table entirely eliminates all errors due to differences in the age and sex constitution of the population, and it shows the effects of conditions which influence mortality in different degrees at different ages of life. It furnishes therefore, the means most free from objection for taking stock of the results of the several factors which influence longevity, whether they are those which tend to lower it, such as the living in aggregation with the risks to life which are inevitable from such aggregation, or whether they are those which tend to prolong it, such as the improved prosperity of the community and the adoption of those measures which experience indicates as militating against disease and death. The opportunities which the Council has afforded during recent years for obtaining more exact information than I possessed before as to the deaths which properly belong to the London population has enabled material to be obtained which provides a sufficiently sound basis to justify the expenditure of time and labour involved in the preparation of an extended table by which more exact comparison than heretofore can be made between the vital statistics of London and of those other communities which have already availed themselves of opportunities for similar statement. This table is, it may be hoped, the first of a series which will also enable similar comparison to be made between the viability of the London population in successive decennia, and thus show whether there is indication of progress or of regress, and whether the movement in either direction corresponds with the changes observed in other parts of the country. Owing to the fact that the results of the recent census have not been published for the whole of the country, there are as yet no extended life tables relating to other communities based on the experience of the decennium 1891-1900 available for comparison with that of London* If, however, comparison be made between the London life table for 1891-1900, and those to which I have already referred, it is found that London occupies a position between the healthy districts of the Registrar General, England and Wales, and Brighton on the one hand, and Manchester and Glasgow on the other. The position of the population of London in relation to these other populations is discussed in more detail on pages 16 to 18, and will be seen by reference to diagram II. In any speculation as to whether the facts that the London figures are based upon the experience of a later decennium than the figures of the other communities, and that the conditions of life are generally improving in the country as a whole, will tend to put London in a less favourable position, when comparison is made between it and the other towns for the same period, it needs to be borne in mind that during the decennium 1891-1900 the mortality in England and Wales generally was increased by influenza. Judged by the figures of the short life table for London in 1881-90, published in my annual report for the year 1893, however, there is reason for thinking * Since this was in type I have received a copy of a "short" life table for Haydock (Lancash re), based upon the mortality in the decennium 1891-1900, and constructed by Dr. Hayward, the Medical Officer of Health of that district. [3157 2 that in London the mortality from influenza has not, wholly counterbalanced the gain due to the diminution in the mortality from other causes. The result will therefore probably be that the population of London as compared with the other communities will be a little less favourably situated than the figures and diagram show. The life table for the period 1891-1900, has been the work of Mr. G. H. Day, assisted by Mr. M. O'Carroll, officials of the Public Health Department. This is the first extended life table for the London population which has been published, and on that account it is necessary that the method of construction should be set out in some detail. The value of the present table for comparative purposes will be greatly enhanced when similar tables have been constructed for future decades, and when the time arrives for the construction of these tables, it will be a matter of considerable importance that the method of construction adopted for the present table should be known, in order that these life tables may be constructed as far as possible on similar lines. For this purpose the following statement by Mr. Day of the method adopted and formulas used has been included, and I desire also to acknowledge the services of Mr. A. C. Waters, of the General Register Office, who has made a number of valuable suggestions as to the statement. Construction of the London Life Table 1891-1900. The facts upon which this life table is based are supplied by the census enumerations of 1891 and 1901 as to the age and sex constitution of the London population in the Registration County of London, and the records of mortality relating to the same area for the decennium 1891-1900. Deaths. An initial difficulty which presented itself in the construction of this life table is due to the fact that it was found impracticable to obtain the deaths at the various age periods which properly belong to the London population for the whole of the decennium. Nearly 30 per cent. of the total deaths registered in London occur in public institutions, and many of the persons dying in these institutions previously resided outside the London area, and such deaths should properly be excluded for the purposes of a life table. Again, there are a number of institutions, lunatic asylums, workhouses, convalescent hospitals, etc., situated in the immediate vicinity of London but outside the London area, which are mainly filled by persons formerly resident in London, and the deaths occurring in such institutions should properly be credited to the London population although they are registered elsewhere. Since the year 1885 the Registrar General in the Annual Summary of Births and Deaths in London and other large towns, has published the number of deaths at "all ages," corrected for institutions, but these numbers, beyond giving the material for finding the total deaths in the decennium at "all ages" properly belonging to the London population are of little value for the purposes of life table construction. What is required for this purpose is the number of deaths at each age period corrected for institution deaths, and these figures are not published in the Registrar-General's reports. During the four years 1897-1900, however, for the purposes of the annual reports of the medical officer of health, the number of deaths at each age period properly belonging to the London population have been obtained from the records of the RegistrarGeneral, and these figures furnish material for estimating the effect of the disturbing influence of institution deaths. In the construction of the life table the deaths for the four years 1897-1900 at each age period fully corrected for institution deaths have been applied to the uncorrected deaths at each age period as published in the Registrar-General's annual reports for the 10 years 1891-1900, and the resulting figures may be taken to represent with sufficient accuracy the deaths in the 10 years 1891-1900 properly belonging to the London population; in any case the figures so obtained are very much nearer the actual facts than the uncorrected figures published by the Registrar-General. The following table shows the deaths at each age period so obtained upon which the life table is based— Registration County of London. Age period. Males. Deaths, 1891-1900. Age period. Females. Deaths, 1891-1900. 0— 116,490 0— 94,953 1— 34,338 1— 31,996 2— 13,564 2— 13,377 3— 8,584 3— 8,625 4— 5,778 4— 5,941 5— 11,091 5— 11,638 10— 5,075 10— 5,219 15— 7,025 15— 6,635 20— 9,396 20— 8,525 25— 25,826 25— 23,059 35— 37,227 35— 30,978 45— 42,381 45— 35,222 55— 43,878 55— 40,629 65— 40,813 65— 47,421 75— 23,770 75— 36,664 85 and upwards 4,589 85 and upwards 10,182 All ages 429,825 All ages 411,064 3 It should here be pointed out that in London as in all large urban communities there must be (1.) a number of deaths occurring among non-Londoners visiting in London or temporarily resident in London for the purpose of medical or surgical treatment, but not recorded in the death register as having been really resident outside and (2.) a number of deaths of persons who have been resident in London but have left it because of illness, for instance, domestic servants who have gone home to their friends to die, or convalescents from London hospitals who have been sent to convalescent homes in the country. It is impossible to obtain any reliable figures under these heads, but the fact that the errors occasioned in the death returns from these causes are in opposite directions is sufficient justification for assuming that any error introduced into the life table on this account is comparatively insignificant. Population. The next step necessary after ascertaining the death3 belonging to the area covered by the life table is to estimate the mean numbers living in the ten years 1891-1900 from the census enumerations of 1891 and 1901. It is usual to assume that a population increases or decreases in geometrical progression, i.e., the rate of increase is constant for given units of time. An approximate mean population may on this assumption be estimated for the decennium by calculating the population living in the middle of each year and taking the average of these numbers, but the true mean population for the decennium, on the hypothesis of a geometrical increase or decrease, may be shown to be for let P and r P be the populations at the beginning and end of a period, and let a; be a fraction of this period, then the population after the fraction x of the period, on the assumption of a constant rate of increase or decrease, is r. P, and the mean population in the period, i.e., the area of the curve traced by the population when x is taken between the limits 0 and 1 is since when correction is made for the fa ct that the interval between two census enumerations does not correspond exactly with ten calendar years but begins and ends a quarter of a year later the formula becomes This formula then may be applied to the figures of the census enumerations to obtain the mean number of persons at all ages " living in the decennium 1891-1900 ; but it is also necessary to obtain the mean number of persons living at each age period in the decennium and a difficulty which presents itself at this stage is the fact that if the mean numbers living at each age period be calculated independently by the above formula the sum of the results will not equal the mean population previously ascertained for " all ages." It is' therefore necessary to adopt some other method in calculating the mean population living at each age. To avoid the difficulty mentioned it has been usual to assume that the population at "all ages" is increasing or decreasing in geometrical progression at a constant rate and that the proportion of any particular part of the population to the whole is uniformly increasing or decreasing in arithmetical progression. In a paper recently published in the journal of the Royal Statistical Society, Mr. A. C. Waters has shown that by combining these two assumptions constants can be calculated which when applied to the census population at two successive enumerations give consistent results. The formulae are as follows— Mean population 1891-1900 = Census population 1891 X + Census population 1901 X Where r = the decennial rate of increase in the total population. These factors give for the mean population of London, 1891-1900— 4,211,743 x -5369769 = 2,261,6087. 4,520,971 x -4634401 = 2,095,199-3. Total 4,356,808-0. The true mean population on the assumption of a constant rate of increase, viz.— 4,211,743 X gives 4,356,808. 4 The constants obtained from these formulae have been applied to the population at each age as enumerated at the census of 1891 and 1901., and the following table shows the mean populations thus obtained— Age period. Males. Females. 0— 248,371-7 249,884-2 5— 223,039-9 225,285S-2 10— 206,698-2 210,6980 15— 202,502-2 225,380-6 20— 204,615-6 246,179-7 25— 350,722-4 408,285-6 35— 261,854-3 290,162-6 45— 183,124-9 205,757-8 55— 107,869-5 131,036-0 65— 52,470-4 74,752-5 75— 15,422-2 27,2480 85 and upwards 1,615-3 3,831-2 All ages 2,058,306-6 2,298,501-4 Calculation of the px column. The fundamental problem in life table construction is the calculation of the px column, a series of values representing the probability of living from age x to age x + 1. According to the " Theory of Probabilities " if there be lx persons living at age x, and if of these lx + 1 persons survive to age x + 1 then the probability that a person aged x will survive 1 year is lx+1/lx To this probability it is usual to assign the symbol px. If therefore the number of persons surviving at each age out of a given number born were known, the probability of living a year at each age could be easiy calculated. The data from which the life table has to be constructed, however, are of a far different character and their use necessitates two preliminary assumptions. In the first place we have ascertained the mean population living in the decennium 1891-1900 at certain age groups, and in the second place we have the corresponding deaths which have occurred at, these age groups. Now, if we have a certain population P, estimated as living in the middle of a year the persons comprised in that population may be of any age from x to x+ 1, and if a certain number d, are registered as dying in that year these deaths are those of persons who also may be of any age from x to x+ 1. in order to calculate the probability of a person living from the exact age x to age x + 1 from these facts, it is assumed, (1.) That the average age of Px persons living in the middle of a year is x + ½, and. (2.) That the deaths have occurred at equal intervals throughout the year. On these two assumptions it is obvious that the number of persons living at the beginning of the year will be P, + ½d„ and the number living at the end of the vear will by Px, -1 d„ therefore : Calculation of p. values for the first Jive years of life. The census returns give the population numbers for each of the first five years of life, but these numbers are generally regarded as unreliable owing to misstatement of age and other causes, and the general practice in life table construction is to accept the total number shown by the census at the age group 0-5 as correct, and to calculate the age-distribution of the population within the age group from the births and deaths. The following are the details of the method adopted in the present instance for calculating the age-distribution of the London population aged 0-5 living in the decennium 1891-1900— (a) Number of births— £ births in 1890 + total births in 1891-99 + i births in 1900. (b) Number at 1 year of age— | births in 1889 +total births in 1890-98+ 5 births in 1899. Less deaths at age 0-1 in the decennium 1890-1899. . The London area to which the deaths of the decennium 1891-1900 relate is not exactly coterminous with the London area as constituted by the London Government Act of 1899. In the census report of 1901 the age and sex constitution of the population living in the former area is not stated, but as the differences between the two areas are comparatively unimportant when the whole area of the county of London is taken into account, it has been considered sufficient for the purposes of the present life table to assume that the age and sex distribution of the 4,520,971 persons enumerated within the old area of London is identical with that of the 4,536,541 persons shown by the census of 1901 to be living within the county of Loudon as constituted by the London Government Act of 1899. †In some life tables the rate of mortality per unit of population (mx) has been first obtained and the px values calculated from the formula: px =1-½mx/ the connection between this formula and the above when it is borne in mind that mx = dx will be easily seen, thus, Px 5 (c) Number at 2 years of age— ^ births in 1888 + total births in 1889-97 + 1 births in 1898. Less deaths at age 0-1 in the decennium 1889-98. „ „ 1-2 „ „ 1890-99. (id) Number at 3 years of age— ½ births in 1887 + total births in 1888-96 + 5 births in 1897. Less deaths at age 0-1 in the decennium 1888-97. „ „ 1-2 „ „ 1889-98. „ „ 2-3 „ „ 1890-99. (e) Number at 4 years of age— 5 births in 1886 + total births in 1887-95 + ½ births in 1896. Less deaths at age 0-1 in the decennium 1887-96. „ „ 1-2 „ „ 1888-97. „ „ 2-3 „ „ 1889-98. „ 3-4 „ „ 1890-99. The sum of these numbers (a), (b), (c), (d) and (e) in the case of males works out at 2,775,278. The mean male population living at ages 0-5 has been shown to be 2,483,717, but this number represents the number living at all ages between 0 and 1 year of age plus the number living at all ages between 1 and 2 years of age etc., and in order to make it comparable with the number obtained from the births and deaths, viz., 2,775,278, which is the sum of the numbers at birth, and at the exact ages 1, 2, 3 and 4 it is necessary to add the deaths occurring in the decennium under 6 months of age, and half the deaths at ages 1-2, 2-3, 3-4 and 4-5, the figures are as follows— Mean population age 0-5 living in the 10 years 1891-1900 2,483,717 Deaths under 6 months of age 1891-1900 79,828 Half deaths aged 1-2 years, 1891-1900 17,169 „ „ 2-3 „ „ 6,782 „ „ 3-4 „ „ 4,292 „ „ 4-5 „ „ 2,889 Total 2,594,677 The number thus obtained, viz., 2,594,677 may be taken to be the sum of the number of males at birth and at the exact ages 1, 2, 3 and 4, and the application of this number to the distribution at each of these ages as obtained from the births and deaths gives the following numbers, which have been adopted for the purposes of the life table— Number at birth 632,698 age 1 522,777 „ „ 2 490,999 „ „ 3 478,440 „ „ 4 469,763 Total 2,594,677 From these numbers and the mortality figures for the five years of life in the decennium the following probabilities of living one year at each age have been calculated— Probability of living one year—Males. At age 0 -81588 = p0 „ 1 -93432 = Pl „ 2 -97237 = p2 „ 3 -98206 = p3 „ 4 -98770 = p4 Calculation of the probability of living one year at age 5 and upwards. It has been shown (page 4) that the probability of living a year at age x (px) may be obtained if the population living at all ages between x and x + 1 years of age and the number dying in this interval be known. The chief difficulty in life table construction, however, lies in the fact that the population and deaths at yearly intervals of age are unrecorded, and the facts can only be ascertained for five year or ten year intervals. Under these circumstances it is necessary to adopt some method of ascertaining the numbers of the population and deaths in each year of age from the recorded facts. In the case of the Carlisle table of mortality it has been shown that a "graphic" process of construction was adopted, and Dr. Newsholme's life table for Brighton, 1831-90, was also constructed by this method, which consists in plotting out the population and deaths to scale as a series of rectangular figures whose height is equal to the arithmetical mean of the populations and deaths, and whose breadth is proportionate to the interval of time covered by the age period, A curve is then drawn, the mean of whose ordinat.es at yearly intervals is equal to the height of the corresponding rectangular figure. The principal objection to this method of construction is that accurate measurement of the ordinates of the curve is extremely difficult unless the curve be drawn on a very large scale, and some allowance must also be made for "personal equation" in drawing the curves, as it is obvious that many curves may be drawn which satisfy the given conditions. As a matter of fact the series of px values obtained by the graphic process is rarely so smooth and regular as the series obtained from the 6 analytical process known as "interpolation by the method of finite differences." The latter method has been used in the construction of the present life table, and a brief description of the assumptions involved in this method may here be given. Suppose we have an arithmetical series (x; x + a; x + 2a; x + 3a, etc.) it will be seen that the first differences are constant and equal to (a) while the second diSerences equal zero. Now suppose the squares of this series are taken (x2; x2 + 2 ax + a2; x2 + 4 ax + 4 a2 etc.) it will be seen that the first differences = 2 ax + a2; 2 ax + 3 a2 ; 2 ax + 5a2 etc., the second differences are constant and equal to 2a2 while the third differences equal zero; and generally it may be shown that if the nth power of the series be taken the nth differences are constant and the n,+ 1th differences vanish. If then we assume that Ux = A + Bx + Cx2 . ... + Nx2, we assume that the nth differences of the series of quantities represented by Ux (when x is made successively x; x + a; x + 2a, etc.) are all equal while the n+1th differences vanish. This then is the assumption made in interpolating for Ux by the method of finite differences given n + 1 values of Ux for equi-distant values of X. As an instance suppose a set of figures represents the population belonging to five equidistant ages, say ages 25 and upwards, 35 and upwards, 45 and upwards, 55 and upwards and 65 and upwards and assume that the number representing the population at each of these ages (Ux) is of the form A + Ba; + Cx2 + Dx3 + Ex4 then we have a series of 5 equations from which the values of the co-efficients A, B, C, D and E, may be calculated; thus for convenience let x = 0 in the case of the middle term, age 45 and upwards, then— U_20 = A — 20B + 400 C — 8000 D -t- 160,000 E U_10 = A — 10B + 100 C — 1000 D + 10,000 E U0 = A U10 = A + 10B + 100 c + 1000 D + 10,000 E U20 = A + 20B + 400 C + 8000 D + 160,000 E From these equations the numerical values of the co-efficients may be calculated and if it is required to interpolate say age 44 and upwards the equation would be U_1=A — B + C — D + E or say for age 47 and upwards, U2 =A + 2B + 4C + 8D + 16E. In practice less laborious methods are adopted for interpolating intermediate values when a succession of such values are required although the principle is exactly the same. Thus the given terms of the series may be set down and differenced and the problem then becomes one of subdividing these 10 yearly differences represented by the symbols ∆, ∆2, ∆3, etc.> into smaller differences represented by the symbols 8, etc., corresponding to one year. The eeneral formula used for finding the values of δ is as follows : five orders of differences— From these equations the sub-divided differences can be calculated for any value of m. In life table construction this value generally = 10, and the following equations show the values of δ when m is equal to 10— This formula has been used for interpolation from age 25 onwards; for ages 5 to 25, which were calculated from the series u4, u10, ul0, u15, u25, and (six orders of differences), it was necessary to use Lagrange's formula, as the given terms are not equi-distant. In the formula of Lagrange another but equivalent form is substituted for the expression ux = A + Bx + Cx2, etc., viz. 7 the expression thns formed is like A + Bx + Cx2, etc., rational and integral and contains n undetermined co-efficients. From this expression it may be shown that This formula was used in calculating the values of u6, v7, u8, and u9, and from the seven equi-distant terms thus obtained, viz., u4, v5, w6, w7, w8, u9, and u10 the successive differences were calculated and the series carried on as far as u.25. The justification for the assumption made in interpolating by the method of finite differences in connection with life table construction, viz., that the general expression of the values under consideration is a rational and integral function of x, the independent variable, lies in the fact that this assumption rests upon the supposition that the successive orders of differences rapidly diminish; and this supposition has been verified in the case of all tabulated functions of a similar nature to those under consideration. It has been shown that in the case of a rational and integral function of x of the nth degree the n+lth differences vanish, therefore if in any other function such differences become extremely small the function may be approximately represented by a function which is rational and integral, and the error introduced by the assumption is so small that, in practice, it may be disregarded. It is an essential condition in the problem, however, that the value of x for which that of the function is required is not far removed from those functions for which the values are given. In life table construction this condition is fulfilled by, as far as possible, using only those values which form the central portion of a given series. It may be further stated in justification for the use of the method of Unite differences in life table construction that this method gives a curve or series which passes by small gradations, from one fixed value to another. It is a known fact that life contingencies also change by small gradations, i.e., that after the perils of birth there is nospecial age at which the chances of death or survival suddenly alter. If there be any critical periods of life these probably occur earlier in some individuals than in others, so that their effect on the life curve is modified, producing only a slight and gradual distortion. It is true that an infinite number of curves may be drawn through a given series of points, but the curves that pass by small gradations will lie very near each other except perhaps at or near the extreme sections of the curves. The gradually changing interpolated curve, therefore, will not differ very greatly from the gradually changing life curve. In constructing the present life table from the data already mentioned, viz., population and deaths in the decennium 1891-1900, two columns were first obtained, one showing population X 2 minus deaths at each given age and upwards, and the other, population X 2 plus deaths at each given age and upwards, the logarithms of these numbers were then taken out and from the values so obtained the logarithms of the intervening terms were interpolated.. By this process two series were obtained, viz., 2P—D at age x and upwards and 2P + D at age x and upwards, the values of 2P—D and 2P + D at ages x, x+1, x+2, etc., being obtained by subtracting each term from the one immediately preceding. It has been previously shown that the probability of living a year at age x 2P—D (px) = 2p+D so that the px values are easily obtained from the two columns showing 2P—D and 2P+D at each age. The following table shows the facts relating to males in London upon which the present life table is based, arranged in the manner above described ; the same method was adopted in the case of females, but from considerations of space the figures relating to females are omitted— Males. Age x and upwards. 2P — D at age x and upwards. Log(2P-D) at age x and upwards. 2P + D at age x and upwards. Log (2P + D) at age x and upwards. 4 and upwards 36,875,597 7-5667390 37,389,295 7-5727473 5 „ 35,947,627 7-5556702 36,449,769 7-5616948 10 „ 31,497,920 7-4982819 31,977,880 7-5048497 15 „ 27,369,031 7-4372594 27,838,841 74446511 25 „ 19,243,096 7-2842750 19,680,064 7-2940265 35 „ 12,254,474 7-0882947 12,639,790 7 1017399 45 „ 7,054,615 6-8484733 7,365,477 6-8672008 55 „ 3.434,498 6-5358632 3,660,598 6-5635521 65 „ 1,320,986 6-1208982 1,459,330 61641535 75 „ 312,391 54946985 369,109 5-5671546 85 „ 27,717 4 4427462 36,895 4-5669675 The interpolations were carried out in four series which may be set out as follows, using the symbol Ux to denote the logarithm of 2 P — D at age x and upwards. Series (1) U4, U5, U10, U15, U25, U35, (six orders of di0fferences). Series (2) U15, U25, U35, U45, U45, U65 (five orders of differences). Series (3) U25, U35, U45, U55, U65, U75 (five orders of differences). Series (4) U35, U45, U55, U65 U75, U85 (five orders of differences). . There is a special reason in favour of interpolation of logarithms in that the interpolation of numbers must finish up at the higher ages either with a rapidly increasing positive value or a rapidly increasing negative value of the function—the one being absurd and the other meaningless. 8 The value3 for ages 5 to 25 were obtained from series (1), the values for ages 25 to 35 were obtained from series (1) and (2), for ages 35 to 45 from series (2) and (3), for ages 45 to 55 from series (3), for ages 55 to 65 from series (3) and (4), and for ages 65 and onwards from series (4). Where two series hare been used the values have been blended by means of values calculated from Calculation of the h column. Having obtained the complete series of pr values these values may be used to obtain the values set out in lx column. This column shows the number surviving at each age out of a given number born. It is of no importance what number is taken at birth, or in other words what number is taken as the " radix " of the life table, but it is usual to divide a million in proportion to the number of males and females born during the decenniurn and to use the numbers so obtained as the radix of the male and female lx columns, by this means it is easy to combine the two columns into one showing the number of " persons " surviving at each age out of a million at birth. The formula used for the construction of the lx column is as follows— + 1 = 'x X px. or if logarithms be used log lx + i = log lx + log px. Thus the number of males at birth /„ is 509,112, and the probability of living one year at age 0 is •8158837, therefore the number living at age 1, i.e., lx = 509,112 x '8158837 = 415,376, and so on for each age shown in the table. To enable comparison to be made of the male and female survivors at each age out of an equal number born two additional lx columns have been similarly obtained showing the number of males and females surviving at each age out of 1,000,000 males and females at birth, respectively. The dx column. This column shows the successive numbers of those dying in the interval from age x to age x + 1, and is obtained from the formula dx = lx — lx + j. The sum of this column must obviously equal the total number at birth and the sum of those dying from age x to the end of the table must equal the number living at age x. Calculation of the Px column. The numbers shown in the P. column represent the mean population living from age x to age x + 1, or in other words the total number of years of life lived by lx persons between the ages x and x + 1 is equal to IV In the case of each year of age except the first, Px has been taken as This involves the assumption that the average age of those dying in the interval x to x + 1 is x + thus it is obvious that Px on this assumption will be equal to lx + i + | 4, or in other words, of lx persons living at age x, lx + i persons will survive at age x + 1, and lx + i will represent the total years of life lived by lx + i persons in the interval between age x and x + 1 ; the remainder of the lx persons, dx> will die in this age interval, and each of these will complete half a year of life in the interval x to x + 1 ; the total years of life lived by dx persons will therefore be represented by i d, thus For the first year of life the arithmetical mean of the numbers represented by l0 and will not represent the mean population living between the ages 0 and 1 with sufficient accuracy, owing to the large proportion of deaths which occur in the first six months of life. The following method has, therefore, been adopted to find the mean number living in the age interval 0—1. It will be seen from the life table relating to males that 93,736 deaths occur in the age interval 0—1 ; from the facts recorded by the Registrar-General it is possible to obtain the number of deaths in the decenniurn among males aged 0—3 months, 3—6 months and 6—12 months. These numbers, when applied to the 93,736 males dying in the first year of life, give the following proportions— Deaths ... ... 0-3 months ... ... 44,283 3-6 „ 19,952 6-12 „ 29,501 Total deaths, ages 0-1 ... ... 93,736 9 These facts may be arranged as under— Survivors at age 0 93,736 = U „ „ 3 months 49,453 = V „ 6 29,501 = W ,, ,, 12 „ 0 = Y Then the mean number of years lived by the 93,736 males dying in the first year of age will be— The method of obtaining this formula is as follows— Assume that the value l0 — ll and intermediate values to zero are the ordinates of a curve whose equation = A + Bx + Cx2 + Dx3 then the area of the curve will be From the four given ordinates U, V, W and Y four equations may be formed by substituting the numerical values of x from which it may be easily shown that The Qx column. This column shows the number of years of life lived by lx persons during the year x to x + 1, and each succeeding year to the end of the life table, and is obtained from the Px column by successive additions beginning from below. The Ez column. The Ex column shows the expectation of life at each age, and is obtained from the lx and it is obvious from the explanations previously given of the construction of the column that if the aggregate number of years of life lived by lz persons is Qx, then the mean after life-time of lx individuals will be equal to Qx/lx Mortality in each year of age. The method of constructing the px column adopted for the purposes of the present life table, i.e., by a double series of interpolation, allows the population and deaths in each year of age to be shown, and from these figures the death rate at each age may be calculated. Although as has been previously stated the population and deaths have been interpolated in a combined form, it will easily be seen that the sum of the columns 2P + D and 2 P — D at each age is equal to four times the population, and the difference between these columns at each age is equal to twice the deaths. The following table shows the age and sex distribution of the 4,356,808 persons estimated as the mean'population. living in London in the decennium 1891-1900, the total deaths at each age in the ten years and the annual death rate per unit of population. Males. Total number of lives at risk and deaths for each year of age. Age. Population. Deaths. of Mortality per unit. In Original Groups. Distributed. In Original Groups. Distributed. 0 2,483,717 552,870 178,754 116,490 •21070 1 505,608 34,338 •06791 2 484,217 13,564 •02801 3 474,148 8,584 •01810 4 466,874 5,778 •01238 5 2,230,399 462,280 11,091 3,989 •00863 6 454,958 2,737 •00602 7 446,347 1,900 •00426 8 437,531 1,380 •00315 9 429,283 1,085 •00253 10 2,066,982 422,106 5,075 952 •00226 11 416,298 929 •00223 12 411,971 974 •00236 13 409,090 1,059 •00259 14 407,517 1,161 •00285 . The figures shown in the table represent the mean population at each age X 10, i.e., the number of lives at risk in the decennium. [2] 10 Age. Population. Deaths. Rate of Mortality per unit. In Original Groups. Distributed. In Original Groups. Distributed. 15 4,071,178 407,021 16,421 1,268 00312 16 407,312 1,371 •00337 17 408,059 1,465 •00359 18 408,931 1,547 •00378 19 409,582 1,621 •00396 20 409,701 1,690 •00412 21 409,008 1,758 •00430 22 407,264 1,826 •00448 23 404,300 1,898 •00469 24 400,000 1,977 •00494 25 \ 3,507,224 394,245 25,826 2,065 •00524 26 386,652 2,134 •00552 27 377,187 2,208 •00585 28 366,301 2,307 •00630 29 354,898 2,434 •00686 30 343,843 2,592 •00754 31 333 780 2,768 •00829 32 324,922 2,946 00907 33 316,775 3,113 •00983 34 308,621 3,259 •01056 35 2,618,543 299,644 37/227 3,373 •01126 36 290,049 3,478 •01199 37 280,545 3,571 •01273 38 271,606 3,650 •01344 39 263,553 3,720 •01411 40 256,289 3,776 •01473 41 249,532 3,831 •01535 42 242,898 3,886 •01600 43 235,952 3,942 01671 44 228,475 4,000 01751 45 1,831,249 220,450 42,381 4,056 •01840 46 212,214 4,107 •01935 47 203,883 4,155 •02038 48 195,499 4,199 •0214S 49 187,105 4,240 •02266 50 178,744 4,274 •02391 51 170,456 4,304 •02525 52 162,278 4,329 •02668 53 154,243 4,350 •02820 54 146,377 4,367 •02983 55 1,078,695 138,690 43,878 4,378 •03157 56 131,154 4,391 •03348 57 123,820 4,402 03555 58 116,749 4,405 03773 59 109,989 4,405 •04005 60 103,543 4,399 •C4248 61 97,387 4,390 •04508 62 91,475 4,380 •04788 63 85,743 4,370 •05097 64 80,145 4,358 •05438 65 524,704 74,662 40,813 4,343 •05817 66 69,323 4,321 •06233 67 64,133 4,290 •06689 68 59,091 4,246 •07186 69 54,198 4,189 •07729 70 49,458 4,115 •08320 71 44,881 4,021 •08959 72 40,474 3,907 •09653 73 36,253 3,770 •10399 74 32,231 3,611 •11203 75 154,222 28,423 23,770 3,430 •12068 76 24,845 3,228 12993 77 21,509 3,007 •13980 78 18,431 2,770 15027 79 15,618 2,522 •16145 80 13,077 2,266 •17327 81 10,811 2,009 •18583 82 8,816 1,754 •19901 83 7,085 1,508 •21291 84 5,607 1,276 •22757 11 Age. Population. Deaths. Rate of Mortality per unit. In Original Groups. Distributed. In Original Groups. Distributed. 85 15,882 4,364 4,461 1,060 •24287 86 3,338 865 •25910 87 2,507 691 •27586 88 1,846 542 •29339 89 1,332 415 •31177 90 940 311 •33080 91 648 227 •35070 92 437 162 •37123 93 287 112 •39253 94 183 76 •41463 95 271 114 128 50 •43723 96 69 32 •46053 97 40 20 •48649 98 23 12 •50910 99 12 7 •53528 100 and upwards 13 7 •58675 Note.—The figures at the higher ages were calculated to one or more places of decimals. For convenience the nearest whole numbers only are printed, but the rates of mortality per unit are derived from the mora exact values. Females. Total number of lives at risk, and deaths for each year of age. Age. Population. Deaths. Rate of mortality per unit. In original groups. Distributed. In original groups. Distributed. o 2,498,842 552,385 154,892 94,953 •17190 1 509,034 31,996 •06286 2 488,287 13,377 •02740 3 478,251 8,625 •01803 4 470,885 5,941 •01262 5 6 7 8 9 2,252,852 469,438 461,774 451,171 440,116 430,353 11,638 4,117 2,858 2,006 1,486 1,171 •00877 •00619 •00445 •00338 •00272 10 11 12 13 14 2,106,980 423,052 418,888 418,130 420,687 426,223 5,219 1,030 982 1,006 1,064 1,137 •00243 •00234 •00241 •00253 •00267 15 4,715,603 434,173 15,160 1,212 •00279 16 443,820 1,291 •00291 17 454,360 1,352 •00298 18 464,935 1,415 •00304 19 474,706 1,473 •00310 20 482,887 1,539 •00319 21 488,797 1,597 •00327 22 491,894 1,673 •00340 23 491,779 1,758 •00357 24 488,252 1,850 •00379 25 4,082,856 480,888 23,059 1,939 •00403 26 468,241 2,004 •00428 27 450,823 2,057 •00456 28 430,467 2,111 •00490 29 410,064 2,183 •00532 30 391,885 2,281 •00582 31 377,366 2,405 •00637 32 366,648 2,559 •00698 33 357,836 2,697 •00754 34 348,638 2,823 •00810 12 Age. Population. Deaths. Rate of Mortality per unit. In Original Groups. Distributed. In Original Groups. Distributed. 35 2,901,626 336,944 30,978 2,905 •00862 36 324,255 2,969 •00916 37 311,926 3,031 •00972 38 300,613 3,071 •01022 39 290,761 3,103 •01067 40 282,252 3,124 •01107 41 274,695 3,146 •01145 42 267,566 3,171 •01185 43 260,238 3,209 •01233 44 252,376 3,249 •01287 45 2,057,578 243,924 35,222 3,298 •01352 46 235,324 3,346 •01422 47 226,709 3,396 •01498 48 218,113 3,448 •01581 49 209,570 3,497 •01669 50 201,117 3,549 •01765 51 192,786 3,598 •01866 52 184,608 3,648 •01976 53 176,610 3,697 •02093 54 168,817 3,745 •02218 55 1,310,360 161,217 40,629 3,796 •02355 56 153,743 3,847 •02502 57 146,469 3,898 •02661 58 139,488 3,952 •02833 59 132,886 4,008 •03016 60 126,668 4,071 •03214 61 120,792 4,141 •03428 62 115,172 4,219 •03663 63 109,686 4,304 •03924 64 104,239 4,393 •04214 65 747,525 98,777 47,421 4,483 •04539 66 93,352 4,571 •04897 67 87,967 4,655 •05292 68 82,611 4,731 •05727 69 77,277 4,795 •06205 70 71,967 4,842 •06728 71 66,686 4,867 •07298 72 61,446 4,867 •07921 73 56,268 4,837 •08596 74 51,174 4,773 •09327 75 76 77 78 79 80 81 82 83 84 272,480 46,194 41,359 36,704 32,262 28,068 24,151 20,536 17,245 14,289 11,672 36,664 4,673 4,536 4,361 4,149 3,904 3,630 3,333 3,017 2,694 2,367 •10116 •10966 •11880 12860 13911 15031 16230 •17498 •18850 •20283 85 37,312 9,393 9,721 2,048 •21803 86 7,439 1,741 •23402 87 5,794 1,455 •25102 88 4,434 1,193 •26893 89 3,330 958 •28764 90 2,453 754 •30746 91 92 1,771 1,251 581 438 •32835 •34998 93 864 322 •37284 94 583 231 •39670 95 1,000 384 461 162 •42156 96 246 110 •44756 97 154 73 •47462 98 93 47 •50269 99 55 29 •53192 100 and upwards 68 40 •59694 Note.—The figures at the higher age6 were calculated to one or more places of decimals. For convenience the nearest whole numbers only are printed, but the rates of mortality per unit are derived from the more exact values. 13 The curve of mortality obtained by the method of interpolation adopted in life-table construction is probably smoother and more regular than the curve which would be obtained were the actual facts relating to population and deaths at each age known and recorded. It is commonly believed that certain ages are more critical to life than others, such ages for example as those of puberty and menopause, but the method of obtaining the life-table curve tends to "smooth out" irregularities of this nature, if such exist, and the curve obtained can only be regarded as a close approximation to the true curve of mortality. When the mortality is considered in age groups, however, it is obvious that the rate of mortality at these age-groups deduced from the life-table figures should closely agree with the observed rate of mortality, i.e., the rate of mortality calculated directly from the numbers of the population and deaths upon which the life-table is based. The rate of mortality per unit among The following table shows the observed rate of mortality at each age-group and the rate of mortality at the same age-groups calculated from the dx and Px columns of the life-table (males)— Age-group. Observed rate of mortality. Rate of mortality from life-table. Difference per cent. 0 — 71-97 72-35 + 0-53 5 — 4-97 4-93 — 0-80 10 — 2-46 2-46 — 15 — 3-47 3-56 + 2-59 20 — 4-59 4-51 — 1-74 25 — 7-36 7-47 + 1-49 35 — 14-22 14-30 + 0-56 45 — 23-14 23-37 + 0-99 55 — 40-68 4106 + 0-93 65 — 77-78 78-31 + 0-68 75 and upwards 166-45 169-12 + 1-60 If the rate of mortality in each year of age be calculated from the life table, it will be found that these rates correspond exactly with the rates shown in the table on pages 9-12; the slight differences between the observed and the life-table rates shown in the above table are therefore wholly accounted for by differences in the age constitution of the population comprised in the respective agegroups. The differences between the age distribution of the life-table population and that of the actually existing London population will be readily understood when the nature of the two populations is considered. Thus the Px column of the life table represents a stationary population sustained by l0 annual births. The age constitution of such a population will necessarily differ from that of an actually existing population, disturbed by migration and a varying birth-rate, notwithstanding the fact that the rate of mortality in the two populations is identical. The population and mortality figures in the preceding tables are graphically shown in diagram I. (see page 1). Analysis of Tables. One of the principal objections to the use of death rates for purposes of comparison is the fact that differences in the age and sex constitution of the population exercise an important influence on the death rate apart from all questions as to the health conditions affecting the population. In a life table this source of error is entirely removed, as the mortality per unit at each year of life can be compared by this means, and the variation in the proportion of persons living at each age in different populations or in the same population at different times does not affect the accuracy of any comparisons which may be made. There is, however, another factor which assumes considerable importance when the mortality in urban communities is made the subject of investigation, and that factor is "migration." In nearly all large urban communities the age distribution of the population is largely affected by migration, but the immigration of young adults exercises probably the most important influence on the death rate. The life table only partially corrects for the factor of "migration." In so far as migration disturbs the age distribution of the population, its effects are compensated for by the life-table method of presenting the facts, and no allowance need be made for the effects of migration in this direction ; but the effects of migration are not limited to a mere disturbance of the age and sex constitution of the population, inasmuch as the average immigrant, largely recruited from the rural population, is probably healthier and more robust than the average unit of urban population. Migration therefore probably alters the character of the population to a considerable extent, and the method of the life table obviously can make no allowance for the effects of migration in this direction. The extent to which the London population is affected by migration may be to some degree gauged by the figures shown in the following table which are derived from the Census Reports for 1861-1901— 14 Table I. Census year. Sex. Total inhabitants enumerated. Born and living in London. ent. 1861 Males 1,307,781 817,227 62-5 Females 1,496,208 923,950 61-8 1871 Males 1.523,151 975,461 64-0 Females 1,731,109 1,080,115 62-4 1881 Males 1,797,486 1,147,063 63-8 Females 2,018,997 1,254,892 62-2 1891 Males 1,990,748 1,323,480 66-5 Females 2,220,995 1,435,915 64-7 1901 Males 2,142,085 1,441,509 67-3 Females 2,394,456 1,575,071 65-8 This table shows (a) that the proportion of persons born and living in London is increasing, in other words, that migration is a diminishing factor, and (b) that the proportion of females born and living in London is smaller than that of males, this is probably to be accounted for by the immigration of females into London as domestic servants, etc. The effect of the factor of "migration" is well illustrated in the following table (II.) in which the expectations of life and probabilities of living one year at certain ages in London and the Selected Healthy Districts of the Registrar General are compared. Table II. Comparison of probabilities of living one year and expectations of life at London, 1891-1900, with those of selected healthy districts, 1881-90— certain ages in Age X. Expectation of life, Probability of liring one year at age x, px Males. Females. Males. Females. Healthy districts, 1881-90. E. London, 1891-1900 Ex Lon 'on to healthy districts taken as 1,000. Healthy districts, 1881-90. E. London, 1891-1900. E. London to healthy districts taken as 1,000. Healthy districts, 1881-90. p. London, 1891-1900. p. London to healthy districts taken as 1,000. Healthy districts, 1881-90. p. London, 1891-1900. p. London to healthy districts taken as 1,000. 0 51-48 40-98 796 54-04 45-33 839 •88085 •81588 926 •90650 •84569 933 5 5705 51-60 904 58-01 5512 950 •99444 •99141 997 •99484 •99127 996 10 5307 47-84 901 5401 51-49 953 •99793 •99775 1,000 •99763 •99757 1,000 15 48-62 43-40 893 49•68 4710 948 •99724 •99689 1,000 •99670 •99721 1,001 20 44-41 3913 881 45•62 42-77 937 •99582 •99588 1,000 •99536 •99682 1,001 25 40-39 34-96 866 41-71 38-46 922 •99459 •99477 1,000 •99438 •99597 1,002 35 32-70 27-25 833 3416 30-42 891 •99262 •98880 996 •99270 •99142 999 45 2519 20-65 820 26-56 23-29 877 •98953 •98177 992 •99110 •98657 995 55 1800 14-76 820 1906 16-72 877 •98239 •96892 986 •98499 •97673 992 65 11-60 9-76 841 1236 1101 891 •96293 •94348 980 •96725 •95562 988 75 6-56 5-91 901 714 6-57 920 •91122 •88619 973 •91980 •90371 983 85 330 348 1,055 3-77 3-75 995 •78421 •78343 999 •81185 80340 990 In this table the influence of the mtiux of healthy lives previously referred to is very apparent and as might be expected from a consideration of the census figures this influx affects the figures relating to females more than it does the figures relating to males. Among other reasons it should also be borne in mind that it is probable that a larger proportion of females (principally of the domestic servant class) than of males return to their homes outside London when their health breaks down. It is therefore a reasonable inference that the figures relating to males are a more trustworthy index of the effect of London conditions on longevity than the figures relating to females although even these figures are unduly raised by the immigration of healthy young men. The effect of migration on the age constitution of the population is well illustrated by diagram I., showing the interpolated population and death numbers at each year of age which formed the basis of the present life table. A comparison of the male and female population curves in the diagram shows how much greater is the disturbance caused by migration in the age constitution of the female population than in that of the male population. One of the most valuable applications of the life table is its use as an instrument for measuring the effects of conditions affecting longevity obtaining in a community at different periods of time. Unfortunately no extended life table for the London population has hitherto been published, and no accurate standard of comparison for any period prior to 1891-1900 exists by which the results of the present life table can be judged. In my annual report for the year 1893, however, I published a short life-table for London, constructed according to Dr. Farr's "short" method, and based upon the mortality in the decennium 1881-90, but the table so obtained cannot be used for comparison with the present table, as the " short " method of Dr. Farr does not give more than an approximation to the actual expectation of life, and this is particularly the case at the higher ages where the differences in the results obtained by the "short" and "extended" methods of construction are so marked as to make any comparison valueless. Since the short table for 1881-90 was constructed, however, a series of papers have been written for the Royal Statistical Society by Dr. Hayward, Medical Officer of 15 Health of Haydock,* in which he shows that by a modification of Dr. Farr's "short" method "expectations of life" at quinquennial or decennial intervals of age can be calculated which are so near the true values that they can, for all practical purposes, be compared with the expectation of life obtained by the more laborious "extended" method of life table construction. With the object of obtaining some indication of the improvement or otherwise in the conditions affecting longevity obtaining in London, the short life table for 1881-90 has been reconstructed on the lines suggested by Dr. Hay ward, and the "expectations of life" thus obtained are set out in the following table— Table III. Comparison of the Expectation of Life at various ages in London, 1881-90 and 1891-1900. [###Age. Males. Females. 1881-90. 1891-1900. Increase. 1881-90. 1891-1900. Increase. 0 39.85 40.98 1.13 44.18 45.33 1.15 5 50.35 51.60 1.25 53.96 55.12 1.16 10 46.79 47.84 1.05 50.48 51.49 1.01 15 42.44 43.40 0.96 46.18 47.10 0.92 20 38.26 39.13 0.87 41.97 42.77 0.80 25 34.24 34.96 0.72 37.85 38.46 0.61 35 26.89 27.25 0.36 30.17 30.42 0.25 45 20.44 20.65 0.21 23.22 23.29 0.07 55 14.64 14.76 0.12 16.67 16.72 0.05 65 9.71 9.76 0.05 10.94 11.01 0.07 75 5.84 5.91 0.07 6.55 6.57 0.02 It will be seen from the table that the "expectation of life" is greater in the case of both males and females at each age in 1891-1900 than in 1881-90, the increase is most marked at the earlier ages and gradually becomes less as age advances. The results obtained appear to be generally consistent † with the decline in the mortality figures at each age-period shown in Table IV. but it should be pointed out that the mortality figures upon which the life table for the period 1881-90 was based were uncorrected for deaths occurring in public institutions as the facts relating to these deaths were not ascertainable for that decennium; the errors introduced into the figures of the earlier life table on this account are probably not of very great magnitude owing to the fact that the deaths of Londoners occurring outside London are more or less counterbalanced by the deaths of non.Londoners occurring within the London area, but inasmuch as the exact amount of error so introduced is not ascertainable too much importance must not be attached to the comparison made in Table III., and the figures for 1881-90 must be regarded as approximate only. When the figures for the decennium 1901-1910 are available, however, and a life table on the experience of that decennium is constructed the present extended life table will furnish an invaluable standard of comparison, the figures being free from the objections just pointed out which can be urged against the life table for 1881-90 on the ground of method of construction and inaccuracy of data. The following table shows the death rates at each age period obtaining in the two decennia to which the life tables for London relate, the figures for the decennia 1861-70 and 1871-80 are included in the table for purposes of comparison. Table IV. Death-rates in London per 1,000 living at different age-periods in the decennia 1861-70, 1871-80, 1881-90, and 1891-1900. Age-period. Males. Females. 1861-70. 1871-80. 1881-90. 1891-1900. 186-70. 1871-80. 1881-90. 1891-1900. Under 5 86.91 77.86 73.09 71.97 76.32 67.66 63.26 61.99 5 9.37 7.42 5.93 4.97 8.85 6.73 5.82 5.17 10 4.24 3.57 2.92 2.46 4.07 3.45 2.89 2.48 15 5.82 5.05 4.05 3.47 5.10 4.36 3.58 2.94 20 8.23 6.95 5.44 4.59 6.22 5.46 4.40 3.46 25 10.86 10.13 8.65 7.36 8.80 8.04 6.82 5.65 35 45 1714 25.68 16.64 25.37 14.96 23.87 1422 23.14 12.84 18.52 12.32 18.08 11.42 17.23 10.68 17.12 55 43.85 43.20 41.33 40.68 33.45 32.95 30.77 31.01 65 82.83 80.08 77.97 77.78 67.23 66.63 63.38 63.44 75 184.51 176.81 169.36 166.45 164.71 159.50 150.26 150.73 All ages 26.55 24.38 22.10 20.88 22.34 20.60 18.83 17.88 * Journal of the Royal Statistical Society, Vol. LXII., Part III. Dr. Hayward does not claim complete mathematical demonstration for his improved method, but by applying his method to several of the extended life tables recently published he obtains results which approximate with remarkable exactitude to those obtained from the "extended" method of construction. † It will be seen that the "expectation" of females aged 55 years and upwards is slightly greater in the later decennium, notwithstanding that the mortality at these ages shows a slight increase. The differences, however, are very small, and the inconsistency is due to the "short" method of construction adopted in the life table for 1881-90. 16 The table indicates the progressive improvement which has taken place in successive periods in the death rates in the last 40 years. Not only is this manifested in the death rate at "all ages," but at each age period and in each sex, the only exceptions shown being a slight increase in the last decennium in the death rates of women at the ages 55 and upwards. It may be that the slight increase at these ages is due to the fact that the deaths in the three earlier decennia are uncorrected for deaths in metropolitan institutions situated within and without the county and as already stated, correction has, as far as practicable, been made for such deaths in the figures relating to the last decennium. Table V. shows the probability, at various ages, of living one year in London according to the experience of 1891-1900, and in Glasgow, Manchester, Brighton and England and Wales according to the experience of 1881-90. In London the probabilities at the ages shown of living one year are greater generally than those of Glasgow and Manchester, but less than those of Brighton and England and Wales. The first year of life in London is an exception to this statement so far as relates to Glasgow. In the period 1891-1900, however, infant mortality was generally higher than in the preceding decennium. Thus in England and Wales in the earlier decennium the deaths under one year of age per 1,000 births were 142, and in the later decennium 154. The probability, therefore, at age 0, of living one year may be found to be less in Glasgow than in London when the experiences of the same period are compared. It is interesting to observe that the probabilities of living one year at ages 20 and 25 in the case of males, and at ages 15, 20, 25 and 35 in the case of females, are actually greater in London than in England and Wales, the explanation of which will probably be found in the facts (a) that the periods compared are not identical, and (b) the immigration at these ages of healthy persons into London tends to increase the probabilities of living one year at these ages. Table V. The probability of living one year at various ages in London, 1891-1900, and in Glasgow, Manchester, Brighton and England and Wales in 1881-90. Age. Males. Females. London, 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales. 1881-90. London, 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales, 1881-90. 0 •81588 •82531 •80650 •84608 •83896 •84569 •85318 •84169 •87672 •86887 5 •99141 •98417 •98707 •99290 •99168 •99127 •98511 •98635 •99405 •99214 10 •99775 •99455 •99397 •99701 •99805 •99757 •99497 •99397 •99726 •99833 15 -99689 •99347 •99576 •99646 -99713 •99721 •99370 •99604 •99710 •99705 20 •99588 -99219 •99447 •99539 •99520 •99682 •99180 •99495 •99683 •99511 25 •99477 •99187 •99168 •99403 •99364 •99597 -99028 -99255 •99589 •99379 35 -98880 •98831 •98449 •98964 -98981 •99142 -98738 -98732 •99271 •99076 45 -98177 •97920 -97513 •98311 •98437 •98657 •98293 -98096 •98857 •98765 55 -96892 •96469 •95904 •97369 •97398 •97673 •97085 •96646 •98098 •97910 65 •94348 •93675 •92307 •95406 •94943 •95562 •94646 -93538 -96487 •95801 75 •88619 •88267 -85891 •91501 •89542 •90371 •90403 •87615 •91233 •90721 The following table (VI.) shows the number surviving at certain ages out of 100,000 born in London according to the experience of 1891-1900, and in Glasgow, Manchester, Brighton and England and Wales according to the experience of 1881-90. So far as the comparison of the two different periods indicates London is at each age more favourably situated in this respect than Glasgow and Manchester, and less favourably situated than Brighton and England and Wales. Table VI. Number surviving at certain ages out of 100,000 born in London in 1891-1900, and in Glasgow, Manchester, Brighton and England and Wales in 1881-90. Age. Males. Females. London, 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales, 1881-90. London, 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales, 1881-90. 0 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 5 71,898 66,870 67,896 75,125 75,149 74,937 69,992 71,792 78,546 78,324 10 70,152 63,550 64,675 73,344 73,348 73,050 66,865 68,256 76,811 76,615 15 69,295 61,799 63,076 72,501 72,619 72,151 65,109 66,614 75,839 75,906 20 68,072 59,610 61,644 71,015 71,255 71,089 62,831 65,219 74,733 74,432 25 66,555 57,288 59,645 69,273 69,381 69,876 60,108 63,300 73,470 72,479 35 61,742 52,148 53,173 64,090 63,964 65,944 53,802 57,335 69,508 67,099 45 53,471 44,653 43,664 56,175 56,444 59,196 46,597 49,192 63,475 60,40] 55 42,224 34,061 31,859 45,303 46,298 49,722 37,441 38,324 54,779 51,637 65 27,764 21,211 18,067 32,455 32,248 36,173 25,156 24,027 42,731 38,550 75 12,199 8,711 6,069 16,666 15,389 18,592 12,074 9,458 25,080 20,421 • Further evidence of the higher rate of infantimortality obtaining in 1891-1900 may be seen on reference to tht Haydock life tables previonsly mentioned. In the Haydock life table for 1881-90 the probability of living one year at age 0 (males) is given as -86506, while in the life table for 1891-1900 this probability is shown to have fallen to -78510. 17 From the previous table (VI.) showing the number of survivors at each age in different communities it is evident that the populations of urban communities such as London, Glasgow and Manchester begin life under more adverse conditions than the population of the country as a whole. Whether those who survive the greater risks to early life which obtain in such communities are still subject, at the later ages, to conditions which are more adverse to longevity will be better seen on reference to the following table (VII.), which shows the numbers surviving given age-periods out of 1,000 entering them ; by this method of comparison the effect ot a high infant mortality on the total survivors at any age out of a given number born is eliminated, and the effects of the conditions affecting longevity obtaining for particular age-periods can be more easily appreciated. At each period of life the conditions affecting longevity were more favourable in London in 1891-1900 than in Glasgow and Manchester in 1881-90 and less favourable in London in 1891-1900 than in England and Wales in 1881-90 except at those ages affected by migration, as has been already pointed out. Table VII. Of 1,000 entering given age-periods the number surviving through the period. Age period. Males. Females. London, 1891-1900. Glasgow, 1881-90. Manchester, 1881-90. England and Wales, 1881-90. London, 1891-1900. Glasgow, 1881-90. Manchester. 1881-90. England and Wales, 1881-90. 0— 5 719 669 679 751 749 700 718 783 5—15 964 924 929 966 963 930 928 969 15—25 960 927 946 955 968 923 950 955 25—45 803 779 732 814 847 775 777 833 45—65 519 475 414 571 611 539 488 638 The expectation of life at various ages in these different communities is shown in the following table (VIII.), and it has again been necessary to compare London figures based on the experiences of 1891-1900 with those of the other communities based on the experiences of the preceding decennium. Thus compared it is seen that London occupies a position between England and Wales and Brighton on the one hand and Glasgow and Manchester on the other. This will be more clearly seen on reference to diagram II. The "expectation curves" for London, England and Wales and the healthy districts are shown in diagram III. Table VIII. Expectation of life at various ages—London, 1891-1900. Glasgow, Manchester, Brighton and England and Wales, 1881-90. Age. Males. Females. London, 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales, 1881-90. London. 1891-1900. Glasgow, 1881-90. Manchester 1881-90. Brighton, 1881-90. England and Wales 1881-90. 0 40-98 3518 34-71 43-59 43-66 45-33 37-70 38-44 49-25 47-18 5 5160 46-97 4559 52-87 52-75 5512 48-27 4806 57-36 54-92 10 47-84 44-32 42-75 4912 49-00 51-49 45-44 45-43 53-60 5110 15 43-40 40-51 38-78 44-67 44-47 47-10 41-59 41-50 49-26 46-55 20 3913 36-90 34-62 40-55 40-27 42-77 ' 38 00 37-33 44-95 42-42 25 34-96 33-29 30-69 36-51 36-28 38-46 34-60 33 38 4C-38 38-50 35 27-25 2606 23-76 29-02 28-91 30-42 28 06 26-30 32.39 3116 45 20-65 19-54 17-80 22-36 22-06 23-29 21-61 19-79 2530 24-05 55 14-76 13-99 12-49 16-48 15-74 16-72 15-60 1391 18-48 1723 65 9-76 9-38 815 1C-96 10-31 1101 10-69 911 1219 11-26 75 591 5-96 511 6-34 610 6-57 6-97 5-76 6-97 6-68 An interesting question to which the life table supplies an answer is how much of the total expectation of life at birth is lived at various age periods of life ? How much of the total expectation of life is lived in infancy, in maturity and in old age ? It will be seen from the life table (page 22) that 509,112 males born in London will live a total of 20,865,753 years, the average lifetime of each being 20,865,753/509,112or 40-98 years; from the figures given in the Qx column of the table it is easily shown how many of these years of life are lived between any given ages thus the number of years of life lived between ages 0 and 5 years will be equal to Q0— Q5 or 20,865,753—18,888,313 — 1,977,440 years and the average number of years lived by each of the 509,112 males at birth between ages 0 and 5 will be equal to or 3-88 years. In Table IX. similar results are shown for four age periods which approximately represent infancy, school-age, working period of life and the period of decline. From this table it appears that, adopting the England and Wales figures as a standard, London males lose 3.5 per cent, ot the period of infancy, 4-4 per cent, of the period of school-age, 5'6 per cent, of the working period of life, and 18.4 per cent, of the period of decline. It should, however, be pointed out in this connection that the age of decline in a community whose mean expectation of life falls below that of England and [3] 18 Wales, probably begins at an earlier age. Thus for the purposes of the table, age 65 has been taken as the first year of age in the period of decline, but the expectation of life for males in England and Wales at age 65 equals 10.31 years, while in London the expectation of life for males of this age is only equal to 9.76 years. If, therefore, the age at which decline begins be defined as the age at which the expectation of life first falls below 10 32 years, this age for males will be age 64 in London, and the resulting loss in the working period and period of decline will work out at 6.5 per cent, and 9.9 per cent, respectively. If the figures shown in the table for females be compared on similar lines it will be found that London females lose 3.1 per cent of the period of infancy, 4.7 per cent, of the school age period, 3.2 per cent, of the working period of life and 8.3 per cent, of the period of decline. If the age at which the period of decline begins be defined in the case of females as the age at which the expectation of life first falls below 11.27 years (the expectation of life in England and Wales at age 65 being 11.26 years) it will be seen that although the expectation of life of females in London at age 65 is lower than that for the same age in England and Wales the expectation of life at age 64 is greater than 11.27 years, and the age of decline for females must therefore be assumed to be almost identical in the two communities. Table IX. Mean life·time in years, divided into infancy, school age, working period and decline. London, 1881-1890 and 1891-1900; Glasgow, Manchester, and England and Wales, 1881-1890. Life·period. Males. Females. London, 1891· 1900. London, 1881·90. Glasgow, 1881·90. Manchester, 1881·90. England and Wales, 1881·90. London, 1891· 1900. London, 1881·90. Glasgow, 1881·90. Manchester, 1881·90. England and Wales, 1881·90. Infancy (0·5) 3.88 3.89 3.77 ?.76 4.02 4.03 4.03 3.92 3.94 4.16 School age (5·15) ... 7.03 6.96 6.38 6.50 7.35 7.32 7.25 6.72 6.86 7.68 Working period (15·65) ... 27.36 26.40 2304 22.98 28.97 30.00 29.04 24.35 25.45 31.00 Decline (65 and up) 2.71 2.60 1.99 1.47 3.3.2 3.98 3.86 2.71 2.19 4.34 Total 40.98 39.85 35.18 34.71 43.66 45.33 44.18 37.70 38.44 47.18 In the Supplement to the Fifty·fifth Annual Report of the Registrar-General, Part II., Dr. Tatham, in discussing the new healthy districts life·table, 1881-90, points out that "the better the health conditions represented by the life table are, the less is the increase of the expectation, the sooner is the age of maximum expectation attained, and the sooner also is an age reached at which the expectation falls below that at birth." These points are illustrated by a table which I here reproduce, supplemented by the results obtained from the present London Life Table, 1891-1900— Table X. England and Wales. Manchester Township, 1881-90. Selected healthy districts. London, 1891·1900. 1838-54. 1871-80. 1881-90. 1849-53. 1881-90. Males. Expectation of life at birth 39.91 41.35 43.66 28.78 48.56 51.48 40.98 Age of maximum expectation ... 4 4 3 4 3 2 3 Increase of expectation from C In years. 9.90 9.66 9.66 12.02 6.28 6.87 11.04 birth to age of maximum ( Percent. 24.8 23.4 22.1 41.8 12.9 13.3 26.9 Year of life during which the expectation first falls below that at birth 20th 18th 16th 22nd 14th 12th 18th Females. Expectation of life at birth 41.85 44.62 47.18 32.67 49.45 54.04 45.33 A^e of maximum expectation ... 4 4 3 4 3 2 3 and 4 Increase of expectation from (In years. 8.58 8.58 8.28 11.14 4.96 5.32 10.09 birth to age of maximum ( Per cent. 20.5 19.2 17.6 34.1 10.0 9.8 22.3 Year of life during which the expectation first falls below that at birth 18th 17 th 15th 21st 12th 10th 18th In London, therefore, in 1891-1900 the expectation of life of males at birth was 40.98 years increasing to a maximum at 3 years of age of 52.02 years or an increment of 11.04 years or 26.9 per cent, of the expectation at birth. After age 3 the expectation decreases year by year until it falls below the expectation at birth in the 18th year of age. In the healthy districts in 1881-90, the expectation among males was 51.48 years at birth, increasing to a maximum of 58.35 years at 2 years of age, one year earlier than in London, an increment of only 6.87 years, or 13.3 per cent., and falling below the expectation at birth in the 12th year of age or 6 years earlier than in London. Among the many valuable applications of the life table is its use in making accurate comparisons of the mortality obtaining at different periods in the same community. Comparisons Diagram III. 19 of death rates do not give more than approximate indications of the net gain or loss to the community by fluctuations of mortality, and it is in arriving at a more accurate result in this respect that a life table is especially useful. The following example of an extreme case may show this more clearly. Assume that in a certain community 800 deaths occur in one year and that 400 of these deaths occur among persons aged 0—25 whose mean future lifetime, is say 30 years and that the remaining 400 deaths occur among persons aged 25 and upwards, whose mean future lifetime is say 15 years, then these 800 deaths will represent a total of 18,000 years of "life capital" lost to the community for— (400 x 30) + (400 x 15) = 18,000 years. Now suppose that 700 deaths occur in the same community in the following year, and that 600 of these deaths occur among persons aged 0—25 and the remaining 100 among persons aged 25 and upwards then the loss of "life capital " to the community will be (600 X 30) + (100 X 15) = 19.500 years. Thus, while there is a saving ot 100 lives in the second year compared with the first, there is an actual loss to the community of l,500years of " life capital." In order to apply the life table to the calculation of "life capital" it is necessary to ascertain the mean future lifetime of the population living at each age period. The life table shows the expectation of life of persons at the exact age x, but it will easily be seen that the expectation of life Mean future lifetime of Males and Females in groups of ages. Age-groups. Males. Females. Years. Years. 0— 50.16 53.66 5— 49.89 53.48 10— 4561 49.30 15— 41.26 44.94 20— 3705 40.62 25— 3105 34.39 35— 23.98 26.89 45— 17.75 20.04 55— 12.35 13.93 65— 7.98 8.90 75— 4.91 5.37 85 and upwards 302 319 This table furnishes an accurate means of comparing the effect of fluctuations of mortality at different periods in the London population, for if the number of deaths which would have occurred at the rates of 1891.1900 in each age-group for any period be calculated and compared with the deaths which actually occurred during the period, the differences between the two sets of figures will be the number of lives saved or lost by fluctuations of mortality in the given period, and by applying to these numbers the figures shown in the table the gain or loss may be expressed in terms of "life capital." In my annual reports for the years 1894 onwards, I have adopted this method of comparison on the basis of the experience of mortality in London daring the decennium 1881-90, in the same manner as shown by Dr. Tatham in a report on " The Health of Greater Manchester during the three years, 1891-3." The figures shown in the table may also be utilised for the purpose of estimating the total " life capital" of the London population at any period, and the result of this calculation is shown in the following table. The population figures represent the estimated mean population living in London during the decennium 1891-1900. 20 Table XII. Estimated mean population and life capital of the County of London in the decennium, 1891-1900. Age-groups. Males. Females. Population. Life capital. Population. Life capital. 0— 248,372 12,458,340 249,884 13,408,775 5— 223,040 11,127,466 225,285 12,048,242 10— 206,698 9,427,496 210,698 10,387,411 15— 202,502 8,355,233 225,380 10,128,577 20— 204,616 7,581,023 246,180 9,999,832 25— 350,723 10,889,949 408,286 14,040,956 35— 261,854 6,279,259 290,163 7,802,483 45— 183,125 3,250,469 205,758 4,123,390 55— 107,870 1,332,194 131,036 1,825,331 65— 52,470 418,711 74,752 665,293 75— 15,422 75,722 27,248 146,322 85 and upwards 1,615 4,877 3,831 12,221 All ages 2,058,307 71,200,739 2,298,501 84,588,833 From the figures in this table the average "life capital" of each member of the population may be ascertained for if the total life capital be divided by the total population the result will give the average "life capital" or "future lifetime" of each member of the population; the amount per cent, of this life capital expended per annum may also be easily calculated as this figure is obviously equal to 100/average life capital. The result of these calculations is shown in the following average lite capital table— Table XIII. Mean population, 1891-1900. Total life capital of the population. Average life capital of the population. Proportion per cent. of life capital expended in a year. Persons 4,356,808 155,789,572 35.76 2.797 Males 2,058,307 71,200,739 3459 2.891 Females 2,298,501 84,588,833 36.80 2.717 From this table it would appear that so long as the age and sex constitution of the population and the death rates at the various age periods remain the same as in the decennium 1891-1900 the average life capital of the population of London is 35.76 years, and the expenditure of this capital per annum is 2.797 per cent. Another interesting application of the "life table" is a comparison of the number of years of life added by the births in the community with the number of years of life expended bv the community. The mean expectation of life at birth in London is shown by the life table to be 40 98 years in the case of males and 45.33 years in the case of females. If these figures be applied to the total births in the decennium 1891.1900 the result will show the number of years of life added to the "life capital" of the population, and the estimated mean population X 10 will give the number of years of life expended by the population during the same period. These figures are shown in the following table — Table XIV. Sex. Births in 1891-1900. Mean future lifetime. Years of life added by births in 1891-1900. Years of life expended by the population, 1891-1900. Males 677,482 40.98 27,763,212 20,583,066 Females 653,232 45.33 29,611,007 22,985,014 Persons 1,330,714 — 57,374,219 43,568,080 It will be seen from this table that the years of life added to the "life capital" of the population of London in the decennium 1891-1900 exceeds the years of "life capital" expended by 13,806,139; in other words, for every 100 years of "life capital" expended 132 years were added by births occurring in the community. A similar calculation for England and Wales in the decennium 1881-90 shows that for every 100 years of "life capital" expended by the population in England and Wales 147 years of "life capital" were added by the births. The results obtained for England and Wales would probably bear even more favourable comparison with the figures shown for London if the facts for the decennium 1891-1900 were available. Shirley F. Murphy, Medical Officer of Health. LONDON LIFE TABLE. (Based on the mortality of the ten years, 1891-1900.) TABLE I—MALES. TABLE II—FEMALES. TABLE III.—MALES AND FEMALES. 22 Table I. LONDON LIFE TABLE. Males. Lije Table for London based on the mortality in the decennium 1891-1900. Age. Dying in each year of age. Born and surviving at each age. Population or years of life lived in each year of age. Population or years of life lived in and above each year of age. Expectation of life at each age. X dx lx P. Q« E. 0 93,736 509,112 450,666 20,865,753 40.98 1 27,283 415.376 401,734 20,415,087 4915 2 10,721 388,093 382,732 20,013,353 51.57 3 6,771 377,372 373,986 19,630,621 5202 4 4,558 370,601 368,322 19,256,635 51.96 5 3,145 366,043 364,470 18,888,313 51.60 6 2,177 362,898 361,809 18,523,843 5104 7 1,532 360,721 359,955 18,162,034 50.35 8 1,131 359,189 358,623 17,802,079 49.56 9 904 358,058 357,606 17,443,456 48.72 10 805 357,154 356,751 17,085,850 47.84 11 794 356,349 355,952 16,729,099 46.95 12 840 355,555 355,135 16,373,147 46 05 13 917 354,715 354,256 16,018,012 4516 14 1,006 353,798 353,295 15,663,756 44.27 15 1,098 352,792 352,243 15,310,461 43.40 16 1,182 351,694 351,103 14,958,218 42.53 17 1,257 350,512 349,884 14,607,115 41.67 18 1,318 349,255 348,596 14,257,231 40.82 19 1,374 347,937 347,250 13,908,635 39.97 20 1,427 346,563 345,850 13,561,385 3913 21 1,480 345,136 344,396 13,215,535 38.29 22 1,537 343,656 342,887 12,871,139 37.45 23 1,602 342,119 341,318 12,528,252 36.62 24 1,679 340,517 339,678 12,186,934 35.79 25 1,771 338,838 337,953 11,847,256 34.96 26 1,855 337,067 336,140 11,509,303 3415 27 1,956 335,212 334,234 11,173,163 33.33 28 2,093 333,256 332,209 10,838,929 32.52 29 2,264 331,163 330,031 10,506,720 31.73 30 2,470 328,899 327,664 10,176,689 30.94 31 2,695 326,429 325,082 9,849,025 3017 32 2,922 323,734 322,273 9,523,943 29.42 33 3,137 320,812 319,243 9,201,670 28.68 34 3,337 317,675 316,007 8,882,427 27.96 35 3,519 314,338 312,579 8,566,420 27.25 36 3,705 310,819 308,966 8,253,841 2656 37 3,885 307,114 305,171 7,944,875 25.87 38 4,048 303,229 301,205 7,639,704 2519 39 4,194 299,181 297,084 7,338,499 24.53 40 4,314 294,987 292,830 7,041,415 23.87 41 4,428 290,673 288,459 6,748,585 23.22 42 4,543 286,245 283,973 6,460,126 22.57 43 4,667 281,702 279,369 6,176,153 21.92 44 4,807 277,035 274,632 5,896,784 21.29 45 4,963 272,228 269,746 5,622,152 20.65 46 5,124 267,265 264,703 5,352,406 2003 47 5,289 262,141 259,497 5,087,703 19.41 48 5,458 256,852 254,123 4,828,206 18.80 49 5,633 251,394 248,578 4,574,083 1819 50 5,807 245,761 242,858 4,325,505 17.60 51 5,983 239,954 236,962 4,082,647 1701 52 6,160 233,971 230,891 3,845,685 16.44 53 6,334 227,811 224,644 3,614,794 15.87 54 6,510 221,477 218,222 3,390,150 15.31 Age. Dying in each year of age. Born and surviving at each age. Population or years of life lived in each year of age. Population or years of life lived in and above each year of age. Expectation of life at each age. X dx 1. P. Q. Ex 55 6,681 214,967 211,626 3,171,928 14.76 56 6,859 208,286 204,856 2,960,302 14.21 57 7,035 201,427 197,910 2,755,446 13.68 58 7,198 194,392 190,793 2,557,536 1316 59 7,349 187,194 183,520 2,366,743 12.64 60 7,482 179,845 176,104 2,183,223 1214 61 7,599 172,363 168,564 2,007,119 11.64 62 7,705 164,764 160,911 1,838,555 1116 63 7,807 157,059 153,156 1,677,644 10.68 64 7,901 149,252 145,302 1,524,488 10.21 65 7,989 141,351 137,356 1,379,186 9.76 66 8,061 133,362 129,331 1,241,830 9.31 67 8,109 125,301 121,246 1,112,499 8.88 68 8,129 117,192 113,127 991,253 8.46 69 8,116 109,063 105,005 878,126 8.05 70 8,064 100,947 96,915 773,121 7.66 71 7,965 92,883 88,901 676,206 7.28 72 7,819 84,918 81,009 587,305 6.92 73 7,622 77,099 73,288 506,296 6.57 74 7,372 69,477 65,791 433,008 6.23 75 7,068 62,105 58,571 367,217 5.91 76 6,715 55,037 51,679 308,646 5.61 77 6,314 48,322 45,165 256,967 5.32 78 5,871 42,008 39,072 211,802 504 79 5,399 36,137 33,437 172,730 4.78 80 4,901 30,738 28,287 139,293 4.53 81 4,393 25,837 23,640 111,006 4.30 82 3,882 21,444 19,503 87,366 407 83 3,379 17,562 15,873 67,863 3.86 84 2,898 14,183 12,734 51,990 3.67 85 2,444 11,285 10,063 39,256 3.48 86 2,028 8,841 7,827 29,193 3.30 87 1,652 6,813 5,987 21,366 314 88 1,320 5,161 4,501 15,379 2.98 89 1,036 3,841 3,323 10,878 2.83 90 796 2,805 2,407 7,555 2.69 91 600 2,009 1,709 5,148 2.55 92 441 1,409 1,189 3,439 2.44 93 318 968 809 2,250 2.32 94 223 650 539 1,441 2.22 95 153 427 350 903 211 96 103 274 223 553 202 97 67 171 138 330 1.93 98 42 104 83 192 1.84 99 26 62 49 109 1.76 100 16 36 28 60 1.68 101 9 20 16 32 1.61 102 5 11 8 17 1.53 103 3 6 4 8 1.45 104 2 3 2 4 1.35 105 1 1 1 1 1.20 23 Note.—The figures at the higher ages in the lx, Px and qx columns were calculated to one or more places of decimals. For convenience the nearest whole numbers only are printed, but the Expectations of Life are derived from the more exact values. 24 Table II. Females. Lije table for London based on the mortality in the decennium 1891-1900. Age. Dying in each year of age. Born and surviving at each age. Population or years of life lived in each year of age. Population or years of life lived in and above each year of age. Expectation of life at each age. X dx lx Px Qx Ex 0 75,748 490,888 444,778 22,253,066 4533 1 25,299 415,140 402,491 21,808,288 52.53 2 10,536 389,841 384,573 21,405,797 54.91 3 6,779 379,305 375,916 21,021,224 55.42 4 4,671 372,526 370,191 20,645,308 55.42 5 3,212 367,855 366,249 20,275,117 5512 6 2,249 364,643 363,519 19,908,868 54.60 7 1,607 362,394 361,590 19,545,349 53.93 8 1,217 360,787 360,178 19,183,759 5317 9 977 359,570 359,081 18,823,581 52.35 10 872 358,593 358,157 18,464,500 51.49 11 838 357,721 357,302 18,106,343 50.62 12 858 356,883 356,454 17,749,041 49.73 13 899 356,025 355,576 17,392,587 48.85 14 946 355,126 354,653 17,037,011 47.97 15 988 354,180 353,686 16,682,358 47.10 16 1,026 353,192 352,679 16,328,672 46.23 17 1,046 352,166 351,643 15,975,993 45.36 18 1,067 351,120 350,586 15,624,350 44.50 19 1,084 350,053 349,511 15,273,764 43.63 20 1,110 348,969 348,414 14,924,253 42.77 21 1,135 347,859 347,291 14,575,839 41.90 22 1,178 346,724 346,135 14,228,548 41.04 23 1,233 345,546 344,930 13,882,413 4018 24 1,302 344,313 343,662 13,537,483 39.32 25 1,380 343,011 342,321 13,193,821 38.46 26 1,460 341,631 340,901 12,851,500 37.62 27 1,548 340,171 339,397 12,510,599 36.78 28 1,657 338,623 337,794 12,171,202 35.94 29 1,789 336,966 336,071 11,833,408 3512 30 1,945 335,177 334,204 11,497,337 34.30 31 2,117 333,232 332,173 11,163,133 33.50 32 2,303 331,115 329,964 10,830,960 32.71 33 2,468 328,812 327,578 10,500,996 31.94 34 2,632 326,344 325,028 10,173,418 3117 35 2,779 323,712 322,323 9,848,390 30.42 36 2,925 320,933 319,471 9,526,067 29.68 37 3,076 318,008 316,470 9,206,596 28.95 38 3,201 314,932 313,332 8,890,126 28.23 39 3,309 311,731 310,076 8,576,794 27.51 40 3,395 308,422 306,724 8,266,718 26.80 41 3,473 305,027 303,291 7,959,994 2610 42 3,553 301,554 299,778 7,656,703 25.39 43 3,651 298,001 296,175 7,356,925 2469 44 3,765 294,350 292,467 7,060,750 23.99 45 3,903 290,585 288,633 6,768,283 23.29 46 4,047 286,682 284,658 6,479,650 22.60 47 4,203 282,635 280,533 6,1 94,992 21.92 48 4,367 278,432 276,248 5,914,459 21.24 49 4,536 274,065 271,797 5,638,211 20.57 50 4,715 269,529 267,172 5,366,414 19.91 51 4,897 264,814 262,365 5,099,242 19.26 52 5,085 259,917 257,374 4,836,877 18.61 53 5,279 254,832 252,192 4,579,503 17.97 54 5,475 249,553 246,816 4,327,311 17.34 25 Age. x Dying in each year of age. dx Born and surviving at each age. lx Population or years of life lived in each year of age. Px Population or years of life lived in and above each year of age. Qx Expectation of life at each age. Ex 55 5,680 244,078 241,238 4,080,495 16.72 56 5,891 238,398 235,452 3,839,257 16.10 57 6,107 232,507 229,453 3,603,805 15.50 58 6,325 226,400 223,238 3,374,352 14.90 59 6,540 220,075 216,805 3,151,114 14.32 60 6,754 213,535 210,158 2,934,309 13.74 61 6,969 206,781 203,296 2,724,151 13.17 62 7,187 199,812 196,218 2,520,855 12.62 63 7,413 192,625 188,918 2,324,637 12.07 64 7,645 185,212 181,389 2,135,719 11.53 65 7,880 177,567 173,627 1,954,330 11.01 66 8,111 169,687 165,632 1,780,703 10.49 67 8,330 161,576 157,411 1,615,071 10.00 68 8,533 153,246 148,979 1,457,660 9.51 69 8,708 144,713 140,359 1,308,681 9.04 70 8,853 136,005 131,578 1,168,322 8.59 71 8,954 127,152 122,675 1,036,744 8.15 72 9,005 118,198 113,696 914,069 7.73 73 8,999 109,193 104,693 800,373 7.33 74 8,928 100,194 95,730 695,680 6.94 75 8,788 91,266 86,872 599,950 6.57 76 8,574 82,478 78,191 513,078 6.22 77 8,288 73,904 69,760 434,887 5.88 78 7,929 65,616 61,652 365,127 5.56 79 7,503 57,687 53,936 303,475 5.26 80 7,015 50,184 46,676 249,539 4.97 81 6,481 43,169 39,929 202,863 4.70 82 5,903 36,688 33,737 162,934 4.44 83 5,303 30,785 28,134 129,197 4.20 84 4,693 25,482 23,136 101,063 3.97 85 4,087 20,789 18,746 77,927 3.75 86 3,499 16,702 14,953 59,181 3.54 87 2,945 13,203 11,731 44,228 3.35 88 2,431 10,258 9,042 32,497 3.17 89 1,969 7,827 6,842 23,455 3.00 90 1,561 5,858 5,078 16,613 2.84 91 1,212 4,297 3,691 11,535 2.68 92 919 3,085 2,626 7,844 2.54 93 681 2,166 1,826 5,218 2.41 94 491 1,485 1,240 3,392 2.28 95 346 994 821 2,152 2.16 96 237 648 529 1,331 2.05 97 158 411 332 802 1.95 98 101 253 202 470 1.85 99 64 152 120 268 1.76 100 39 88 69 148 1.67 101 22 49 38 79 1.59 102 13 27 20 41 1.51 103 7 14 11 21 1.43 104 4 7 5 10 1.35 105 1 3 3 4 1.26 106 1 2 1 2 1.14 107 1 1 1 1 0.92 Note—The figures at the higher ages in the lx, Px, and Qx columns were calculated to one or more places of decimals. For convenience the nearest whole numbers only are printed, but the Expectations of Life are derived from the more exact values. [4] 26 Table III. Males and Females. Life-table for London based on the mortality in the decennium, 1891-1900. Age. x Probability of living one year from each age. Px Of 1,000,000 males born, the number surviving at each age. lx Of 1,000,000 females born, the number surviving at each age. lx Of 1,000,000 of both sexes (509,112 males and 490,888 females) born. The number surviving at each age. lx Population or years of life lived in and above each year. Qx Males. Females. 0 .81588 .84569 1,000,000 1,000,000 1,000,000 43,118,819 1 .93432 .93906 815,884 845,692 830,516 42,223,375 2 .97237 .97297 762,293 794,155 777,934 41,419,150 3 .98206 .98213 741,235 772,692 756,677 40,651,845 4 .98770 .98746 727,936 758,882 743,127 39,901,943 5 .99141 .99127 718,982 749,367 733,898 39,163,430 6 .99400 .99383 712,805 742,824 727,541 38,432,711 7 .99575 .99556 708,530 738,241 723,115 37,707,383 8 .99685 .99663 705,521 734,967 719,976 36,985,838 9 .99748 .99728 703,298 732,489 717,628 36,267,037 10 .99775 .99757 701,523 730,498 715,747 35,550,350 11 .99777 .99766 699,942 728,721 714,070 34,835,442 12 .99764 .99760 698,382 727,015 712,438 34,122,188 13 .99741 .99747 696,733 725,268 710,740 33,410,599 14 .99716 .99734 694,931 723,435 708,924 32,700,767 15 .99689 .99721 692,955 721,508 706,972 31,992,819 16 .99664 .99710 690,799 719,496 704,886 31,286,890 17 .99641 .99703 688,477 717,407 702,678 30,583,108 18 .99623 .99696 686,008 715,274 700,375 29,881.581 19 .99605 .99690 683,419 713,101 697,990 29,182,399 20 .99588 .99682 680,720 710,892 695,532 28,485,638 21 .99571 .99674 677,918 708,631 692,995 27,791,374 22 .99553 .99660 675,010 706,319 690,380 27,099,687 23 .99532 .99643 671,991 703,920 687,665 26,410,665 24 .99507 .99622 668,844 701,409 684,830 25,724,417 25 .99477 .99597 665,547 698,757 681,849 25,041,077 26 .99450 .99573 662,069 695,944 678,698 24,360,803 27 .99416 .99545 658,425 692,971 675,383 23,683,762 28 .99372 .99511 654,582 689,816 671,879 23,010,131 29 .99316 .99469 650,471 686,441 668,129 22,340,128 30 .99249 .99420 646,025 682,797 664,076 21,674,026 31 .99174 .99365 641,174 678,835 659,661 21,012,158 . 32 .99097 .99305 635,879 674,522 654,849 20,354,903 33 .99022 .99249 630,139 669,832 649,624 19,702,666 34 .98950 .99194 623,978 664,803 644,019 19,055,845 35 .98880 .99142 617,425 659,442 638,050 18,414,810 36 .98808 .99089 610,512 653,781 631,752 17,779,908 37 .98735 .99033 603,234 647,822 625,122 17,151,471 38 .98665 .98983 595,603 641,556 618,161 16,529,830 39 .98598 .98938 587,653 635,034 610,912 15,915,293 40 .98537 .98899 579,415 628,293 603,409 15,308,133 41 .98477 .98861 570,941 621,378 595,700 14,708,579 42 .98413 .98822 562,243 614,303 587,799 14,116,829 43 .98343 .98775 553,321 607,066 579,703 13,533,078 44 .98265 .98721 544,154 599,627 571,385 12,957,534 45 .98177 .98657 534,711 591,957 562,813 12,390,435 46 .98083 .98588 524,963 584,007 553,947 11,832,056 47 .97982 .98513 514,899 575,762 544,776 11,282,695 48 .97875 .98431 504,511 567,201 535,284 10,742,665 49 .97759 .98345 493,790 558,304 525,459 10,212,294 50 .97637 .98251 482,725 549,065 515,290 9,691,919 51 .97506 .98151 471,319 539,459 504,768 9,181,889 52 .97367 .98044 459,567 529,483 493,888 8,682,562 53 .97219 .97929 447,468 519,124 482,643 8,194,297 54 .97061 .97806 435,026 508,371 471,030 7,717,461 27 Age. x Probability of living one year from each age. Px Of 1,000,000 males born, the number surviving at each age. lx Of 1,000,000 females born, the number surviving at each age. lx Of 1,000,000 of both sexes (509,112 males and 490,888 females) born. The number surviving at each age. lx Population or years of life lived in and above each year. Qx Males. Females. 55 .96892 .97673 422,239 497,218 459,045 7,252,423 56 .96707 .97529 409,116 485,647 446,684 6,799,559 57 .96507 .97374 395,645 473,645 433,934 6,359,251 58 .96297 .97206 381,826 461,206 420,792 5,931,888 59 .96074 .97028 367,688 448,321 407,269 5,517,857 60 .95840 .96837 353,253 434,998 393,380 5,117,532 61 .95591 .96630 338,557 421,239 379,144 4,731,270 62 .95324 .96403 323,630 407,041 364,576 4,359,410 63 .95029 .96152 308,497 392,401 349,684 4,002,281 64 .94706 .95873 293,163 377,299 334,464 3,660,207 65 .94348 .95562 277,644 361,727 318,918 3,333,516 66 .93956 .95220 261,950 345,674 303,049 3,022,533 67 .93528 .94844 246,118 329,151 286,877 2,727,570 68 .93064 .94432 230,189 312,180 270,438 2,448,913 69 .92558 .93982 214,222 294,798 253,776 2,186,807 70 .92012 .93491 198,281 277,058 236,952 1,941,443 71 .91425 .92959 182,442 259,024 220,035 1,712,950 72 .90791 .92381 166,797 240,785 203,116 1,501,374 73 .90114 .91759 151,438 222,440 186,292 1,306,669 74 .89389 .91090 136,466 204,108 169,671 1,128,688 75 .88619 .90371 121,986 185,921 153,371 967,167 76 .87800 .89604 108,103 168,018 137,515 821,724 77 .86933 .88786 94,914 150,551 122,226 691,854 78 .86024 .87917 82,512 133,668 107,624 576,929 79 .85061 .86994 70,980 117,516 93,824 476,205 80 .84054 .86020 60,376 102,232 80,922 388,832 81 .82997 .84989 50,749 87,940 69,006 313,869 82 .81900 .83910 42,120 74,739 58,132 250,300 83 .80758 .82773 34,496 62,713 48,347 197,060 84 .79568 .81584 27,858 51,910 39,665 153,053 85 .78343 .80340 22,166 42,350 32,074 117,183 86 .77062 .79049 17,366 34,024 25,543 88,374 87 .75758 .77697 13,382 26,896 20,016 65,594 88 .74414 .76295 10,138 20,897 15,419 47,876 89 .73027 .74852 7,544 15,943 11,668 34,333 90 .71615 .73351 5,509 11,934 8,663 24,168 91 .70162 .71795 3,946 8,754 6,306 16,683 92 .68689 .70214 2,768 6,285 4,494 11,283 93 .67187 .68574 1,902 4,413 3,134 7,468 94 .65657 .66896 1,278 3,026 2,135 4,833 95 .64121 .65183 839 2,024 1,421 3,055 96 .62567 .63428 538 1,319 922 1,884 97 .60869 .61641 337 837 582 1,132 98 .59420 .59828 205 516 357 662 99 .57774 .57983 122 309 214 377 100 .56111 .56117 70 179 124 208 101 .54553 .54230 39 100 69 111 102 .52914 .52330 22 54 38 58 103 .51309 .50413 11 28 20 29 104 .49694 .48499 6 14 10 14 105 .48073 .46573 3 7 4 5 106 — .44672 1 3 2 2 107 — .42690 1 1 1 1 108 — — — 1 — — Appendix II. DIAGRAM shewing (a) cases of Scarlet Feuer; (b) houses newly invaded by Scarlet Fever, supplied with milk by certain retail vendors obtaining milk from the contractor, Mr. X.; and (c) cases of Scarlet Fever in Bethnal Green and Shoreditch occurring among persons supplied by vendors who did not obtain milk from Mr. X. N.B.—The shaded portion of the diagram represents the period prior to the stoppage of the infective milk. Martin Hood & Larkin Lith,London,W.C. London County Council. SCARLET FEVER IN LONDON. Report by the Medical Officer as to certain recent local prevalences of Scarlet Fever in London. (Printed by order of the Public Health Committee, 20th June, 1901.) Public Health Department, 8, St. Martin's-place, W.C., October, 1901. On Wednesday afternoon, 1st May, Dr. Bryett, the medical officer of health of Shoreditch, informed me that he had in the past twenty-four hours received numerous notifications of cases of scarlet fever in his district, that he had found that the persons affected were mostly supplied with milk by two vendors, B. in Shoreditch, and A. in Bethnal-green, and that B. derived his supply from two sources, from a firm of middlemen, Y., and from a middleman, X. He further stated that he had ascertained from Dr. Bate, the medical officer of health of Bethnal-green, that there was a simultaneous outbreak of scarlet fever in that district, the milk supplied to the sufferers being derived from A., who obtained his milk from X. Dr. Hamer at once called on Mr. X., and inquired as to the sources of milk supply to the two local vendors. Mr. X. was uncertain as to the details of distribution, and referred Dr. Hamer to his vanman, who lived in Barnsbury. Dr. Hamer went to Barnsbury, but was unable to find the man. Later in the evening I accompanied Dr. Hamer to Barnsbury, but we were again unsuccessful, and it was not till early on the following morning (Thursday, 2nd May), that we were able to see him. He said he had no exact knowledge as to the source from which the milk he distributed was derived, but he gave us certain particulars as to six farms, and after seeing Mr. X., and endeavouring to obtain further information, I wrote the same day to the medical officers of health of the districts in which five of these farms were situated. Mr. X., the following day (Friday, 3rd May) supplied me with a list of 38 other farms, the milk of which had been distributed by him in London, and I later wrote to the county medical officers of health of Staffordshire and Derbyshire, and to medical officers of health of particular districts in one or two other counties, asking whether any local distribution of milk from these farms had been accompanied by the occurrence of scarlet fever. Dr. Hamer made further inquiry of Mr. X.'s vanman, and saw several of the local vendors in Shoreditch and Bethnal-green, and the medical officers of health of these districts supplied me with particulars of the cases of scarlet fever which had occurred. The evidence thus obtained by Friday afternoon, 3rd May, strongly suggested that the farm most likely to be involved was either that of Mr. M. or that of Mr. X., both in Staffordshire. Dr. Hamer visited Mr. M.'s farm on Saturday, the 4th May, and while there I informed him by telegram that I had received information of the occurrence of cases of throat illness resembling scarlet fever at Mr. N.'s farm. Moreover, on the morning of the 4th May I informed Mr. X. that milk ought not to be supplied from Mr. N.'s farm, and Mr. X., on receipt of my letter, himself visited the farm on Saturday, the 4th May, and stopped the supply of milk. He subsequently assured me that, with the exception of one churn taken from that farm on Friday, and distributed in Bethnal-green on Saturday morning, 4th May, no more milk from this source was distributed by him. Dr. Hamer, on the 4th May, saw Dr. Freer, the medical officer of health, who had given me information as to the throat illness on Mr. N.'s farm, and also visited the farm. He found that Mrs. N. had been attacked on the evening of the 27th April, Mr. N. and his daughter on the 28th April, and Mr. N.'s son on the 29th April. They were all suffering from sore throat, and Mrs. N. said she had observed an eruption on her chest and arms on Wednesday, the 1st May. On Tuesday evening, the 7th May, Dr. Newman, medical officer of health of Finsbury, informed me that a number of cases of scarlet fever had been notified to him on the morning of the 7th May, all the patients being supplied with milk by a local vendor named P., of Finsbury, who obtained his milk from X. I visited Mr. R. at once with him. He was unable to give any precise information as to the source of the milk he had received, but did not think he had had N.'s milk. We then called on Mr. X.'s vanman who distributed milk in Finsbury. He was unable to give any precise information, and also thought he had not recently had N.'s milk in his van. On Wednesday morning, the 8th, I called with Dr. Hamer on Mr. X., who informed me that Mr. R. had been supplied with a churn of N.'s milk on the morning of either the 2nd or 3rd of May, but almost certainly on the 3rd. Later in the day Dr. Newman told me he had ascertained from Mr. R. and the vanman that their previous statement was, they believed, erroneous; that Mr. R. had had a churn of N.'s milk, probably on Friday, the 3rd May, and that he had supplied three or four gallons to another local vendor. Two members of a family supplied by this vendor were attacked with scarlet fever. Dr. Newman found that a third vendor, K., two of 2 whose customers had been attacked, had also been supplied with Mr. X.'s milk, and probably with N.'s milk. Meantime careful watch was kept upon the notifications of scarlet fever in other parts of London, and on May 11th Dr. Harris, medical officer of health of Islington, was able to associate the occurrence of some six or eight cases, in a portion of his district abutting upon the boundary of St. Pancras, with the distribution of the milk of a particular vendor. This vendor was also found by Dr. Sykes, medical officer of health of St. Pancras, to have supplied with milk four households in which cases of scarlet fever developed coincidently with the occurrence of the cases supplied by the vendor in Islington. The vendor referred to was, it was ascertained by Dr. Harris, obtaining milk from Mr. X., but no information was forthcoming as to the particular farm from which this milk had been supplied. There were thus in all *5 districts invaded (Bethnal-green, Shoreditch, Finsbury, St. Pancras and Islington), in each of which milk supplied by Mr. X. had been consumed by the sufferers. The five districts, it may be noted, were on three different " van-rounds," the number of persons who were consumers of Mr. X.'s milk and who were attacked was in Shoreditch and Bethnal-green considerable, in Finsbury and in St. Pancras and Islington it was much less. The evidence implicating a particular farm. While the evidence implicating Mr. X.'s milk was of a conclusive character almost from the outset, great difficulty was experienced in determining which of the particular farms supplying him was at fault. The evidence implicating a particular farm, the milk supply from which was stopped on May 4th, is of a threefold character. (a) There is the evidence afforded by consideration of the manner of distribution among local vendors in Shoreditch, Bethnal-green and Finsbury, of churns sent up from the different farms. (b) There is the fact that scarlet fever occurred in the family of the farmer, coincidently with the outbreak of the disease among consumers of the milk supplied by him in London. (c) There are the facts relative to the cessation of the occurrence of new cases, in correspondence, allowing for period of incubation, with the stoppage of the implicated supply. These facts again are of two-fold character, and include— (i). The broad fact that, if the entire area involved in Shoreditch and Bethnal-green be considered, the correspondence in question was marked. (ii.) The fact that information furnished by Mr. X., concerning the source of the milk distributed by particular vendors on May 2nd, 3rd and 4th, the three days on which milk from the suspected farm was last distributed, corroborates, so far as it goes, the conclusion that this farm was at fault. This question will be referred to later. The evidence under the head (c) completes the proof, but this evidence was not, of course, available until after the cessation of the outbreak. The action taken had, therefore, to be based upon the evidence under the other two heads, and as regards (b) it should be noted that the nature of the illness which affected the farmer's family was not established beyond all question until the occurrence of desquamation in one of the cases, and this phenomenon was not observed until May 11th. Need for record, of sources of milk supply. The need for record of the sources of milk supply was strongly manifested during the inquiry. As illustration of this need may be cited the nature of the evidence upon which it was necessary to proceed in determining the source of the infected milk. This evidence consisted— (i) Of information given by Mr. X. This information related to the origin of the milk sent on the Shoreditch and Bethnal-green rounds, but Mr. X. admittedly knew little or nothing of the way in which the vanman disposed of his milk, this matter resting almost entirely in the said vanman's own hands. (ii) Of information given by local vendors. This information was doubtless reliable so far as it went, but the local vendors, in some instances, knew nothing as to the ultimate source from which their supply was derived, in other instances, even if they took some interest in the matter, they were content with being assured that one or more churns delivered to them came from a particular farmer, and did not attempt to learn where the rest of the milk supplied to them came from. (iii) Of information given by the vanman. This man alone had had opportunity for acquiring anything approaching precise knowledge as to the distribution of the milk. According to his statements he had adopted a rough scheme of distribution of the churns of milk, and, inasmuch as certain broad outlines of this scheme were understood both by his employer and by the vendors whom he supplied, to be adhered to by him, it would appear that to some extent he felt under obligation to follow the prescribed routine in its main outlines, but he deviated considerably on occasion from what he regarded as his ordinary practice, and he was either unable or unwilling to give a detailed account of the variations which had occurred. Under any circumstance it is doubtful whether he could have supplied, having regard to his plan of procedure, very precise information; but it needs to be stated as a matter of fact, that some of his statements were found quite inconsistent with information given by Mr. X. and by the local vendors. * A case or two occurring in that part of Hackney which adjoins the Shoreditch boundary was subsequently traced to the implicated milk. DIAGRAM II. DIAGRAM shewing houses newly invaded by Scarlet Fever and supplied with milh by certain retail vendors, all of whom obtained milh from the contractor, Mr. X. N.B.—The shaded portion of the diagram represents the period prior to the stoppage of the infective milk. Martin Hood & Larkin Lith,London,W.C. 3 Had the vanman been able and willing to give an intelligent account of his distribution of the milk at the outset, there can be no question that the implicated supply could have been stopped at least forty-eight hours earlier than it actually was. In the absence of this muchneeded information it was impossible to indicate with certainty the particular farm involved. The local vendors were urged by the medical officers of health of Shoreditch and Bethnalgreen to discontinue to supply Mr. X.'s milk. Mr. X., however, did continue to supply a number, and any change in the detail of supply which may have been made did not suffice to exclude the infected milk supply from distribution, as he did not himself know which farm was at fault. In the interest, noi only of milk consumers, but also of local vendors and of contractors, it is obviously desirable that at a time of emergency complete records should be forthcoming. Considerably more than half the milk distributed in Shoreditch and Bethnal-green by Mr. X.'s vanman was delivered to the various local vendors in the form of "whole churns," and it would have been a simple matter for record of the origin and mode of distribution to have been kept by Mr. X. The local vendors, while in some instances stipulating that they should be supplied with churns from particular farms, appear to have implicitly relied upon the vanman in regard to the matter, and made no serious attempt to check his deliveries, or to keep any record of the source of the milk which they received. The source of infection of the milk. The illness affecting the farmer and members of his family was practically contemporaneous in its development with the outbreak in London. The latter may be said to have commenced on April 25th, when six cases of illness developed among persons drinking Mr. X.'s milk. Two previous cases were noted as beginning, one on the 22nd and one on the 24th, but marked incidence of disease on consumers of the milk first occurred on the 25th, and the incidence notably increased during the days immediately following this date. The wife of the farmer at the Staffordshire farm was sick and complained of sore throat on the evening of the 27th, and she noticed a rash on May 1st. The farmer himself and his daughter developed sore throats on April 28th; his son was sick and complained of sore throat on April 29th. The illness was mild in three of the cases, but the farmer's wife had a more severe attack. She presented definite evidence of desquamation when seen on the 11th May by several medical men. Inquiry was made as to illness among other persons resident 011 the farm and in the neighbourhood, but on case could be heard of, and the other residents themselves—a son, two milkers, a man and a boy, and a domestic servant —presented no evidence of illness, and there was 110 history of their having been exposed to infection. Inquiry was also made as to the cows on the farm. They were housed in four sheds, and numbered 29 in all, with two bulls. No cows had newly arrived at the farm for several months. A cow had calved about the beginning of April, and another calved 011 April 18th; neither of these cows presented any notable abnormality. Samples of milk were taken from three cows by Dr. Hamer on the 4th May, on which date the only indication of ulceration of the teats was a crust on the teat of one cow, while the milk of two cows was abnormal in appearance. The milk was examined bacteriologically by Dr. Gordon, and on May 11th, Drs. Klein and Gordon inspected the cows, and a further sample of milk was taken for examination from one of the cows having abnormal milk. Dr. Reid, the medical officer of health of Staffordshire, Dr. Freer, the medical officer of health of the district, and Dr. Hamer being present at the time. Bates of attack of customers of particular vendors. The falling off in the special incidence of scarlet fever 011 the 7th, 8th, 9th and 10th May, upon persons and upon houses supplied with Mr. X.'s milk is shown in diagram I. On reference to the black columns showing the number of houses invaded on successive days it will be seen that the number underwent marked diminution on the 6th, 7th and 8th, and after the 10th the incidence on houses supplied with Mr. X.'s milk ceased to be greater than might have been expected, having regard to the many centres of infection then established. Diagram II. shows for successive days the number of houses newly invaded, the occupants of which obtained milk from individual local vendors deriving their supply from X. Particular attention may be called to the fact that the incidence of disease in point of time varies in the case of the different vendors. A.'s, B.'s, and C.'s customers were early involved. There can be no question that these vendors received milk from the implicated farm during the period immediately preceding the outbreak. D.'s customers were attacked a few days later than A.'s, B.'s, and C.'s, and F.'s (the Islington and St. Pancras cases) were involved at about the same time, or if anything a little later than D.'s. No record had been kept as to the origin of the milk supplied by Mr. X. to 1). and F., and the question as to which farms it came from could not be cleared up. The vendor E.'s customers, the Finsbury cases (G.) and the cases (H.), to be later referred to, were the last to suffer. It was ascertained that milk from the implicated farm was distributed in Finsbury on either May 2nd or May 3rd, probably on May 3rd, and E. received the last consignment of infected milk—that distributed on the morning of May 4th. The vendor B. received, according to Mr. X., the bulk of the infected milk both on May 2nd and May 3rd. Only a few fresh cases developed among his customers during the week succeeding the latter date, but it may be noticed that this vendor's customers had already suffered to a marked extent during the week beginning 28th April, and it may be that the majority of those who were susceptible were infected prior to 2nd May. An interesting point in the history of the outbreak is the occurrence of cases on the four days subsequent to the stoppage of the milk in houses supplied by twenty other vendors obtaining X.'s milk. These cases are grouped together in the diagram and shown opposite the letter H. There is no reason for suggesting other explanation of their occurrence than the milk, and 4 the invasion of these houses is explicable on the hypothesis that some of the milk from N.'s farm was distributed to these vendors in small proportions. These vendors were spoken of by the vanman as "the small shops," and what is known of the distribution of the infective milk does not negative the possibility that some of this milk reached these vendors during the period under consideration, except after the 4th May. The dates of attack among the customers supplied by these vendors undoubtedly suggests distribution of N.'s milk at the close of the week, and if supplied to the small shops on the 3rd or 4th May, as in the case of the one churn which E. received on the 4th, the result would probably have agreed with the result in E.'s milk walk. Upon the question of the disposal of the milk on the 4th May Mr. X. was, however, quite positive that the whole of this milk, with the exception of that received by E., was thrown away; hence the 3rd must be regarded as being the date on which it is most probable "the small shops" received this milk. The short period which in some cases intervenes between consumption of infective milk and the onset of the illness is indicated by the diagram. Thus some of the milk in question was distributed on the morning of the 4th May, one churn of it being supplied to the vendor E., and scarlet fever occurred on the following day in two house supplied by him. It needs, however, to be pointed out that too much precision must not attach to the actual day shown on the diagram as the date of commencement of illness. Illness beginning during the night might be returned as belonging to either of two days even if the inquirv had been made with sufficient exactitude to eliminate other error. Moreover, parents may have confused the dates on which they observed illness in their children, and it is quite likely that iu some cases illness may have commenced at an earlier date than that on which it was observed. Age incidence of attacks. Another point, to which attention has been called by Dr. Bryett, may here be referred to. The age incidence of the disease in this outbreak differed in his district from what may be regarded as the usual age incidence of scarlet fever in Shoreditch. The age incidence in Shoreditch and Bethnal-green combined will be seen on reference to diagram III. This diagram shows that the proportion of persons attacked at the age periods 5 to 10 and 10 to 15 (and to less extent at ages 0 to 5) among consumers of Mr. X.'s milk was less than the corresponding proportion obtained in Shoreditch and Bethnal-green under normal conditions. On the other hand, the proportion of persons attacked at ages 15 and upwards was greater in the milk outbreak than in the two districts generally. The history of this outbreak is particularly instructive as showing the need for amendment of the law with regard to outbreaks of iufectious disease attributed to milk. The procedure contemplated by section 71 of the Public Health (London) Act involves, as has already been pointed out, in the report of the Public Health Committee to the Council on 9th May last, considerable delay. In the present instance the distribution of the infected milk was discontinued at the instance of Mr. X., who, acting upon advice which I gave him, stopped its supply some days before it would have been practicable to put in force section 71. The fact that the milk supply involved was that of Mr. X. was readily demonstrated, but the need of being able to differentiate promptly between the farms supplying him was acutely felt. The infective milk was as a matter of fact distributed in Finsbury, Islington, and St. Pancras at a time when the risk attaching to consumption of Mr. X.'s milk had been demonstrated in Shoreditch and Bethnal-green. Local vendors in the two districts last named, who had been urged by the medical officers of health to change their supplies, were content to leave it to Mr. X. to send them milk of different origin from that they had hitherto been receiving, and he, in the absence of knowledge as to which farm was at fault, was unable, save by abandoning altogether the whole of his sources of supply, to limit the spread of mischief. As a matter of fact the milk of all the farms supplying Mr. X. was distributed until the morning of May 4th, alterations being made merely with regard to the allotment of churns to particular vendors. These alterations led in at least two instances to vendors iu Shoreditch and Bethnal-green, who were not previously receiving infective milk, being supplied with it, and also to consignments of infective milk, which would otherwise have been consumed in Shoreditch and Bethnal-green, being sent to other parts of London. The medical officers of health of other London districts, if they had Known of the danger with which their districts were threatened could not have prevented it, and the County Council had no jurisdiction in regard to such a matter. The lessons of the outbreak illustrate the need for such alteration of the law as will obviate unnecessary delay in dealing with the supply of infected milk, and for giving sanitary authorities and the Council the powers referred to in the report dated 18th June, 1901, of the Public Health Committee to the Council. SHIRLEY F. MURPHY, Medical Officer of Health. DIAGRAM III. DIAGRAM shewing age and sex distribution of cases of Scarlet Fever occurring from 25th April to 10th May, inclusive, among customers of milh vendors supplied by Mr. X. in 1901, in comparison with the age and sex distribution of cases of Scarlet Fever notified in Shoreditch and Bethnal Green during the 17th—22nd weeks, inclusive, of the years 1896—1900. Martin Hood & Larkin Lith,London,W.C. Appendix III. London County Council. EXPERIMENTS ON DISINFECTION. Report by the Medical Officer presenting joint report by Drs. Klein, Houston and Gordon on the result of their experiments in connection with the subject of disinfection. (Ordered to be printed by the Public Health Committee, 16th January, 1902.) In accordance with the resolution of the Council of 31st July, 1900, experiments have been conducted by Drs. Klein, Houston, and Gordon with the object of ascertaining the value of various disinfectants under the ordinary conditions of their use in dwelling houses. A room in an unoccupied house in the possession of the Council was in the first instance utilised for the purpose of testing methods of gaseous disinfection, and later a room of about the same size in the shelter of the Finsbury Borough Council. Among fluid disinfectants carbolic acid, permanganate of soda bleaching powder, and corrosive sublimate have been tested. Among gaseous disinfectants formalin and sulphurous acid gas have been made the subject of experiment, the disinfection in this branch of the inquiry being supervised by Dr. Newman, medical officer of health of Finsbury, who has kindly facilitated the carrying out of the work. Seven microbes have been experimented with, organisms representative of highly resistant and less resistant pathogenic forms being chosen. Consideration was necessarily given, in making the selection, to the question of the ease with which the particular microbes employed could be subsequently identified, but the list includes, it may be noted, the organisms of enteric fever, diphtheria, cholera, and tuberculosis. Four different sorts of material, in ordinary practice requiring to be disinfected, namely, cloth, unvarnished or unpainted wood, linen, and wall paper, were chosen. To them, microbes distributed in broth, in milk, or in melted gelatine, were liberally applied, and the charged materials were then exposed to the various disinfectants. As regards gaseous disinfectants it was found that both formalin and sulphurous acid failed in the case of wood and cloth charged with spores. The contrast observed between wood and thick cloth on the one hand, and linen and paper on the other, may probably be explained by the fact that the microbe-containing mixtures soaked into the materials first named; the microorganisms were thus not limited to the surface, whereas, in the case of linen and paper, the organisms were so limited, and therefore were more exposed. In one experiment even the little-resistant bacillus typhosus, exposed on wood or cloth, was not destroyed by formalin, but the reporters raise question as to whether the result was due to some fault in the experiment. This organism was, however, destroyed under like circumstances by sulphurous acid. Formalin vapour, on the other hand, showed to greater advantage than sulphurous acid in the case of tubercular sputum dried on linen and paper. As regards fluid disinfectants, corrosive sublimate, 1 in 1,000, with 24 hours' exposure, destroyed all microbes, including the spores of anthrax and the tubercle bacilli; carbolic acid in 5 per cent. solution, with 24 hours' exposure, failed to destroy anthrax spores, but was efficacious for all others. In the case of Condy's fluid, one teaspoonful to a pint with 24 hours' exposure gave a negative result; when used in five times that strength it was still practically of negative value; bleaching powder, generally speaking, only destroyed the less-resistant forms of microbes, though in the case of anthrax spores on paper and on linen, this material proved more effective than carbolic acid. In summary it may be stated that the typhoid bacillus was killed by all the disinfectants except Condy's fluid and bleaching powder. Condy's fluid gave a negative result in each experiment and bleaching powder for the disinfection of wood and cloth infected with this organism failed with 1 hour's exposure but was efficacious on 24 hours' exposure. The bacillus diphtherire was killed by formalin and sulphur dioxide. The vibrio of cholera was in each experiment destroyed by all the disinfectants except Condy's fluid and bleaching powder. Condy's fluid was practically of negative value, and bleaching powder was not always efficacious on 1 hour's exposure, but was successful with 24 hours. Bacillus pyocyaneus was acted upon in much the same way. It was killed in each experiment by all except Condy's fluid and bleaching powder. Staphylococcus aureus was also killed in each experiment by all except Condy's fluid and bleaching powder. Anthrax spores were only destroyed with certainty by perchloride of mercury, the other disinfectants either failing on each occasion or being uncertain, and almost invariably failing when wood and cloth were the materials to be disinfected. For tubercle bacilli, carbolic acid and perchloride of mercury were the only disinfectants efficacious on each occasion. Condy's fluid and sulphur dioxide were of negative value and the other disinfectants unreliable. It is deserving of notice that neither formalin nor sulphur dioxide were efficacious for the wood or cloth infected with this bacillus. Shirley F. Murphy, Medical Officer of Health, Public Health Department, 8, St. Martin's-place, W.C., 10th February, 1902. [1562 EXPERIMENTS ON DISINFECTION. Report by Drs. Klein, Houston and Gordon. In the following pages we beg to report on the experiments which we have carried out, in conformity with the arranged plan, in order to test various disinfectants, commonly used, on a variety of microbes, such as would be occurring in practice, and under conditions as nearly as possible similar to those generally met with. The disinfectants tested were—(1) carbolic acid, (2) permanganate of soda, (3) bleaching powder, and (4) corrosive sublimate; these were used in the fluid state as appropriate solutions to be fully described later. In addition to these, two substances were used in the gaseous state, viz., (5) formaldehyde, or formalin, and (G) sulphurous acid gas. For the opportunity and facility of using these two substances we are indebted to Dr. Newman, medical officer of health of Finsbury, who has been most willing throughout to help us, and who on several occasions himself superintended the process of disinfection. Dr. Newman has kindly furnished us with all the details, to be presently mentioned, concerning the amount of the gases used, cubic space of room, etc. For his help and great interest in the experiments we beg to tender him our very best thanks. The microbes that we experimented with were— (a) Spores of bacillus anthracis, representing one of the most resistant forms of pathogenic microbes. (b) The staphylococcus pyogenes aureus, representing one of the most resistant forms of non-sporing pathogenic microbes. (c) The bacillus of typhoid fever. Non-sporing forms of pathogenic bacilli. (d) The bacillus of diphtheria. Non-sporing forms of pathogenic bacilli. (e) The bacillus pyocyaneus. Non-sporing forms of pathogenic bacilli. (f) The vibrio of cholera; and (g) The bacillus of human tuberculosis. From this list it will be seen that most of the microbes chosen, in the first place include such as would in common practice be required to be disinfected, and in the second place are readily identified in the course of the experiment by their colour (staphylococcus aureus, bacillus pyocyaneus) or by their cultural characters (vibrio choleræ, bacillus typhosus, bacillus anthracis) or by their specific action on the animal (bacillus anthracis, bacillus diphtheriæ, bacillus tuberculosis). These are advantages which are not to be under-rated, considering that the materials subjected to disinfection are not themselves sterile, and are for hours exposed to mixture with saprophytic bacteria, conditions which naturally increase the difficulties of subsequent identification of the particular microbes subjected to disinfection. The microbes enumerated above were in all instances (except the spores of bacillus anthracis and the bacillus tuberculosis) taken from a recent actively-growing culture (agar culture grown for 24 to 48 hours at 37° C.) so as to ensure the active and vigorous state of the microbe to be disinfected. This is a point to be borne in mind, being of importance in all disinfection experiments. It must be obvious that in all cultures of non-sporing microbes, many of the individual microbes become less vigorous, and others even die off with the age of the culture; thus, for example, in the case of bacillus diphtheriæ, the virulence of the microbe becomes, in agar culture grown at 37° C., rapidly attenuated after the first two or three days; bacillus typhosus taken from a 24 to 48 hours' agar culture shows all bacilli actively motile; later, the number of such acting motile forms rapidly diminishes, indicating that the bacilli with age of the culture undergo distinct changes, whereby some of their important characters are for the time lost. As regards the spores of anthrax, these, as is known, are formed in the course of several days to a few weeks on the surface of the agar growth. The spores used in our experiments were ascertained to be fully virulent on the animal. The bacillus tuberculosis was used as it occurs in human pulmonary sputum, this being not only the form in which this microbe would be dealt with in actual practice, but also the form known to be virulent, and therefore suitable to be subjected to disinfection. The experiments having been undertaken to ascertain which of the substances commonly in use are best for the object of disinfection under conditions such as exist in actual practice, it was of course necessary so to arrange our experiments that they would, as far as possible, imitate the conditions commonly obtaining. For this purpose we distributed the microbes on various materials, such as wall-paper, linen, cloth and wood, these being the chief materials which in ordinary practice are subjected to the process of disinfection in rooms, tenements and inhabited spaces. The modus procedendi was this— (a) Virulent spores of anthrax taken from the surface of agar cultures were distributed in separated milk, or in melted gelatine, so as to form a turbid emulsion. This emulsion was applied liberally on the above materials and allowed to dry in the air of the laboratory. 3 (b) From a recent culture on agar of the bacillus typhosus, bacillus pyocyaneus, bacillus diphtheriai, staphylococcus aureus and vibrio cholera) respectively a turbid emulsion was made in broth or in separated milk; this was then applied liberally to the above materials and allowed to dry in the air of the laboratory. In the later experiments we made our cultures, not on agar, but direct on gelatine, and incubated the culture tubes for 24 hours at 37° C., whereby the gelatine became, of course, melted, and turbid from the growth. For the object of carrying out the experiment we applied the turbid (melted) gelatine culture liberally on the above materials. On cooling, the gelatine set. In all these proceedings, therefore, the microbes used were emulsified, not in water, but in menstrua somewhat thicker, e.g., milk and melted gelatine. In choosing these menstrua we were guided by the fact that under the conditions obtaining in practice the virus to be disinfected is not suspended in water but in thicker menstrua, e.g., fluid typhoid stool, pus, blood, fluid cholera stool, diphtheritic throat secretions, and the same applies to the tubercle bacillus, for this as a rule is voided by the infected persons in the expectoration, which is muco-purulent, As was mentioned above, in all our experiments with tubercle we used pulmonary sputum, containing the tubercle bacilli; this was liberally applied on the materials and allowed to dry in the air of the laboratory. The materials, paper, linen, cloth, wood, charged with the above microbes, were then exposed to the various disinfectants in the following manner— (A.) In the case of the gaseous disinfectants, i.e., formalin, or sulphurous acid gas, the materials charged with the microbes were carried in large glass cylinders (plugged) from the laboratory to the room where the disinfection was to be carried out, and here, having been taken out, were placed and fixed on a table. Next day they were replaced again in the glass cylinders and carried to the laboratory. Here the materials separately were placed in a tube of sterile broth—except the cholera-charged materials, which were placed in peptone salt solution —in this they were slightly washed, and then transferred to a fresh tube of broth (or peptone salt solution respectively) and both tubes incubated at 37° C. The first washing was made for the sake of removing any excess of the disinfectant left in the materials. The resulting growth was examined microscopically, culturally, and by animal experiment, in order to identify the microbe with which the material had been charged. It must be obvious that the materials, not having been sterile, and moreover, having been exposed after the disinfection, for some hours at least, to the air, would harbour a variety of microbes deposited on them from the air, and therefore the above broth tube, by incubation, would, and as a matter of fact did, in some instances, produce growths additional to, or other than, the microbes with which the materials had been intentionally charged. It was, therefore, a matter of no small importance to diminish the difficulties of identification by plate cultures or otherwise, of the original microbe, and this was done by our choosing the more easily identifiable microbes. In the case of the spores of bacillus anthracis, of staphylococcus aureus, of vibrio of cholera and of bacillus pyocyaneus the identification by one or another method (microscopically, culturally, animal experiment) is comparatively simple on account of the marked characteristics of the microbe. But in the case of the typhoid bacillus and the bacillus diphtherise the identification was considerably more difficult; the difficulties, as will be stated further below, were in great part due to a possible confusion with similar microbes (bacillus coli or bacillus xerosis, respectively) widely diffused in Nature and particularly in town air and dust. In the case of tubercular sputum, the materials charged with it were, after the gaseous disinfection, treated in a different way, viz., the surface layers (dried sputum) were scraped off and distributed in salt solution, and this was injected in considerable amounts subcutaneously into the groin of a guinea pig and the result watched. Cultural experiments, owing to the wall-known enormous difficulties connected with the culture of the tubercle bacilli from sputum were not attempted, injection into the guinea pig being far the easiest and most reliable method of discovering whether or not the injected materials contained the tubercle bacillus in a living state. If the injection into the subcutaneous tissue of the guinea pig is, after several weeks (6—8), not associated with and not followed by tubercular enlargement of the inguinal lymph glands of the injected side, and if on a post mortem examination no tubercles or tubercular changes are found in the viscera (liver, spleen, lung), then we may take it for certain that the injected matter did not contain living tubercle bacilli, and therefore the disinfection was successful and positive. But if in these and other experiments (carbolic acid, Condy's fluid, etc.) the inguinal glands and viscera did show the tubercular changes (anatomically, and after staining for tubercle bacilli), typical of inoculation tuberculosis, then the conclusion was drawn that the matter injected did contain tubercle bacilli in a living state, and therefore that the disinfection was unsuccessful and negative. (B.) Disinfection with the fluid substances: carbolic acid, perchloride of mercury, Condy's fluid, bleaching powder, was carried out as follows:—The different materials, wood, cloth, linen and paper having been charged with the recent and active culture (melted gelatine) of the microbes (bacillus typhosus, bacillus pyocyaneus, bacillus diphtherise, vibrio choleræ, spores of bacillus anthracis, staphylococcus aureus) were, after setting of the gelatine in the air of the laboratory, exposed for the required time in a large test tube to the disinfectant solution; after that the materials were taken out from these solutions and placed in a tube of broth (or peptone salt in the case of vibrio choleræ), and from here transferred to a new tube of the same culture medium and then incubated at 37° C., and treated in the same way as was mentioned in the case of testing gaseous disinfectants. 4 The same plan that was described above in the case of gaseous disinfectants with regard to the tubercular sputum, was also followed in the case of the fluid disinfectants, viz., the materials, wood, linen, paper, cloth, were charged with the sputum, and when dry, exposed to the disinfectant solution. After the exposure they were well washed in sterile water to remove the disinfectant, and then the scrapings from the surface of the materials (the dried sputum) were injected into the subcutaneous tissue of the groin of guinea pigs and the result watched. We now proceed to describe the results of our experiments, and commence with those carried out with the gaseous disinfectants, formalin, and sulphurous acid gas. A. Gaseous Disinfectants. Series I.—Formalin. The first experiments were carried out in a room which Dr. Newman had kindly measured and found to be of cubic capacity of 1344 cubic feet. 30 formalin tablets* were used, this being in Dr. Newman's opinion, a full allowance for a room this size. The time allowed was exactly 5 hours. Before lighting the lamp, the window and fireplace were sealed up with stickfast paper. The lamp was then lit, and the door was sealed up on the outside with similar stickfast paper. After 5 hours the room was opened, the lamp extinguished, and the window and door were left partially open all night. The materials exposed to the disinfection were fetched in the morning and treated in the manner already described. 1.—Bacillus typhosus. Experiment A.—The materials, wood, paper, linen, cloth were liberally charged with bouillon emulsion of bacillus typhosus from a 24 hours' old agar culture. The emulsion was strongly turbid, that is to say, it contained an abundance of the typhoid bacilli. After drying the materials, they were exposed to formalin, except one sample of paper which was to serve as control. After the disinfection (see above), the materials were placed in phenol broth and incubated at 37° C. After 24 hours the wood, linen, and cloth phenol broths showed much turbidity, while the paper phenol broth was only faintly turbid, but the control paper showed strong turbidity. From each phenol broth tube, one phenol agar surface plate was made and incubated at 37° C. for 24 hours. The phenol agar plate of wood typhoid showed abundance of colonies which looked, in all respects, like those of typhoid, the phenol agar plate of cloth typhoid had amongst numerous colonies some which looked like those of typhoid. The phenol agar plates of linen and paper typhoid showed no typhoid-like colonies. The phenol agar plate of the control paper broth was practically a pure culture of typhoid. Sub-cultures were made of the typhoid-like colonies of the wood and cloth typhoid and they corresponded in every morphological and cultural respect with those of the true typhoid bacilli. Further, they were tested with blood serum of a guinea pig immunised by previous injection with typhoid culture and kept in the laboratory for the general purpose of agglutination (Widal) test. The blood serum was used in the dilution of 1 to 40, i.e., one blood serum to forty emulsion of the microbe to be tested; agglutination of the bacilli of the emulsion was distinct in 15 minutes, and complete within half an hour. From this experiment it appears that while the typhoid bacilli on the paper and on the linen were killed by the formalin vapour, those on wood and cloth had not been disinfected. The reason for this difference in the two sets is obvious, viz., the bouillon emulsion rich in the typhoid bacilli readily soaked into the wood and the thick cloth, whereas the thin linen and the thin paper contained the typhoid bacilli not only in smaller numbers but more exposed. Therefore, the formalin vapour in this experiment apparently did not reach the bacilli in the depth of the wood or cloth, while in the thin linen and paper the formalin could more easily and more readily accomplish the disinfection. Control experiments were made which showed that the typhoid bacilli are not killed by drying on paper in the air of the laboratory for 24 hours. It must, however, be at once added that this unfavourable result is not the rule, for we shall presently see a different result in further experiments. Whether or not the negative result qua disinfection on wood and cloth in experiment A was due to some fault in the actual experiment, remains open. As a matter of fact, it was the very first experiment of the whole series. Experiment B.—In this experiment the emulsion of the typhoid bacilli (agar surface growth, incubated 24 hours at 37° C.) was made in separated milk, the amount of growth added to, and shaken up with the milk was considerable, and the emulsion was liberally applied to the surface of the materials, viz., wood, cloth, linen and paper. The exposure to formalin (5 hours) was carried out in the same place and with exactly the same amounts, and in all respects in the same way as in experiment A. The materials next day were placed as in experiment A in phenol broth, which was then incubated at 37° C. No growth of any kind took place in any of the broth tubes. Experiment C.—In this experiment the culture of typhoid bacilli was made in gelatine and incubated for 24 hours at 37° C. After this time the (liquefied) gelatine showed great turbidity, and in this liquid form was liberally applied to the surface of the materials: wood, cloth, linen and paper. On cooling, the gelatine set, and in this form was kept a few hours and then exposed to formalin in exactly the same manner, duration and amount as in experiment A. Here also the result was complete disinfection of the typhoid bacilli. The following table I. summarises the above three experiments— A tablet weighs .034 oz. 5 Table I.—Showing the result of exposure of the bacillus typhosus to form ilia vapour. Nature of emulsion in which the typhoid bacillus was exposed. Nature of the material on which the emulsion had been placed. Result of culture after exposure. Broth emulsion Wood + „ Cloth + „ Linen — „ Paper — (Separated) milk emulsion Wood — „ „ Cloth — „ „ Linen — „ „ Paper — Melted gelatine culture allowed to set Wood — „ „ Cloth — „ „ Linen — „ „ Paper 2.—Bacillus diphtheria,. Experiment A.—Emulsion of bacillus diphtheriæ from a 24 hour old agar culture in separated milk was liberally applied to wood, linen, cloth and paper, and, after drying, exposed to formalin in the same place and under exactly the same conditions as in previous experiments. One control diphtheria paper was kept (24 hours) till the exposed materials were ready, after disinfection, to be used for culture. All these materials were placed in broth in test tubes and incubated at 37° C. After this time only the broth inoculated with the control diphtheria paper and from the disinfected diphtheria wood, were found turbid. Agar surface plates were made and these were kept for 24 hours at 37° C. The agar plate of the diphtheria wood was covered with a film of bacillus mesentericus, the agar plate of the control diphtheria paper showed numerous diphtheria-like colonies. These were tested by microscopic specimens, by Neisser's stain, and by injection in guinea pigs, and found to be typical virulent diphtheria, the same as was applied originally to the paper. This experiment proves, therefore, that while the diphtheria bacilli, dried on paper in the laboratory for 24 hours, remain living, those exposed on wood, cloth, linen and paper to formalin for 5 hours became completely disinfected and killed. Experiment B.—This experiment was of the same nature as the former, except that the diphtheria bacilli were applied to the materials as a (liquefied) gelatine culture incubated for 24 hours at 37° C. The result was also negative, inasmuch as none of the materials after exposure to the formalin yielded diphtheria growth. The following table II. gives a summary of the results— Nature of the emulsion. Nature of the materials. Result of culture after exposure. Separated milk emulsion Wood — „ „ Cloth — „ „ Linen — „ „ Paper — (Melted) gelatine culture Wood — „ „ Cloth — „ „ Linen — „ „ Paper — In both experiments, therefore, the 5 hours' exposure to formalin was effective in completely destroying the bacillus diphtheriæ on all the four materials employed. 3.—Bacillus pyocyaneus. Experiment A.—The emulsion of this organism was made in separated milk, the materials, wood, cloth, linen and paper were charged liberally with the emulsion, and then, after drying in the air of the laboratory, were exposed to formalin in the same manner as in previous experiments. The result was that the microbe was disinfected and devitalised on all four materials; the broth cultures that received the materials after the treatment with the formalin yielding no pyocyaneus growth. Experiment B.—The former experiment was repeated with hot gelatine culture, i.e., the microbe was grown in gelatine at 37° C. for 24 hours, and then this was applied to the surface of the materials. The result of exposure to the formalin was the same as in the previous experiment, viz., complete disinfection. The following table III. shows these results— 6 Nature of the emulsion. Nature of the materials. Result of culture after exposure. Separated milk Wood — „ „ Cloth — „ „ Linen — „ „ Paper — (Hot) Gelatine culture Wood — „ „ „ Cloth — „ „ „ Linen — „ „ „ Paper — Formalin is then, in the form and the amounts used in our experiment, a perfect disinfectant of bacillus pyocyaneus, on all the materials used. 4.—Vibrio of Asiatic cholera. Experiment A.—This, as also the following experiment, 13., were made with the vibrio which has now been kept for many subcultures in the laboratory. It was originally derived from a case of true Asiatic cholera, and in morphological and cultural respects possesses all the characters of the typical cholera vibrio; except that its virulence on the guinea pig has suffered slight diminution. The emulsion was made by distributing in separated milk a relatively large amount of agar surface culture that had been incubated for 24 hours at 37° C. The culture was then liberally applied to wood, cloth, linen and paper, and was allowed to dry on these materials in the air of the laboratory, after which they were exposed to the action of formalin as in the previous experiments. Next day the materials were transferred to peptone salt solution, as mentioned on a former page, and incubated for 24 hours at 37° C. If the peptone solution became turbid, microscopic specimens—stained films—alone could be relied upon as showing the presence of the vibrio; if a positive result was hereby obtained the cholera red reaction was tested in order to confirm the previous results. Experiment B.—In this experiment the culture of the vibrio that was used was gelatine (melted) culture incubated for 24 hours at 37° C. The result of this, as also of the previous experiment, was entirely negative, that is to say, the culture in peptone salt made with the materials after exposure to the formalin yielded no growth of the cholera vibrio. Table IV . shows these results— Nature of emulsion of the vibrio. Nature of the materials. Result of culture after exposure. In separated milk On wood — „ On cloth — „ On linen — „ On paper — As hot gelatine culture On wood — „ „ On cloth — „ „ On linen — „ „ On paper — In order to make sure that the keeping per se ot the vibrio on the materials for 24 hours, apart from any exposure to a disinfectant, has no deleterioas effect on the vitality of the vibrio, a control experiment was made. In this the vibrio, grown in hot gelatine (i.e., at 37° C.), was applied to the same paper as used in all these experiments and kept for 24 hour's. From the nature of the paper being denser than any of the other materials, the microbe would on it (paper) remain more superficial, i.e., more exposed to the drying process than on any of other materials, and therefore we would get a reliable answer to the above question, viz., whether or no the 24 hours' drying in the air of the laboratory did or did not injure the vitality of the microbe. The result of this control experiment was that the control cholera-paper yielded, in peptone salt culture, copious growth of the vibrio after 24 hours' incubation. 5.—Staphylococcus aureus. The experiments that were made with this microbe were of exactly the same kind as with the above, and it is not necessary to describe them in detail. There is only one point that it is necessary to mention, it is this:—After exposure to formalin of the materials, wood, cloth, linen and paper impregnated with the emulsion—broth emulsion of a recent (24 hours' old) agar culture—they were placed in broth, and after 24 hours' incubation of this at 37° C., agar surface cultures were made; these would, after incubation for 24 hours at 37° C., infallibly show the golden yellow colonies of the microbe, if such were present, in a living condition. The experiments made showed that the formalin as used had completely killed the microbe. 7 The following table Y. shows the summary of the experiment— Nature of the emulsion. Nature of materials. Result of culture after exposure. Broth emulsion On wood — „ „ On cloth — „ „ On linen — „ „ On paper 6.—Spores of bacillus anthracis. As mentioned above, virulent spores of an agar culture of bacillus anthracis were used for the experiment; they were distributed in separated milk, and in this form were liberally applied to wood, cloth, linen and paper, and after drying were exposed to the formalin in the way above described. After exposure the materials were placed in broth, and whether or not after incubation at 24 hours at 37° C., growth appeared, a small amount of the broth was injected subcutaneously into a guinea pig, and the result watched. Where growth appeared in the broth, subculture was made on agar or on gelatine, and the resulting growth studied for identification of bacillus anthracis. The positive or negative result indicated in the following table VI. refers, it will be understood, both to the cultural test as also to experiment in the animal. Nature of emulsion. Nature of material. Result of culture and experiment. Tn separated milk „ „ „ On wood On cloth On linen On paper + + + It follows then that anthrax spores applied to linen were killed by the formalin, while those on wood, cloth and paper yielded growth of bacillus anthracis and killed a guinea pig with typical anthrax. 7.-—Tubercular sputum. In this, as also in all other cases of disinfection with fluids, the sputum was derived from human tubercular lung, and on microscopic examination showed a fair number of tubercle bacilli. The sputum was applied on the surface of the materials and allowed to dry. This took generally 24-48 hours; but in order to insure that by this process the tubercle bacilli of the sputum remained uninjured, a control was at the same time made by allowing the sputum to dry on paper for 48 hours, and then using this directly without exposure to the disinfectant for injection of a control guinea pig. As might have been expected, this control guinea pig developed typical general tuberculosis in due course of time. The materials were exposed to the formalin in the manner already described. Next day the surface of the materials was scraped and the scraping distributed in a little salt solution, and guinea pigs were injected subcutaneously into the groin. After four weeks the animals were killed and a careful post-mortem examination was made on them. In this, as also in other experiments with the sputum to be described later, a positive result means local tuberculosis of the inguinal glands of the injected side, with typical tubercle bacilli in the caseous purulent gland, and tuberculosis of the viscera; either spleen alone, or spleen, and liver and lung; and the tubercles containing the typical tubercle bacilli. A negative result means negative locally and viscerally. The following table shows the result after exposure to formalin as in the previous experiments— Table VII.—Disinfection with formalin of tubercular sputum. Nature of the sputum. Nature of the material. Result of experiment. The sputum contains crowds of tubercle bacilli On wood + „ „ On cloth + „ „ On linen — „ „ On paper — We have here the same distinction as was found in the first experiment with typhoid bacillus, viz., owing to the thickness of the wood and cloth the microbe that had been able to 8 penetrate into the depth was protected against the action of the formalin, whereas owing to the thinness of the linen and paper the microbe could well be acted upon by the formalin. Table VIII., General result.—Disinfection with formalin, cubic space 1,344 cubic feet, 30 formalin tablets burnt, time of exposure 5 hours. On wood. On cloth. On linen. On paper. Bacillus typhosus + + „ — — — — „ — — — — Bacillus diphtheriæ — — — — „ — — — — Bacillus pyocyaneus — — — — „ — — — — Vibrio choleræ — — — — „ — — — — Staphylococcus aureus — — — — Spores of anthrax + + — + Tubercular sputum + + — — Table VIII. gives in a comprehensive manner the general results of this series of disinfection experiments, viz., with formalin for five hours. The + sign means positive culture and experiment on animal after exposure, the sign — means failure to recover the microbe in a living condition. It will be seen from this table that all the microbes exposed on linen to the formalin were completely disinfected, and, with the exception of the spores of anthrax, also on paper. Further, complete disinfection of the wood and the cloth was effected by formalin except in three cases. One of these was in the first experiment with typhoid, when a broth emulsion of it was used; in two later experiments, however, typhoid was completely devitalised. The second case in which formalin failed to disinfect the wood and cloth was that of anthrax spores, and the third that of tubercular sputum. This appears to be due to the greater thickness of, and, therefore, imbibition into, the materials, and the consequently greater chance of escape of some of the microbes from the attack by the formalin. In cases, therefore, where wood flooring, unpainted or unvarnished articles of furniture, or similar absorbing materials and cloth fabrics are to be subjected to disinfection on account of their being possibly polluted with tubercular sputum, or highly resisting microbes like the spores of anthrax or other spores (e.g., tetanus), the disinfection with formalin alone will not suffice. But in the case of paper, linen, or similar thin fabrics (calico) the disinfection with formalin (except spores of anthrax or similar highly resisting spores) will presumably be attended with success. Series II.—Sulphurous Acid Gas (Sulphur Dioxide). The experiments with the sulphurous acid gas were performed in a room, the capacity of which was 1,075 cubic feet; three pounds and a half of sulphur were burned in the middle of the room on an ordinary "sulphur devil." As in the case of the formalin experiments the fireplace, window, and door were carefully and accurately sealed up with pasted paper. The room was left closed up for exactly 24 hours. The preparation of the microbes, their application on the materials, wood, cloth, linen, and paper, and the treatment subsequent to the exposure were exactly the same as in the case of the formalin experiments, and it is not therefore necessary to repeat the details of the individual experiments. 1.—Bacillus Typhosus. Table IX. gives the summary of the results in two experiments made with this microbe experiment (a), with an emulsion in broth, experiment (6), with an emulsion in separated milk. Table IX. Nature of emulsion. Nature of material. Result of culture, after exposure. (a) In broth On wood — „ On cloth — „ On linen — „ On paper — (b) In separated milk On wood — „ On cloth — „ On linen — „ On paper — 9 From this it appears, then, that the typhoid bacillus on all materials had been completely devitalised. It has to be added that in both experiments (a and b), one "paper" on which the corresponding emulsion of the typhoid bacillus had been allowed to dry, had been kept for control; this, on subsequent culture in phenol broth, and from this on phenol agar plate, yielded in 24 hours copious growth of the typhoid bacillus, typical in respect of morphology, culture, and agglutination by typhoid blood. 2.—Bacillus Diphtheria. The following table X. shows the result of the three experiments, a, b and c, performed with this microbe. Nature of emulsion. Nature of material. Result of culture after exposure. (a) In broth On wood ,, On cloth — ,, On linen — ,, On paper — (b) In separated milk On wood — ,, On cloth — ,, On linen — ,, On paper — (c) As hot gelatine culture On wood — ,, On cloth — ,, On linen — ,, On paper — Here, also, disinfection was complete on all materials and in all three experiments. 3.—Bacillus pyocyaneus. Table XI.—Showing the result of exposure to S02. Nature of emulsion. Nature of material. Result of culture after exposure. (a) In broth On wood — ,, On cloth — ,, On linen — ,, On paper — (b) In separated milk On wood — ,, On cloth — ,, On linen — ,, On paper — 4.—Vibrio cholerœ. Table XII.—Showing the result of exposure to SO2. Nature of emulsion. Nature of material. Result of culture after exposure. (a) In broth On wood — ,, On cloth — ,, On linen — ,, On paper — (b) In separated milk On wood — ,, ,, On cloth — ,, ,, On linen — ,, ,, On paper — (c) As (hot) gelatine culture On wood — ,, ,, On cloth — ,, ,, On linen — ,, ,, On paper — 10 5.—Staphylococcus aureus. Table XIII. Nature of emulsion. Nature of material. Result of culture after exposure. (a) In broth On wood — ,, On cloth — ,, On linen — ,, On paper — (b) In separated milk On wood — ,, ,, On cloth — ,, ,, On linen — ,, ,, On paper — Table XIV. 6,—Spores of bacillus anthracis. Nature of emulsion. Nature of material. Result of culture after exposure. (a) In broth On wood + ,, On cloth — ,, On linen — ,, On paper — (b) In separated milk On wood + ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Here, also, the disinfection was successful on linen and paper, but failed on wood (in both experiments) and on cloth (in one experiment); this same result we have mentioned already in the case of formalin disinfection, and we would explain it also here (S02) in the same way, viz., that owing to the thickness of the wood and the cloth, the deeper portions of the materials are not acted upon by the gas. It is, therefore, necessary to remember that as regards highly resisting microbes, such as spores, some stronger measures than formalin or sulphurous acid gas have to be employed for disinfection of wood or cloth materials. 7.—Tubercular sputum. The sputum was derived, as in the former case, from a case of pulmonary tuberculosis, and, as microscopic examination proved, was very rich in tubercle bacilli. The table XV. shows the result- Nature of microbe. Nature of material. Result of experiment on animal after exposure. Tubercular sputum On wood + ,, On cloth + ,, On linen + ,, On paper + It ought to be stated that all four animals, as also a control animal (injected with control tubercular paper), were killed four weeks after injection, and all had the same lesions, viz., tubercular changes in the inguinal glands, and distinct tubercles in the spleen and liver. In this experiment, then, the inferiority of S02 (24 hours) to formalin (5 hours) as regards its efficacy on dried tubercular sputum is very striking, since the S02 bad no effect even on thin material like linen and paper that had been charged with the sputum. 11 Table XVI.—Gives a general summary of the experiments made with SO2 exposure 24 hours. On wood. On cloth. On linen. On paper. Bacillus typhosus — — — — ,, ,, — — — — ,, diphtherias — — — — ,, ,, — — — — ,, ,, — — — — „ pyocyaneus — — — — ,, ,, — — — — Vibrio choleræ — — — — ,, ,, — — — — ,, ,, — — — — Staphylococcus aureus — — — — ,, ,, — — — — Spores of bacillus anthracis + — — — ,, „ + + — — Tubercular sputum + + + + B.—Fluid disinfectants. The microbes were the same as used in former experiments, viz., bacillus typhosus, bacillus pyocyaneus, vibrio choleræ, staphylococcus aureus and spores of bacillus anthracis. The bacillus diphtheriæ was left out because previous experience showed the very feeble resistance of this microbe. In all further experiments tubercular sputum was substituted for it. Except the spores of anthrax, the microbes were used as a 24-hour old gelatine culture incubated at 37° C., and therefore fluid. In this condition the culture was liberally applied to the surface of the materials; wood, cloth, linen and paper. The spores of anthrax were distributed in melted gelatine, and this was then applied to the surface of the materials and treated in the same manner as the other microbes. In cooling the gelatine set solid, and in this state the materials were placed in a large volume of the disinfectant solution. In this they were kept for 24 hours, then taken out and the fluid thoroughly sucked up with blotting paper. The materials charged with the typhoid culture were then placed successively in two lots of ordinary broth, those charged with the cholera vibrio were placed in peptone salt solution, and, after superficial washing herein, were transferred to a fresh tube of the peptone salt solution; both tubes were incubated at 37°C. The same was done in the case of the staphylococcus aureus and the spores of bacillus anthracis, two tubes of broth being substituted for peptone salt solution. The materials charged with the tubercular sputum, after removal from the disinfectant fluid, were washed in water, then the fluid was mopped up with blotting paper; after this the sputum was scraped off from the materials and distributed in salt solution and injected into guinea pigs. Series I.—Carbolic acid. This was ordinary pure carbolic acid, and was used as a watery 5 per cent. solution. Time of exposure, 24 hours. The result is shown in the following table XVII.— Nature of microbe. Nature of material. Result of culture and experiment after exposure. Bacillus typhosus On wood — ,, On cloth — ,, On linen — ,, On paper — Bacillus pyocyaneus On wood — ,, On cloth — ,, On linen — ,, On paper — Vibrio choleras On wood — ,, On cloth — ,, On linen — ,, On paper — Staphylococcus aureus On wood — ,, On cloth — ,, On linen — ,, On paper — Spores of anthrax On wood + ,, On cloth + ,, On linen + ,, On paper + Tubercular sputum On wood — ,, On cloth — ,, On linen — ,, On paper — It follows then, from these experiments, that 5 per cent. carbolic acid liberally applied for 24 hours—placing the materials in a large volume of the acid—caused complete disinfection 12 on all materials of all microbes, inclusive of tubercle, except the resisting spores of anthrax. With the latter the result of disinfection was entirely negative, notwithstanding that they were practically soaked in the acid for 24 hours. It is, on the other hand, interesting to find that the tubercular sputum was completely disinfected, all the animals remaining well, whereas a control guinea pig injected with a control sputum paper succumbed in six weeks from typical local and visceral tuberculosis. Series II.—Condy's fluid. This was used in the proportion of one teaspoonful to one imperial pint of water; this would correspond to about 1 in 142. Time of exposure, 24 hours (see footnote). Table XVIII. Nature of the microbe. Nature of material. Result of culture and experiment after exposure. Bacillus typhosus On wood + ,, On cloth + ,,... ... ... On linen + ,, On paper + Bacillus pyocyaneus On wood + ,, On cloth + ,, On linen + ,, On paper + Vibrio choleræ On wood + ,, On cloth + ,, — On linen + ,, On paper + Staphylococcus aureus On wood + ,, ,, On cloth + ,, ,, On linen + ,, ,, On paper + Spores of anthrax On wood + ,, On cloth + ,, On linen + ,, On paper + Tubercular sputum On wood + ,, On cloth + ,, On linen + ,, On paper + From this experiment it follows that the use of Condy's fluid, in the proportion stated, is of negative value, since steeping the materials for 24 hours in the solution failed to devitalise any of the non-sporing microbes on any of the materials. On account of this unfavourable result, we have repeated the experiment, using, however, the solution five times as strong. Table XVIIIa gives the results obtained. Table XVIIIa.— Condy's fluid, 5 teaspoonfuls to one pint of water; time of exposure 24 hours. Nature of the microbe. Nature of material. Result of culture and experiment after exposure. Bacillus typhosus On wood + ,, On cloth + ,, On linen + ,, On paper + Bacillus pyocyaneus On wood + ,, On cloth + ,, On linen + ,, On paper + Vibrio choleræ On wood + ,, On cloth + ,, On linen — ,, On paper + Staphylococcus aureus On wood + ,, On cloth + .. On linen — .. On paper + Spores of anthrax On wood + .. On cloth + ,, On linen + ,, On paper + Tubercular sputum On wood + ,, On cloth + ,, On linen — ,, On paper + Note.—The spores of anthrax were, as a matter of fact, exposed to the disinfectant for three times 24 hours. 13 From this last Table XVIIIa, it follows that the disinfecting power of Condy's fluid, even when used in the proportion of five teaspoonfuls to one pint of water, remained practically negative in our experiments. Whether this result is due to the disinfecting power of the fluid being consumed in the oxydising of the organic matter submitted with the microbes, we are unable to say. Series III.—Corrosive Sublimate. This was used according to the formula of the Local Government Board; 1 in 1,000. Time of exposure 24 hours. Table XIX. gives the results of the culture and experiment after exposure; as might be expected, all microbes, including the spores of anthrax and the tubercular sputum, had been killed by the solution. Table XIX. Bacillus typhosus On all materials — Bacillus pyocyaneus ,, — Vibrio choleræ ,, — Staphylococcus aureus ,, — Spores of bacillus anthracis ,, — Tubercular sputum ,, — Series IV.—Bleaching Powder.* This was used in the form of a one per cent. solution. Time of exposure 1 hour. The result of the experiment is shown in Table XX. Nature of microbe. Nature of material. Result of culture and experiment after exposure. Bacillus typhosus On wood + ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Bacillus pyocyaneus On wood — ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Vibrio choleræ On wood — ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Staphylococcus aureus On wood + ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Spores of bacillus anthracis On wood + ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — Tubercular sputum On wood + ,, ,, On cloth + ,, ,, On linen — ,, ,, On paper — The result of this experiment is then this: a 1 per cent. solution of the bleaching powder is capable in one hour of disinfecting the spores of bacillus anthracis on paper and on linen, an effect more favourable than that obtained with a 5 per cent. solution of carbolic acid or five times Condy, even after an exposure of 24 hours. The experiment with the 1 per cent. solution of bleaching powder was repeated, this time leaving the materials 24 hours in the solution. Table XXa gives the results of this series. *Bleaching powder is a mixture of calcium chloride, CaCl2 and calcium hypochlorite, CaCl2O2 It is sometimes called chloride of lime and sometimes calcium hypochlorite. The substance used in our experiments is the article employed in commerce for bleaching purposes, and which is also largely used as a disinfectant and deodorant. 14 Table XXa.—Bleaching powder, 1 per cent.; time of exposure, 24 hours. Nature of microbe. Nature of material. Result of culture and experiment after exposure. Bacillus typhosus On wood — ,, On cloth — ,, On linen — ,, On paper — Bacillus pyocyaneus On wood — ,, On cloth + ,, On linen — ,, On paper — Vibrio choleræ On wood — ,, On cloth — ,, On linen — ,, On paper — Staphylococcus aureus On wood — ,, On cloth — ,, On linen + ,, On paper — Spores of bacillus anthracis On wood + ,, On cloth + ,, On linen + ,, On paper — Tubercular sputum On wood — ,, On cloth + ,, On linen — ,, On paper — From this table it appears that while a 24 hours' exposure to the 1 per cent. solution of the bleaching powder completely disinfected the typhoid bacillus and the cholera vibrio on all materials, it was not so uniformly successful with the other microbes. E. Klein. A. C. Houston. M. H. Gordon. Appendix IV. London County Council. SANITARY OFFICERS. Report by the Medical Officer on the Sanitary Staffs of the Metropolitan Boroughs. Printed by order of the Public Health Committee. Public Health Department, 8, St. Martin's-place, W.C., June, 1901. The last return presented to the Committee on this subject related to the year 1898. Similar returns had been prepared in 1889, 1893, 1894 and 1895; the return of 1889, however, gave no information as to the number of sanitary inspectors in the City and Whitechapel. The following table enables comparison to be made of the number of inspectors in London for each of the years for which complete returns have been obtained— Tear. Number of sanitary inspectors in the whole of London. 1893 188* 1894 219* 1895 228* 1898 256* 1901 275 In the following table will be found the number of sanitary inspectors employed in each of the metropolitan boroughs at the present time. It is not possible without knowledge of the character of the population in each borough to make comparison between them, or to come to conclusions as to the sufficiency of their staff. The proportion of population to each sanitary inspector does not afford sufficient data for accurate conclusions. Owing to the re-districting of London under the Act of 1899 it is difficult to compare in respect of each district the proportions which existed at the date of the last return with those at the present time. It is, however, possible to do this in most of the sanitary areas, and in the following table the data relating to these districts have been given for this purpose. Metropolitan Boroughs. Enumerated population 1901 (preliminary census). Number of sanitary inspectors. Increase (+) or Decrease (—) in 1901 compared with 1898. Population to each sanitary inspector. 1898 1901 1898 1901 Paddington 143,954 †6 †6 ... 20,751 23,992 Kensington 176,623 7 13 + 6 24,352 13,586 Hammersmith 112,245 7 8 + 1 14,886 14,031 Fulham 137 289 5 6 + 1 22,756 22,881 Chelsea 73,856 3 4 + 1 32,215 18,464 Westminster 182,977 †l5 11 — 4 12,874 16,634 St. Marylebone 133,329 6 7 + 1 23,531 19,047 Hampstead 81,942 5 5 ... 15,090 16,388 St. Pancras 235,284 10 14 + 4 24,076 16,806 Islington 334,928 18 ‡20 + 2 18,709 16,746 Stoke Newington 51,247 †2 2 • •• 16,742 25,623 Hackney 219,288 14 †15 + 1 15,217 14,619 City of London 26,897 ||†14 ||14 • •• 2,212 1,921 Shoreditch 118,705 6 6 • •• 20,391 19,784 Bethnal-green 129,681 7 §11 + 4 18,452 11,789 Stepney 298,548 15 17 + 2 19,639 17,562 Poplar 168,838 7 8 + 1 24,181 21,105 Southwark 206,128 13 ‡18 + 5 15,891 11,452 Bermondsey 130,486 7 ‡7 • •• 19,655 18,641 Lambeth 301,873 13 13 ... 22,695 23,221 Battersea 168,896 10 9 — 1 16,511 18,766 Wandsworth 232,030 13 13 • •• 14,405 17,848 Camberwell 259,258 12 12 • •• 21,090 21,605 *Excluding inspectors employed in districts mentioned in Schedule C of the Metropolis Local Management Act. †Including one temporary inspector. ‡Including one vacancy. §Including three vacancies. || Including seven inspectors, who are concerned only with meat inspection; if these be omitted, the population per sanitary inspector is in 1898, 4,424; and in 1901, 3,842. ii In the remaining districts the facts cannot be thus stated, but the following may be noted— Holborn.—This comprises the old sanitary district of St. Giles and the major portion of the old sanitary district of Holborn, the only comparison possible for the present purpose is that between the facts for the present Metropolitan Borough of Holborn and those for the former sanitary districts of St. Giles and Holborn. Finsbury.—This borough comprises the old sanitary district of Clerkenwell and St. Luke, together with a small portion of the old sanitary district of Holborn. As the facts for this portion of Holborn cannot be ascertained those relating to the old sanitary districts of Clerkenwell and St. Luke afford the only basis of comparison with those relating to the present borough of Finsbury. Deptford.—This borough practically coincides in area with that of the parish of St. Paul, Deptford. The facts relating to the sanitary staff in the year 1898 relate to the parishes of St. Paul and St. Nicholas, Deptford, and cannot be separately distinguished for the latter parish. Greenwich.—This borough comprises the parishes of St. Nicholas, Deptford, Greenwich, Charlton and Kidbrooke. The return of 1898 does not record the facts for Kidbrooke and St. Nicholas, Deptford, and comparison with the present borough of Greenwich in the table is therefore limited to the parishes of Charlton and Greenwich. The number of sanitary inspectors in 1898 is somewhat under-stated inasmuch as the duties of one of the inspectors employed by the Lee Board of Works in that year related to the whole of the district under the Board's jurisdiction. Lewisham.—This borough comprises the parish of Lee and the former sanitary district of Lewisham less the hamlet of Penge. In the following table comparison has been instituted between the facts relating to the old sanitary area of Lewisham and the present metropolitan borough. Woolwich.—This borough comprises the old sanitary districts of Woolwich and Plumstead, and the parish of Eltham. The facts relating to 1898, shown in the table, relate practically to the same area as those for 1901, but the number of sanitary inspectors in 1898 is somewhat understated, as in the case of Greenwich, inasmuch as the duties of one of the inspectors employed by the Lee Board of Works in 1898 related to the whole of the district under the jurisdiction of the Board. Metropolitan Boroughs. Areas to which the facts of 1898 relate. Enumerated population 1901 (preliminary census). Number of Sanitary Inspectors. Increase (+) or decrease (—) in 1901 compared with 1898. Population to each sanitary inspector. 1898 1901 1898 1901 Holborn Old sanitary districts of St. Giles and Holborn 59,390 †9 *5 †— 4 7,716 11,878 Finsbury Old sanitary districts of Clerkenwell and St. Luke 101,476 5 7 + 2 21,546 14,497 Deptford Parishes of St. Paul and St. Nicholas, 110,513 6 5 — 1 19,166 22,103 Greenwich Parishes of Greenwich and Charlton 95,757 4 5 + 1 18,633 19,151 Lewisham Old sanitary district of Lewisham 127,460 7 6 — 1 14,932 21,243 Woolwich Old sanitary districts of Woolwich and Plumstead, together with the parish of Eltham 117,165 8 8 ... 13,310 14,646 *Including one vacancy and one temporary inspector. †One of these inspectors was concerned with meat inspection only, and is now employed by the Finsbury Borough Council. It should also be pointed out that three of the Dine inspectors shown in the table were attached to the surveyor's department of St. Giles' Board of Works. The information upon which this return is based has been supplied by the medical officers of health of the several boroughs. Shirley F. Murphy, Medical Officer of Health. Details as to Sanitary Staff in the several Metropolitan Boroughs. Paddington—Population 1901, 143,954. A medical officer of health (whole time appointment). £600 per annum. Half repayable by County Council. Also holds the appointment of examining officer under the Canal Boats Act. Five sanitary inspectors, one temporary sanitary inspector. 1. C. J. B. £200 and £10 for canal boat duties. Half repayable by County Council. 2. E. J. P. £160. Half repayable by County Council. 3. J. W. W. £130. ,, ,, ,, 4. P. T. L. £130. „ ,, „ 5. E. A. £110. ,, ,, ,, 6. G. W. (temporary) £80. No portion paid by County Council. Assistants.—An inspector under the Food and Drugs Act. One disinfecting assistant. A mortuary keeper. A caretaker and his wife at the shelter. The man is also employed at the dustyard. Five navvies in the employment of a contractor with whom the vestry have a contract to open up ground for the examination of drains. Clerical staff.—Two clerks are entirely engaged in duties arising out of the work of the public health department. Duties.—Each of the inspectors has been allotted a district, and in it each is concerned with all duties arising under the Public Health and Factory and Workshop Acts. Each inspector supervises the construction of drainage work in old houses. The drainage of new premises is supervised by the surveyor's department. For the examination of drains suspected to be defective the inspectors have the assistance of men who open up the ground. These men are not directly employed by the vestry, but are provided by a contractor with whom the authority have a contract. For the collection of samples under the Food and Drugs Act an officer is specially employed, and is included among the above-mentioned assistants. The sanitary inspectors are under the entire supervision and direction of the medical officer of health. Scavenging of dustbins and of streets.—The scavenging of streets and of dustbins is supervised by officers in the surveyor's department. The reorganization of the staff has been referred to a special committee. At the present time there are five inspectors allotted to districts, a sixth temporary inspector allotted to the area (transferred from Chelsea to Paddington), one keeper for the mortuary on Paddington-green, another for the Kensal-road mortuary (who also assists in the disinfecting), one disinfecting officer, and two clerks. Kensington—Population 1901, 176,623. A medical officer of health (whole time appointment). £1,000 per annum. Half repayable by County Council. Thirteen sanitary inspectors — 1. G. P. (chief inspector), present salaries, £220 Half repayable by County Council. 2. A. F. ,, £180 ,, ,, ,, 3. H. D. ,, £170 ,, ,, ,, 4. J. S. ,, £170 ,, ,, ,, 5. N. M. ,, £160 ,, ,, ,, 6. C. G. S. ,, £150 ,, ,, ,, 7- T. C. ,, £150 ,, ,, ,, 8. J. B. ,, £150 ,, ,, ,, 9. E. B. ,, £150 ,, ,, ,, 10. A. L. ,, £150 ,, ,, ,, 11. G. McQ. ,, £150 ,, ,, ,, 12. Miss de C. ,, £130 ,, ,, ,, 13. Miss G. L. ,, £110 ,, ,, ,, Seniority of inspectors is indicated by amount of salary. The chief inspector's salary will be raised by two annual increments of £15 to .£250 per annum. The scale of salaries of other male inspectors commences at £150 per annum, rising by conditional annual increments of £10 to £200 per annum. The lady inspectors' salaries commence at £110 per annum, rising by conditional annual increments of £10 to £150 per annum. Assistants.— 1. One assistant for disinfection. 2. A mortuary keeper. Clerical staff.—There are five clerks entirely engaged in duties arising out of the work of the department. 2 Duties.—Each of ten of the male inspectors on the above list has been allotted a district, and in it each is concerned with all duties arising under the Public Health Act. The first on the list is chief sanitary inspector, and exercises supervision over the work of the other officers. The female inspectors are engaged in the inspection of workshops, workplaces and laundries where females are employed. The ten male inspectors obtain samples under the Food and Drugs Act. For the examination of drains suspected to be defective the inspectors have the assistance of a labouring man. This man is not directly employed by the Council, but is provided by a contractor with whom the Council have a contract. The disinfecting assistant carries out the work involved in fumigating rooms, and sees to the removal by the contractor of articles needing disinfecting, such articles, moreover, being also cleansed. He also sees the articles weighed at the disinfecting station. In the closing of rooms he is assisted voluntarily by the man employed by the contractor to remove articles. It is not part of the disinfecting assistant's duty to open the room on the completion of fumigation; this is done by the householder. The sanitary inspectors are under the direction and supervision of the medical officer of health. Scavenging of dustbins and streets.—For the scavenging of dustbins there are, under the borough engineer, two dust inspectors or foremen, whose duty it is to supervise this work, and there is also a foreman who superintends the cleansing of roads by men employed by the Council. Hammersmith—Population 1901, 112,245. A medical officer of health (part time appointment, also allowed to engage in consulting medical work). £550 per annum. Half repayable by County Council. Eight sanitary inspectors— 1. W. B. £150, rising to £180. Half repayable by County Council. 2. J. S. C. £122 10s., ,, ,, ,, ,, ,, 3. S. A. £110, ,, ,, ,, ,, ,, 4. J. C. £150, ,, ,, ,, ,, ,, 5. C. G. £150, ,, ,, ,, ,, ,, 6. H. O. £150, ,, ,, ,, ,, ,, 7. S. H. B. £127 10s., „ „ ,, ,, ,, 8. H. N. £110, ,, ,, ,, ,, ,, Assistants.—Two disinfecting assistants (at present). A mortuary keeper (who is resident at the new coroner's court and mortuary buildings). Two drainage inspectors. One or two labourers from surveyor's department, who do the cleansing of rooms in connection with disinfection. Clerical stnff.—Two clerks are engaged solely in duties arising out of the work of the department. Duties.—The first four sanitary inspectors on the above list have each a district, and in it they are concerned with duties under the Public Health Act, including infectious diseases. The fifth on the list is entirely engaged in a systematic house-to-house inspection of the whole district, and noting their condition, which is then recorded in a register kept for the purpose. If there be any defects in a house, the remedying of the defective conditions passes under the inspector in whose district the premises are situated. Some 4,092 houses were thus visited during the twelve months ending 1896. The sixth inspector on the list is employed in duties arising under the Food and Drugs Act and in seeing that dustbins are properly cleansed. The seventh on the list is concerned with the duties transferred by the London County Council, and smoke nuisances; and the 8th is concerned with factories and workshops. The sanitary inspectors are under the control and supervision of the medical officer of health. Scavenging of streets.—In addition to this staff, there are under the surveyor three road foremen (two for day and one for night work) who attend to the scavenging and repairing of roads. Fulham—Population 1901, 137,289. A medical officer of health (whole time appointment). £750 per annum. Half repayable by Countv Council. Six sanitary inspectors— 1. C. B. J. £170 per annum Half repayable by County Council. 2. W. H. G. £170 ,, 11 11 11 3. F. M. £140 ,, 11 11 11 4. C. B. L. £140 ,, 11 11 It 5. S. J. C. £130 ,, ,, 11 11 6. J. W. £130 ,, 11 11 It Assistants.— three drainage inspectors. Two disinfectors and three men and a driver employed at the Council's disinfecting station. A mortuary keeper. Clerical staff.—Two clerks. 3 Duties.- -Each sanitary inspector, except No. 6, is allotted a district in which he performs all duties arising under the Public Health Act, the Factory and Workshop Act, and the Food and Drugs Act. The 6th inspector has till recently been employed in the inspection of houses let in lodgings. He is a present, pending the confirmation of the amended by-laws, employed in the inspection of dairies, cowsheds, &c. The drainage inspectors are concerned with controlling the construction of the drainage of new houses and the supervision of the reconstruction of drains in cases where notices have been served. Two disinfectors are employed in room disinfection, and the three men and a driver are employed at the Council's disinfecting station. The mortuary keeper looks after the mortuary, post-mortem room and the coroner's court. He is non-resident, but lives close to the mortuary. The sanitary staff is under the immediate control and supervision of the medical officer of health. Scavenging of dustbins and of roads.—In addition to the above staff there are in connection with the collection of house refuse and the scavenging of roads, the following officers under the surveyor— One dust inspector, whose duty is to see that dustbins are properly emptied. One road foreman who supervises road cleaning, and a superintendent who has charge of all men in the works department under the surveyor. Chelsea—Population 1901, 73,856. A medical officer of health (part time appointment). £500 per annum. Half repayable by County Council. Also holds the appointment of analyst. sanitary inspectors— 1. A. G. £225 per annum Half repayable by County Council. 2. G. R. M. £150 ,, ,, ,, ,, 3. W. J. K. £150 ,, ,, ,, ,, 4. W. T. £150 ,, ,, ,, ,, Assistants.— A mortuary keeper. Two disinfecting and drain-testing assistants. Clerical staff.—There is no clerical assistance. Duties.—The first inspector on the above list carries out duties connected with infectious disease and complaints, and obtains samples under the Food and Drugs Act. Each of the other inspectors is allotted a district in which each is concerned with house-to-house inspection, and inspection under the Factory and Workshop Act. Each inspector, with the aid of one of the assistants, also disinfects articles of clothing and bedding. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of dust-bins and streets.—For the scavenging of streets and of dust-bins, there are under the surveyor a road foreman and a dust inspector. City of Westminster—Population 1901, 182,977. A medical officer of health (whole time appointment). £800 per annum. Half repayable by County Council. Eleven sanitary inspectors— 1. T. F. S. £250 per annum. Half repayable by County Council. 2. A. T. £220 ,, ,, ,, ,, 3. F. A. A. £180 ,, ,, ,, ,, 4. T. W. C. £170 ,, ,, ,, ,, 5. J. P. F. £190 ,, ,, ,, ,, 6. J. W. K. £220 ,, ,, ,, ,, 7. E. J. M. £160 ,, ,, ,, ,, 8. J. S. £180 ,, ,, ,, ,, 9. J. W. W. £150 „ ,, ,, ,, 10. T. G. D. £220 ,, ,, ,, ,, 11. A. McP. £220 ,, ,, ,, The salaries of these eleven inspectors, which are under £220, are to increase by annual increments of £10 until £220 is reached. In addition to above, E. G. G. (salary £157, half repayable by County Council), who was partly engaged in duties under the Public Health Act, has not yet been dealt with. Assistants.—F. C. (salary £91), who visited houses let in lodgings, is temporarily retained for that purpose. No part of his salary is repayable by County Council. Eight disinfecting assistants. Three mortuary keepers. One disinfecting assistant acts also as keeper of the mortuary and shelter, and one mortuary keeper also has charge of shelter and coroner's court; one mortuary keeper is also a hall-keeper. Clerical staff.—One chief clerk and committee clerk, and three assistants. (Question of additional clerical staff under consideration.) 4 Duties.—The first inspector on the list is the chief sanitary inspector and exercises a general supervision over the work of the others. Nos. 2, 3, 4, 5, 6, 7, 8, 9 perform all the duties of sanitary inspectors, except such duties as are allotted to Nos. 10 and 11. Nos. 10 and 11 perform all the duties under the Food and Drugs Act, abatement of smoke nuisances, inspection of street markets, slaughterhouses, offensive trades, cowhouses, and inspection of food generally. St. Marylebone—Population 1901,133,329. A medical officer of health (part time appointment). £500 per annum. Portion repayable by County Council. Also holds the appointment of public analyst. sanitary inspectors— 1. R. P. £3 a week Portion paid by County Council. 2. W. Y. £2 17s. 6d. „ 3. D. A. £2 17s. 6d. „ 4. T. G. £2 15s. ,, 5. A. P. £2 17s. 6d. „ 6. J. H. £2 12s. 6d. „ 7. Miss L.M.O'K. £1 17s. 6d. ,, Assistants.—Three disinfecting assistants. Caretaker at shelter (female). One mortuary keeper. Clerical staff.—Two clerks. Duties.—The first and seventh on the above list of sanitary inspectors devote their time to duties arising under the Factory and Workshop Act, the first also dealing with smoke nuisances. The remaining officers have each a district in which they are concerned with all duties arising under the Public Health Act and the Food and Drugs Act, assistance in taking samples of food, &c., being occasionally obtained by the inspectors. One of the disinfecting assistants is engaged in carrying out the disinfection of articles, another goes with the vans to collect articles of clothing, a horse and driver being hired for the van, and the third disinfecting assistant is employed in attendance on persons who come to cleanse themselves and their clothing under the Cleansing of Persons Act. The bathing and disinfecting apparatus under the Cleansing of Persons Act—comprising four baths for men and two for women, with w.c. accommodation and a steam disinfector for the purification of bathers' clothes—are situated in an annexe to the Council's shelter house which adjoins the stoneyard, Capland-street. The caretaker of the shelter also performs supervisory duties over the female section of the cleansing of persons department. The sanitary inspectors supervise all drainage work taking place within premises, both as regards new premises and reconstructions. They also supervise the cleansing of dustbins. There is no special inspector for this purpose. The inspectors and other officers are under the full supervision and direction of the medical officer of health. Scavenging of streets.—The scavenging of roads comes under the supervision of officers in the surveyors' department. Hampstead— Population 1901, 81,942. A medical officer of health (part time appointment). £350 per annum. No portion repayable by County Council. The office of medical officer of health is at present filled by Dr. E. Gwynn, who is acting as temporary medical officer of health pending the appointment of his successor. Salary of future medical officer of health will probably be £600: half repayable by County Council. Five sanitary inspectors— 1. G. A. S. £275 per annum. Sanction of Local Government Board under General Order now being applied for. 2. J. H. L. 185 „ Half repayable by County Council. 3. W. H. E. 170 „ ,, ,, ,, 4. R. G. 170 ,, ,, ,, ,, 5. F. H. H. 150 ,, ,, ,, ,, It is proposed to appoint two additional inspectors shortly at £120 per annum each. Half to be repayable by County Council. Assistants.—Two disinfecting assistants. One assistant for testing drains. A mortuary keeper. Clerical staff.—There are two clerks solely engaged in duties arising out of the work of the Public Health department. Duties.—The first on the above list of inspectors acts as senior inspector and has special duties. Thus he has the management of summary proceedings and is responsible for the drafting and service of notices. He makes all inquiries in connection with the notification of infectious diseases and superintends the disinfection of articles and of rooms. He inspects periodically bakehouses, slaughterhouses, cowsheds and dairies, and is also concerned with duties under the Factory and Workshop Act. 5 The remaining four are divisional inspectors, and each, in his district, is concerned with all duties under the Public Health Act (except those mentioned above) and the Food and Drugs Act. Of the disinfecting assistants, one acts as driver to the vans, the other fetches and returns the articles, manipulates the disinfecting apparatus during the process of disinfection and disinfects rooms. The sanitary inspectors are under the control and supervision of the medical officer of health. Scavenging of dustbins and of roads.—There is a dusting superintendent in the surveyors' department who attends to the systematic cleansing of dustbins, and there are two foremen of scavengers for the cleansing of streets. St. Pancras—Population 1901, 235,281. A medical officer of health (whole time appointment). £700 per annum. Half repayable by the County Council. fourteen sanitary inspectors— District r inspectors. 1. G. R., £120 to £150 per annum. Half repayable by County Council. 2. E. J. D. ,, ,, ,, ,, 3. C. H. J. ,, ,, ,, ,, 4. W. B. ,, ,, ,, ,, 5. H. G. W. ,, ,, ,, ,, 6. J. I. L. „ „ ,, ,, 7. H. R. C. ,, ,, ,, ,, 8. J. L. ,, „ ,, ,, Food and food places. 9. W. G. A., £120 to £180 per annum. ,, ,, 10. J. O. ,, ,, Workshops and workplaces. 11. F. B., £120 to £150 per annum. ,, ,, 12. Miss A. J. S., £80 to £100 per annum. ,, ,, Tenement houses. 13. W. J. S., £120 to £150 per annum. ,, ,, 14. A. H. W. ,, ,, ,, ,, Assistants.—Three assistants for disinfection. A caretaker of the mortuaries and coroner's court. An attendant (wife of mortuaries keeper) upon the temporary shelter at the disinfecting station. A messenger. Clerical staff.—There is a chief clerk for the public health department, five other clerks and a boy clerk. Duties.—The first eight sanitary inspectors on the above list have each been allotted a district in which each deals with infectious diseases, complaints, drainage, and nuisances generally. 9 and 10 are inspectors of food and food places and carry out the Food and Drugs Acts, and the bylaws for slaughterhouses and dairies, and the inspection of food. 11 and 12 carry out the duties of the Factory and Workshop Acts. The male inspector also deals with the bakehouses, offensive trades and smoke, and the female with outworkers' lists, domestic workshops, laundries and day schools. 13 and 14 deal with tenement houses, making inquiry as to occupation, measuring them for registration purposes, inspecting them when registered, and the re-inspection of closed underground dwellings. Of the disinfecting assistants one works the steam chamber, one drives the vans, and one fumigates the rooms and removes the articles of clothing to and fro, assisted at either end by one of the other two. Note.—The Public Health Committee have recommended that the salaries of the sanitary inspectors should in future be £150 to £200 per annum, and this is now under consideration (April, 1901). The borough council have since resolved that the salaries of the sanitary inspectors shall commence at £120, rising by annual increments to £150 per annum, the increases to take effect at the commencement of the next financial year (May 1901. Islington—Population 1901, 334,928. A medical officer of health (whole time appointment). £800 per annum. Half repayable by County Council. Twenty sanitary inspectors — 1. J. R. L. £300 per annum. Half repayable by County Council. 2. W. C. £160 ,, ,, ,, ,, 3. H. J. B. £130 ,, ,, ,, ,, 4. W. W. W. £160 ,, ,, ,, ,, 5. E. J. G. £160 ,, ,, ,, ,, 6. W. H. F. £160 ,, ,, ,, ,, 7. A. B. £160 ,, ,, ,, ,, 8. C. L. £160 „ ,, ,, ,, 9. J. M. £160 ,, ,, ,, ,, 10. W. I. £160 ,, ,, ,, ,, 11. H. J. J. W. £160 ,, ,, ,, ,, 12. E. J. F. £160 ,, ,, ,, ,, 6 13. (Vacant) £130 per annum. Half repayable by County Council. 14. W. R. £160 ,, ,, ,, ,, 15. H. C. £130 ,, ,, ,, ,, 16. G. W. £160 ,, ,, ,, ,, 17. J. J. J. £160 ,, ,, ,, ,, 18. J. W. C. £160 ,, ,, ,, ,, 19. T. D. Y. £200 ,, ,, ,, ,, 20. Miss J. M. S. G. £150 ,, ,, ,, ,, Assistants.—Nine assistants for disinfection. A mortuary keeper. Caretaker of shelter. Clerical staff.—Seven clerks and a messenger who also helps in clerical work. Duties.—The first on the above list of inspectors acts as chief sanitary inspector. He visits all premises in regard to which it is necessary to serve a statutory notice, and generally supervises and assists the inspectors in their work. Numbers two to fifteen inclusive are each district inspectors, and in their respective districts they each perform all duties arising under the Public Health Act (except as regards houses let in lodgings and workshops) and on Sundays in rotation take samples of milk under the Food and Drugs Act. Number sixteen is the inspector for workshops, bakehouses, and smoke nuisances; number seventeen for houses let in lodgings, and number eighteen divides his work between inspecting houses let in lodgings and obtaining samples for analysis under the Food and Drugs Act; number 19 devotes his entire time to the inspection of meat and food; and number 20 is an inspector for workshops, &c., in which females are employed. The assistants engaged in the work of disinfection are employed as follows—One as engineer in charge of the disinfecting ovens, two with the vans, one as driver, the other to assist in fetching the articles, three do the stripping of walls and cleansing and fumigating of rooms, and one distributes disinfectants at the vestry hall, and occasionally assists in fumigation. The sanitary inspectors are under the direction and supervision of the medical officer of health. Scavenging of dustbins and streets—In the surveyor's department there is a superintendent of dusting and slopping, who supervises the cleansing of roads and scavenging of dustbins, which is done by men in the employment of the vestry. Stoke Newington —Population 1901, 51,247. A medical officer of health (part time appointment). £300 per annum. Half repayable by County Council. The staff of sanitary inspectors is as follows— 1. D. W. M., £3 10s. a week; half repayable by County Council. 2. S. H. K., £2 10s. a week; „ „ „ Assistants.—A disinfecting assistant. Clerical staff.—There is one clerk who is engaged solely in duties arising out of the work of the public health department. For purposes of sanitary inspection the borough is divided into two, and one inspector is allotted to each half. The present arrangements are under trial. It is probable that the services of a third inspector will be found necessary. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of dustbins and streets.—For superintending the scavenging of roads there is a road foreman under the surveyor, and the Council have appointed four officers whose duty it is to see that dustbins are regularly cleansed by the contractor who carries out the work. Hackney—Population 1901, 219,288. A medical officer of health (whole time appointment). £600 per annum. Half repayable by County Council. Fourteen sanitary inspectors— 1. S. C. L. £180 - - Half repayable by County Council. 2. S. P. £180 - - ,, ,, ,, 3. W. H. £176 10 - ,, ,, ,, 4. E. S. W. £163 10 - ,, ,, ,, 5. G. F. H. £163 10 - ,, ,, ,, 6. J M. £163 10 - ,, ,, ,, 7. E. F. K. £163 10 - ,, ,, ,, 8. A. J. B. £157 - - ,, ,, ,, 9. F. W. M. £157 - - ,, ,, ,, 10. R. H. E. £157 - - ,, ,, ,, 11. H. B. £140 10 - ,, ,, ,, 12. R. J. S. £134 - - ,, ,, ,, 13. G. W. £134 - - ,, ,, ,, 14. Miss A. T. £134 - - ,, ,, ,, An additional inspector is also engaged temporarily upon house to house inspection. 7 Assistants.— One dust inspector. Nine assistants in connection with disinfection work. One mortuary keeper. One assistant to help in drain testing. One assistant for smoke nuisances. A varying number of dustmen. One messenger is attached to the department who is directly appointed by the Council. Clerical staff.— There are four clerks engaged in duties arising out of the work of the public health department. Duties.— The whole district is divided into twelve sub-districts, and in each of these an inspector is concerned with all duties arising under the Public Health Acts, Factory and Workshop Acts, and Food Adulteration Acts, and number 13 is also canal boat inspector under the Canal Boats Act. By arrangement with the chief inspector of canal boats (Local Government Board) this inspector devotes one entire day in each week to this work, and £26 of his salary is apportioned to the work, and no part of this sum is repaid by the County Council. Inspector number 12 in the list is engaged in house to house inspection and in inspection of houses let in lodgings. Number 14 is engaged in inspecting workshops, laundries, &c., where females are employed, and the houses of outworkers. The inspectors supervise reconstruction and alteration of drains, but the drains of new premises are under the supervision of the surveyor. Of the five disinfecting assistants, one is in charge of the disinfecting apparatus and station, two fetch and return articles of clothing with the disinfection van, two fumigate rooms; the others are employed to strip walls, to lime-white and to cleanse rooms. The messenger gives out disinfectants and helps in the service of the department generally, and especially in connection with infectious diseases. The dust inspector supervises and sees that the Council's dustmen are on duty. The dust removal is carried out by a contractor, and in order that the Council may have direct control in the execution of the work the entire district has been divided into thirty-five sub-districts, to each of which a man employed by tbe Council is allotted. It is the duty of these men to help and to see that the house refuse is properly removed from each house, and they are under the superintendence of the dust inspector. The sanitary inspectors are entirely under the direction and supervision of the medical officer of health. Scavenging of streets.—Road scavenging is supervised by the surveyor, and for this purpose there are three road surveyors under him. Holborn—Population 1901, 59,390. A medical officer of health (whole time appointment). £700 per annum. Half repayable by county Council. Five sanitary inspectors who are concerned solely with duties in the public health department— 1. A. B. £160 and uniform. Half repayable by County Council. 2. F. W. C. £150 ,, ,, ,, 3. G. J. G. £150 ,, ,, ,, 4. Vacant (advertised for) £150 ,, ,, ,, 5. W. F. (temporary) £150 ,, ,, ,, Assistants.— Two disinfecting assistants. A mortuary keeper, who looks after mortuary and coroner's court. Clerical staff.— There are one chief clerk and one assistant clerk solely engaged in duties arising out of the work of the department. Duties.— To each of the inspectors, numbers 1 to 4 in above list, a district is allotted, and in it each is concerned with all duties arising under the Public Health, Factory and Workshop, and Food and Drugs Acts, except so far as relates to any nuisance not arising on private premises, that is to say, in the public way, streets, or from carriage of offensive matter. No. 5 is engaged temporarily on the special inspection under the direction of the medical officer of health, of milkshops, dairies, cowsheds, slaughter-houses and other premises where food is sold or prepared for sale. All drainage work is supervised and all testing of drains is carried out by the surveyor's department. The disinfectors are engaged in the disinfection of rooms, in fetching and returning articles of bedding, &c., and in disinfecting them at the station. They also work for the borough surveyor in the stoneyard. The sanitary inspectors are entirely under the supervision and direction of the medical officer of health. Scavenging of streets.—There are two inspectors acting under the direction of the borough surveyor, entirely occupied in seeing that the streets are properly scavenged. There are also three inspectors who deal with nuisances occurring on the public way which are not dealt with by the sanitary inspectors. Removal of dust.—The dust is removed by contract under the supervision of the borough surveyor. There are two inspectors solely concerned with the cleansing of ashbins. 8 Finsbury—Population 1901, 101,476. A medical officer of health (whole time appointment). £700 per annum. Half repayable by County Council. Seven sanitary inspectors— 1. W. G. (chief) £220 and uniform. Half repayable by County Council. 2. G. T. B. (meat) £220 no uniform. „ „ ,, (7s. 6d. for each attendance at police-court). 3. W. P. E. £182 and uniform. Half repayable by County Council. 4. R. A. £150 ,, ,, ,, ,, 5. H. E. C. £140 ,, ,, ,, ,, 6. G. E. J. D. £130 ,, ,, ,, ,, 7. M. E. L. £120 ,, ,, ,, ,, Note.— Each of the three latter rise to £150 per annum by yearly increments of £10. Assistants.— A mortuary keeper, who also has charge of and works the disinfecting apparatus (Goddard, Massey and Warner), at 49, Northampton-road. A mortuary keeper at Warwick-place, Whitecross-street, who assists in the disinfection of rooms, bedding, &c., and works the Thresh disinfector when it is required. A shelter keeper, who also does disinfection of rooms, and with the van-driver fetches infected bedding and articles of clothing, and returns them when disinfected. Clerical staff.— Two clerks solely engaged in clerical duties arising out of work of the department. Duties.—Each inspector is allotted a district, and in it carries out all duties under the Public Health, Metropolis Local Management, Factory and Workshops, and Food and Drugs Acts; including the supervision of the execution of all drainage works within new and old buildings. The whole of the public health department is under the supervision and direction of the medical officer of health, to whom the inspectors make their reports. Scavenging of streets and dustbins.—The duties relating to this department of work are under the direction of a superintendent who has control of the whole district, and is assisted by a staff in the employ of the borough council. City of London—Population, 1901, 26,897. A medical officer of health (whole time appointment). £1,000 per annum. Half repayable by County Council. Seven sanitary inspectors— lst class.—A. R. H. £250 Half repayable by the County Council. W. H. J. G. W. H. M. 2nd class.—E. J. S. £140 to £200 Half repayable by the County Council. F. J. R. H. J. J. B., assistant inspector senior inspector of slaughterhouses and meat; and six inspectors— G. P. T., senior inspector £400 J. L. £225 O. S. £225 H. J. £200 (commencing salary). W. E. D. W. E. W. K. Assistants.— A keeper of the mortuary and engineer in charge of the disinfecting apparatus. Two assistants in connection with disinfection and other duties. Clerical staff.— There is a clerk who is entirely concerned with duties of the department of the medical officer of health. Clerical assistance is also given by clerks on the general staff of the public health department, which comprises the department of the medical officer of health and public analyst, the streets and cleansing department, and the finance department. Duties.— Each of the sanitary inspectors is concerned with all duties arising under the Public Health Act and the Food and Drugs Act, except the last on the above list, who is concerned with smoke nuisances, duties in connection with cases of notified infectious disease, and with the service of notices on the occupiers of factories and workshops. The meat inspectors are engaged in connection with meat inspection. The inspectors are under the entire supervision and direction of the medical officer of health. Scavenging of roads and dustbins.— This work is carried out by men employed by the city, under the control of a superintendent of the cleansing department. 9 Shoreditch—Population 1901, 118,705. A medical officer of health (whole time appointment). £500 per annum. Half repayable by County Council. Six sanitary inspectors— 1. H. A. £200 per annum. Half repayable by County Council. 2. J. W. L. £160 ,, ,, ,, ,, 3. C. H. Q. £160 ,, ,, ,, ,, 4. W. F. £150 ,, ,, ,, ,, 5. E. J. £140 ,, ,, ,, ,, 6. A. L. £135 ,, ,, ,, ,, Assistants.—One general assistant. One disinfector and two assistants. Mortuary keeper, who lives close to mortuary and gives his whole time to the work. Caretaker (female) of the shelter. Clerical staff.—One clerk. One assistant clerk. The general assistant also helps in clerical work. Duties. —The senior inspector acts as chief sanitary inspector and is concerned with duties under the Public Health and Factory and Workshop Acts throughout the entire parish, and in generally superintending and giving assistance to the other inspectors. He also attends to the registration of houses let in lodgings. The remaining inspectors have each a district, and in it they each perform all duties arising under the Public Health and Factory and Workshop Acts. Number 3 in the above list having the most compact district, is also concerned with carrying out duties under the Food and Drugs Act for the whole district and with smoke nuisances. The supervision of all drainage work both in new premises and existing houses, as well as the testing of drains, forms part of the inspectors' duties. The general assistant helps in the testing of drains, in obtaining samples under the Food and Drugs Act, in serving notices and in clerical work. The disinfector is occupied in disinfecting articles of clothing and bedding which are brought from and returned to houses by the two assistants. The latter officers also carry out the disinfection of rooms, and strip and cleanse rooms after fumigation where it is considered necessary. Dairies, Cowsheds and Milkshops Orders. Transfer of Powers.—The work in connection with milkshops and milk vendors is carried out by the five district inspectors (Nos. 2 to 6) in the above list. Each inspector is responsible for the work in his own sanitary sub-district. The sanitary inspectors are under the general supervision of the medical officer of health. Scavenging of dustbins and roads—In addition to the above staff, there is in the surveyor's department a general superintendent who supervises the scavenging of streets and the cleansing of dustbins. This work is done by men in the employment of the vestry under the control of two scavenging foremen, and one dusting foreman who have gangers in charge of each gang of men. Bethnal-green—Population 1901, 129,681. A medical officer of health (part time appointment). £300 per annum. Half repayable by County Council. Eleven sanitary inspectors. (One of these was formerly clerk of the department. He has now been appointed an inspector, but still devotes some of his time to clerical duties.) per annum. I. J. F. £250 to £350 at Present £287 10 Half of £250 repayable by County Council. 2. B. S. W. £200 Half repayable by County Council. 3. A. S. H. £180 ,, ,, 4. E. R. £170 ,, ,, 5. H. F. B. £160 ,, ,, 6. F. W. M. £150,, ,, 7. E. A. £120 ,, ,, 8. M. G. £120 ,, ,, 9. Vacant (new appointments £120 „ „ being made) 10. do. do. £120 „ „ 11. do. do. £120 ,, ,, Assistants.—Three assistants for disinfection. A mortuary keeper. A urinal flusher. Nine dust foremen. In addition, twelve men are employed in connection with the work of reconstruction of combined drains. Clerical staff.—In addition to the above-mentioned sanitary inspector, who receives and enters complaints, keeps the nuisance and other registers, and has general charge of the indoor work of the department there is a junior clerk, and two others are about to be appointed. Duties.—The first on the above list of inspectors is chief sanitary inspector. Subject to consultation with the medical officer of health, he is responsible for, has control of, and directs the operations of the entire sanitary staff. Subject to the directions of the committee, the chief inspector gives instructions 10 and takes such measures as he considers necessary for the proper and effectual carrying out of the whole work and business of the department. He attends all meetings of the committee, and in conjunction with the medical officer of health, makes all necessary reports and recommendations. He superintends all correspondence respecting the work of the department except that relating to the medical officer. He supervises the execution of all drainage works, and in company with the medical officer of health, visits all premises before any police-court proceedings are taken. In all cases where the advice and assistance of the medical officer of health is necessary, he is to confer with him, and act under his instructions, and he has to report daily to the medical officer, and to take his instructions in regard to all cases of infectious disease concerning which visits have been made by the inspectors on the previous day. Inspectors numbered above, 2, 3, 4, 5 and 7 are each allotted a district, and in it each is concerned with ail duties arising under the Public Health and Factory and Workshop Acts, except registered tenement houses, cowsheds, milkshops, slaughterhouses and offensive trade premises, for which special duties, inspectors numbered 9 and 10 are to be appointed on the 2nd May next. Inspector No. 8 supervises the construction of new buildings as to the enforcement of the Council's by-laws and regulations. Inspector No. 11 will also be appointed on the 2nd May to inspect the food deposited for sale in the markets and shops, and to enforce the smoke nuisance clauses of the Public Health (London) Act. Of the disinfecting assistants, one acts as engineer, and deals with articles of bedding and clothing in the Washington Lyon apparatus. The other two fetch and return the articles, disinfect the rooms, and serve as messengers, in connection with the removal of patients. The urinal flusher attends to the cleansing of public urinals other than those under the control of the sanitary authority. The dust foremen superintend and assist in the proper cleansing of dust pails, this work being carried out by a contractor. The inspectors are entirely under the control of the chief inspector. Scavenging of streets.—For the scavenging of roads a contractor is employed. The execution of the work is superintended by a foreman and three assistants under the surveyor of the Council. Stepney—Population 1901, 298,548. Medical officer of health (whole time appointment) £750 per annum. Half repayable by the County Council. Also holds appointment as chief public analyst, no remuneration. The Council is considering the appointment of an assistant analyst at a salary of £250 per annum (whole time appointment). Seventeen sanitary inspectors— 1. C. C. £250 per annum Half repayable by the County Council 2. F. H. L. £240 to £250 by £10 increments yearly „ „ 3. J. T. £240 to £250 ,, ,, ,, ,, 4. J. W. J. £210 per annum „ „ 5. J. W. £210 ,, ,, ,, 6. T. P. W. £200 ,, ,, ,, 7. A. C. £200,, ,, ,, 8. A. W. W. £185 ,, ,, ,, 9. G. O. P. £180 „ „ „ 10. E. T. C. £180 „ „ „ 11. H. M. £162 „ „ „ 12. W. S. £150 to £200 by £10 increments yearly „ „ 13. J. W. £150 ,, ,, ,, ,, 14. E. F. £150,, ,, ,, ,, 15. R. S. £150 ,, ,, ,, ,, 16. H. Q. £150 ,, ,, ,, ,, 17. A. W. S. £150,, ,, ,, ,, The Council is proceeding to appoint an additional sanitary inspector for the special inspection of wharves and food landed at such premises, at a salary of £200, rising by yearly increments of £10 to £250, half re-payable by the County Council. Clerical staff.— There are six clerks entirely engaged in duties arising out of the work of the public health department. Duties of sanitary inspectors.— The first fifteen sanitary inspectors on the list have each been allotted a district, and are concerned with all the duties arising under the Public Health (London) Act, 1891, the Factory and Workshops Acts, and the Food and Drugs Acts. In the last two cases the inspectors have been appointed to enforce the by-laws with regard to houses let in lodgings. Disinfecting staff.— Ten men are employed for the purpose of disinfecting, fumigating rooms, stripping the walls of rooms, disinfecting bedding, &c., removing and returning bedding, &c., after disinfection, testing drains, and generally assisting the sanitary inspectors. Scavenging of streets and removal of dust.— These duties come within the jurisdiction of the borough engineer. The whole of the staff of the public health department is under the direct supervision of the medical officer of health. 11 Poplap.—Population 1901, 168,838. One medical officer of health for the whole of the borough. It is proposed to start his salary at £550, rising by two annual increments of £25 to £600. This salary at the present moment is a matter of discussion between the Local Government Board and the Poplar Borough Council. Eight sanitary inspectors— Male inspectors— 1. F. J. A. £185 per annum. Half repayable by County Council; also £5 as canal boat inspector. 2. J. B. £170 to £185 per annum. Half repayable by the County Council; also £5 as canal boat inspector. 3. W. B. £185 per annum. Half repayable by County Council; also £5 as canal boat inspector. 4. C. F. £180 to £185 per annum, by rises of £10 and one of £5. Half payable by the County Council; also £5 as canal boat inspector. 5. C. F. £185 per annum. Half repayable by County Council; also £5 as canal boat inspector. 6. J. J. £130 to £185 per annum, by rises of £10 and one of £5. Half payable by the County Council; also £5 as canal boat inspector. 7. R. E. M. £185 per annum. Half repayable by the County Council; also £5 as canal boat inspector. Female inspectors— 8. A. T. £140 to £185 per annum, by rises of £10 and one of £5. Half payable by County Council. Assistants—There are five labourers who act as assistants to the inspectors. The labourers are paid 30s. per week. There are four men engaged in the disinfectant department. Disinfectants are distributed as occasion arises from the various depots and the offices of the local authority. Men are engaged as the case may arise in bottling disinfectants, and making disinfectant powder up into bags at the Hale-street depot. Clerical staff—There are four clerks engaged in duties arising out of the work of the public health department. Duties—The sanitary inspectors in their respective districts carry out the whole of the duties cast upon the local authority under the Public Health (London) Act, 1891, the Metropolis Local Management Acts, Food and Drugs Act, and Canal Boat Act. The assistants help the inspectors in testing and opening up drains, purchasing samples, and serving the various documents. The female inspector inspects all places where female labour is employed. The disinfectors are engaged as follows— 1. Chief disinfector disinfects premises, and supervises and sees that the others do their work. 2. Second disinfector accompanies the vans which fetch and return articles. 3. Drivers of van. 4. Man in charge of the boiler of the disinfecting apparatus. There are two apparatus—(1) Washington Lyons; (2) Equifex saturated steam. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of streets— The scavenging of streets and dustbins is carried out by the surveyor's department. Southwark—Population 1901, 206,128. A medical officer of health (whole time appointment), £750 per annum. Half repayable by the County Council. The inspectorial staff consists of 13 male inspectors and five female inspectors. Male inspectors— 1. A. L. (acts as chief) £275 per annum Half repayable by County Council. 2. J. W. £225 ,, ,, ,, ,, 3. J. R. £140 ,, ,, ,, ,, 4. E. H. £150 ,, ,, ,, ,, 5. W. S. £150 ,, ,, ,, ,, 6. J. W. £130 ,, ,, ,, ,, 7. C. L. £130 ,, ,, ,, ,, 8. J. N. £120 ,, ,, ,, ,, 9. J. O. £130 ,, ,, ,, ,, 10. R. S. £150 „ ,, ,, ,, 11. P. D. £150 ,, ,, ,, ,, 12. A. G. £200 ,, ,, ,, ,, 13. W. C. £175 ,, ,, ,, ,, Female inspectors— 14. A. E. £160 ,, ,, ,, ,, 15. S. M. £120 ,, ,, ,, ,, 16. M. R. £110 ,, ,, ,, ,, 17. F. N. 18. Vacant. £110 ,, ,, ,, ,, 12 Assistants.— Disinfecting staff. Nine in number. An engineer and two assistants are engaged at the disinfecting station, whilst two are employed in fetching from and returning to houses articles of bedding, &c., requiring disinfection. The remaining four attend to the disinfecting, stripping of walls, and the cleansing of rooms. There are two mortuary keepers, and a superintendent and his wife at the reception house. There is also an assistant inspector to help in the testing of drains. Clerical staff.—There are five clerks entirely engaged in duties arising out of the work of the department. Duties.—The first inspector on the above list supervises generally the work of the other inspectors. The second inspector on the list is engaged in carrying out the Adulteration Acts, the inspection of bakehouses, slaughterhouses, dairies and milkshops, and places at which noxious trades are carried on. The inspectors, Nos. 3 to 13, have each a district, and in it each carries out all the duties arising under the Public Health Act, and the inspection of factories and workshops where males are employed. The inspectors supervise drainage work in old houses. In new premises the work is seen to by officers from the surveyor's department. Nos. 14, 15 and 16, are engaged in visiting houses let in lodgings, and factories and workshops where females are employed. The last two inspectors (Nos. 17 and 18) visit all infectious cases and report from time to time for the information of the medical officer and the department generally. Besides the two women inspectors engaged in infectious disease, there is a male assistant whose duty it is to proceed to the house immediately on the receipt of a notification certificate in order to get the patient removed to hospital as soon as possible. The medical officer of health directs reports, and is responsible for the organisation and good management of the department. Scavenging of roads and dustbins.—These matters are under the direction of the surveyor. Bermondsey—Population 1901, 130,486. A medical officer of health (whole time appointment). £500—£600 per annum. Half repayable by County Council. sanitary inspectors— 1. H. T. £375 per annum. Half repayable by County Council. 2. H. J. T. £135 to £175 „ ,, ,, ,, 3. J. B. £150 to £175 ,, at present £150 ,, ,, ,, 4. Vacant £150 to £175 ,, ,, ,, ,, 5. T. L. D £200 ,, ,, ,, ,, 6. H. C. £175 ,, ,, ,, ,, 7. T. A. £250 ,, ,, ,, ,, Assistants.—Four disinfecting assistants, one of whom also acts as caretaker of the mortuary. (Neckinger): a mortuary keeper at St. Mary Church-street, who is also caretaker of the recreationground in which the mortuary is situated; a mortuary keeper (St. Olave) who in addition does scavenging work in the immediate neighbourhood of the mortuary; a caretaker (female) at shelter. Clerical staff.—There are three clerks who devote their whole time to duties arising out of the work of the public health department. Duties.—The inspector who is first on the above list is chief sanitary inspector, and in this capacity exercises a general supervision over the work of the other inspectors. He also performs duties arising under the Food and Drugs Act in the whole parish, and takes part in house to house inspection. He also inspects bakehouses, slaughterhouses, cowhouses, and common lodging-houses. As regards the remaining inspectors, to each inspector a part of the district has been allotted, and in this he is concerned with duties arising under the Public Health, Factory and Workshop and Food and Drugs Acts. The inspectors supervise drainage work, either construction or reconstruction. The disinfecting assistants are engaged as follows—two in conveying articles to and from premises, and in placing them in the apparatus for disinfection, one in the disinfection of rooms, one as engineer for the disinfecting apparatus and for removing articles from it after the process is completed. The sanitary inspectors are under the supervision of the medical officer of health and chief sanitary inspector. Scavenging of roads and dustbins.—The removal of house refuse is done by men employed by the sanitary authority under the direction of a foreman. The pail system has been adopted. The scavenging of roads is under the supervision of the surveyor. Lambeth—Population 1901,301,873. A medical officer of health (whole time appointment). £800 per annum. Half repayable by County Council. 13 Twelve acting sanitary inspectors, and an inspector who is partly engaged in clerical duties— Half repayable by County Council. 1. R. E. £170 2. R. B. 170 ,, ,, ,, 3. F. E. B. 160 ,, ,, ,, 4. S. S. 160 ,, ,, ,, 5. J. M. J. 160 ,, ,, ,, 6. J. B. 160 ,, ,, ,, 7. G. G. 160 ,, ,, ,, 8. W. G. F. B. 125 ,, ,, ,, 9. T. H. H. 125 ,, ,, ,, 10. T. H. J. 125 ,, ,, ,, 11. W. W. 125 ,, ,, ,, 12. W. J. P. 120 ,, ,, ,, 13. W. W. H. 120 ,, ,, ,, The borough council has decided to appoint one female sanitary inspector. Assistants.—Ten assistants in connection with disinfection. Two mortuary keepers, one at each building, and a deputy to relieve the one at the northern mortuary. A temporary caretaker (female) is engaged when the rooms provided for use as a temporary shelter are in use. Seven men in charge of underground lavatories and urinals and five women. Clerical staff.—There are three clerks entirely engaged in duties arising out of the work of the public health department. The inspectors have no clerical duties beyond keeping a diary. Duties.—Twelve of the inspectors have each been allotted a district in which they are concerned with all duties arising under the Public Health and the Factory and Workshop Acts. One of these inspectors whose district is small also acts as inspector for smoke nuisances, and as inspector under the Food and Drugs Act for the entire district, being assisted in obtaining samples by deputy. The remaining inspector is reserved as an emergency officer to attend to any urgent complaints made at the office after the others have left, and he also assists in clerical work. The inspectors supervise the execution of drainage works in both new and old houses. They are under the entire supervision and direction of the medical officer of health. The disinfecting assistants are engaged as follows— Two act as engineers, one at each apparatus, two fetch infected articles, and two return them after disinfection, the other four men act as drivers of the vans. Scavenging of dustbins and streets.—For the scavenging of dustbins and of streets there are district inspectors under the control of the surveyor. Battersea—Population 1901, 168,896. A medical officer of health (whole time appointment). £600 per annum. Half repayable by County Council. Nine sanitary inspectors— 1. I. Y., chief inspector. £280 per annum Half repayable by County Council. 2. H. M. £165 ,, ,, ,, ,, 3. A. E. P. £165 ,, ,, ,, ,, 4. A. O. £165 ,, ,, ,, ,, 5. J. H. £165 ,, ,, ,, ,, 6. J. L. £160 ,, ,, ,, ,, 7. A. C. £140 „ ,, ,, ,, 8. H. H. M. £160 ,, ,, ,, ,, 9. J. T. B. £140 ,, ,, ,, ,, Assistants.—Eight assistants for disinfection of rooms and testing of drains Clerical staff.—There are four clerks solely engaged in duties arising out of the work of the public health department. Duties.—The chief inspector supervises generally the work of the inspectors, inspects in all cases of importance or difficulty, and where statutory proceedings are about to be taken. The district inspectors have a district in which each is concerned with all duties arising under the Public Health, the Food and Drugs, and the Factory and Workshop Acts. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of streets and dustbins.—The scavenging of dustbins and of roads is done by men employed by the sanitary authority, and there are officers under the surveyor who are concerned with the execution of this work. Wandsworth—Population 1901, 232,030. A medical officer of health (whole time appointment). £800-1,000 per annum. Half repayable by County Council. 14 Thirteen sanitary inspectors— 1. W. M. £122 4s. per annum Half repayable by County Council. 2. S. G. F. £3 5s. per week No portion repayable by County Council. 3. B. N. £3 5s. ,, ,, ,, ,, 4. W. G. C. £3 1s. ,, ,, ,, ,, 5. E. K. £3 5s. ,, ,, ,, ,, 6. R. B. £2 17s. 6d. ,, ,, ,, 7. — N. £2 2s. ,, ,, ,, ,, 8. S. C. £3 5s. ,, ,, ,, ,, 9. C. H. H. £2 2s. to £3 5s. „ ,, ,, ,, 10. A. W. £2 2s. to £3 5s. „ ,, ,, ,, 11. H. A. P. £2 2s. to £3 5s. „ ,, ,, ,, 12. G. R. £3 5s. ,, ,, ,, ,, 13. R. M. £2 4s. 6d. to £3 5s. „ ,, ,, ,, An additional sanitary inspector is to be appointed. The question of the re-appointment of the sanitary inspectors under the Public Health (London) Act, 1891, is at present under consideration. Assistants.—Disinfecting staff, seven. Assistance is also obtained on occasion from the surveyor's department. A mortuary keeper (Clapham), not resident, who also assists in disinfection, &c. A mortuary keeper (Wandsworth), who is also a local tradesman in the vicinity and a mortuary keeper (Streatham and Tooting). Clerical staff.—There are three clerks entirely occupied in duties arising out of the work of the public health department. Duties.—The question as to the arrangement of districts and duties of the sanitary inspectors is under consideration. Scavenging of streets and dustbins.—For the scavenging of dustbins and of roads there are, under the surveyor, dust inspectors and road foremen. Camberwell— Population 1901, 259,258. A medical officer of health (whole time appointment), £600-700 per annum. Half repayable by County Council. Twelve sanitary inspectors— 1. W. E. G. £200 Half repayable by London County Council. 2. J. S. P. £175 ,, ,, ,, 3. W. E. £175 ,, ,, ,, 4. A. C. £175 ,, ,, ,, 5. G. W. S. £175 ,, ,, ,, 6. E. R. C. £175 ,, ,, ,, 7. J. H. H. £175 ,, ,, ,, 8. C. H. K. £175 ,, ,, ,, 9. G. G. M. £175 ,, ,, ,, 10. E. H. £175 ,, ,, ,, 11. W. R. F. £175 ,, ,, ,, 12. G. T. D. £127 ,, ,, ,, A female inspector is about to be appointed at a salary of £125, rising by annual increments of £5 to £150. Assistants.—Six assistants for disinfection and a mortuary keeper. Clerical staff.—There are three clerks entirely occupied in duties arising out of the work of the public health department. Duties.—One inspector (W. E. G.) is authorised specially to carry out the duties connected with the office of a sanitary inspector under the Public Health (London) Act, 1891, with regard to smoke nuisances, and inspector under the Food and Drugs Acts, 1875 to 1899, and also emergency inspector under all Acts of Parliament relating to the public health. Each of the remaining eleven male inspectors is allotted to a district in which each is concerned with all duties arising under the Public Health and Factory and Workshop Acts, and exceptionally under the Food and Drugs Acts. As regards the disinfecting assistants, one acts as superintendent, one is entirely occupied with the disinfection of articles at the depot, and the remaining four convey the articles to and from premises. Two of these collect the infected articles and carry out the disinfection of rooms, while the other two return the articles after they have been disinfected. The sanitary inspectors are under the supervision and direction of the medical officer of health. They superintend the construction of drains in both new and old premises, and as regards the former and cases of combined drains, they are in relation to the surveyor of the borough council. Scavenging of dustbins and roads.—There are six superintendents in the surveyor's department who attend to the systematic cleansing of dustbins and of roads. Deptford—Population 1901, 110,513. A medical officer of health (part time appointment). £225 per annum. No portion repayable by County Council. 15 Five sanitary inspectors— 1. T. T. £165 Half repayable by County Council. 2. R. S. £165 ,, ,, ,, 3. A. P. £165 ,, ,, ,, 4. P. S. £165 ,, ,, ,, 5. J. D. £125 ,, ,, ,, Assistants.— Two disinfecting assistants. Clerical staff.—No clerical assistance. Duties.—Each of the above inspectors has a district, and within that district has to perform generally the duties of a sanitary inspector. One of the disinfecting assistants is engaged at the disinfecting apparatus, the other in fetching articles and in fumigating and cleansing rooms. The sanitary inspectors are under the supervision and direction of the medical officer of health. Scavenging of dustbins and streets.—There are two dust inspectors to supervise the cleansing of dustbins, and a road foreman who superintends the cleansing of streets. They are under the road surveyor. There is also a drainage inspector in the surveyor's department, who supervises the construction of drains in new houses. Reconstruction in existing premises is attended to by the sanitary inspectors. Greenwich—Population 1901, 95,757. A medical officer of health (whole time appointment). £700 per annum. Half repayable by County Council. sanitary inspectors— 1. C. W. £190 Half repayable by County Council. 2. A. E. B. £165 ,, ,, ,, 3. E. M. £125 ,, ,, ,, 4. C. N. £165 ,, ,, ,, 5. T. E. C. £150 ,, ,, ,, Assistants.—Two disinfecting assistants. Clerical staff.—No clerical assistants. Duties.—The third on the above list is engaged in duties arising in connection with the occurence of infectious disease. The other four inspectors have each been allotted a district, and in it each is concerned with all duties under the Public Health Act (except those connected with infectious disease) and Factory and Workshop Act. The disinfecting assistants are engaged, the one at the apparatus, the other in fetching and removing articles, and disinfecting and cleansing rooms. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of roads and dustbins.—This work is carried out under the supervision of the borough engineer and surveyor by means of one road foreman, three district foremen, and three dust inspectors. There are also orderly boys engaged in the main streets. There is also in the surveyor's department a drainage inspector, who supervises the drainage of new premises. In existing houses reconstruction of drains is attended to by the sanitary inspectors. Lewisham—Population 1901, 127,460. A medical officer of health has been appointed, subject to the approval of the Local Government Board. £600 per annum. Half repayable by County Council. Also holds the appointment of public analyst; £200 per annum. Six sanitary inspectors— 1. J. F. C. £100 to £150 (by annual increments of £10.) Half repayable by County Council. 2. J. D. 11 ,, ,, ,, 3. A. H. G. 11 ,, ,, ,, 4. E. T. P. 11 ,, ,, ,, 5. B. A. K. 11 ,, ,, ,, 6. R. W. £175 10s. Half repayable by County Council. Assistants.—Two assistants, who are employed, in conveying articles to and from houses in connection with disinfection and in the fumigation of rooms. There is also an assistant who acts as engineer in connection with the disinfecting apparatus. Clerical staff.—No clerical assistance is provided. Duties.—The whole question as to the arrangement of districts and duties of the sanitary inspectors is under the consideration of the Borough Council. Scavenging of dustbins and streets.—For the systematic cleansing of dustbins there are three foremen who supervise the collection of house refuse, and in connection with road cleansing there are three inspectors of works. These officers form part of the surveyor's department. Woolwich—Population 1901, 117,165. A medical officer of health (whole time appointment) £600 per annum. Half repayable by County Council. 16 Eight sanitary inspectors— 1. A. G. D. £250 Half repayable by County Council. 2. J. W. R. 140 11 11 3. W. L. 140 11 11 4. W. W. 150 11 11 5. A. G. P. 130 11 11 6. A. M. 140 11 11 7. W. W. 150 11 11 8. W. B. 110 11 11 Assistants. —Three assistants in connection with disinfection. Three drain-testing assistants. A mortuary keeper who gives part of his time to the duty of attending to the mortuary and part to the shelter. Clerical staff.—There are two clerks who are entirely occupied in duties arising out of the work of the public health department. Duties.—The first inspector on the above list acts as chief inspector. He supervises generally the work of the other inspectors, makes inspection of premises in regard to which complaints have been received, is concerned with special drainage matters and questions of combined drains, and the inspection of new buildings, with a view to the issuing of certificates as to their provision with an adequate water supply. The remaining are divisional inspectors, and each is concerned in his district with all duties arising under the Public Health and the Factory and Workshops Acts. Duties under the Food and Drugs Act are at present carried out by two district inspectors. The assistants for disinfection are engaged as follows—one for carrying out the disinfection of the articles in the disintecting apparatus, the other to convey articles to and from premises and disinfect rooms. The inspectors are under the supervision and direction of the medical officer of health. Scavenging of dustbins and roads.—The collection of house refuse is done by contract; there is no special inspector or officer of the Borough Council to see that the work is carried out properly; the sanitary inspectors are expected to supervise this. The scavenging of roads is done under the supervision of the borough engineer's department. London County Council. THE LONDON AMBULANCE SERVICE. Reports, etc., containing information collected by the General Purposes Committee of the Council with reference to ambulance provision existing in London, and in provincial and centinental cities and towns, for dealing with cases of accident or sudden illness in the streets or other public places. G. L. Gomme, Cleric of the Council. County Hall, S.W., 5th December, 1902. [5267 CONTENTS. PAGE. (i.) Prefatory note 3 (ii.) Report by the medical officer 5 (iii.) Abstracts, prepared by the medical officer, from a work by Dr. George Meyer, of Berlin 23 (iv.) Notes of evidence given by witnesses before the Sub-Committee 27 (v.) Notes on the horsed - ambulance services of Manchester, Liverpool, Dublin and Belfast 31 (vi.) Return, prepared by the Clerk of the Council, showing kind of conveyance actually used during a period of four weeks in removing casualties to some of the London hospitals 34 3 (i.) Prefatory note by Sir William J. Collins, chairman of the Ambulance Sub-Committee of the General Purposes Committee. 1. A consideration of the ambulance service of London naturally falls under the following heads, viz.— (а) A description of the existing services. (b) The question as to whether or not these are adequate. (c) A comparison with the systems in operation in other cities and towns. 2. The existing services.—The medical officer's report sets out in some detail the present services from which it will be seen that these are in the hands of the following—(i.) the police; (ii.) the St. John Ambulance Association; (iii.) the Bischoffsheim service and (iv.) the Volunteer Medical Staff Corps. The police, who in most cases have the first handling of street accidents, are provided with hand-stretchers and wheel-litters, and opportunity is afforded to constables for instruction in first-aid. For rapid transport only three horsed-ambulances exist, maintained by private effort, at Rochester-row, Carter-street, and Stoke Newington police-stations, and a charge is made to the public for their use to cover the payment for the horse, driver and cleansing; these are not kept in constant readiness, but on each occasion when requisitioned a horse and driver are supplied from a contractor. The St. John Ambulance Association trains in "first-aid" and provides litters and appliances at certain fixed stations, but except at three of these no officer is on duty. The Bischoffsheim service also provides at fire brigade stations and other fixed points wheeled litters and stores, but has no officer on duty. The Volunteer Medical Staff Corps renders valuable ambulance service on rare and special occasions such as public processions. Thus, so far as accidents are concerned, horsed-ambulances are practically non-existent in London. Although much is done by these organisations, there is no uniform adequate and co-ordinate system for dealing with street accidents in London and no central supervising authority in quick touch on the one hand with casualties as they occur and on the other with the hospitals in which they can receive prompt attention. In out-lying districts there are naturally fewer facilities than in central ones for dealing with street casualties. The telephone is not utilised. On the other hand the ambulance arrangements for the conveyance of those certified to be suffering from infectious diseases are already adequately provided by the Metropolitan Asylums Board, and are in striking contrast to this lack of provision for street casualties, 3. Question of adequacy.—In order to ascertain what are the actual means at present in vogue for the conveyance of persons suffering from the results of accidents or sudden illness in the streets or other public places, the Sub-Committee placed itself in communication with the metropolitan hospitals, some 30 of which receive such cases in London. A record was kept, at the request of the SubCommittee, at several of the large London hospitals for a period of four weeks, of the actual mode in which cases of accident and other casualties were brought to the hospitals. Of 994 injured persons arriving at 10 hospitals otherwise than on their own legs, 642 came in cabs or carts, 302 in different kinds of ambulance, and 50 by other means of conveyance. That is to say nearly 70 per cent, of the casualties at present conveyed to hospitals by some vehicle or other are taken in cabs or carts and not in ambulances. From the figures that have been furnished for the year 1899, it would appear that nearly 10,000 street accidents are dealt with by the metropolitan police in the course of the year. In the E division during the six months ended February, 1902, the police ambulance was used 110 times, the Bischoffsheim ambulances 56 times and cabs 120 times. No witness who appeared before the Sub-Committee considered that the present system of dealing with street casualties in London was adequate. Nearly all advocated the use of more rapid means of transport of the sufferer to the hospital. Horsed or motor ambulances, either in addition to or in substitution of hand stretchers and litters, were recommended. The use of cabs or carts for casualties where the nature of the injury was either undetermined or such as to be likely to be complicated or augmented by placing the injured person in a cab was condemned by all. Dr. Perry, the superintendent of Guy's Hospital said "it is very painful to watch' the arrival of accidents at hospitals under the present system." The use of the telephone for prompt summons of rapid means of transport to the injured, and his equally prompt removal to hospital were suggested rather than the elaboration of means of treatment on the spot. 4. A comparison with the ambulance systems in provincial and foreign cities and towns.— From the Medical Officer's report it would appear that in some provincial towns and in certain Continental and American cities more modern and efficient systems of ambulance service are at work than is the case in London.* Horsed ambulances summoned by telephone are employed at Liverpool, Birkenhead, Manchester, Newcastle, Huddersfield, Bolton, Burnley, Hull, Sheffield, Leeds and Wolverhampton. In some cases the police, and in others the fire brigade, have the working of the ambulances. The system introduced by Captain Wells, by means of which telephonic messages may be sent from fire-alarm posts, and which has been adapted to the 792 posts in London, has been utilised in Liverpool for the purpose of summoning ambulances in case of street casualties. The mode in which this has been effected will be found in an appendix to Dr. Collie's evidence on page 32. In New York, Now Orleans, Paris and Vienna there are organised systems of town ambulances well worthy of attentive study (see pp. 16-20). * Sec also article on "Horsed Ambulances," by Hon. Dudley Leigh in "Nineteenth Century," October, 1896. 4 The comparison of London with provincial towns is of course complicated by the fact that in their case there is not the same divided jurisdiction over the police and the fire brigade as there is here. It will be remembered that this dual control was not the plan originally entertained. The Select Committee of the House of Commons which was appointed soon after the disastrous Tooley-street fire in 1861 recommended that the duty of fire extinction in London should be entrusted to the police. The Government did not, however, approve this proposal, and so it came about that the Fire Brigade Act of 1865, which terminated the responsibilities of the parochial authorities and the insurance companies for the extinction of fires in London, also transferred to the Metropolitan Board of Works the duty of protecting life in case of fire. This duty had been previously discharged by "The Royal Society for the Protection of Life from Fire," an incorporated association which had commenced its operations in 1844. As no arrangement had been made prior to the passing of the Act of 1865 for relieving the society of its duties, it was not until July 1, 1867, that as the result of negotiations the fire-escapes and staff of the society were transferred to the Board, and the duty of saving life from fire and the extinction of fires were carried on by one organisation. At the present time fiirst-aid is efficiently rendered by the Metropolitan Fire Brigade, but serious cases of burns are handed over to the Police and by them removed to hospitals. Contrast is frequently drawn between the respect which law pays to property in comparison with that which it accords to the person; and while we have in London an elaborate organisation for protecting life and property when threatened with destruction by fire, there is no such adequate and properly organised provision at present available for securing prompt assistance when life and limb are endangered by accident, or when sudden sickness calls for aid in public places. W. J. Collins. 5 (ii.) Report by the Medical Officer. 24th July, 1901. The Sub-Committee on 24th May last instructed me to report generally on the ambulance system in London. In accordance with this instruction the following report has been prepared which, as will be seen, in addition to the system in London deals with those in force in provincial towns and also in foreign countries — For convenience this report is divided under the following heads, viz.— (1.) Arrangements for Ambulance Services in London at the present time. (2.) Similar arrangements in Provincial Towns. (3.) Similar arrangements in Foreign Countries. (4.) As to the Establishment of a Horse-ambulance Service in London. (1.) The Arrangements for Ambulance Services in London at the present time. Ambulance provision in the County of London relates to— (A)—The removal of cases of infectious disease. (1) To hospitals for this class of malady. (2) From one house to another. (B)—Conveyance of non-infections invalids. (C)—Conveyance of persons who have met with accident or who are picked up in the streets suffering from epilepsy, apoplexy, alcoholism, etc. (A) (1)— The removal of cases of infectious diseases to hospitals for this class of malady.—The removal of the infectious sick to hospital is almost wholly performed by the Metropolitan Asylums Board. The land ambulances of this Board are stationed on premises situated as follows— 1. Eastern Ambulance Station, Brooksby's-walk, Homerton, N.E. 2. North - Western Ambulance Station, Lawn-road, Fleet-road, Hampstead (near Hampstead-heath railway station), N.W. 3. Western Ambulance Station, Seagrave-road, Fulham (near West Brompton railway station), S.W. 4. South-Western Ambulance Station, Landor-road, Stockwell (near Clapham-road railway station), S.W. 5. South-Eastern Ambulance Station, New Cross-road (near Old Kent-road railway station), S.E. 6. Brook Ambulance Station, Shooter's-hill, Kent. At these stations are maintained a number of carriage ambulances aud horses which, accompanied by a driver and nurse, proceed to all parts of the metropolis for the removal of infectious persons. Each station is in telephonic communication with the central office in Norfolk-street, Strand, and an application at this office for the removal to one of the Board's hospitals of a patient suffering from smallpox, fevers or diphtheria, is immediately followed by the departure of a fullyequipped ambulance for the patient. Cases of smallpox are usually conveyed to one of the wharves of the managers where the invalid is transferred to an ambulance steamer and thus carried to one of the floating hospitals near Purfleet. In addition to the above there are two ambulances belonging to the London Fever Hospital, Islington, as well as others belonging to one or two persons who are prepared to let out carriages on payment to those who may need them. (A) (2)—The removal of cases of infectious disease from one house to another.—In accordance with the provisions of section 6 of the Poor Law Act of 1889 the asylum managers may allow their carriages to be used for the conveyance of persons suffering from any dangerous infectious disorder to and from hospitals and places other than asylums provided by the asylum managers, and may make reasonable charge for that use. So far therefore as infectious diseases are concerned the arrangements of London are complete. (B)—Conveyance of non-infectious invalids.—The conveyance of non-infectious invalids is undertaken by— (a) The St. John Ambulance Association, which possesses a number of ambulance carriages, to be had on application and payment at St. John's-gate, Clerkenwell. (b) Ambulances in the possession of livery stable owners. 6 (c) Ambulances belonging to some of the metropolitan hospitals and used for the conveyance of sick persons to these institutions. (d) Conveyances belonging to the different Boards of Guardians and used for the carriage of paupers to workhouses and workhouse infirmaries. (e) Ambulances belonging to some of the railway companies and used for the conveyance of sick persons to and from railway stations. A charge is made for the use of all these carriages except those belonging to the Boards of Guardians. I believe it is customary to make some small charge for horse hire in connection with ambulances belonging to the hospitals. There is need for some arrangement by which poor persons generally can secure the conveyance of their sick without the use of public vehicles which are ill adapted for the removal of persons suffering from many maladies, the charges made by owners of private ambulances being prohibitory for the poor. (C)—Conveyance of persons who have met with accident or who are picked up in the streets suffering from epilep.ii/, apoplexy, alcoholism, etc.—The arrangements for the removal of persons suffering from accidents or who are picked up in the streets are more complex. It cannot be said that London is entirely without arrangements for dealing with cases of accidents or of sudden sickness occurring in the streets, but neither can it be said that there exists any well co-ordinated system, the object of which is the prompt and speedy removal of the person or persons from the scene of the accident to a hospital in such a manner as to minimise to the utmost any harm which may result to the sufferer from the removal. The existing services for dealing with persons suffering from accidents, or who are picked up in the street, can be most conveniently described in respect of each service. They are the following— (1.) The St. John Ambulance Association or the Ambulance Department of the Grand Priory of the Order of the Hospital of St. John of -Jerusalem in England. (2.) The Bischoffsheim Ambulance Service of London. (3.) The Volunteer Medical Staff Corps. (4.) The Police. (1.) The St. John Ambulance Association.—This association, which has its headquarters at St. John'a-gate, Clerkenwell, is chiefly concerned in the training of men and women in first aid and ambulance work, the object being to provide skilled assistance of this sort in all districts, and especially in those localities where accidents are of frequent occurrence; it has already trained a large number of police and fire brigade men, and has placed stretchers at various places, and the police have largely purchased litters from the association. At the headquarters there is a plentiful supply of litters, stretchers, bandages, splints, etc., and a permanent staff of trained men. It has further a number of small stations, in each of which is a stretcher and hamper of stores, thus there are stations at (Report, 1899, St. John Ambulance Association)— District. Description. Hours available. 1. St. John's-gate, Clerkenwell 2. St. Paul's Cathedral 3. Duncan Memorial lance Station, St. Clement Danes Church, Strand 4. General Post Office 5. Ludgate-hill railway- station 6. St. Pancras passenger- station 7. Bryanston Working Men's Club, Lisson-grove 8. 44, Claremont-road, High- gate 9. Borough of Hackney Club, Haggerston 10. Hyde-park-corner 11. The Winchester-hall hotel stables, Highgate-hill 12. St. James'-vicarage, Mus- well-hill 13. 6 and 7, Borough-market, S.E. 14. South Metropolitan Gas- Works, Canal - bridge entrance, Old Kent-road, S.E. 15. The Children's Home, Bonner-road, E. Ambulance wagons, litter*, stretchers, etc. Ashford litter, stretcher, hamper, etc. Ashford litter, stretcher, hamper, etc. Box containing stretcher and first-aid appliances 11 ,, Ashford litter, etc. Stretcher and small hamper Stretcher and first aid appliances Ashford litter, stretcher and first-aid appliances Ashford litter, etc. Litter and first aid appliances 11 ,, Stretcher and small hamper Ashford litter and first aid appliances Litters, stretchers and first aid dressing*, antidotes, nourishments, etc. At all hours. 9 a.m.—6 p.m.; Sundays 2.30—8,30 p.m. 9 a.m.—6 p.m. and 7 p.m. —11 p.m. At all hours. 11 11 11 ,, 10 a.m.—12.30 a.m. At all hours. ,, 11 11 11 During business hours. At all hours. This station is under the control of the authorities of the home and is available at all hours. 7 District. Description. Hours available. 16. Harlesden-lane, near Royal Oak 17. Toynbee Hall, Commercial- street, E. 18. Kilburn Provident Medical Institute, 1, Grevilleroad, Kilburn 19. Saxby and Farmer's Signal Works, Canterbury-road, Kilburn 20. Queen's-park-station, burn, L. & N.W. Railway 21. Brondeebury-station, politan Railway 22. West Hampstead railway- station 23. Swiss Cottage railway- station 24. St. Mark's Schools, Violet- hill 25. 112, Shirland-road, Pad- dington Aehford litter, stretcher, etc. Stretchers and first aid appliances Ashford litter, stretcher, etc. St. John Ambulance litter Stretcher ,, ,, ,, ,, ,, At all hours. 9 a.m. to 11 p.m. These eight stations were established and are kept up by No. 9 District Metropolitan Centre of the St. John Ambulance Association At these stations, except the first three on the list, there are no men on duty. They are merely stations containing appliances available for the use of the public by anyone who knows where the stations are situated and how to use the appliances. These stations are periodically inspected by officials of the St. John Ambulance Association to see that the appliances are in proper working order. At the first three stations the staff in attendance is as follows— At St. John's-gate —There are several paid officials as well as volunteers. At St. Paul's Cathedral—One paid official. At the Duncan Memorial—One paid official. At the first of these, viz., St. John's-gate, the ambulance appliances include ambulance wagons, but these are not available for use in cases of accidents occurring in London day by day. Their use is limited to occasions of great public gatherings such as Lord Mayor's Day or the Jubilee processions, or for invalid transport across London from one railway terminus to another or to private houses. At all the other stations the appliances include only hand ambulances. The intention of the association may be understood from the organisation which has been developed in Kilburn. The Kilburn Provident Medical Institute is a central station at which are placed a Furley wheeled litter, a stretcher, an invalid chair, and an ambulance hamper; in neighbouring parts of the district are branch stations at which are deposited stretchers, thus medical aid can be obtained at the central station and first aid assistance from volunteers scattered throughout the district. This is the beginning of a fairly complete system for London, but the association cannot with its present opportunities organise this throughout the metropolis. The idea is undoubtedly a good one, it would make stretchers available in all parts, and litters or the wheels upon which stretchers could be placed within easy reach of any locality where an accident happened; and would ensure the removal of the injured by skilled persons competent to undertake this duty. It will be seen from what has been said above that the functions undertaken by the St. John Ambulance Association are— (1.) The training of men and women in ambulance and first aid work. (2.) The organising of an ambulance and first aid service for use in connection with large assemblages of persons on the occasions of public processions or other gatherings, the appliances such as ambulance wagons, litters and temporary dressings, as well as the staff volunteers, being provided by the association. This work is carried out in conjunction with the police. (3.) Invalid transport. (4.) The establishment in different parts of the metropolis of stations fitted with hand ambulance appliances, which are available for use in cases of emergency by the public or the police. No staff is kept at these with three exceptions. (2.) The Bischojjsheim ambulance service of London (formerly known as the Hospitals Association Street Ambulance Service). This service was established in 1890, and has been conducted at the expense of Mr. H. L. Bisclioffsheim. The Association has prepared a scheme for placing a wheeled litter and stores at different places throughout the metropolis, which are available for use by the police or other persons who have knowledge of their situation and knowledge of how to use the appliances. The Hospitals Association differs from the St. John Ambulance Association in that it takes no part in the training of bearers and those who can render first aid, and in that it does not make any special preparations for special occasions when a large concourse of persons is expected. It is concerned only with making provision of hand ambulances for use at any and all times. 8 The stations at present provided are the following— Postal district. Postal district. E.C. Carter's, 47, Holborn-viaduct. S.E. Fire brigade station, Evelyn-street, Deptford. ,, St. Bartholomew's Hospital. ,, Royal Exchange. 11 Fire brigade station, Crystal palace-parade. Strand, St. Clement Danes. ,, Bishopsgate-street fire brigade station. W.C. ,, Tabernacle-square, Old-street. 11 King's College Hospital, Lincoln's-inn. W.C. University College Hospital. N. North-Eastern Hospital for Children, Hackney-road. ,, Theobald's-road fire brigade station. ,, Royal Free Hospital, Gray's-inn-road. 11 Great Northern Central Hospital, Holloway-road. E. Bethnal-green, Green-street fire brigade station. 11 Metropolitan Hospital, Kingsland-road. ,, Vine House, Mile-end-road N.W. Camden-town fire brigade station, King'sroad, N.W. ,, London Hospital, Whitechapel. ,, New Dundse-wharf, 82, Wapping Highstreet. ,, Albert-road cab rank, Regent's-park. ,, Cab rank, Midland-road. ,, East London Hospital for Children, Glamis-road, Shadwell. W. Faraday-road fire brigade station, Kensington. ,, York-street, Ratcliff, E. ,, Royal-crescent cab rank, Notting-hill. ,, Junction of East and West India Dock roads. ,, Archer-street cab-rank, Notting-hill. ,, Pickering-place cab-rank, Paddington. ,, All Saints' Church, Poplar. ,, St. Mary's Hospital, Paddington. ,, Poplar Hospital for Accidents, East India Dock-road. ,, Maida-vale cab rank, Paddington. ,, Langham-place cab rank, Paddington. S.E. St. Thomas' Hospital. ,, Middlesex Hospital. ,, Fire brigade station, Waterloo-road. ,, Fire brigade station, Great Marlboroughstreet. ,, Cab rank, Blackfriars-road. ,, St. George's-road, Southwark (near Elephant and Castle). S.W. Cab rank, St. James'-square. ,, Cab rank, Eccleston-bridge. ,, Marshalsea-road, Borough. ,, Sloane-square. ,, Guy's Hospital. ,, Queen's-gate. ,, Fire brigade station, Camberwell. ,, Town-hall, King's-road, Chelsea. ,, Rye-lane, Peckham. ,, Vauxhall-cross. In the annual report for 1899 as to the work of this service the following statement is made— " Prior to the establishment of the Hospitals Association Street Ambulance Service at the end of 1889, " cabs were almost exclusively employed in the transport of cases of street accident, with the well" known result—frequent conversion of slight casualties into grave injuries. Daring the first three " years of the existence of the service our ambulances superseded the cab as a means of transport for " cases of accident in one out of every three cases. In round figures 3,400 cases were removed on our "conveyances in these three years, an annual average of 1,133. Your Committee were able to " announce last year that no fewer than 2,209 were dealt with, and this year they are happy to " announce a still further increase, the number removed during 1899 being 2,319." " The following table shows the number oi accidents removed by the ambulances in the years " 1891-1899— 1891-2. 1892-3. 1893-4. 1894-5. 1895-6. 1896-7. 1897-8. 1898-9. 18991900. Fire brigade stations 96 113 132 109 170 201 197 221 237 Hospitals 222 479 582 928 576 460 629 601 633 Thoroughfare stations 660 670 604 500 810 775 1,051 1,140 1,239 Other stations — 5 40 115 115 248 236 247 210 978 1,267 1,358 1,652 1,791 1,684 2,113 2,209 2,319 " Once again the Committee have to express their regret that these figures are incomplete and " that as thoroughfare stations become, by reason of their greater usefulness, more numerous, this " incompleteness will probably increase. In the case of fire brigade stations and hospitals a record is " kept of the use of the ambulance, but at thoroughfare stations this is impossible, except in the " instances where the station is near a cabmen's shelter and the shelter attendant is sufficiently " interested to keep a record." This service is one for providing stations throughout the metropolis fitted up with hand ambulance appliances for use in cases of emergency by the police or the public—one of the functions also undertaken by the St. John Ambulance Association. (3) The volunteer medical staff corps—This corps is primarily a military organisation, but on special occasions such as public processions it has worked with the police. This is a duty also shared by the St. John Ambulance Association. Apart from giving assistance on occasions such as these the volunteer medical staff corps has no concern with the removal of accidents to hospitals at ordinary times. 9 (4) The police—The metropolitan police possess both liand ambulances and wheeled litters for use in cases of emergency, and members of the force receive on joining, instruction in ambulance and first aid work as part of their ordinary training. In addition to this a large number of policemen have voluntarily attended courses of instruction given by the St. John Ambulance Association and have received certificates of efficiency. One or more ambulances or litters are kept at all police stations, but in the absence of any means of telephonic communication with the police station, by which the ambulance can be readily obtained, their use must be largely restricted, in cases requiring prompt action, to such accidents as occur in the immediate vicinity of the police stations. The custom of the police is not to leave the sufferer, and the course taken in any given case depends largely upon the circumstances of the accident, the place where it occurs and the presence in the crowd of persons ready and capable of giving assistance to the police. Thus if it occurs near a police station, or a place where an ambulance has been deposited by the St. John Ambulance Association, or the Hospitals Ambulance Association, the ambulance would be used; if however these be at some distance and a cab is readily available, its services would be requisitioned, or before resorting to a cab, if there be a doctor living near at hand, he may be called out to see the injured person before removing him to hospital or to his private abode. The police also possess three horse ambulances, but these are not equipped and staffed, nor are they in direct telephonic communication, so as to be available for use at a moment's notice. On each occasion, when required, horses are obtained from a contractor. On occasions of great public gathering the police largely, if not entirely, depend upon the voluntary organisation provided for the occasion by the St. John Ambulance Association, the work being carried out by the two bodies in conjunction. On such occasion the service is organised on a military model, viz., a base hospital (one of the general hospitals), a field tent, with a horse ambulance, at which first aid can be given in the neighbourhood of the crowd, and in connection with this, bearer parties with hand ambulances amongst the crowd. From what has been said in the foregoing account of ambulance service in London it will be seen that there does not exist a service, fully equipped, adequately staffed, and connected by means of a system of communication with different parts of London as to ensure speedy removal to hospital in the best available manner of all persons who may meet with accidents or bo overtaken with illness. Such means as exist at the present time, together with the fact that a large number of persons are trained by the St. John Ambulance Association in first aid and ambulance work must do much good in alleviating suffering in the removal of persons to hospital. Owing, however, to the absence of any system of communication the use of the ambulance stations which do exist must be largely limited to their own immediate neighbourhood, and in view of the fact that the ambulances are all hand ambulances, considerable loss of important time must often occur in getting cases to hospital. (2.) The arrangements in provincial towns for ambulance services, so far as relates to accidents or cases of emergency. With a view to obtaining information as to what, if any, provision has been made in provincial towns in regard to an ambulance service for use in cases of accidents or sudden emergency as distinct from ambulance services for the transport of cases of infectious disease, I addressed a circular letter to the medical officers of health of the chief provincial towns, taking for this purpose the 32 large towns included in the list of the Registrar-General. The information which they have been good enough to send me I have set out in tabular form. From this it appears that in 16 towns a horse ambulance service has been provided, while in 12 towns only hand ambulances are used. Regarding those towns where a horse ambulance service has been established, it will be observed that it has been provided in many cases by the local authority, in some by private subscriptions, and afterwards taken over for maintenance and control by the local authority, and in one case by the local hospital. A special staff is not provided, but the services are worked by means of the police force or the fire-brigade staff, and in nearly all cases the horse ambulances are kept ready for use at either police or fire-brigade stations. In the case of the service at Liverpool—which appears to be the one most systematically worked out—the ambulances are kept at the chief hospitals and at a police station. The means of communication depended upon in these towns for summoning the ambulance are largely street telephonic call-boxes. In the information obtained from Sheffield reference is made to the increasing number of calls received since the service was organised. The chief constable who supplies the information states as follows—"The ambulance service is much appreciated in this city and the number of calls is increasing yearly as will be seen from the following table— Tear. Calls received. Year. Calls received. 1891 48 1897 79 1892 44 1898 100 1893 32 1899 138 1894 25 1900 298 1895 33 To July 2nd, 1896 55 1901 296" [2] 10 The following extracts from the Annua, Report for 1899 of the St. John Ambulance Association as regards horse ambulance services are of interest. "At Birkenhead where the horse ambulance is worked by the fire brigade, the men are all certificated by the St. John Ambulance Association. The superintendent reports that the ambulance "has received 433 calls in 1899, all of which have been responded to, being an increase of 43 calls "compared with the year 1898. The distance travelled was 1,304 miles, or an average of three miles per "journey, and the work is still increasing owing to the public recognising the advantages of obtaining "the service of the horse ambulance when accidents occur. At Halifax the horse ambulance has been "out 198 times, and travelled 620 miles in 1899, and one of the leading surgeons informs me, 'I don't "know what we should do without it at the infirmary.' In his last annual report the head constable " of Liverpool states under the heading— " Services rendered to the public. "Ambulance work.—The new police horse ambulance system came into operation on the 25th "April last, and there are now six fully-equipped ambulances, stationed as follows—Royal Infirmary, "Royal Southern Hospital (the Royal Southern Hospital for the present provide their own ambulance, "which, however, is worked in harmony with the police system), Northern Hospital, Stanley Hospital, "Central fire station (for night service) and Old Swan police station (for outlying districts). "Number of turns out— " 25th April to December 31st 1,173." The information as to the area which can be served by one ambulance shows that there is considerable difference on this point in the different towns. It is possible that explanation of this is to be found partly, at all events, in the fact that the establishment of horse ambulance services in this country is a matter of recent date, and that at the present time they are still in an experimental stage, except, perhaps, in the case of one or two of the larger towns such as Liverpool. Other reasons which would however account for difference as to the area served, are differences in the character of the town, such as the amount of heavy traffic and the nature of the industrial occupations and consequent difference in the number of accidents. In Liverpool there are five ambulance districts for an area of 13,236 acres, or one ambulance to about 2,650 acres, assuming that the districts are equal, though this may not be so. This is the smallest area served by one ambulance, and from this size they range to 22,000 acres in the case of Bradford. TOWNS WHICH HAVE PROVIDED OR P0SSESS A HORSE AMBULANCE SERVICE. TOWNS WHICH DO NOT MAINTAIN OR POSSESS A HORSE AMBULANCE SERVICE. 12 Towns which have provided or Town. Has an emergency ambulance service been established, if so, by whom. 1 Whether a horse or hand ambulance service. 2 Area which ambulance serves. 3 Liverpool Yes, by Corporation (Watch Committee) Horse ambulances, supplemented by hand ambulances City area of 13,236 acres is divided into five districts, and in each is a horse ambulance Birkenhead Yes, a horse ambulance, bought by subscription, has been presented to Corporation Horse ambulance. Other ambulances are kept at the hospitals and other institutions One horse ambulance serves the whole district. Area, 3,850 acres Manchester, 544,894 Yes, by Corporation (Watch Committee) Horse ambulance service Two horse ambulances at present in use. Four will be provided, one for each police division of the city. Oldham Yes, presented to town and now maintained by Watch Committee Horse ambulance service One horse ambulance serves the whole town. Area 5,000 acres about. Occasionally used for surrounding district Bradford Yes, provided by subscription and afterwards taken over by Corporation A horse ambulance and hand ambulance service One horse ambulance serves the area of sanitary district. Area 22,000 acres Newcastle-on-Tyne Yes, by the Watch Committee Horse ambulance service Two horse ambulances for the whole city area Haddersfield Yes, by the police Horse ambulance service One horse ambulance for 11,852 acres Bolton Yes, by private individual Horse ambulance service One horse ambulance for the borough (15,283 acrcs) and for short distances outside Blackburn, 127,527 Yes, by private subscription Horse ambulance service, and hand ambulances belonging to police One horse ambulance for 6,973 acres Bristol Yes Horse ambulance service with hand ambulances and stretchers at the police stations ... Gateshead Yes, by police Horse and hand ambulance service The area served by a horse ambulance is 3,138 acres Burnley Yes, partly by public subscription, partly bylocal authority Horse ambulance service One horse ambulance serves the borough. Area, 4,015 acres Hall Yes. (1) Provided and maintained by private subscription. (2) By Corporation (1) One horse ambulance. (2) Hand ambulances (1) For whole city area. (2) For whole city area Sheffield Yes, by local authority Horse ambulance service (there are also private hand ambulances at all big works) There are two horse ambulances for the city. Area, 19,651 acres 13 possess a horse ambulance service. How staffed. Location of ambulance. Means for summoning the ambulance. Expenses. 4 5 6 7 By men of the police force. The horses are provided by the police depot. If the hospitals so desire they can provide an ambulance surgeon Four ambulances are kept at hospitals, viz., (1) Royal Infirmary; (2) Royal Southern; (3) Stanley; (4) Northern. One is kept at an outlying police station. For use during the night time for the four hospital districts, an ambulance is kept at the central fire station By telephonic communication from all police stations and hospitals, also by a system of police telephone call - boxes throughout the city Cannot be differentiated from general expenses of the horsing department of police. By the fire brigade staff (13 permanent men), who are all instructed in ambulance work Central fire station By telephone. There are 34 telephone fire-alarm boxes in the borough which are used for ambulance calls Cannot be differentiated from fire brigade accounts. No separate staff. Worked by the police at each divisional station At the police divisional station Telephone communication between all police and fire brigade stations Costof each ambulance, £135 maintenance. Worked as part of police duties. By two members of the fire brigade, who are instructed in ambulance work Central fire station No information Not separable from fire brigade account. The staff is provided by the fire brigade Fire station By application to the police department. Horse ambulance, £123. Hand, £7 7s. Repairs, £37 4s. 3d. Ambulance classes, etc., £98 7s. 3d. The staff of the department of the mounted police force At police stations Telephones and fire alarmposts (telephonic) Ambulances, £87 10s., £97 3s.; repairs, £25. By the police At the fire station Street telephone call boxes for ambulance and firealarms No information. By the Corporation fire brigade At the Corporation fire station Ordinary telephone and fire-alarm telephones No information. No special staff Local livery stables Either through the police or the infirmary Initial expenso about £100. By the police Central police station No information No information. By the police At police stations The ambulance can be obtained at any time by the police Ambulance vans, £110; horse hire, £40 per annum. The fire brigade (1) By members of St. John Ambulance brigade. (2) By the police. Each member of the force is expected to become efficient in rendering firstaid The fire station (1) At an appointed station. (2) A wheeled ambulance at each police station and stretchers at the various fire-boxes. By telephone (1) By telephonic communication between all parts of city and appointed station Cost of ambulance, £133. Maintenance not separable from fire brigade expenses. No special staff. Worked by the fire brigade One at the chief fire station, one at a police fire station By telephone calls to station. Number of calls in 1891 was 48, but have increased considerably. In 1900 there were 298 calls Ambulance, £130. One horse, £50. Maintenance not separated from fire brigade account. 14 Town. Has an emergency ambulance service been established, if so, by whom. 1 Whether a horse or hand ambulance service. 2 Area which ambulance serves. 3 Leeds Yes. (1) By police. (2) By infirmary (1) Horse and hand ambulance service. (2) A horse ambulance There are two horse ambulances for the city area Wolverhampton Yes. (1) By hospital; (2) by police; (3) by railway companies (1) Horse and hand ambulances; (2) hand ambulances; (3) hand ambulances ... Towns which do not maintain Plymouth By local authority and by hospital Hand ambulance service. No horse ambulance Four hand ambulances for the whole town Sunderland ... Hand ambulance service. No horse ambulance Five hand ambulances at police stations. Also private one at ship yards West Ham By police Hand ambulance service. No horse ambulence One hand ambulance at each police-station and private hand ambulances Nottingham By Corporation Hand ambulance service. No horse ambulance Eleven hand ambulances for the town Portsmouth By Watch Committee Hand ambulance service. No horse ambulance Seven hand ambulances for the town Brighton By local authority Hand ambulance service. No horse ambulance Five ambulances for the town Derby No public ambulance service Norwich By police Hand ambulances Two hand ambulances for the town Salford By Watch Committee Hand ambulances Ten hand ambulances for Salford, Pendleton and Broughton Croydon By police Hand ambulances Three hand ambulances for town Cardiff By police Hand ambulances Seven hand ambulances for town Birmingham (1) By police and fire brigade; (2) by St. John Ambulance Association Hand ambulances Twenty-nine hand ambulances 16 (3.) The Ambulance Services of Foreign Towns.—Having regard more especially to the arrangements made for the removal to hospital of persons suffering from accidents or sudden illness in the street. In the year 1890 the Foreign Office addressed a circular letter to Her Majesty's representatives at the chief foreign towns in Europe and in the United States requesting that information be forwarded as to the means adopted for "the ambulance transport of civilian sick and injured from their homes or the place of injury to the hospitals, or from the place of injury to their own homes." The information which was obtained was presented to Parliament in the same year, and the following account as to the arrangements which existed at that time has been obtained from this parliamentary paper. Reference will only be made to those towns at which a horse ambulance emergency service had been established, and the account of which appears to be useful in connection with the purpose of this report— New York City. The ambulance service of this city is controlled by three separate departments, namely, the Police, the Health, and the Commissioners of Public Charities and Corrections. The ambulance service is conducted by the respective departments as follows— Police department.—As to persons taken ill or injured in the public places or streets, the policeman on post reports the matter at once to the nearest station-house by telephone, telegraph, or other expeditious way, and am ambulance-call is sent at once from thence to the nearest hospital provided with ambulances. Whether the injured or sick person is taken to his home or to hospital depends upon his condition. If such person desires to be taken to his home, and the surgeon sees no objection, this is done. A competent surgeon accompanies each ambulance, and his examination of the sick or injured person determines the first disposition of the case. In addition to the street cases, there are many others in which ambulances are called to the station-houses, in order to secure the most expeditious surgical opinion and treatment. Of these, about one-half are taken to the hospitals, but the remainder, consisting of cases of delirium tremens, contagious diseases, profound insensibility from intoxication, insanity, parturient women, &c., which the general hospitals—those not entirely sustained by the City Government —decline to receive, are handed over to the Commissioners of Charities and Corrections, and are sent by them to institutions or asylums on islands adjacent to New York, specially under the Commissioners' control. The total number of ambulances in use in the city of New York at the hospitals is 23, distributed as follows— Hospitals— Bellevue* 5 Harlem* 2 Gouverneur* 1 Ninety-ninth-street* 2 St. Vincent 2 New York 2 Chambers-street 3 Manhattan 2 Presbyterian 2 Roosevelt 2 23 * Under Department of Charities and Corrections. In addition to these, ambulances are kept at the head-quarters of the Charities and Corrections and Health Departments namely— Charities and Corrections, 3. Health Department, 3, and 2 coupes. Department of Public Charities and Corrections.—As to the means adopted by this department for ambulance transportation of the sick and injured, calls are received in the following manner— 1. Through the Police Department, by the officer on whose post the accident occurs reporting the case at the station-house. It is then transmitted by telephone to this Department through the Police Central office. 2. By an officer of the Fire Department sending a signal (twenty continuous taps) on the fire telegraph. This is done only in extreme cases, as when an accident occurs at a fire requiring a number of ambulances, when ambulances from all available sources are signalled for. 3. By relatives or friends making application to the Commissioners or the Warden of the hospitals under the control of the Commissioners. 4. On a physician's certificate that the patient, unable to pay for the same, requires hospital treatment. Each ambulance is supplied with surgical appliances, medicines, &c., and a surgeon goes with each. On the arrival of the ambulance at the place where the accident occurs the patient's wounds are dressed,and, should he desire to go home, if the surgeon is of opinion that he may safely do so, he is taken there, provided he lives within the city limits. Calls are received at all hours of the day or night, and the surgeons, drivers, and ambulances we ready for every emergency. Health Department.—The ambulances of this Department (three in number and two coupes) are used only for the transportation of persons, sick with contagious diseases, from private dwellings, tenement houses, hospitals, and public institutions, to the hospitals of this department for their reception and treatment. Chicago. The system adopted in the city of Chicago for the ambulance transport of civilian sick and injured is that of patrol waggons under the charge of the police attached to nearly all the stations in the different police precincts. These are kept always ready, day and night, to answer a call 17 from any of the numerous police-alarm telephone boxes, where a signal-bell communicates with the nearest station, and on the receipt of the call the patrol waggon at such station is at once sent to the spot indicated. There are at present thirty-four police stations and thirty-one patrol waggons in this city, and several hundred call-boxes. Every policeman, and some private persons, have a key of the call-boxes ; a key is kept for public use at a drug store nearest adjacent to the box. Each patrol waggon is supplied with a stretcher, medicine-chest, and instruments and appliances for the relief of the injured, and useful instructions and directions are issued to the officers in charge of the waggons for the immediate treatment of the most general and serious injuries. On arrival at the spot the first means of relief are taken, if necessary, by the police officers in charge of the patrol waggon in accordance with these directions, and if the injury is such that the person cannot be moved from the spot where found without danger, the waggon is sent for a doctor. If the injured person is unknown, or insensible, he is taken to the County Hospital. At the request of the injured person he can be taken to any other hospital, or his own home. There are also three emergency hospitals in different parts of the city. No charge is made for the transport services rendered. Besides the patrol waggons there is one ambulance waggon, lately presented to the city by a lady, which is also under the charge of the police, and it is expected shortly there will be four more waggons presented by private persons. New Orleans. The ambulance service of New Orleans is under the direction of the administrators of the Charity Hospital (who are appointed by the Governor of the State), and has been in operation for a little over five years. The headquarters of the ambulance department are in a spacious and well-constructed building situated almost immediately opposite the hospital gates. Its equipment is as follows—three waggons, seven horses, two drivers, two stablemen. Two resident students are on duty for twenty-four hours, and accompany the ambulance waggon upon a "call." Should a second "call" occur before the return, the next two students for duty accompany the ambulance. The waggons are covered four-wheel vehicles, each drawn by a pair of horses. On the floor is a spring leather-covered bed which can be drawn out horizontally, and is fitted with handles and adjustable iron legs. This can itself be used as a stretcher in very bad cases, and there is a portable canvas stretcher besides, made in two pieces so as to be easily withdrawn from under a patient. Each waggon stands ready provided with a medicine-chest containing the remedies usually required in cases of poisoning, burns, scalds, &c., chloroform hypodermic preparations, and restoratives. Also a stomach-pump, tourniquets, bandages, plaster, and all requisites for checking haemorrhage and sewing up wounds. The horses stand in stalls at each side of the waggon, their harness so arranged over the pole that it can be immediately adjusted. In front of the driver's seat is a gong, which can be struck in the streets as a signal to clear the way. The "calls" are usually by telephone. There are many public telephone offices all over the city, and in its business portions, where accidents most commonly occur, private means of communication in this way are readily available, as no one would grudge the use of his instrument. The "call" goes into the library of the Charity Hospital, where it is verified and any special particulars obtained. Then it is wired over the way. I will suppose that it comes during the night. By one electric action a gong is sounded in the ambulance station and in the bed-room of the students on duty above, the chains of the horse-stalls drop, a trap in the ceiling opens, and the officers on duty slide down a polished steel shaft just behind the waggon, which by the time they can do so, is harnessed and ready to start. The average time between the striking of the gong and the departure of all concerned upon their mission is fifteen seconds. They have gone forth in ten. The route is given by intersection of streets thus: "Carondelet and Poydras." (An equivalent might be, "Fleet and Chancery," meaning corner of Fleet-street and Chancery-lane.) Nearly all the streets in New Orleans run either parallel or at right angles to each other at intervals; (known as " blocks ") of 100 yards. When the ambulance arrives on the scene of the accident the students do all that is immediately required for the patient, and he is taken either to the hospital for regular treatment or to his own house, in which case, if he be able to pay it, a charge from 2 to 10 dollars is made according to circumstances, or from 8s. 4d. to £2 1s. 8d. In this way many persons who have been poisoned by accident or malice (and both causes are frequent), who have received wounds or injuries causing serious loss of blood or prostration of the system, who are suffering from fits (easily mistakeable for drunkenness), and other causes calling for immediate medical attendance, owe their lives to this admirable service. Copenhagen. According to the instructions for the executive police of Copenhagen, it is the duty of the police patrol, in cases where any individual is attacked by illness in the streets, or is otherwise found to be in a helpless condition, to render immediate assistance, and, if necessary, take steps to call medical aid to the spot as soon as possible, or else to have the person carried either home or to the hospital. This instruction is of daily application in cases of sickness or injury in the streets, the persons being in most instances conveyed to the various hospitals of the town, the usual means of conveyance being cabs. In the year 1886 there wa3 founded in the town by a number of private individuals the society known as "The Society of Medical Watch Stations," the object of which is to insure to the inhabitants access to medical help in the; night-time, when occasion may require, and to provide materials for temporary surgical appliances, and for the convenient transport of injured persons, whether by day or night. This society caused to be established in April, 1887, with [3] 18 the consent of the police, cases of bandages and provisional surgical appliances in the seven police stations of the town, as well as an ambulance stretcher, constructed after the model of those used in the army; and later, in some of the police stations, a hand-cart for the transport of injured persons. As, however, both stretcher and hand-cart were found to be unsuitable, and therefore were seldom used, the society resolved to attach an ambulance carriage to every police station. Such carriages have accordingly been placed at two of the police stations in the inner town, and in the course of the present year it is anticipated that they will be supplied to the remaining stations. The horse to draw the carriage may be requisitioned from the nearest cab to be found, and the cabman is paid as for an ordinary course by the hour. The carriage can be summoned by telephone, either through the police wire, or through that of the Telephone Company, or through a private wire; and every police patrol carries in his note-book an instruction, drawn up by the society, showing what telephones are handy to his beat for summoning the ambulance carriage. Vienna. The Volunteer Humane Society of Vienna ("Wiener Freiwillige Rettungs-Gesellschaft") was established after the burning of the Ring Theatre in 1881. It is supported entirely by voluntary contributions, and its services to the public are given gratis. Its sphere of operations is limited to the police area of the metropolis. In case of fire the society can count upon the assistance of a volunteer fire brigade, consisting of nearly 400 men, and furnished with a steam fire-engine and the necessary apparatus. It also commands the services of 200 trained watermen, with boats and the newest appliances for saving life. Two hundred and twenty-one doctors and one hundred volunteer assistants (all medically educated) are at the society's disposal. During the last eight years there have been 12,159 cases of illness and injuries treated, and 24,000 sick transported, altogether 36,159 cases dealt with by the society. It has rendered assistance on 2,139 separate occasions at fires, railway accidents, &c., and on 1,467 occasions it erected temporary ambulances at places of public resort. The society owns twenty ambulance waggons for the transport of sick and wounded, together with a large number of other vehicles and sanitary appliances. Twenty-five doctors, whose residences are distinguished by coloured lamps, have given their services gratuitously to the society for night work. Their addresses are published in a handbook containing a list of telephone numbers and the places, such as police stations, theatres, tramway offices, Ac., where stretchers are to be had; also the names and addresses of the sanitary assistants (" sanitats manner "). The society requests that the telephone may be employed for communicating with its officials as being more expeditious than the telegraph. Although the society limits itself to dealing with cases of illness, accidents, &c., which occur in the streets of Vienna and in public places, exception is made when the civil or military authorities require assistance if a medical man sends a certificate stating that a patient requires to be immediately transported to a hospital. Cases of ordinary infectious disease are, however, not transported by the society, but an exception is made in view of an epidemic of cholera, in which event a special service of ambulances would be organised. Paris. The system of ambulances in Paris is entirely in the hands of the police. Paris is divided into 20 arrondissements, each one of which contains four police stations and a commissariat de police. A stretcher and a box of medical stores, necessary for the first dressing of a wound, is kept at each police station and at the commissariat, and a list of directions as to the manner of treating various injuries is put up in each police station. Stretchers and boxes of medical stores are also kept at a certain number of fire brigade posts, at a certain number of guardrooms of the republican guard, at all the cemeteries, and at some octroi posts. At any public fete or demonstration where a large crowd is likely to be assembled, the police organise a special ambulance known as an "ambulance volante." It consists of a doctor and two policemen, with a stretcher and a box of medical stores. The police possess in Paris 219 hand stretchers, requiring from two to six men to carry them, and 16 stretchers on wheels requiring only one man; these latter are kept at the central police station of each arrondissement. In the event of a person receiving a slight injury in the street, the gardien de la paix takes him to the police station, or, if there is not one near enough, to a chemist's shop, and despatches one of his colleagues to fetch the stretcher from the nearest police station; he is then conveyed home or to the hospital. If he is in a position to defray his own expenses, he does so, if not, they are paid by the Prefecture de Police. Should the accident be of a more serious nature, the gardien de la paix telephones to the Hospital St. Louis, the headquarters of the "ambulances urbaines," and a special ambulance carriage, one of which is always kept ready harnessed, provided with a stretcher, and containing the medical stores necessary for the first dressing of a wound, is at once despatched, accompanied by a doctor, who conveys the injured person to the hospital or to his home. The "Ambulances Urbaines" is a private philanthropic enterprise started at Paris two years ago, and recognised by the police as being of the greatest service. This society operates in a radius of several arrondissements, which is being constantly enlarged. It has a private telephone, with thirty-five points of communication established in chemists' shops and police stations, the central office being the Hospital St. Louis. In the event of a person undergoing an injury in his own house, and wishing to be conveyed to the hospital, there is no organised system of ambulance transport; the police station will sometimes, on application, lend their stretcher, but in this case a regular report has to be made to the Prefecture de Police. In regard to Paris information of more recent date is contained in papers and in a statement by Dr. Nachtel, forwarded to the Council in connection with the question of the need of an emergency horse ambulance service for London. 19 A report on " Les Ambulances de la Ville de Faris" (Ambulances Municipales et Ambulances Urbaines), dated June 1st, 1898, gives the following information— The ambulance services of Paris at that date consisted of— 1. Ambulances municipales. 2. Ambulances urbaines. The first of these is concerned with the removal of persons ill with contagious or noncontagious complaints. The second deals with the removal to hospital of persons suffering from accidents, and is never available for the transport of the contagious sick. It was in 1887 that, on the initiative of Dr. Nachtel, a station for a service of the Ambulances Urbaines was established at the Hospital of St. Louis. In 1889 the town of Paris established two stations for the service of the Ambulances Municipales, one in the Rue de Stael, one in the Rue Chaligny. In 1895 the service of Ambulances Urbaines at the St. Louis Hospital was taken over by the municipality, who shortly after decided to adopt a scheme for providing a complete ambulance service for the removal of persons suffering from illness or from the effects of accident. After receiving the report of a special commission on the subject, the municipality determined in favour of the construction of new ambulance stations, the provision of additional staff and the provision of greater facilities being given to the public for obtaining the use of the ambulances; and it was to commence at once and to proceed with the elaboration of the scheme as quickly as possible. The report states that it was anticipated that by January 1st, 1899, ten stations (including two special stations), comprising four stations for the service of the Ambulances Urbaines, four for the service of the Ambulances Municipales, and two for both services, would be in working order. The staff at each ambulance station comprises telephone attendants, coachmen, and ambulance assistants, the latter, in the case of the Ambulances Urbaines, being senior medical students. As this report deals with the subject of an ambulance service for London for cases of accidents only it will not be necessary to refer further to the Paris system, except as regards the service which exists for bringing speedy means of removal to the scene of an accident, and for this purpose to give here the description of it by Dr. Nachtel, which he recently forwarded to the Council, of the service which was initiated by him in 1888 in connection with the Hospital of St. Louis, and which was taken over by the municipality in 1894. During the six years we were working as a private charitable society we succoured about 200 persons per month, or 2,400 per year. I should state that the area within which we operated covered about one-sixth of Paris.* The cost of carrying on the Saint-Louis station was about twelve hundred pounds per annum. I planned the Paris ambulance system in a way conformable with Parisian customs. The French place great faith in the ability of the nearest chemist to attend to victims of street accidents. Utilising this fact, I caused a number of chemists' shops to be connected by direct wires with the Saint-Louis Hospital. When a person is injured or taken ill in the street at any point within the area served by the Saint-Louis station he is immediately taken to the nearest chemist's shop; the hospital is advised by wire; the horse, which stands ready harnessed, is attached to the ambulance; a printed form is put into the driver's hands, marked with the time the call was received and the time at which the carriage is starting, and in a few minutes the ambulance is at the scene of the accident. The doctor who is in the carriage makes a rapid diagnosis of the case and applies a dressing, for which he has all the necessary appliances in the ambulance. The vehicle then conveys the patient either to his home or to a hospital. It should be understood that the patient is taken to the nearest hospital. If this should not be the SaintLouis Hospital the medical attendant telephones from it to the latter for instructions, and very often finds that a fresh call has been received and that it is necessary for the ambulance to go to the scene of another accident. As soon as the ambulance returns to headquarters the form on which the doctor has entered the name and address of the patient, the nature of the accident, &c., is handed in to the hospital to be filed. Now, it is very important that I should give a description of the ambulance. I do not exaggerate in the least when I say that the carriage used in Paris is the outcome of several years' reflection and experiments. It is a unique vehicle, for the New York ambulances are very inferior to it. In the first place, it should be borne in mind that the carriage must be built with a view to the conveyance of an injured person. Having to serve a different purpose from those intended for carrying sick people, it must be constructed on a different plan. It should fulfil the following conditions— It should be sufficiently light to be drawn by one horse. It must be spacious enough to contain two persons, one lying down and the other seated in such a position as to be able to attend to the first. It is also desirable that a second injured person may be conveyed, provided he does not need to be in a reclining position. The bed or stretcher on which the injured person is placed must admit of being put in and taken out of the carriage without jolting the patient. The carriage should have good springs, so as to avoid shaking. As to the first point, the Paris ambulance is light enough to travel, when loaded, at the rate of eight miles an hour with a single horse. The second point calls for some brief explanations. The New York carriage is open at the sides, the openings being fitted with curtains. This is a defect, for there is no protection from the cold. Besides, the floor is entirely occupied by the stretcher and mattress on which the patient is placed, so that the doctor is obliged to stand on the step, holding on by a strap. This is another and more serious defect, seeing that, apart from the doctor's dangerous and inconvenient position, he is practically unable to render the patient any assistance during the journey, * Area of Paris—P,000 hectares, about 19,768 acres, say 20,000 acres, therefore one-oixth of Paris i J about 3,300 acres, or five squa: e miles. 20 however urgently it may be needed. Furthermore, the presence of a mattress, which cannot well be changed for each patient, causes the carriage to appear less clean than it should do. The vehicle used in Paris, on the other hand, has glass windows which, if air is wanted, can be lowered, while the blinds afford a protection from the sun and from the gaze of too inquisitive persons. The doctor has room to sit beside the patient, or, if necessary, move round him. There is no mattress and no sheet but only a blanket, which can be used or not. The patient lies on a stretcher, of which the following is a description— The stretcher question is a difficult one. Stretchers, as usually constructed, f.re either in wood and canvas or entirely in wood, and covered by a mattress. In either case the stretcher is necessarily very large and therefore requires a very large carriage to contain it. Besides, the canvas becomes brittle, and, like the mattress, is always more or less dirty. Sometimes one or more stretchers in wood and canvas are suspended from the roof of the carriage. This solution of the difficulty may be necessary in the case of military ambulances, but it is only a pis-aller, as it is next to impossible to suspend the patient, who is first placed on the stretcher, without subjecting him to painful and even dangerous jolts. Moreover, there is still the drawback of the blood-stained canvas. Our stretcher is made of wickerwork, is constructed in one single piece, and follows the shape of the human body. The arms and legs rest in hollows, and the patient, having each part of his body supported, is in a comfortable position, while the apparatus occupies a minimum amount of space. At the head there is a leathern pad forming a pillow. It will easily be understood that a stretcher of this shape, built of such a light material and provided with rollers, can, if care is taken, be put into the carriage almost without any jolting. The small volume of the stretcher also enables it to pass up narrow staircases and be carried, either at the hospital or the patient's dwelling, to the very bedside. This is not the case with wooden stretchers. Another good feature about the wicker stretcher is that it can easily be cleanued with a sponge. The necessity of placing the stretcher on the carriage-floor made it essential that the body of the vehicle should be well-hung. We have succeeded so well in this respect that in the Paris ambulances it is not at all difficult to write whilst the carriage is going at a fast speed along the paved streets. The carriage lamps give light to the inside as well as externally. The ambulance is provided with splints and everything else that is necessary for a first dressing, as well as with a medicine chest. The driver can be communicated with from the interior by means of a speakingtube. A bell, worked by the driver's foot, serves as a warning to clear the road, while a Red Cross flag floating above the carriage acts as an ocular sign that an ambulance is approaching. Everybody will agree that, when an accident occurs, it is of prime importance to inform the ambulance station immediately. It is desirable that I explain how I came to organise this part of the Paris system, and how, in this as in many other respects, the Paris ambulances are superior to those of New York. At the latter city the fire-alarm system is also used for notifying accidents. This has the evident advantage of using one apparatus for two distinct purposes. There is, however, the drawback that, with an electric fire-alarm, the point at which help is needed can only be indicated approximately. In the case of a fire this is not of great importance, because the presence of a crowd, or the presence near the alarm-box of the person who gave the alarm, is sufficient to direct the firemen to the exact spot. In the case of an accident it is not the same thing, and in New York the ambulance people have often been in doubt. It was the habits of the Parisians in cases of accident which led me to a better method. In Paris, as said above, when an accident occurs the first step is to take the injured person to the nearest chemist's shop. This was my starting point. I went to all the chemists within the area which we proposed to serve by means of the Saint-Louis station, and ascertained from each of them the number of injured persons brought to his shop per week. Out of about 200 chemists I selected 30, being those who had had the greatest number of accident cases brought to them, and in each of these 30 shops a telephone was placed, connecting it directly with the Saint-Louis Hospital. It is impossible to conceive of a more rapid call system. The alarm apparatus is placed exactly where it is most likely that the injured person will be brought; the call, " Come to No. , Rue is conveyed electrically, and in an instant the carriage, equipped with everything needful for affording succour, starts for the place where the injured person is lying. Of course, in those neighbourhoods where there is no chemist's shop the call-apparatus can be placed in the police station, as has been done in Paris. As to the medical attendants who accompany the ambulances, they are selected from those students who are in their last year, and they have to pass a special examination as to their fitness for this duty. It is highly important that the victims of accidents should receive the earliest possible attention, and this from qualified medical men. The persons life often depends upon the promptitude with which efficient aid is rendered. In some cases a few moments' delay proves fatal. The medical profession know well that injured parts which have been in contact with septic substances, such as earth, coal, dust, &c., need to be disinfected immediately, and it is only to an ambulance system organised on the lines described that wo can look for rendering this aid rapidly. A hemorrhage can quickly become dangerous; an ambulance-carriage provided with the proper appliances may reach the spot in the nick of time to save the person's life. A broken limb cannot be handled by the first-comer; it is a competent medical student, attached to the ambulance, who should place the temporary splints and see to it that the patient is not caused intense pain by being carelessly handled. In a case of poisoning, the use of the stomach-pump immediately after the absorption of the toxical substance may snatch the patient from certain death or at least save him from grave injury. We know that many accidents of all kinds occur daily, such as falls, burns of all degrees of severity, syncopes, cerebral and other forms of congestion, collapse through hunger, murders, suicides, confinements in public places, sudden indispositions, injuries caused by vehicles, explosions, fires and by machinery, &c., &c., and they can only be properly dealt with by means of a system of horse ambulances organised on the lines of the Paris "Ambulances Urbaines." Vienna, Berlin, St. Petersburg, Moscow, Warsaw, as well as many provincial towns in France, have followed the lead set by the French capital, and London, where such a system is perhaps more imperatively needed, is the only great European city lacking it. 21 (4.)—AS TO THE ESTABLISHMENT OF A HORSE AMBULANCE SERVICE for EMERGENCY CASES IN LONDON. Tlio fact that in many towns both in the provinces and in other countries it has been considered advisable to establish and to maintain a horse ambulance service for emergency cases may be taken as evidence that such a service is of use and supplies a want which is not fulfilled by a hand ambulance service alone, at least so far as the more busy centres of population are concerned. If this is so as regards provincial towns it is to be expected that the same would apply to London, or at least to some portions of it. The County of London may, however, be regarded as containing districts comparable both to the busy industrial provincial town with considerable traffic in the streets, and to the quieter town such as those in which a hand ambulance service is still considered to meet the requirements of the district, and it is possible, therefore, that the provision of a horse ambulance service for the whole area of the county need not be considered, at all events in the first instance. It might be well in the first instance to initiate such a service tentatively in one part of London. In any case it is highly probable that a complete ambulance service for London would be found to be one which comprised both horse and hand ambulances in each ambulance district, that is to say the horse ambulance would be supplemented by hand ambulances. I believe this is the case in Buda-Pesth, and that it is proposed to add hand ambulances to the existing service in Paris. One or more ambulance districts might be established, and the number of these could afterwards be extended if found necessary. If it were decided to establish such a service, the points which would present themselves for consideration include the following— 1. What part of London should be taken for ambulance districts ? 2. What should be the area of the districts ? 3. Where should the ambulance station be established ? 4. What would be the best means for readily summoning the ambulauce ? 5. How should it be staffed ? 6. What kind of horse ambulance should be provided ? Considering these headings in detail— (1.) Ambulance districts.—The parts of London where it would be well to first form tin ambulance district or districts would be those where during the daytime traffic is greatest aiid accidents are most likely to occur. With a view to gaining information on this latter point the annual report of the Commissioner of the Metropolitan Police has been studied, and from the report for 1899 the following table as to accidents coming to the knowledge of the police has been taken. This table refers to police districts and therefore includes areas part of which are without the county boundary. But for the purpose in view this is not of much moment. Two districts with the highest number of accidents, viz., Holborn and Whitechapel, are entirely within the county. Return of accidents known to the police which occurred in the sheets during the year 1899. Accidents by which persons were killed. Accidents by which persons were injured. Order in relation to frequency of accidents. Police Division. By day. By night. By day. By night. Total. A.—Whitehall 2 ... 199 35 236 20 B.—Chelsea 6 1 315 61 383 14 C.—St'. James's 4 ... 436 122 562 6 D.— St. Marylebone 6 1 415 83 505 9 E.—Holborn 3 2 654 108 767 2 F.—Paddington 2 ... 181 29 212 21 G.—Finsbury 14 ... 391 64 469 12 H.—Whitechapel 15 1 627 72 715 3 J.—Bethnal-green 5 ... 234 29 268 19 K.—Bow 17 l 542 60 620 4 L.—Lambeth 13 l 656 153 825 1 M.—Southwark 14 3 509 68 594 5 N.—Islington* 15 ... 248 51 314 17 P.—Camberwell 5 3 337 45 390 13 R.—Greenwich 6 ... 298 60 364 15 S.—Hamptead .... ... 256 34 290 18 T.—Hammersmith .... 3 422 54 479 11 Y.—Wandsworth 8 ... 490 50 548 7 W.—Clapham 16 3 387 88 494 10 X.—Kilbnrn 12 1 282 39 334 16 Y.—Highgate 15 1 436 64 516 8 Total 186 21 8,315 1,369 9,891 2. Areas of ambulance districts.—As regards the area for which one ambulance station would serve, no precise statement can well be made. The area would depend on circumstances, such as the number of accidents during one day, the distance from hospitals, and the unequal distribution of the latter in relation to the area of London. The information bearing on this point in the replies received from provincial towns, shows that the area for which one ambulance serves varies considerably, viz., from an area of about 2,050 acres 22 in Liverpool, to an area of about 22,000 acres in Bradford. Reference has already been made to the area served by one ambulance in the case of Paris (see information under heading Paris). If, in establishing a horse ambulance service, it was decided to commence by forming one or two districts only, it would be better not to definitely settle the area which can be served by one ambulance station, but rather to map out an area provisionally and to lessen or increase it after experience had been gained. In all probability, experience would show that an area which could be served by a one-horseambulance station would vary according to the part of the county in which it was situated. 3. The position of the ambulance station in each district.—The ambulance stations would contain one or more ambulances ready to start at a moment's notice according to the character of the district. The experience of provincial towns suggests that there is advantage in having the ambulance station at a police station, a fire station, or at a hospital. As regards the first two of these it must be borne in mind that in these towns the horse ambulance is worked through the police force or the fire brigade staff, and this fact has probably led to the use of these places as stations. In Liverpool, where the service is worked by the mounted department of the police force, and where tbe conditions to be dealt with are perhaps most like those of London, the hospitals are used as ambulance stations. There is obviously considerable advantage in this arrangement, and the adoption of a similar plan in London has much in its favour, but the fact that most of the hospitals in London are situated within a small area on the north bank of the river would render it necessary that stations at other places should >>e established. 4. Means of communication with the ambulance station.—The means which should be adopted for this should consist of a system of direct telephonic communication from various points to the ambulance station. The points of call should include police stations, railway stations, hospitals and street standards similar to those in use for summoning fire engines. A good position for the last would be at each of the principal cab ranks. 5. The staff.—This would have to be a special staff, and should consist of an attendant to receive calls at each station and a driver for each ambulance. It would also be well that provision should be made for despatching some one with medical and surgical knowledge to render first aid and attend to the sufferer on his way to hospital. In all probability it might not be necessary that this officer should be a qualified medical man, if persons willing to undertake the duty could be continually obtained from among senior students. For this reason, there would be considerable advantage in having ambulances stationed on or adjoining the -premises of the general hospitals, but as has been already said, owing to the position of these hospitals horse-ambulance stations in other situations would need to be provided in a complete system of horse ambulances for the whole of London. 6. The ltind of hoi'se ambulance.—I have not sufficient experience of the different kinds of horse ambulances now in use in different towns to express any opinion on this point. Shirley F. Murphy, Medical Officer. 23 (iii.) Abstracts, prepared by the medical officer, from Zur Organisation des Rettungswesen, by Dr. George Meyer, of Berlin.* Ambulance Systems in Continental Towns. Vienna. The Vienna Volunteer Life-saving Society controls a central station, provided with accommodation for 30 carriages and stables for 19 horses. Many vehicles are always kept ready for use, and immediately a call comes, a medical man with sanitary staff and all necessary remedies starts at once for the place of accident. The kind of vehicle used by the Society takes the Form of a carriage, the litter being placed on the lower part of the carriage and rolled inside. There are also numerous other means of conveying the sick, litters, hand stretchers, etc., always ready. The staff is in uniform, medical men wearing caps and badges. Fourteen medical men are attached to the Society, of whom a number are always at the station; there are in addition 60 medical students as temporary assistants, and 322 medical men as honorary members at the disposal of the Society. All work done by the Society is free, whether inside or outside the station. It is specially ordered that only first-aid, and help only in urgent cases, is to be given. The Society help in cases of accident in the streets, in factories, public buildings, places of amusement, at processions, on railways, etc. At night the society gives first-aid in houses to persons attacked with illness or accidents. For the conveyance of persons suffering from infectious diseases the society possesses some vehicles lined with tin, which are disinfected immediately after the conveyance of each patient. Lately the Society has converted a railway carriage into an ambulance carriage, fitted out with all necessary materials and means of carrying persons. The medical men hold fixed appointments under the Society, the chief being paid as well as the others. Money is obtained by voluntary contributions, by collections, receipts at festivals, etc. In 1900 the number of occasions on which aid was given was in round numbers 9,000, while 6,400 were removed by the Society's vehicles—total 15,400 cases. The removal of cases of infectious disease is carried out by the city authorities, who have their own staff and excellent arrangements with vehicles, horses, etc. Buda-Pesth. The Volunteer Life-saving Society of Buda-Pesth was founded in 1887 and possesses a building of its own in which a number of senior medical students are always on duty, 12 living in a special part of the building. The ambulances resemble those of Vienna. The Society is also able to convert ordinary landaus into ambulance carriages. All vehicles are heated in winter and after each time of removal are disinfected, though cases of infectious disease are never supposed to be removed in them. At the station four men are on duty ; one of five specially appointed medical men supervising the whole in turn. A principal medical officer is also appointed. The removal-of cases of infectious disease is arranged for by the city authorities by means of their own station and staff. Graz. The life-saving branch of the volunteer fire brigade at Graz has since 1889 organised the arrangements for saving life in that town. The members of the life-saving branch, who are at the same time unpaid members of the fire brigade, consist of 30 medical men or medical students in their last terms, and 40 sanitary officers. In the armoury of the fire brigade is a room for dressing wounds and containing bandages, and a dwelling for the medical man on duty. The medical men take it in turns to be always on duty. There are two baggage waggons and five ambulances (life-saving carriages) in which a medical man and three sanitary officers go to the place of accident. First-aid only is rendered in sudden illness or accidents. Other sick persons, especially those suffering from infectious diseases, are removed by the hospital authorities by means of wheeled litters. Clinical treatment does not take place. All help is rendered free. As in Graz so in many places in Austria-Hungary the fire brigades have organised the arrangements for saving life. The members of the numerous Austrian volunteer fire brigades are trained in first-aid, and even in the smallest places a service is thus made possible. * Zur Organisation des Rettungswcsen von Dr. George Meyer in Berlin. Abdruck aus dem Klinischcn Jahibuch Jena. Vcrlag von Gustav Fischer, 1901. 24 Berlin. In Berlin there are many arrangements for rendering first aid which have been brought into existence and carried on by various bodies. The police authorities have litters and other ambulance appliances, but little use is made of these. The town authorities render first aid in the "sanitary stations," in the town hall and other public places, and these stations are open free for the use of any medical man in cases of accident. The fire brigade is specially connected with the life saving service in Berlin, each fire-station possessing litters and life saving apparatus. If there is danger to human life from any cause whatever, the fire brigade can be summoned by means of a fire call. City parish doctors are provided for persons suddenly taken ill, and may be called by the police to render aid in such cases. Moreover, everyone is bound by law to hasten to the assistance of the police in cases of accident, assuming that this can be done without danger to oneself. A number of private associations exist for procuring medical aid in the night, especially in that quarter called "old Berlin," south-west and south. The name and address of a number of medical men ready to render night help on certain days is known in the police stations, chemists' shops, by policemen, night watchmen, and also by notices in houses. For persons without means the association pays; the well-to-do pay at once or through the association. The efficiency of these arrangements has in the last few years, however, somewhat declined. The sanitary stations, the accident stations, and the Berlin Life Saving Society play now the principal parts in the life-saving service. All three were initiated by private enterprise, and to a certain extent owe their continuance to private assistance. Of these, the first to appear in Berlin were the sanitary stations founded in 1872 in the Briiderstrasse by the Red Cross Union (now so called). In the following years other stations were erected, till in 1886 there were 11, and in 1894, 20. These sanitary stations restrict themselves entirely to giving aid at night, the union having always declined a day service, as they did not wish to enter into competition with the practising physicians. The Berlin "accident stations" were founded in 1894 and at first four stations were opened, but they now number twenty. The medical service at the stations is so arranged that usually for each station there is a superintending medical man who can call on several assistants to help him. The accident stations have ten vehicles which are kept at nine depots, mostly breweries, whence the coachman and horses are obtained. The vehicles contain bandages in cases. Every station is on the city telephone and also by direct telephone with the nearest police district office, so that the help of the stations may be obtained through any telephone office. The police bureaus are furnished some with telephones, others with telegraphic communication. Since 1900 the accident stations have been allowed to call themselves " Accident Stations of the Red Cross." The Berlin Life Saving Society was founded in October, 1897, with the object of securing on a firm basis first-aid in connection with the hospitals, of placing the life-saving system under medical guidance and supervision, and thirdly of inducing all the Berlin medical profession to take part in this work of saving life. The union of the hospitals with first aid was effected by connecting them by telephone with a special central office now in Langenbeckhause, which is twice daily informed of the number of beds vacant in every hospital. This central office is besides telephonically in communication with eight life-saving stations in different parts of the city and with the depots of the persons undertaking to remove cases who have placed their 27 vehicles at the disposal of the society. The central office is also in direct telephonic communication with the nearest district police office which is also connected with the general police telephone, so that it is possible from every police station and also through every fire-call in the street (fire brigade officials at fires or important accidents are connected by a microphone) to be connected with the central office, and in that way with all the apparatus necessary for first aid. Lately the central office has become an indispensable adjunct to the care of the sick in Berlin. For those quarters of the city furthest from the hospitals there are now established in eight different places life-saving stations, with a night and day service. In six, the night service is performed by the sanitary stations, while in two, the life-saving society arranges for medical night and day service. A "medical union of the Berlin Life-Saving Society" has been formed to provide for the medical service in these stations. There are 1,100 members, of whom one part serves in the stations. The day service is served by a number of medical men changing one after another; at night one medical man is on duty, and the same is the case in the sanitary stations. A medical man is at the head of each station, and he has to watch over the service to see that it is regularly performed, that the instruments and bandages are ready, and all other arrangements concerning the station. Only firstaid is permitted and the patient is only to be made ready for removal. The conduct of the business is left to the president, the secretary, and two directors chosen from the whole committee. Stettin. In Stettin the life-saving system is carried on in a similar manner to that of the Berlin Life Saving Society. In October, 1899, a sanitary station was arranged in the fire brigade building, with medical service. Before then first-aid was rendered by trained fire brigade men. The scientific union of medical men has taken over the maintenance of the service at the station. During the whole night one medical man is at the station. There is a superintendent to manage the service. Every medical man who wishes to share in the service can do so, so that the life-saving service is in the hands of the medical profession. 25 Breslau. In Breslau the life-saving service is in the hands of the fire brigade which possesses six firestations in the town, of which one, in the inner circle of the town, serves as a centre. The hospitals, police stations, military guard houses etc., are all telephonically connected with this centre. A large number of members of the fire brigade are trained in first-aid and divided amongst the six stations. There is also an accident station erected by a private association. In the town hospital are six hospital waggons of which two are always ready with horses harnessed from the town stables. The above-mentioned institutions as well as the fire-call apparatus are all at the disposal of cases of accident, even in the night. As soon as an accident is notified, the fire brigade starts for the place as if it were a fire and arranges at once the sending of one or more ambulance carriages from the hospital. The service is so arranged that the staff only render the patient capable of being removed, and obtain for him the nearest medical or surgical treatment. There are also 12 accident call stations in different parts of the town which are well fitted up, and in each first-aid can be rendered. Further, the sanitary corps of fire-saving union has 10 places for dressing wounds whence help is sent out especially to fires. A new arrangement of the system is to be introduced by which all the above-mentioned first-aid, etc., is to be under town control and with money from town funds. Bremen. In Bremen the fire brigade has in a special manner organised the life-saving system. There are five sanitary stations in connection with the fire stations, in which the service is maintained by fire men trained as "Samaritans." Each station is provided with all necessary material, means of removal (four vehicles), etc. These last are placed in the fire stations, and provided with horses from that source. The service has done good work since 1890. The number of times aid was given has continually increased, and in 1900-1901 reached 2,109. In only 113 of these was a medical man called. Altona. In Altona also the fire brigade manages the life-saving service. The patients are conveyed as quickly as possible to a hospital. Hanover. The fire brigade is not less useful in Hanover, though it is not concerned directly with lifesaving service, but with the removal of the sick and especially cases of infectious disease. At the present time there is a movement on foot for the rearrangement of the system by which life-saving stations with alternating medical service as in Berlin are to be organised. In Linden, near Hanover, an active Samaritan Society has arranged the life-saving system. Konigsterg. In Konigsberg the town fire brigade has undertaken the life-saving affairs and removal of the sick. A carriage ready harnessed always stands at one of the fire stations waiting for a call, which comes by public telegraph; two fire brigade "Samaritans" accompany the vehicle. At the police stations there are cases for wound dressing and bandages. The removal of the other sick is undertaken by the town authorities. Frankfort-on-the-Main. There is in Frankfort-on-the-Main a volunteer life-saving society, which has been at work since 1891. The society has life-saving stations; surgeon dressers give their services; and since last year a new central life-saving station has been erected in the chief fire station. In this central station the service is undertaken by medical men who follow each other in succession during the day, and during the night one medical man is on duty. A medical union provides for the service being maintained. The society gives instruction in first-aid to the officers of the police, of the post office, and other great industries, factories, etc. The service of the life-saving society is now so arranged that immediately after an alarm a carriage with a medical man and two surgeons leaves the station. The society has also cases of life-saving apparatus in various institutions in the town, and it has also placed along the banks of the Main lifebuoys to save drowning persons. In the little waiting rooms of the tramways—by the main guard station—are two cases of bandages and a litter for public use, to be obtained by day by the employees of the tramway company, by night by the officer of the main guard. The society renders first-aid free. Besides this there is in Frankfort a Samaritan Society, which was founded in 1898, and proceeded from the Samaritan branch of the Frankfort cyclists. The society has now two stations, the second of which was erected in 1900. It consists of a "medical service always ready," in which a number of medical men take part. The superintendent is a surgeon dresser. The usefulness of the stations has increased. They possess a carriage of their own, in which two litters are placed one above the other; there is also room for five persons seated. These two associations are now to be regulated and placed under the control of the town authorities and of the medical profession. Munich. The volunteer life-saving association in Munich was founded in 1894. The help given by the society is restricted to actual need and only first-aid is afforded, so that the interests of the medical men should in no way be prejudiced. In the station itself the service is performed by sanitary officers, while for severe illness in private dwellings the medical men of the day from the hospitals are called in, and these are specially warned only to render first-aid and not to continue the treatment. The claims on the society have increased from year to year especially as regards the removal of the sick. They possess three carriages as well as three litters, etc. The horsing of the carriages is only carried cut [4] 26 partially from the town stables as the society have lately bought two horses for themselves. For removal of cases of infectious disease a special wheeled litter is used. There are also in Munich volunteer sanitary stations of the Red Cross which were founded in the same year, though somewhat earlier than the Volunteer Society. Cologne. In Cologne in 1888 a Samaritan Society was founded which erected a number of stations; they are placed at various parts of the city and consist of a chest which contains a litter and a case of bandages. The litter is covered and can be drawn out ready for use. The Samaritan Society has been affiliated lately with the Red Cross. In 1899 the Cologne Life-saving Society of the Red Cross was founded under medical supervision. The stations are in various hospitals and there are now 13 in Cologne fairly equally distributed over the city. A central office is now in existence. The fire brigade manages the removal of the sick. The society has also undertaken to provide for the Red Cross nurses and attendants in case of war. Hamburg. There is one sanitary station in Hamburg which has a night service, and from 11 to 1 a day service during which time a medical man is on duty. A plan has besides been formed in Hamburg to use the hospitals as stations for first-aid, as has been successfully done in Berlin. In addition to tbe stations maintained by private funds there is an excellent system for the transport of the sick which has been arranged by the police authorities. The removal system is so organised that a sufficient number of vehicles for cases of infectious disease are at 4 depots of a livery stable keeper which can be easily telephoned for from any police station. There is besides a carriage for the removal of several persons injured simultaneously. Nuremberg. The volunteer sanitary ambulance train of the Red Cross in Nuremberg has organised a lifesaving system, and a sanitary station exists which, situated nearly in the centre of the town, wa3 formerly occupied by volunteer sanitary officials, but lately the service has been maintained by medical men interchanging. The removal of the sick takes place in their own vehicles. Danzig. An accident station has been arranged at Legan, in the neighbourhood of Danzig, a room on the ground floor of a factory having been fitted out with all necessary appliances in which persons in the factory meeting with accidents can be treated by those members of the Red Cross who have been trained. The station ia under medical control. Leipzig. In Leipzig, as in most of Saxony, the life-saving system is arranged in an extraordinarily suitable and satisfactory manner by Samaritan associations. That in Leipzig was founded in June 1882. The association has three sanitary stations, each supervised by a medical man, while the service in the stations is maintained by medical men living in the neighbourhood. The medical men remain at home when on duty, and are called to the station by telephone or messenger; they receive from the association the fee for the aid given according to a specially fixed rate. The medical men of the association, whose staff consist of paid and volunteer members, both being in a military uniform, instruct the police and fire brigade men, officials on the railway and private individuals in first-aid. In the stations are litters, one carriage on the Vienna model, and belonging to the Samaritan Association, is placed in the principal fire station and can be quickly fetched by telephone message. Horses and coachmen are provided by the fire brigade. This association has also erected small stations in places where crowds congregate, viz., markets, slaughter-houses, fire and police stations, theatres, railway stations. These are provided with a surgeon's dresser as well as a litter and bandages. The removal of the sick is in the hands of the local authority; in the city hospital are a number of carriages which on demand immediately go to bring in the patient. Dresden. In Dresden the Samaritan Society has organised the life-saving system while the removal of the sick is arranged for by the sanitary police. The Samaritan Society was founded in May, 1896. At first it confined its energy to giving courses of instruction in first aid; later, however, it organised the life-saving arrangements. It now has three sanitary stations, the first of which was opened in 1898, the 6econd was erected on the site of the town relief station. There are in Dresden seven surgical relief places, of which four are attached to hospitals. For removal of persons injured in the streets or taken suddenly ill a carriage ready to start is kept in the chief fire station, and they go as rapidly as a fire engine to a fire. The order can be given by word of mouth or by telephone at a fire station, or at the nearest sanitary police etation. Every carriage is accompanied by a fireman and a sanitary police official trained in first-aid. A third carriage is in reserve in the city stables. In every district police station, in the slaughterhouse and the town hall are hand-litters, sedan chair carriers (on duty day and night) acting as bearers. Shirley F. Murphy, Medical Officer. 27 (iv.) Notes of evidence given before the Sub-Committee. (1.) Sir Henry Burdetfc, K.C.B., Chairman of Council of the Hospitals Association and of the Committee of the Street Ambulance Branch. (2.) Air. Thomas Ryan, Hon. Sec. of the Bischoffsheim Ambulance Service. (3.) Dr. Danford Thomas, Coroner. (4.) Dr. E. C. Perry, Superintendent of Guy's Hospital. (5.) The late Admiral Adeane, formerly Chairman of the Ambulance Committee of the Metropolitan Asylums Board. (6.) Dr. R. J. Collie, the Council's Medical Examiner. (7.) Police Superintendents. (8.) Dr. Nachtel. (1.) Sir Henry Burdett, K.C.B. (Chairman of Council of the Hospitals Association and of the Committee of the Street Ambulance Branch). Sir Henry Burdett explained the establishment of the Bischoffsheim Ambulance Service, particulars of which are given in the medical officer's report, and stated his views on the subject of the relative advantages of hand and horsed ambulances. His experience is that it is very doubtful whether a system of horsed ambulances would justify the cost, and he thinks the Paris system is a very extravagant service and not as efficient as the street ambulance service which exists in London at the present time. If it can be shown that there is any useful purpose to be served by the introduction of horsed ambulances or by motor ambulances which are much preferable, the money will be given. It has been offered over and over again. The great object of an ambulance should be to bring an ambulance litter to an injured person at once, and the less he is moved the better. He said that while he was not opposed to horse or motor ambulances he was strongly of opinion that they did not afford a panacea for street accidents. It would be impossible to cover the whole of London with such an ambulance service, and the provision of an elaborate system-on these lines would not be justifiable until it was found where they could be most usefully employed. It would, moreover, be very difficult to get stations. A hand ambulance 6ervice can be supplemented by these means, but to substitute horse and motor ambulances for hand litters would be a misfortune. With regard to the police, Sir Henry Burdett stated that their co-operation is essential. But the police already have as much as they can do, and it is unreasonable to expect them to undertake elaborate arrangements for the removal of injured persons. At the same time the police should be afforded greater facilities for acquiring first-aid knowledge, and they should not be expected as at present to undergo a course of training in their own time, for in practice the majority of police have to find their own time to attend first-aid lectures. The City police co-operate heartily with the system. The service has instructed them in first-aid, and they use the ambulances more than the metropolitan police. He suggests that some reward should be given to the police, say half-a-crown, for every accident case, removed to a hospital on an ambulance, in which they render assistance. Sir Henry said that the present ambulance provision is no doubt inadequate, and that the existing voluntary efforts do not cover the whole ground required. The people he represents would be willing to disappear in a moment if they could get the system taken over by the Council. He thinks it is properly part of the work of the Council to organise a proper service for London, and if the Council did nothing more it could afford the existing service sites for other stations. The Council could also help in inspiring enthusiasm amongst its large staff for first-aid and ambulance work. Sir Henry Burdett would like to see a trust fund organised by the Council, to which he was sure Mr. Bischoffsheim and other people would contribute. The Bischoffsheim service has no telephones at its disposal. Telephones might be useful. The stations on cab ranks are most useful. (2.) Mr. Thomas Ryan, Secretary of St. Mary's Hospital, and Hon. Secretary of the Bischoffsheim Ambulance Service. Mr. Ryan expressed the opinion that the existing provision is not adequate but that it is on the right lines, and that the way to improve it is by developing what we have and not by discarding it in favour of something else. There are at present a large number of hand ambulances distributed over the metropolitan area. In his opinion this system is what the conditions prevailing in London require and not four or six horsed ambulances. If the object were to make a brave show which would appeal to " the man in the street" then four or six fire-engine-like horsed ambulances are just the thing, but if we want an effective service adapted to the conditions which prevail in London, a large number of light litters to be wheeled by hand is what is required. Among the reasons for this are— 1. That in at least 75 out of 100 cases a horsed ambulance and surgeon are simply not wanted. The great majority of accidents, etc., are happily comparatively slight, and firstaid and a well constructed hand ambulance are the desiderata. 2. That the 10,000 or 12,000 accidents that happen every year in London do not occur regularly, about one per hour, throughout the day and night. No doubt if they did it would be an ideal condition for 4 horsed ambulances to cope with. But no, these accidents are intermittent and erratic. On a foggy day for instance, or when frost succeeds to a light rain, they occur in scores at the same time all over London. It is certain that 4 or 6 or even 10 horsed ambulances are not calculated to successfully deal with a situation such as that. 28 It is therefore tolerably clear that whatever other qualities the transport conveyances possess, they must be numerous. One other point he laid stress upon, that the police are, and must be, the basis of any ambulance system in London. It is the policeman who has to take the first step—often the making or marring of the whole business—viz., to decide to move or not to move the injured person, and, if he must be moved, to do it properly. In most cases he must be moved a few yards out of the way of traffic, and the policeman as a rule has to do it. Then comes the question of transporting him to a hospital. Shall the patient be at once "got into" a hansom or four-wheeled cab, or, if a wheeled stretcher be not at hand, be allowed to lie still till one is available. Momentous question for the patient! At the root of both these points is "First-Aid" training. Without training the policeman does not understand that, in many cases, to let the patient lie still until proper means of transport are available is the best thing that can be done; without training he cannot splint the broken limb, or stop bleeding, which in the majority of cases is an adequate preliminary treatment. Yet trained or untrained the policeman as a rule is the person who has in practice to deal with the problem. With training, we have present constantly in the streets of London somewhere about 2,500 men capable of rendering efficient preliminary treatment, in the great majority of cases, and in every case of avoiding faults of commission which are at present the source of the most mischief, and of safely conveying the victims of street accidents to hospital; moreover, such a corps can be provided in no other way. But even if an effective corps could otherwise be provided it is important to note that it would not fully meet the needs of the case. In street accidents the policeman is the first on the spot. The sufferer has to be moved out of the way of traffic; the policeman has to do it. In short, the policeman in London is an indispensable part of an ambulance service, and he must be properly trained and kept efficient; at present he often is not. What the proportion of untrained police is he could not say, but it is considerable. With regard to the "Bischoffsheim" service which was established in 1889, it was based on the fact that the police were the personnel of the street service, and its object was to provide them with proper transport materiel. The service has at present 55 ambulances distributed over the metropolis, on which about 2,000 cases are transported every year. Its establishment cost about .£1,500, and its annual maintenance about £300. Nearly all the first outlay and the whole of the annual maintenance was provided by one person, Mr. H. L. Bischoffsheim, who is not only prepared to continue to provide that annual sum but to increase it if necessary for the development of the service. It should not be understood that Mr. Bischoffsheim would object to the service being supplemented by a small number of horsed or motor ambulances, as it might well be that such an addition would be useful; but he was satisfied after an extensive experience that the general characteristic of the service must be a large number of light hand ambulances, supplemented, it may be, by a few of the horsed or motor type. The "Bischoffsheim" service originated from a paper on "The conveyance of injured persons to the metropolitan hospitals," which he (Mr. Ryan) read before the Hospitals Association in 1889, and its work has been carried on under his personal supervision from that date to the present time. The cost of a street-station was from £20 to £25. (3.) Dr. Danford Thomas, Coroner. Dr. Danford Thomas said that practically London had no ambulance service for accidents and other cases, and that much important time is lost. The present system with regard to infectious cases is a very excellent one. He thinks it would be publicly recognised as a proper and useful thing to originate the organisation of a system in London. The police at present render very excellent service; they are on the spot, and as a rule exercise discretion. The police should have the use of any horsed ambulances that might be provided. There are plenty of hand appliances, but what is wanted is a horsed ambulance. The great point is the need of some more rapid means of conveyance. Cabs are not appropriate, and are used no doubt because they are hondy, but great injury may be done in cases in which persons with, say a fractured thigh, are taken to the hospitals in cabs. Organisation and horsed ambulances are undoubtedly wanted. It would be better in many cases to wait a quarter of an hour to get a proper ambulance than to use a cab at once, and it is wiser to let a patient lie still and wait until some suitable vehicle comes along. In New York, such a service as he indicated is provided, and horsed ambulance, doctor and nurse, are ready at the hospital to go to any spot on receipt of a telephonic or other communication. (4.) Dr. E. C. Perry, Superintendent of Guy's Hospital. Dr. Perry said that the present ambulance services are most inadequate, that much suffering is caused by the way in which accident cases are brought to the hospitals, and that there is considerable risk in the use of cabs for the purpose. He is of opinion that a proper system must be managed by a central body, and that the London County Council is the most suitable body to undertake the work. The hospitals had no funds for the purpose. Dr. Perry said he sincerely hoped that the Council would lose no time in dealing with the matter, as it was very painful to watch the arrival of accidents at hospitals under the present system. With regard to such a system a considerable staff and organisation would be required, and both hand stretchers and horsed ambulances should be provided, the latter clearly being best and likely to be frequently used. The number of cases brought to hospitals day by day varies little, and a large number of accidents come from great distances. 29 He did not think it necessary that a doctor should accompany the ambulance, and with regard to the treatment to be rendered to a sufferer on the spot the safest way is to take the case in a recumbent position as quickly as possible to the hospital. He thinks the police show an intelligent interest in the work. Although hospitals could not contribute towards the expense of organising an ambulance system Dr. Perry believed that they would be glad to give facilities in the way of providing stations where practicable. (5.) The late Admiral Adeane, formerly chairman of the Ambulance Committee of the Metropolitan Asylums Board. Admiral Adeane explained the system of the Metropolitan Asylums Board, for the removal to the Board's hospitals of persons suffering from infectious disease. The system is very complete, there being stations in telephonic communication with the central office and cases are removed with the least possible delay—100 a day. There are about 100 horsed ambulances. Speed is not considerd of such importance as the avoidance of accidents. In reply to a suggestion that there would be considerable objection to an infectious and non-infectious system being organised by the same authority, Admiral Adeane expressed the opinion that there would be no difficulty in having an entirely separate organisation and that as a matter of fact the Board had a non-infectious system for removing imbecile children. He thought that if the Board were asked to provide an ambulance system for accidents they would do it and without difficulty. He had formed no opinion as to the need for such a system. (6.) Dr. R. J. Collie, Medical Examiner to the Council. At the present time there is, considering the size of London, practically no method available in cases of accident. Dr. Collie mentioned a case of a painter who fell down opposite his house and said that he sent to one of the London hospitals asking for assistance and received a reply to the effect they would be very pleased to see the case, if brought to them, but could not send for the man. Dr. Collie also referred to a case in which a man with a broken leg had been taken away in a four-wheeled cab, and was ill for six months in consequence. The present system is wholly inadequate. Few people have any idea of the number of accidents which occur in the streets of London in the course of a year. With the growth of the metropolis the number of accidents is rapidly increasing, in 1891 and 1892 they were 4,756 and 4,806 respectively. In 1900 and 1901 they were 8,010 and 7,995 respectively. For removing accident cases there ought to be a specially organised arrangement worked by men accustomed to the work. Dr. Collie stated that he would be very sorry, should he meet with an accident in the street, to be moved on a police ambulance. Often much time is lost before the ambulance is at the scene of the accident. An ambulance used for inebriates is not suitable for accident cases. It is left to the police to afford the first-aid, and one of the most important parts of the work is the arrangement made for lifting a patient. First-aid knowledge is very useful but the police are not sufficiently trained therein, one short course of instruction consisting of but five lectures being in the case of some of the men considered sufficient. Dr. Collie thought that improvement would be found in providing an organisation which though distinct, should be worked in conjunction with the fire brigade. Wherever there is a fire-station there should be an ambulance station or one for every two or three. Horsed or motor ambulances urgently called for. Time is of course important. The Asylums Board have a very efficient system for removing cases of infection. Note.—Br. Collie has been good enough to examine and furnish descriptions of, the horsed ambulance services of Manchester and Liverpool. These descriptions are printed below as an appendix to the notes of evidence (see pp. 31-32). (7.) Police Superintendents. (a) Superintendent Cole, E Division-—In the majority of serious cases patients are taken to the hospital in cabs, but in cases where the injury is slight the persons walk. There is generally a cab on the spot, but if the case is a very serious one the police send to the police station for the ambulance. There are two litters at Bow-street, one at Gray's-inn-road and one at Hunter-street. Most people prefer to be conveyed in cabs rather than in an ambulance. Constables are supplied with a list of all hospitals in their own and adjoining districts, and also a list of all the places at which ambulances are to be found. In the E division during the six months ended February, 1902, the police ambulance was used 110 times, the Bischoffsheim ambulances 56 times, and cabs 120 times. Most of the police are instructed in first aid. The police always send for medical aid or take the case to the hospital. Ambulances would be sent for by a second constable, the message being conveyed by hand. If a second constable was not available, a private person would take the message. The point is that an injured person must be moved. A policeman would ask private individuals to assist him in moving the injured person out of the street or roadway. The police have conveyed cases of injured assistants in factories, but this would not occur very often as firms have their own arrangements. In the outlying districts there are not the same conveniences as in the central divisions. There are 10 hospitals in the E division and six ambulance stations. Cabs are used because they are quicker. Cases of broken legs would not be put in a cab. In the inner districts the majority of accidents are dealt with by the police. 30 (b.) Superintendent Mulvany, H Division—In his district cabs are not so plentiful. During the six months ended February, 1902, the police ambulance was used 84 times, the Bischoffsheim ambulances 14 times, and cabs 24 times. Vans are responsible for most of the accidents, and in many cases the van would take the injured person to the hospital. There are in his district two Bischoffsheim ambulances and four police ambulances. Policeambulances are cleaned by the person detailed for the work of cleaning the station, etc. Telephones are not used in his district. Mr. Mulvany said that he had never known the want of an ambulance. (8.) Dr. Nachtel. Dr. Nachtel'a views are embodied in the description of the Paris service, which he was good enough to place before the sub-committee, and which is printed in extenso in the medical officer's report (pp. 19-20). 31 APPENDIX I. Notes on the horsed ambulance services of Manchester, Liverpool, Dublin, and Belfast. (a) Manchester. (Population—Census, 1901—543,872).—The whole of the ambulance arrangements are provided for by the police, and are under the supervision of the Watch Committee. Until a year ago there was no properly established horsed ambulance service in the town. There is but one ambulance station, which is situated at Goulden-street, a busy centre of the city, and adjoins the Goulden-street police station. The ambulance station accommodates four ambulance waggons, six horses, five police constables and the inspector. The inspector and constables who act as drivers, live on the premises. As the number of applications for assistance is rapidly increasing, the Watch Committee are now building two additional ambulance stations, and the question of providing an ambulance for each division is under consideration. Everything is kept in a state of complete readiness for an urgent call, the horse stands ready harnessed, and as a rule, the waggon is on its way to the accident in less than a minute from the receipt of a call. Method of summoning the ambulance. Massages are received by— 1. The Police telephone. 2. The National telephone. 3. By messenger direct to the station. The majority of calls are sent through the police telephone, but if an accident occurs at some distance from a police station the police constable avails himself of the nearest public (National) telephone. Each police division has a list of the names of the public who are willing to allow the use of their private telephones in case of accident. At night the only means of communication with the ambulance station is by the police telephones (20 stations), and any of the National telephone instruments (such as electric light stations) as may be available during the night. The ambulance waggon is at once despatched to any address whether summoned by the police or the public. The number of false alarms is very small. The six men, one inspector and four drivers have all undergone instruction in first-aid to the injured. The rule seems to be that the driver only, accompanies the van to an ordinary street accident; but to private cases another man always accompanies the driver. It would appear that on arrival at an accident one of the public is left to look after the horse while the driver attends to the injured man, assisted by a police constable who may be in charge of the case at the scene of the accident. If it is reported that a woman has been injured, the matron of the police station accompanies the van to the scene of accident. If on arrival only, it is found that a woman has been injured, one of the public, preferably a woman, is invited to accompany the constable and return with the injured woman. The patient is then conveyed to the nearest hospital. The ambulance drives at a rapid pace, the driver warning the public of its approach by an ordinary police whistle. Although this system has only been in use for a little over a year, the public are already getting to understand, and readily make room for it, even in crowded thoroughfares. The police constable on point duty always assist in facilitating its rapid progress. It is suggested that each van should in future carry a small flag with a Geneva cross on it. Besides ordinary street accidents, occasionally lunatics are removed from the street, or from the police cells to the police court, await the decision of the magistrate, and convey the patient to the asylum or the workhouse as ordered. Use of the ambulance. The City ambulances are used for the removal of private patients at a fee varying from three shillings and sixpence to five shillings, within the City boundary. Number of calls. The average number of calls per week for the whole City varies from 25 to 30, 4 or 5 of which are private, the maximum for one day being 12 calls and that for one week was 36. On the day of my visit I found that there had been the following calls—4.13 a.m., confinement in the street—telephone message from a doctor—patient taken home. 8.28 a.m., personal call at the ambulance station by one of the public—patient taken to hospital—died in ambulance on the way. 11.44 a.m., summoned by telephone to a man suffering from delirium tremens—taken to hospital. The books show that the number of calls from the 18th of July to the 18th of August inclusive was 199 cases, 50 of which were private. The amount paid by the public for the conveyance of private cases during that period was £18 10s. 6d. A careful entry is made of the exact hour at which the message is received, the time when the ambulance left, the nature of the injury, etc. At the time of mv visit at my request the horse was harnessed and the van on its way to a supposed accident within three quarters of a minute. The van. Two of the vans used are built by Wilson and Stockall, Bury, Lancashire. They are of an excellent pattern, fitted with rubber tyres, good springs, are strong, light and roomy. They cost £135 each. 32 Each van accommodates two stretchers, which are placed above each other. There are two seats, a small one for the attendant, and a larger one where two patients may sit in an emergency. There is a small shelf for splints, tourniquet, etc., and a drawer in which are kept hot water bottles and other appliances. The whole is systematically washed with Izal fluid. (b) Liverpool. (Population—Census 1901, 684,947).—At Liverpool the horse ambulance system is under the direct control of the police. Horse ambulances are stationed at four of the principal hospitals, and one at an outlying suburb at a police station. In all cases the police provide the ambulance waggons, tbe horses and harness, and a driver, who is a police constable. The hospitals provide the necessary coach-house and stabling, and a surgeon from the hospital, who invariably accompanies the ambulance when summoned. In the case of the ambulance stationed at the outlying suburb, there being no hospital, the ambulance waggon is kept at the chief police station of the district. No surgeon in this case accompanies it, but a constable qualified to render first aid accompanies the waggon. The ambulance station at the outlying suburb is available at any time day or night. The four waggons stationed at the different hospitals in the city are only available during the day. One of these is each evening removed to the central fire station and is therefore, with the exception of the outlying one, the only one available for night duty, and no surgeon accompanies it at night or on Sundays. All cases are taken to the hospital of the district in which they are found. The ambulances are not used to convey medical cases to or from the hospitals except in exceptional cases where the house surgeon is of opinion that the patient can only be moved safely in an ambulance, that he lives near, and is not in a position to pay for a private ambulance. If from any accident an ambulance waggon at any of the hospitals is disabled, it is replaced by one from headquarters. Frequent examinations of the ambulances are made by the superintendent. The fire brigade as well as the horse ambulance service in Liverpool is worked by the police, and the horses are used indiscriminately for either. Method of calling the ambulance. There are four methods by which the police or public may summon an ambulance waggon. 1st.—By direct application either to the hospitals, to the police, or to the fire-stations. 2nd.—By the public (National) telephone. A number of private telephone subscribers with the consent of the Postmaster-General have given permission for police officers to use their telephonesin emergencies. 3rd.—There is a complete private police telephone system, which has instruments at all the police and fire stations and hospitals, all of which are in direct communication night and day with the central police office. 4th.—An elaborate system of signal-boxes. There are in all 264 signal-boxes distributed at regular intervals in the busiest parts of the town. These boxes are about two feet by one foot by six inches, are of iron, and painted red. They are affixed in prominent positions to walls, railings, etc. They are arranged in circuits of about ten boxes each. The circuits within a mile of the central police station communicate directly with the central office, but the outlying circuits are grouped and communicate with four sub-stations which receive and re-transmit the message direct to the central office. The signal-box is opened only by a key with which each constable is provided. A limited number of keys is also supplied to the public. When the door of the signal box is opened six levers and a small telephone instrument are to be seen. The first is for an ordinary fire. The second for a serious fire. The third for a patrol waggon (used for carrying a resisting prisoner). The fourth for a patrol waggon (used for bringing extra police in the case of a disturbance). The fifth is for the horse ambulance. The sixth signals that the telephone is about to be used. When a lever is pulled it automatically prints at the office (by a system similar to the Wheatstone telegraph) symbols giving the time, the number of the box and the signal. These messages may be supplemented by using the telephone, thereby giving more precise directions where for instance the ambulance waggon is to be sent. When the signal for the ambulance is received at the central police station, the locality in which the accident has occurred is noted, and the nearest hospital to the scene of the accident is directly communicated with, and the ambulance at once dispatched. This is done through the police (not the National) telephone. The public may of course use the National telephone and communicate directly with the hospital, and in the case of an accident order the ambulance straight from the hospital. The supply to the public of keys for the signal boxes is limited by charging an annual fee of two shillings and sixpence for the key and requiring a deposit of one guinea from each holder of a key. The improper use of the keys by the public is prevented by an ingenious arrangement whereby the key, when once used to open the door, cannot be withdrawn without use of the master key (which is only in possession of the constables). Each key is numbered, malicious use is thus at once detected. (c) Dublin. (Population—Census 1901, 290,638).—In Dublin there is an active ambulance service worked as part of the Fire Brigade, the men being instructed in first-aid by the medical officer. 868 cases were dealt with last year, including all kinds of injuries and sudden illnesses occurring in the streets. 33 Calls are most numerous on Saturdays and fewest on Sundays. A new district station in Dorset-street is being established, and this year some 110 calls in each month have been received. (d) Belfast. (Extract from report of Belfast Fire Brigade, year ending June, 1901.) (Population—Census 1901, 349,180).—The work in connection with this branch of the service is highly appreciated: 1,867 calls were received (showing a decrease of 8 from last year), occupying 918 hours 47 minutes (being a decrease of 72 hour3 25 minutes from last year), showing an average of 29½ minutes per journey from the receipt of the call until the carriage returned to its station. The distance traversed was 4,487½ miles, or an average of 2½ miles per single journey. Carriages are worked from the headquarters and Whitla-street-street stations. The number of calls received between the hours of 6 a.m. and 6 p.m. was 1,063, and between the hours of 6 p.m. and 6 a.m. was 804. On the 21st July special services were rendered with the ambulance waggons on the occasion of the lamentable collision between two passenger steamers in Belfast Lough, for which the superintendent received many expressions of gratitude from friends of the injured persons and from the owners of the vessels, and the greatest compliment on the manner in which the cases were dealt with was received by way of the following resolution passed at a meeting of the medical and surgical staff of the Royal Hospital, to which institution the cases were removed— Resolved—"That the staff express their appreciation of the skill and care with which the members of the Belfast Fire Brigade attended to the sufferers from the recent steamboat collision in Belfast Lough." [SJ 34 APPENDIX II. The following return has been prepared by the clerk of the Council from information supplied by the hospital authorities and shows the kind of conveyance actually used during a period of four weeks in removing casualty cases to the hospitals — ]Hospital. Walked in. Cabs and carts. Ambulance. Otherwise. Total. Poplar 46 9 9 12 76 St. Bartholomew's 123 141 80 5 349 Royal Free — 33 16 — 49 Guy's — 207 93 4 304 Great Northern Central — 35 11 — 46 London 812 118 35 1 966 King's College 14 17 11 — 42 Westminster 7 8 4 — 19 St. Thomas's — 40 30 28* 98 Charing Cross 4 34 13 — 51 Total 1,006 642 302 50 2,000 * Including waggons, carts, trams, walking, etc. The returns have been sent in in various forms, and in the foregoing table it has not been possible to show interesting details included in some of the returns. The three largest returns are therefore set out in full as received from the hospitals. They are as follows— St. Bartholomew's hospital. By City police ambulance 52 „ Metropolitan police ambulance 9 „ Hospitals' association (Bischoffsheim) ambulance 10 „ St. John ambulance 4 „ London ambulance service 1 „ Railway ambulance 3 „ G.W.Ry stretcher 1 „ Fire brigade carnage 1 „ Carried by men 9 „ Omnibus 2 „ Barrow 2 „ Van 41 „ Cab 91 „ Walked 123 349 Guy's hospital. Gases of Accident. Cases of Illness. Cabs 66 Cabs 66 Vans and carts 62 St. John Ambulance 4 Police ambulances 55 Hospitals' Association (Bischoffsheim) Ambulance 4 Barrows 10 Perambulators 2 Police ambulance 30 Bath chairs 2 Barrow 1 Vans 2 197 107 London Hospital. Accidents. Sudden illness. Fits. Totals. † § † § † § Police ambulance... 19 2 5 — 1 — 27 St. John ambulance 3 1 — — 1 — 5 Railway ambulance 3 — — — — — 3 Cabs 36 2 2 3 2 — 45 Shutters ... 1 — — — — — 1 Other vehicles 67 2 2 — 2 — 73 Walking ... 749 63 — — — — 812 Totals 878 70 9 3 6 — 966 † 1 mile and under. § Over 1 mile. London County Council. REPORT BY THE MEDICAL OFFICER OF HEALTH AS TO HOUSES LET IN LODGINGS. (Printed under an order by the Public Health Committee dated 23rd October, 1902.) In presenting the annexed summary of replies received from medical officers of health of metropolitan boroughs, together with other particulars, with reference to houses let in lodgings, I should point out that in several instances the codes of by-laws now in operation have only recently come into force, and there has not been opportunity of studying their working. Again in several instances new by-laws have been drafted, but are not yet confirmed. This is the case in the City of Westminster and the Metropolitan Borough of Woolwich, where for the time being the original codes of by-laws of the districts now combined to form Westminster and Woolwich respectively are still in force. New by-laws have also been under consideration in Fulham, Greenwich and Kensington. With respect to replies to the question whether difficulties have been experienced in the administration of the by-laws, may be mentioned the statement of the medical officer of health of Bethnal-green that, since the decision in the case of Weatheritt v. Cantley, owners decline to supply particulars for registration, but it would appear that when similar objection was made in Finsbury the sanitary authority obtained a favourable decision from the magistrate. A few of the medical officers of health refer to difficulty experienced in requiring "landlords," who are often without means, to carry out works of cleansing, and suggest that "owners" should be made responsible for such works/ The reply received from the medical officer of health of Fulham shows that the Local Government Board expressed their willingness to confirm a by-law having this effect, but the sanitary authority has not adopted these by-laws. I have pointed out in presenting former returns the difficulty that has arisen from the existence of rent-limits of exemption by reason of the fact that these limits have in some instances been fixed so low as to exclude houses much needing regulation from the operation of the by-laws, and the medical officer of health of Hammersmith states that this is the effect of the rent limits of the by-laws in operation in that district at the present time, while the medical officer of health of Battersea states that, upon receiving notice of registration, landlords have very frequently raised the rents in order to take the premises beyond the scope of the by-laws. In several cases the difficulty has been from time to time in part met by amending the limits of rental specified, and in four of the existing codes of by-laws, those of Camberwell, Fulham, Poplar and Stoke Newington, such amended limits obtain at the present time, while in Paddington there are amended rent-limits, and there is also exemption of houses where the landlord himself resides on the premises and the sub-letting by such landlord is to not more than one lodger. An exemption of a similar character to that last specified is contained in the Finsbury by-laws. At the present time by-laws containing rent-limits of exemption are in force in 11 of the 29 boroughs, viz., Battersea, Camberwell, Fulham, Hackney, Hammersmith, Paddington, Poplar, Southwark, Stoke Newington, Wandsworth and the City of London, and the by-laws of two districts, St. Martin-in-the-Fields and St. Margaret and St. John Westminster, which now form part of the City of Westminster, and of the Bltham district, in which by-laws framed originally by the Lee Board of Works are still in force, contain similar clauses. The Southwark by-laws were confirmed as recently as November 20th, 1902. In six codes of by-laws, viz., those of Greenwich, Hampstead, Islington, Lambeth, Lewisham and Shoreditch, there is a clause which provides that houses shall be exempted from the operation of the by-laws until the landlord has been requested to furnish a statement as to certain particulars. A clause of a similar kind occurs in the by-laws of three of the districts (St. James,Westminster, St. George, Hanover-square and the Strand) now forming part of the City of Westminster. In a few boroughs the by-laws are so worded that a house is exempted from the operation of the by-laws until the borough council or one of its committees has determined that it shall be registered. This is the case in Bethnal-green, in St. Pancras and in the districts formerly know as Woolwich and Plumstead, and now included in the Metropolitan Borough of Woolwich; pbinted fob THE LONDON COUNTY COUNCIL by jas. truscott and son, ltd., And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, 2 and 4, Great Smith-street, Victoria-street, Westminster, S.W., Agents for the sale of the Publications of the London County Council. No. 610. Price, 2d., post free 2½d. [5489 2 as already stated, the by-laws last referred to will probably be shortly superseded. The regulations of Chelsea, which were made as long ago as 1868 under the Sanitary Act of 1866, contain a provision that "whenever the vestry may deem it expedient to put these regulations into operation in respect to any house . . . they shall give notice in writing to the owner thereof . ." No use has been made of these by-laws in Chelsea for some years. In six codes of by-laws there is no exemption clause. In three of the six (Bermondsey, Deptford and Stepney) the by-laws have been recently confirmed. As regards the other three, in Holborn the by-laws in force are those of the former districts of Holborn and St. Giles (now combined to form Holborn), which were confirmed in 1885 and 1887 respectively (these by-laws contain provisions as to registration, specifying that the landlord of a house which it is proposed to register shall supply certain particulars upon being required to do so by the Board of Works by a notice in writing signed by the clerk to the Board of Works); in Marylebone by-laws confirmed in 1890 are in force: they contain a similar provision to that just referred to ; in Kensington by-laws confirmed in 1885 are still in force, and the desirability of replacing them by new by-laws has for some time past been under consideration Shirley F. Murphy, Medical Officer of Health. Public Health Department, 8, St. Martin's-place, W.C., January, 1903. 3 HOUSES LET IN LODGINGS. labnlar Statement of Replies from the Medical Officers of Health to the Council's letter of 28th November, 1902, together with other particulars. Metropolitan borough. Population (1901). Number of inhabited houses (1901). Tenements (1901). Number of houses now on register. Number newly entered on register during present year. Frequency with which registered houses are inspected. Are the registered houses inspected by special officers, acJ if so how many are employed on this duty and on what other duties, if any, are they engaged ? Number of proceedings instituted under the by-laws before the magistrate during the present year— (a) Concerning cleansing. (b) „ overcrowding. (c) „ other matters. Date when by-laws were confirmed. Whether by-laws contain rent-limits or other exemptions Whether, and if so what, difficulties have been experienced in the administration of the by-laws in respect of the definition of landlord, rent-limits of exemption or any other matter. Remarks. Total number. Less than 5 rooms. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Battersea 168,907 23,462 38,987 24,089 49 30 Annually The houses are inspected by the three sanitary inspectors in whose districts the premises are situated. General duties of a sanitary inspector None 28-8-93 Yes† Upon receiving notice of registration, landlords have very frequently raised the rents in order to take the premises beyond the scope of the by-laws. Bermondsey 130,760 15,817 29,073 22,064 350 None About every 3 months No None 4-12-01 No No difficulties have been experienced in these matters New by-laws recently confirmed. Bethnal-green 129,680 14,005 28,209 23,732 9 None Very frequently Yes; one. Other duties in connection with H.W.C. Act No proceedings beyond statutory notices 16-1-95 (See bylaw no‡ Yes. Owners decline to supply requisite particulars for registration since decision in Weatheritt v. Cantley. Camberwell 259,339 36,671 56,985 31,926 191 23 Annually and at irregular intervals No None 10-9-01 Yes† Limits of exemption were too low. The fixing of legal responsibility has been practically impossible in cases where the house as a whole is let on a weekly tenancy, and the weekly tenant himself sublets, and thus brings the house into this category. The medical officer hopes these difficulties will be all obviated by some new by-laws made by the Council, but which have not yet been finally approved by the Local Government Board. Chelsea 73,842 8,641 17,467 12,082 — — — — — 7-10-68 (See bylaw III.) — No action has recently been taken as to by-laws for houses let in lodgings. City of London 26,923 3,865 5,339 3,307 396 (1900) - - By an inspector in each district, in addition to other duties Notices served being complied with, no further proceedings were necessary 8-5-96 § Yes† No difficulties have arisen Number removed from register during 1900—Nine. Deptford 110,398 15,823 24,615 13,956 34 None. Quarterly Not by special officers, but by the sanitary inspector for the district None 22-11-02 No Frequent changes of occupiers. Finsbury 101,463 9,280 24,097 20,515 849 522 No stated periods, but every year thoroughly, generally in the spring. Also from time to time No. Each sanitary inspector supervises in his district (a) 11, (6) 10, (c) 1 16-10-01 Yes* None. In a case where the landlord had declined on technical grounds to supply the particulars necessary for registration, a summons was issued in the Clerkenwell police court, at the hearing of which, on March 4th, 1902, defendant was represented by counsel who took the objection: "That as the house was let in floors of two rooms each, the landlord being non-resident, it ceased to be a house liable to registration, but became a set of houses, as the occupier of each set of rooms was entitled under the franchise to a vote as a householder." The case of Weatheritt v. Cantley was quoted. The learned magistrate, Mr. Bros, overruled the objection and fined the defendant Is. and £2 2s. costs. Fulham 137,289 18,534 32,137 21,681 329 - - Yes. Has been otherwise employed this year - 29-1-94 4-11-95 (amending clause as to exemption) Yes† Difficulties have been experienced in the administration of the existing by-laws consequent upon the definition of the term "landlord." The Local Government Board expressed their willingness to confirm some new by-laws drafted by the Public Health Committee in which this definition was amended and some other alterations made, but the Borough Council refused to adopt the by-laws. Greenwich 95,770 14,240 19,702 10,877 19 - Many informal inspections have been made to obtain data upon which to base revised requirements No None 22-12-96 (See bylaw II.) || Nothing has been done during the year with respect to actual registration and inspection, because during the whole of the period the Borough Council has been engaged in drawing up fresh bylaws, which has necessitated much correspondence with the Local Government Board as they would insist upon an exemption clause fixing definite amounts of rent. An arrangement respecting the matter has been come to, and the formal sanction of the Board is now awaited. The medical officer anticipates that more houses will be entered on the register as soon as the new by-laws come into force. † Rent-limits of exemption. ‡ If, and so Jong as, the vestry deem it unnecessary to register. § Whenever the vestry may deem it expedient to put regulations in force. || Until the landlord has been required to furnish a statement as to certain particulars. * When the landlord resides upon the premises and the letting by such landlord is to not more than one lodger. 4 Metropolitan borough. Population (1901). Number of inhabited houses (1901). Tenements (1901). Number of houses now on register. Number newly entered on register during present year. Frequency with which registered houses are inspected. Are the registered houses inspected by special officers, and if so how many are employed on this duty and on what other duties, if any, are they engaged ? Number of proceedings instituted under the by-laws before the magistrate during the present year— (a) Concerning cleansing. (b) „ overcrowding. (c) „ other matters. Date when by-laws were confirmed. Whether by-laws contain rent-limits or other exemption. Whether, and if so what, difficulties have been experienced in the administration of the by-laws in respect of definition of landlord, rent-limits of exemption or any other matter. Remarks. Total number. Less than five rooms. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Hackney 219,272 30,634 48,794 29,089 442 None If possible once yearly By the sanitary inspector for the district in which they are situated None 25-11-95 Yes * The medical officer refers to his report for the year 1898, in which he discusses the definition of " landlord," and points out the difficulty which arises when the landlord is without resources. Hammersmith 112,239 15,198 25,810 15,505 1,359 559 At least once in each year Yes. One. None None 28-4-96 Yes* So far the work is progressing satisfactorily. No difficulty has been experienced, with the exception of the fact that there are many houses that ought to lie registered but cannot be registered owing to the rent limit. 198 notices served. It has not been found to be necessary to apply for a summons. Hampstead 81,942 11,294 16,998 7,178 911 41 Constantly By female inspector and by four district inspectors None 17-1-95 (See bylaw II.)† None. Holborn 59,405 4,703 13,790 10,772 596 About 150 in process of registration Varies. Some require more inspection than others By the sanitary inspectors in whose districts they are situated, assisted in one district by the additional inspector (a) 6, (b) 0, (c) 13, but not under the regulations. New by-laws not yet approved ( 9-3-85 (Holborn) 3-3-87 (St. Giles) No No limits of exemption. The medical officer thinks limits of rent for exemption would much increase difficulties of registration. Houses are registered only after the consent of the Public Health Committee and of the Council. In many cases the proceedings are for nuisances, etc., which are not included in the regulations, and any of the former are included with the latter in the same summons. Islington 334,991 38,645 79,129 55,801 533 13 The frequency varies according to the manner in which they are occupied. Some are visited once and twice a week, some about every 14 days, and all not less than once in 3 months Yes. Two One of the inspectors is also engaged in the purchase of samples under the Sale of Food and Drugs Acts (а) 12 (b) None (c) 3 6-7-94 (See bylaw II.)† When the premises are required to be cleansed, it is frequently found that the "landlord" does not possess the means to carry out the cleansing required under the by-laws. The owner of these houses should be held responsible for the cleansing, because he, as a rule, gets an increased rental owing to the fact that the house is let in tenements. Kensington 176,628 22,131 38,349 21,115 2,063 360 Variable; according to the special needs of individual cases No. The duty is performed by the ten sanitary inspectors each in his own district 3 (a and c) 24-1-85 No There is no rent limit or other limit of exemption; the Public Health Committee use their discretion in each case brought to their notice. No difficulties have been experienced in administration in any respect. Modified by-laws have been framed by the Public Health Committee, and are, at present, in the hands of the Local Government Board with a view to the tentative approval of that body prior to submission to the Council. This course was adopted in conformity with the wishes of the Board. Lambeth 301,895 41,511 70,887 44,495 371 containing 2,117 rooms One during 1901 Regularly from time to time. Not less often than twice monthly No None yet 11-5-97 (See bylaw n.)† "Owners" should be made liable for cleansing instead of "landlords." This would be a very useful amendment. "Landlords" are unable financially, or otherwise, to carry out the annual cleaning. Lewisham 127,495 22,750 27,701 8,561 29 2 Monthly Yes, one inspector employed also on house-to-house inspection None 31-5-95 (See bylaw II.)† None to the knowledge of the medical officer of health. Paddington 143,976 17,684 33,661 21,815 543 152 No interval prescribed. They will be closely looked after. Two inspectors devote their whole time to the work (a) 20 (c) 1 13-2-94 6-3-01 (amending clause as to exemption) Yes *§ The main difficulty experienced so far is that of getting the annual whitewashing promptly carried out. Different arrangements will be made next year with a view to getting the work completed before summer comes on. The two inspectors commenced work during the second quarter of the year. The houses are at present being added to the register at the rate of about 10 a week. Poplar 168,822 22,613 35,787 26,216 270 82 Constantly One special officer devotes his whole time to the work Four summonses for cleansing 29-11-95 27-9-00 (amending clause as to exemption) Yes * Limits of exemption have been raised, as original limits were found to militate against the usefulness of the by-law. Difficulty is experienced in obtaining the cleansing of the houses as the by-laws require this to be done only once a year, in the month of April. By reason of a specific time being named the cleansing can be readily avoided by a change of tenancy. This has been done on several occasions. St. Marylebone 133,301 13,536 31,623 22,947 916 11 Several times a year No. Seven sanitary inspectors are engaged on this and the other work of the department No proceedings have been taken. If proceedings are taken, it is under the Public Health (London) Act 15-5-90 No No difficulties are experienced. St. Pancras 235,317 23,715 57,045 45,023 1,270 (to end of Sept.) 409 (from Aug., 1901 to Sept., 1902) Half-yearly Yes. Two officers are engaged upon this special duty only None 13-11-93 (See by-law in.)‡ None. † Until the landlord has been required to furnish a statement as to certain particulars. * Rent-limits of exemption. ‡ The sanitary authority shall cause notice to be served at any tenement house with respect to which the Health Committee shall report that such house ought to be registered. § Where the landlord himself resides on the premises and the sub-letting by such landlord is to not more than one lodger. 4 Metropolitan borough. Population (1901). Number of inhabited houses (1901). Tenements (1901). Number of houses now on register. Number newly entered on register during present year. Frequency with which registered houses are inspected. Are the registered houses inspected by special officers, and if so how many are employed on this duty and on what other duties, if any, are they engaged ? Number of proceedings instituted under the by-laws before the magistrate during the present year— (a) Concerning cleansing. (b) „ overcrowding, (c) „ other matters. Date when by-laws were confirmed. Whether by-laws contain rent-limits or other exemption. Whether, and if so what, difficulties have been experienced in the administration of the by-laws in respect of definition of landlord, rent-limits of exemption or any other matter. Remarks. Total number. Less than five rooms. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Hackney 219,272 30,634 48,794 29,089 442 None If possible once yearly By the sanitary inspector for the district in which they are situated None 25-11-95 Yes * The medical officer refers to his report for the year 1898, in which he discusses the definition of "landlord," and points out the difficulty which arises when the landlord is without resources. Hammersmith 112,239 15,198 25,810 15,505 1,359 559 At least once in each year Yes. One. None None 28-4-96 Yes* So far the work is progressing satisfactorily. No difficulty has been experienced, with the exception of the fact that there are many houses that ought to be registered but cannot be registered owing to the rent limit. 198 notices served. It has not been found to be necessary to apply for a summons. Hampstead 81,942 11,294 16,998 7,178 911 41 Constantly By female inspector and by four district inspectors None 17-1-95 (See bylaw II.)† None. Holborn 59,405 4,703 13,790 10,772 596 About 150 in process of registration Varies. Some require more inspection than others By the sanitary inspectors in whose districts they are situated, assisted in one district by the additional inspector (a) 6, (6) 0, (c) 13, but not under the regulations. New by-laws not yet approved ( 9-3-85 (Holborn) 3-3-87 (St. Giles) No No limits of exemption. The medical officer thinks limits of rent for exemption would much increase difficulties of registration. Houses are registered only after the consent of the Public Health Committee and of the Council. In many cases the proceedings are for nuisances, etc., which are not included in the regulations, and any of the former are included with the latter in the same summons. Islington 334,991 38,645 79,129 55,801 533 13 The frequency varies according to the manner in which they are occupied. Some are visited once and twice a week, some about every 14 days, and all not less than once in 3 months Yes. Two One of the inspectors is also engaged in the purchase of samples under the Sale of Food and Drugs Acts (а) 12 (b) None (c) 3 6-7-94 (See bylaw II.)† When the premises are required to be cleansed, it is frequently found that the "landlord" does not possess the means to carry out the cleansing required under the by-laws. The owner of these houses should be held responsible for the cleansing, because he, as a rule, gets an increased rental owing to the fact that the house is let in tenements. Kensington 176,628 22,131 38,349 21,115 2,063 360 Variable; according to the special needs of individual cases No. The duty is performed by the ten sanitary inspectors each in his own district 3 (a and c) 24-1-85 No There is no rent limit or other limit of exemption; the Public Health Committee use their discretion in each case brought to their notice. No difficulties have been experienced in administration in any respect. Modified by-laws have been framed by the Public Health Committee, and are, at present, in the hands of the Local Government Board with a view to the tentative approval of that body prior to submission to the Council. This course was adopted in conformity with the wishes of the Board. Lambeth 301,895 41,511 70,887 44,495 371 containing 2,117 rooms One during 1901 Regularly from time to time. Not less often than twice monthly No None yet 11-5-97 (See bylaw IT.)† "Owners" should be made liable for cleansing instead of "landlords." This would be a very useful amendment. "Landlords" are unable financially, or otherwise, to carry out the annual cleaning. Lewisham 127,495 22,750 27,701 8,561 29 2 Monthly Yes, one inspector employed also on house-to-house inspection None 31-5-95 (See bylaw II. )† None to the knowledge of the medical officer of health. Paddington 143,976 17,684 33,661 21,815 543 152 No interval prescribed. They will be closely looked after. Two inspectors devote their whole time to the work (a) 20 (c) 1 13-2-94 6-3-01 (amending clause as to exemption) Yes *§ The main difficulty experienced so far is that of getting the annual whitewashing promptly carried out. Different arrangements will be made next year with a view to getting the work completed before summer comes on. The two inspectors commenced work during the second quarter of the year. The houses are at present being added to the register at the rate of about 10 a week. Poplar 168,822 22,613 35,787 26,216 270 82 Constantly One special officer devotes his whole time to the work Four summonses for cleansing 29-11-95 27-9-00 (amending clause as to exemption) Yes * Limits of exemption have been raised, as original limits were found to militate against the usefulness of the by-law. Difficulty is experienced in obtaining the cleansing of the houses as the by-laws require this to be done only once a year, in the month of April. By reason of a specific time being named the cleansing can be readily avoided by a change of tenancy. This has been done on several occasions. St. Marylebone 133,301 13,536 31,623 22,947 916 11 Several times a year No. Seven sanitary inspectors are engaged on this and the other work of the department No proceedings have been taken. If proceedings are taken, it is under the Public Health (London) Act 15-5-90 No No difficulties are experienced. St. Pancras 235,317 23,715 57,045 45,023 1,270 (to end of Sept.) 409 (from Aug., 1901 to Sept., 1902) Half-yearly Yes. Two officers are engaged upon this special duty only None 13-11-93 (See by-law III.)‡ None. † Until the landlord has been required to furnish a statement as to certain particulars. * Rent-limits of exemption. ‡ The sanitary authority shall cause notice to be served at any tenement house with respect to which the Health Committee shall report that such house ought to be registered. § Where the landlord himself resides on the premises and the sub-letting by such landlord is to not more than one lodger. 5 Metropolitan borough. Population (1901). Number of inhabited houses (1901). Tenements (1901). Number of house now on register. Number newly entered on register during present year. Frequency with which registered houses are inspected. Are the registered houses inspected by special officers, and if so how many are employed on this duty and on what other duties, if any, are they engaged ? Number of proceedings instituted under the by-laws before the magistrate during the present year— (a) Concerning cleansing. (b) „ overcrowding. (c) „ other matters. Date when by-laws were confirmed. Whether by-laws contain rent-limits or other exemption. W hether, and if so what, difficulties have been experienced in the administration of the by-laws in respect of definition of landlord, rent-limits of exemption or any other matter. Remarks. Total number. Less than 5 rooms. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Shoreditch 118,637 12,743 27,031 22,940 190 16 Varies according to circumstances. Some are more frequently visited than others. There is no rule as to the number of visits Registered houses let in lodgings are under the supervision of the chief sanitary inspector None 20-7-94 (See bylaw H.)‡ So far, no special difficulty has been met with. Southwark 206,180 20,878 47,808 39,612 1,005 133 Some are visited once a week; others only once in three months Yes. Two women inspectors are employed. Proceedings have been taken in— (a) 5 (b) 0 (c) 7 20-11-02 Yes† No difficulties have arisen in the administration of the by-laws during the year. Stepney ... 298,600 31,462 61,113 49,182 1,353 1,353 No specified time Two (a) 2 24-7-02 No In the question of "landlord" when the agent who receives the rent is changed often. By-laws not been in operation sufficient time to give particulars. The two special inspectors have only recently been appointed, and all those houses that were formerly on the register are being re-registered. By the end of the year probably 2.000 at least will be on the register. The houses previouslv on the register have been re-registered by the Council under the new by-laws during the present year. Stoke Newington 51,247 7,717 11,824 5,813 119 17 Twice a year No None 15-8-95 25-1-00 (amending clause as to exemption) Yes† S'one. Wandsworth 232,034 37,764 49,756 21,052 116 49 Twice a year Inspected by sanitary inspectors None 9-8-93 Yes† Difficulties have arisen this year in respect of definition of " Landlord." In some cases the owner lets to one person and the latter sub-lets one or two flats to other tenants. Where the owner lets to separate tenants there has been no difficulty. Other 27 houses have been ordered to be placed on the register by the borough council, but the owners object and the matter is now under consideration. Westminster (City of) 183,011 18,366 41,244 26,668 2,004 — Some weekly others monthly, twice a year, or once a year In the case of the weekly and monthly houses one special officer is employed. He generally assists the inspectors No proceedings have been taken directly under the by-laws, but a number of registered houses have been the subject of proceedings under the Public Health Act and the Housing of the Working Classes Act 26-6-84 Yes† (St. Mar tin-inthe-Fields) 30-11-93 Yes† (St. Margaret, Westminster) 16-1-95 (See bylaw II.)‡ (St. Jam es, West mins ter) 10-12-94 (See bylaw II.)‡ (St. Geo rge, Han over- square) 12-7-94 (See bylaw II.)‡ (Str and) The borough council is still in communication with the Local Government Board on the question of rent limits with reference to new by-laws which have been submitted but not yet approved. The delay has interfered with the work which might be done under the by-laws, and has prevented houses being placed on the register. Woolwich 117,178 18,086 24,585 14,017 117 21 Some every three months. Some every six months There is a special inspector for (1) Registered houses in Woolwich parish; about four-fifths of the total (2) Food inspection (3) A small district (a) One (b) One 16-11-95* (See bylawIII.)§ (Wool wich) 2-7-94 (See bylawIII.)§ (Plum stead) No actual difficulty in administration as to definition of "landlord," but much discussion and uncertainty. As regards rent-limits of exemption, the by-laws do not apply in this district to any house until the Council has resolved to register such house. A report by the medical officer of health is, however, awaiting consideration, which recommends that the by-laws should be re-drafted so as to apply to all houses below a certain rental occupied by two and more familes. London 4,536,541 571,768 1,019,546 672,030 16,433 3,944 Revised by-laws under the consideration of the Local Government Board. * Woolwich also includes the district of Eltham, which prior to 1899 was in the Lee district. By-laws containing rent-limits of ‡ Until the landlord has been required to furnish a statement as to certain particulars, exemption were made by the Lee District Board in 1895. § Houses with respect to which it shall have been reported by the Public Health Committee that such house ought to be † Bent limits of exemption. registered.