43/3 * LCC 11 London Countg Council. PUBLIC HEALTH-COUNTY OF LONDON. REPORT of the PUBLIC HEALTH COMMITTEE of the LONDON COUNTY COUNCIL, Submitting the REPORT of the MEDICAL OFFICER OF HEALTH OF THE COUNTY FOR THE YEAR 1902. (Printed by order of the Council, 13the October, 1903.) PRINTED BY JAS. TRUSCOTT AND SON, LTD., LONDON. E C. London Countg Council. Report of the Public Health Committee submitting the report of the Medical Officer of Health of the County of London for the year 1902. The passing of the Public Health (London) Act, 1891, placed the London County Council in direct relation with sanitary administration in the county of London. This Act came into operation on 1st January, 1892, aud for that and each succeeding year the medical officer has prepared and presented to the Council a report on the health of London. These reDOrts show the results of the tabulation and study of the vital and other statistics of the county contained in the Registrar-General's returns, and in the weekly returns of infectious diseases supplied by the Metropolitan Asylums Board, or obtained from other sources, as well as information collated from the annual reports of the medical officers of health of London sanitary districts. The date at which the annual report of the county medical officer can be issued each year is therefore necessarily dependent upon the dates at which the reports of the local medical officers are received, aud it has not in practice been found possible to issue the report of the county medical officer much before the end of the year succeeding that to which it relates. In submitting the medical officer's report for 1902, we observe that the London death rate from all causes per 1,000 living was only 1712, the lowest ever recorded except that for 1901, which was 17.1. The health of London, judged by its general death rate, has steadily improved within registration times, and the last ten or fifteen years compare favourably in this respect with any similar series of years preceding them. In 1889 the death rate was lower than any recorded before that year; during the four succeeding years there was a set-back, accunted for largely, no doubt, by the prevalence of influenza; in 1894 a miuimum death rate of 17.4 was registered, and this record has now been twice broken, viz., in the years 1901 and 1902. We are glad to observe that the rate of infant mortality in London was particularly low in the year under consideration, and for the period of 1892-1901 was lower in London than in any of the othei principal English towns except Bristol. The number of marriages in London in 1902 was 40.817, giving an annual rate of persons married of 17'8 per 1,000 living, a slight increase on the rate (17 6) for 1901. The birth rate is still steadily declining, the rate for 1902 being 28-5 per 1,000 living, the lowest recorded in London since the institution of civil registration. In July, 1902, we presented to the Council an extended life table based upon the mortality in the decennium 1891-1900 and showing for the London population the expectation of life at each year of age. The report now presented contains life tables based on figures relating to two metropolitan boroughs, one rich and the other poor. The difference in the expectation of life in these boroughs (Hampstead and Southwark) is, as might be anticipated, marked. The figures can be compared with the corresponding figures, obtained by Dr. Farr 60 years ago, in respect of two districts similarly contrasted by him, viz., St. George, Hanover-square, and Whitechapel, and it is of special interest to note that the expectation of life at the younger ages in the poor district of to day approaches that in the rich district of 60 years ago. During 1902 no fewer than 1,814 deaths occurred in London from smallpox, the death rate being higher than had been the case since 1885. Several cases were notified at intervals in various parts of London in the first six months of 1901, but the first considerable extension of the disease took place in St. Pancras in August, 1901, and cases subsequently occurred in all the metropolitan boroughs. As it became apparent that difficulty was being experienced in the diagnosis of cases owing to the fact that a generation had grown up in comparative ignorance of smallpox, and that many cases of this malady were being mistaken for cases of chicken-pox, the Council decided on our recommendation to make chicken-pox a notifiable disease. We also obtained authority from the Council to employ experts whose services were made available for the diagnosis of doubtful cases of smallpox, and arrangements were made for daily reports as to cases to be sent in, manifolded, and distributed to medical officers of health throughout London. Information as to the occupations of persons attacked by the disease is given in a report by Dr. Hamer, presented to us by the medical officer. (Appendix II.) Under our instructions special efforts were made to minimise the spread of the disease in common lodging-houses. Houses in infected localities were kept under close observation by the Council's officers, visits in the early morning being found particularly useful. It became necessary to incur expenditure in connection with the provision of food and lodging in some instances in which there was special reason for concluding that lodgers were sickening with the disease, and were hence likely, if lost sight of, to spread it. The close supervision of the movements of some 5,000 "contacts" was accomplished, and the expenditure incurred upon food and lodging amounted to only about £35. iv The success of the Council's efforts is shown by the fact that only about 800 cases occurred in common lodging-houses out of 9,296 cases notified during the year ended Slat August, 1902, by which date the epidemic was practically at an end. Full details of the outbreak as affecting common lodging-houses are given in a report prepared by Dr. Hamer and presented to us by the medical officer. (Appendix I.) We have repeatedly had before us the question of the risk of the spread of diphtheria and scarlet fever owing to the aggregation of children in schools. We conferred on this subject with members of the School Board for London some years ago, and we now note that it appears from the recently published annual report of the medical officer of the Board that this matter is receiving the careful attention of the Board, and we gather that in the future due regard is likely to be paid to the need of adopting preventive measures adequate to the occasion in cases of necessity. The deaths from measles in the Administrative County of London during 1902 numbered 2,360, as compared with 1,952 in 1901. The large mortality which this disease causes amongst the children of the poor has led us to advise the Council to apply to measles certain sections of the Public Health (London) Act, 1891, which in effect, while not making this malady notifiable, place it on a level in other respects with the chief infectious diseases. We hope that the Council's order, which has only recently come into force, will enable sanitary authorities to grapple more successfully with the disease, and bring home to parents and guardians of children, especially among the poorer classes, the dangers which result from the neglect of proper precautions. The agency of milk in the spread of infectious disease was evidenced in the case of a serious outbreak of scarlet fever in the early part of May, 1901. in the north and east of London, due to infected milk from a farm in Staffordshire. In connection with this outbreak our attention was directed to the fact that there was no power under the existing law to exclude an infective milk supply from London as a whole, and that the machinery which could be put in force with regard to the 29 sanitary districts into which London is divided involved serious delay. The Council, on our recommendation, decided to apply in its General Powers Bill of 1902 for further powers on this subject, and also in relation to tuberculous milk. We regret to say that these powers were not granted by Parliament, although similar powers have been given to the local authorities of a number of districts outside London. The pronouncement of Dr. Koch, to the effect that there is little probability of tuberculosis being communicated from animals to man, was, of course, quoted against the Council's proposals, and we are therefore interested to observe that recent experiments made by other observers have not tended to support Dr. Koch's theory. In the exercise of the powers already possessed by the Council, 13 examinations of all the cows in London cowsheds have been made and the milk of numerous cows found to have tubercular disease of the udder has been eliminated from the London milk supply. The number of cases of enteric fever in London attributed to the eating of oysters or other shellfish which had been exposed to contamination by sewage led to a number of representations being made to the Council as to the necessity for further legislation on the subject. The Council, on our recommendation, has urged the Local Government Board to seek such an amendment of the law as would prohibit, under heavy penalties, the laying down of edible forms of shellfish in sewage-polluted creeks or other dangerous localities and the sale of such shellfish for human consumption, and so that unpolluted layings and beds may be protected from pollution. The need of adequate enforcement throughout London of by-laws regulating houses let in lodgings has been continuously before us. The census returns show a decrease in 1901 as compared with 1891 in the extent to which tenemented houses are overcrowded, and there is a growing appreciation of the advantages to be gained by making use of the by-laws now in question. We have continued to urge the importance of this matter upon sanitary authorities, and a further return, showing the work done in the various metropolitan boroughs has, by our direction, been prepared by the medical officer and published, and is now under our consideration. (Appendix III.) While unsuccessful in its endeavour to secure legislation as regards milk the Council obtained in its General Powers Act of last year the power to annually license common lodging-houses, together with powers enabling the sanitary authorities to deal with ice cream. The licensing of common lodginghouses, involving as it does the question of the suitability of each house in relation to the number, health, safety and convenience of the occupants, has added very considerably to our labours. In connection with the question of establishing a municipal lodging-house for women, we had farther inquiry made as to the accommodation of women and children in common lodging-houses. The result is shown in a special report by the medical officer. (Appendix IV.) We have devoted much consideration to the question of the adequacy of the sanitary staffs employed in the various districts of London. A return prepared by the medical officer (Appendix VI.) shows the number of inspectors employed in the several districts in comparison with the population. In some cases we have thought it desirable to ascertain the needs of the district by a special inquiry into its administration. The result of such an inquiry in Hammersmith by Dr. Young, in the early part of 1902, is shown in his report. (Appendix V.) We have called the attention of the London sanitary authorities to the importance of systematically inspecting the kitchens of hotels, restaurants, and other places where food is sold or prepared for sale, and have urged these bodies to exercise their powers for the removal of any insanitary conditions which may be found as the result of such inspections. G. J. Cooper, Chairman. County Hall, Spring-gardens, S.W. 17th December, 1903. ELEVENTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. TABLE OF CONTENTS. Part I.— Pag Population 5 Overcrowding, etc., in tenements of less than five rooms 5 Marriages 11 Births 11 Deaths 12 Rates of mortality in the several metropolitan boroughs 13 London mortality in 1902 compared with the mortality in the decennium 1891-1900 15 Short life-tables for two selected metropolitan districts 16 Infant mortality 21 Deaths from certain diseases and groups of diseases 22 Principal epidemic diseases 24 Smallpox and vaccination 25 Administrative measures adopted for the limitation of the spread of smallpox 29 (a) The diagnosis of smallpox 29 (b) Removal to hospital 29 (c) The supervision of persons exposed to infection 30 (d) Vaccination or re-vaccination of persons exposed to infection 31 (e) Measures adopted for the prevention of smallpox in children 33 (/) Measures adopted for the prevention of the spread of smallpox in common lodging-houses 34 (g) General administrative measures 36 Social condition of persons attached by smallpox 38 Age and sex incidence of smallpox 39 Analysis of London cases of smallpox in respect of age and vaccination 40 Chicken-pox 42 Measles 46 Scarlet fever 48 Scarlet fever and elementary schools 50 Age and sex distribution 50 Diphtheria 51 Proportion of cases removed to hospital 55 Age and sex distribution 55 Whooping cough 56 Typhus 57 Enteric fever 58 Age and sex distribution 61 Diarrhoea 62 Erysipelas 63 Puerperal fever 64 Influenza, bronchitis and pneumonia 64 Phthisis 65 Cancer 68 Bubonic plague 70 Meteorology 70 Part II.— Dairies, cowsheds and milkshops 71 Offensive businesses 72 Removal of trade refuse 73 Complaints to the London County Council 74 Nuisances 74 Smoke nuisances 74 Nuisance from stable manure 74 Removal and disposal of house refuse 75 Nuisance from sewers 75 The Regtnt's Canal 75 The River Lee 76 Housing of the Working Classes 76 Representations under Part I. of the Housing of the Working Classes Act 76 Schemes undertaken by the County Council under Part I. of the Act 76 Schemes undertaken by the County Council under Part II. of the Act 77 Schemes undertaken by district authorities under Part II. of the Act, the County Council contributing to the cost 77 Proceedings of the County Council under Part III. of the Act 78 Rehousing of persons displaced by street improvements 78 Displacement of persons of the working class 78 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 80 Houses let in lodgings 81 Common lodging-houses 83 Seamen's lodging-houses 85 Customs and Inland Revenue Acts, 1890 and 1891 85 Underground rooms 85 4 PAGE Workshops and workplaces 86 Inspection of food, etc. 93 Ice creamt 93 Unsound food 94 Disinfection 96 Shelters 96 The cleansing of persons 97 Mortuaries 97 Water supply 97 The London Equalisation of Rates Act, 1894 98 Sanitary administration of Hammersmith 99 Legislation 99 Sanitary inspectors 100 Medical officers of health of metropolitan boroughs in 1902 101 APPENDICES— I.—Smallpox in London common lodging-houses. II.—Occupation of persons attacked by smallpox. III.—Houses let in lodgings. IV.—Accommodation for women and children in common lodging-houses. V.—The sanitary administration of Hammersmith. VI.—Sanitary officers. LIST OF DIAGIRAMS. facing page Diagram I.—Marriages, 1851-1902 11 II.—Births, 1851-1902 11 „ III.—Deaths (all causes), 1841-1902 12 „IV.—Smallpox, deaths, 1841-1902 25 „ V.—Smallpox, weekly number of notified cases in metropolitan boroughs, 1901-2 28 „ VI.—Smallpox, 1901-2, in relation to vaccination default in metropolitan unions 34 „ VII.—Smallpox and chicken-pox ; weekly notifications, 1902 42 „VIII.—Measles, 1841-1902 46 „ IX.—Scarlet fever; deaths, 1859-1902 48 „ X.—Scarlet fever; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 48 „ XI.—Scarlet fever; monthly notifications and case mortality, 1891-1902 49 „ XII.—Diphtheria and croup; deaths, 1859-1902 51 XIII.—Diphtheria; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 51 „ XIV.—Diphtheria; monthly cases and case mortality, 1891-1902 52 „ XV.—Whooping cough ; deaths, 1841-1902 56 „XVI.—Typhus; deaths, 1869-1902 57 „ XVII.—Enteric fever; deaths, 1869-1902 58 „ XVIII.—Enteric fever ; weekly notifications, 1902, and mean weekly notifications, 1890-1902 58 „ XIX.—Enteric fever ; monthly notifications and case mortality, 1891 -1902 59 REPORT OF THE MEDICAL OFFICER OF HEALTH. 1902. PART I. Population. The population of tlie administrative county of London, estimated to the middle of the year 1902, was 4,579,110. The population of each of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1902, is shown in the following table— Metropolitan Boroughs. Estimated population, 19U2. Metropolitan Boroughs. Estimated population, 1902. Metropolitan Boroughs. Estimated population, 1902 Paddingt-on 145,107 Stoke Newington 51,700 Bermondsey 130,278 Kensington 177,605 Hackney 221,926 Lambeth 305,102 Hammersmith 114,210 Holborn 58,535 Batterxea 171,401 Fulham 143,102 FiDsbnry 100,487 Wandsworth 241,810 Chelsea 74,018 City of London 25,598 Camberwell 262,775 City of Westminster 180,800 Shoreditch 118,004 Deptford 111.577 St. Marylebone 132,145 Bethnal-green 129, b65 Greenwich 98,013 Hampstead 83,743 Stepney 300,551 Lewisham 132,432 St. Pancras 235.521 Poplar 169,214 Woolwich 119,556 Islington 337,270 South wark 206,825 Overcrowding, etc., in tenements of less than five rooms. The last annual report contained a table (page 2, et seq.) showing the number of persons living in tenements of less than five rooms, and the number of such persons living more than two in a room in each of the metropolitan boroughs. At the date of the 1901 census a similar table relating to the previous census of 1891 was published in my annual report for 1892, but owing to the changes in the area of the London sanitary districts consequent upon the London Government Act of 1899, these tables do not admit of strict comparison. The Registrar-General has, however, recently supplied the Council with the figures relating to the occupation of tenements of less than five rooms at the date of the last census in the sanitary areas of the county, as constituted prior to the passing of the London Government Act of 1899, and the following table, so far as it relates to the year 1901, is based upon these figures; the percentages shown, relating to the year 1891, are taken from my annual report for 1892, and are based upon the figures of the 1891 census— Sanitary area. Tenements with Percentage of total population in each group of tenements. Overcrowding. Percentage of total population living more than 2 in a room in tenements of less than 6 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. Battersea 1 room 4.6 3.7 — 0.9 2.35 1.59 - 0.76 2 rooms 12.1 11.4 — 0.7 5.08 3.95 — 1.13 3 „ 19.0 18.0 — 1.0 4.53 3.31 — 1.22 4 „ 18.7 19.6 + 0.9 2.24 2.00 — 0.24 Total 54.4 52.7 — 1.7 14.20 10.85 — 3.35 Bermondsey 1 room 92 7.5 — 1.7 5.11 3.66 — 1.45 2 rooms 190 20.0 + 1.0 8.63 7.77 — 0.86 3 „ 191 20.4 + 1.3 5.53 5.78 + 0.25 4 „ 22.8 20.2 — 2.6 4.03 3.27 — 0.76 Total 70-1 681 — 2.0 23.30 20.48 — 2.82 6 Sanitary area Tenements with Percentage of total population in each group of tenements. Overcrowding. Percentage of total population living more than 2 in a room in tenements of less than 5 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. Betlinal-crreen 1 room 133 9.8 — 3.5 8.90 5.84 — 3.06 2 rooms 21.5 22.0 + 0.5 12.36 11.09 — 1.27 3 „ 23.1 24.9 + 1.8 8.90 8.56 — 0.34 4 „ 18.2 19.4 + 1.2 4.07 4.19 + 0.12 Total 76.1 76.1 0.0 34.23 29.68 — 4.55 Camberwell 1 room 4.1 3.4 — 0.7 2.06 1.36 — 0.70 2 rooms 8.8 9.4 + 0.6 3.53 3.11 — 0.42 3 „ 14.7 15.4 + 0.7 3.70 3.29 — 0.41 4 „ 15.9 17.3 + 1.4 1.81 1.80 — 0.01 Total 43.5 45.5 + 2.0 11.10 9.56 — 1.54 Chelsea 1 room 10.0 8.3 — 1.7 4.85 2.99 — 1.86 2 rooms 17.6 15.9 — 1.7 7.70 5.83 — 1.87 3 „ 15.2 16.1 + 0.9 4.14 4.05 — 0.09 4 „ 13.6 12.3 — 1.3 1.89 1.39 — 0.50 Total 56.4 52.6 — 3.8 18.58 14.26 — 4.32 Clerkenwell 1 room 17.6 12.4 — 5.2 10.36 6.65 — 3.71 2 rooms 32.1 30.5 — 1.6 18.74 15.88 — 2.86 3 „ 19.0 20.9 + 1.9 7.65 7.55 — 0.10 4„ 9.4 11.4 + 2.0 2.03 2.23 • + 0.20 Total 78.1 75.2 — 2.9 38.78 32.31 — 6.47 Fulham 1 room 5.0 3.2 — 1.8 2.48 1.27 —1.21 2 rooms 11.7 9.8 — 1.9 4.58 2.94 — 1.64 3 „ 22.9 23.5 + 0.6 5.37 4.17 — 1.20 4 „ 16.5 22.8 + 6.3 2.08 2.46 + 0.38 Total 56.1 59.3 + 3.2 14.51 10.84 — 3.67 Greenwich 1 room 4.8 3.4 — 1.4 2.53 1.54 — 0.99 2 rooms 8.9 91 + 0.2 3.14 2.65 — 0.49 3 „ 13.0 131 + 0.1 3.18 2.46 — 0.72 4 20.0 20-9 + 0.9 2.32 2.46 + 0.14 Total 46.7 46-5 — 0.2 11.17 9.11 — 2.06 Hackney 1 room 4.0 38 — 0.2 1.90 1.55 — 0.35 2 rooms 9.6 100 + 0.4 3.69 3.11 — 0.58 3 „ 14.2 159 +1.7 3.26 2.82 — 0.44 4 „ 14.2 16-4 + 2.2 1.98 1.86 — 0.12 Total 42.0 461 + 4.1 10.83 9.34 — 1.49 Hammersmith 1 room 5.0 4-3 — 0.7 2.53 1.69 — 0.84 2 rooms 11.9 12-5 + 0.6 4.97 4.43 — 0.54 3 „ 15.7 17 1 + 1.4 4.12 3.36 — 0.76 4 13.4 151 + 1.7 1.82 2.00 + 0.18 Total 46.0 490 + 3.0 13.44 11.48 — 1.96 Hampstead 1 room 3.4 2-3 —1.1 1.71 0.77 — 0.94 2 rooms 9.7 •8-9 - 0.8 4.88 3.01 — 1.87 3 „ 9.8 10-6 + 0.8 2.86 1.97 — 0.89 4 „ 6.3 7-8 + 1.5 0.87 0.75 — 0.12 Total 29.2 29-6 + 0.4 10.32 6.50 — 3.82 7 Banitary Tenements with Percentage of total population in each group of tenements. Orercrowding. Percentage of total population liring more than 2 in a room in tenement of less than 4 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. Holborn 1 room 20.2 16.0 — 4.2 13.44 9.18 — 4.26 2 rooms 29.6 28.7 — 0.9 16.72 14.72 — 2.00 3 „ 17.3 20.4 + 3.1 6.56 6.94 + 0.38 4 „ 7.0 8.8 + 1.8 1.36 1.47 + 0.11 Total 74.1 73.9 — 0.2 38.08 32.31 — 5.77 Islington 1 room 8.8 7.8 — 1.0 4.75 3.54 —1.21 2 rooms 19.0 19.6 + 0.6 8.94 7.85 —1.09 3 „ 15.6 17.2 + 1.6 4.31 3.85 — 0.46 4 „ 13.1 14.1 + 1.0 2.25 1.83 — 0.-42 Total 56.5 58.7 + 2.2 20.25 17.07 — 3.18 Kensington 1 room 8.2 6.3 - 1.9 4.31 2.87 — 1.44 2 rooms 15.6 15.5 — 0.1 8.14 7.39 — 0.75 3 „ 8.9 11.2 + 2.3 3.47 3.29 — 0.18 4 „ 7.8 8.0 + 0.2 1.30 1.10 — 0.20 Total 40.5 41.0 + 0.5 17.22 14.65 — 2.57 Lambeth 1 room 8.2 6.2 — 2.0 4.20 2.57 — 1.63 2 rooms 14.0 13.3 — 0.7 5.74 4.79 — 0.95 3 „ 15.2 15.6 + 0.4 3.91 3.15 — 0.76 4 „ 14.8 15.8 + 1.0 2.02 1.70 — 0.32 Total 52.2 50.9 — 1.3 15.87 12.21 — 3.66 Lewisham 1 room 1.8 1.3 — 0.5 0.58 0.38 — 0.20 2 rooms 3.7 3.6 - 0.1 0.89 0.76 — 0.13 3 „ 6.9 6.9 00 1.13 0.80 — 0.33 4 „ 10.5 11.4 + 0.9 0.99 0.78 — 0.21 Total 22.9 23.2 +0.3 3.59 2.72 — 0.87 Limehouse 1 room 11.0 8.5 — 2.5 6.78 5.27 —1.51 2 rooms 19.1 20.8 + 1.7 9.82 10.42 + 0.60 3 „ 18.2 20.0 + 1.8 5.76 5.92 + 0.16 4 „ 18.0 18.5 + 0.5 3.40 3.23 — 0.17 Total 66.3 67.8 + 1.5 25.76 24.84 — 0.92 London, City of 1 room 10.3 5.3 — 5.0 5.46 2.11 — 3.35 2 rooms 17.6 14.1 — 3.5 8.61 5.82 — 2.79 3 „ 13.3 11.9 — 1.4 3.67 2.42 — 1.25 4 „ 8.6 7.9 — 0.7 1.44 0.59 — 0.85 Total 49.8 39.2 — 10.6 19.18 10.94 — 8.24 Mile-end Old-town 1 room 10.0 8.9 — 1.1 5.88 4.93 — 0.95 2 rooms 16.8 17.4 + 0.6 7.40 8.04 + 0.64 3 „ 19.2 19.7 + 0.5 5.71 6.52 + 0.81 4 „ 18.3 19.9 + 1.6 3.01 4.12 + 1.11 Total 64.3 65.9 + 1.6 22.00 23.61 + 1.61 Newington 1 room 10.3 8.1 — 2.2 5.28 3.67 — 1.61 2 rooms 19.3 19.3 0.0 8.18 6.79 — 1.39 3 „ 20.6 22.9 + 2.3 5.65 4.88 — 0.77 4 „ 19.6 20.2 + 0.6 3.15 2.67 — 0.48 Total 69.8 70.5 + 0.7 22.26 18.01 — 4.25 8 Sanitary area. Tenements with Percentage of tolal population in each group of tenements. Overcrowding. Percentage of total population living more than 2 in a room in tenements of lesa than 5 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. Paddington 1 room 8.2 6.8 — 1.4 3.93 2.79 — 1.14 2 rooms 16.6 16.3 — 0.3 8.14 7.03 — 1.11 3 „ 16.1 17.8 + 1.7 3.56 3.33 — 0.23 4 ,, 8.3 10.1 + 1.8 1.18 1.09 — 0.09 Total 49.2 51.0 + 1.8 16.81 14.24 — 2.57 Plnmstead 1 room 2.2 1.4 — 0.8 0.85 0.43 — 0.42 2 rooms 7.1 6.2 — 0.9 186 0.90 — 0.96 3 „ 11.1 10.9 — 0.2 1.63 1.29 — 0.34 4 „ 18.8 18.4 — 0.4 2.09 1.63 — 0.46 Total 39.2 36.9 — 2.3 6.43 4.25 — 2.18 Poplar 1 room 5.6 4.9 — 0.7 2.90 2.51 — 0.39 2 rooms 13.0 13.0 0.0 5.44 4.88 — 0.56 3 „ 20.4 21.0 + 0.6 5.66 5.42 — 0.24 4 „ 23.6 23.6 0.0 3.83 3.63 — 0.20 Total 62.6 62.5 — 0.1 17.83 16.44 — 1.39 Rotherhithe 1 room 6.2 5.1 — 1.1 3.42 2.56 — 0.86 2 rooms 12.7 13.8 + 1.1 5.13 5.12 — 0.01 3„ 17.0 17.1 + 0.1 5.47 4.82 — 0.65 4 „ 24.4 23.5 — 0.9 3.98 3.16 — 0.82 Total 60.3 59.5 — 0.8 18.00 15.66 — 2.34 St. George, Hanoversquare 1 room 6.8 4.9 — 1.9 2.58 1.42 — 1.16 2 rooms 15.4 12.2 — 3.2 5.47 3.22 — 2.25 3 „ 12.2 11.1 — 1.1 2.25 1.78 — 0.47 4 „ 7.7 7.4 — 0.3 0.81 0.63 — 0.18 Total 42.1 35.6 — 6.5 11.11 7.05 — 4.06 St. George-in-the-East 1 room 22.1 17.3 — 4.8 14.71 12.24 — 2.47 2 rooms 21.2 24.6 + 3.4 12.22 16.35 + 4.13 3 „ 21.4 23.4 + 2.0 9.36 11.86 + 2.50 4 „ 13.3 14.7 + 1.4 3.54 4.71 + 1.17 Total 78.0 80.0 + 2.0 39.83 45.16 + 5.33 St. George-the-Martyr 1 room 16.5 11.7 — 4.8 9.40 5.62 — 3.78 2 rooms 27.0 26.8 - 0.2 14.18 13.75 — 0.43 3 „ ... 18.9 22.5 + 3.6 6.86 8.38 + 1.52 4 „ 14.2 15.6 + 1.4 3.15 2.67 — 0.48 Total 76.6 76.6 0.0 33.59 30.42 — 3.17 St. Giles 1 room 19.2 12.8 — 6.4 12.-26 7.41 — 4.85 2 rooms 22.9 20.7 — 2.2 12.62 9.74 — 2.88 3 „ 12.9 13.9 + 1.0 3.95 3.56 — 0.39 4 „ 5.9 6.1 + 0.2 0.97 0.63 — 0.34 Total 60.9 53.5 — 7.4 29.80 21.34 — 8.46 St. James, Westminster 1 room 11.4 5.4 — 6.0 6.05 2.57 — 3.48 2 rooms 23.8 20.2 - 3.6 11.10 8.69 — 2.41 3 „ 15.3 15.1 — 0.2 5.71 5.10 — 0.61 4 „ 6.3 6.6 + 0.3 0.92 1.20 + 0.28 Total 56.8 47.3 — 9.5 23.78 17.56 -6.22 9 Sanitary area. Tenements with Percentage of total population in each group of tenements. Overcrowding. Percentage of total population living more than 2 in a room in tenements of less than 5 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. St. Luke 1 room 21.8 16.9 — 4.9 14.25 10.15 — 4.10 2 rooms 29.9 30.8 + 0.9 18.57 17.07 —1.50 3 „ 19.1 20.3 + 1.2 9.17 8.73 — 0.44 4 „ 9.3 10.9 + 1.6 2.25 2.53 + 0.28 Total 80.1 78.9 — 1.2 44.24 38.48 — 5.76 St. Margaret and St. John, Westminster 1 room 15.4 11.1 — 4.3 7.94 4.87 — 3.07 2 rooms 23.7 21.2 — 2.5 7.46 7.79 + 0.33 3 „ 14.0 14.4 + 0.4 4.29 3.50 — 0.79 4 „ 8.5 9.1 + 0.6 1.16 1.05 — 0.11 Total 61.6 55.8 — 5.8 20.85 17.21 — 3.64 St. Martin-in-theFields 1 room 12.5 7.2 — 5.3 7.11 3.28 — 3.83 2 rooms 18.1 11.7 — 6.4 8.50 4.23 — 4.27 3 „ 11.8 9.5 — 2.3 3.20 1.56 — 1.64 4 „ 5.5 7.9 + 2.4 1.01 0.55 — 0.46 Total 47.9 36.3 — 11.6 19.82 9.62 —10.20 St. Marylebone • 1 room 17.6 12.1 — 5.5 9.65 5.48 — 4.17 2 rooms 23.0 22.2 — 1.3 12.25 10.36 — 1.89 3 „ 12.0 13.4 + 1.4 3.73 3.83 + 0.10 4 „ 6.7 7.9 + 1.2 1.15 1.25 + 010 Total 59.8 55.6 — 4.2 26.78 20.92 — 5.86 St. Olave 1 room 8.3 6.0 — 2.3 4.91 2.34 — 2.57 2 rooms 25.2 24.5 — 0.7 13.94 11.97 — 1.97 3 „ 19.4 22.6 + 3.2 7.55 8.79 + 1.24 4 „ 15.1 13.8 — 1.3 2.70 2.49 — 021 Total 68.0 66.9 — 1.1 29.10 25.59 — 3.51 St. Pancras 1 room 14.6 11.7 — 2.9 8.11 5.64 — 2.47 2 rooms 25.9 26.0 + 0.1 13.15 12.15 — 1.00 3 „ 16.1 16.7 + 0.6 4.87 4.34 — 0.53 4 „ 9.8 11.5 + 1.7 1.49 1.81 + 0.32 Total 66.4 65.9 — 0.5 27.62 23.94 — 3.68 St. Saviour 1 room 18.1 14.7 — 3.4 10.43 7.19 — 3.24 2 rooms 24.6 24.8 + 0.2 12.27 12.82 + 0 .5 3 „ 17.3 17.5 + 0.2 6.41 5.22 — 1.19 4 „ 12.7 13.6 + 0.9 3.26 2.62 — 0.64 Total 72.7 70.6 — 2.1 32.37 27.85 — 4.52 Shoreditch 1 room 16.2 12.6 — 3.6 9.71 6.90 — 2.81 2 rooms 24.4 24.4 0.0 12.98 12.08 — 0.90 3 „ 19.8 21.2 + 1.4 7.51 7.42 — 0.09 4 „ 16.3 17.3 + 1.0 3.48 3.32 — 0.16 Total 76.7 75.5 — 1.2 33.68 29.72 — 3.96 Strand 1 room 18.1 12.1 — 6.0 11.17 6.25 — 4.92 2 rooms 24.2 18.5 — 5.7 13.35 8.76 — 4.59 3 „ 16.8 18.2 + 1.4 5.00 4.71 — 0.29 4 „ 6.2 8.0 + 1.8 1.43 1.55 + 0.12 Total 65.3 56.8 — 8.5 30.95 21.27 -9.68 [2] 10 Sanitary area. Tenements with Percentage of total population in each group of tenements. Overcrowding. Percentage of total population living more than 2 in a room in tenements of less than 5 rooms. 1891. 1901. Increase or decrease. 1891. 1901. Increase or decrease. Wandsworth 1 room 2.1 1.4 — 0.7 0.81 0.42 — 0.39 2 rooms 5.2 4.1 — 1.1 1.62 0.87 — 0.75 3 „ 9.5 11.6 + 2.1 1.76 1.73 — 0.03 4 „ 13.9 15.4 + 1.5 1.38 1.41 + 0.03 Total 30.7 32.5 + 1.8 5.57 4.43 — 1.14 Whitechapel 1 room 18.2 14.3 — 3.9 13.45 10.64 — 2.81 2 rooms 26.5 28.5 + 2.0 18.26 20.51 + 2.25 3 „ 16.6 19.6 + 3.0 851 10.98 + 2.47 4 „ 9.6 9.8 + 0.2 3-28 3.76 + 0.48 Total 70.9 72.2 + 1.3 43.50 45.89 + 2.39 Woolwich 1 room 7.2 4.6 — 2.6 3.72 1.80 — 1.92 2 rooms 11.9 10.7 — 1.2 4.83 3.48 — 1.35 3 „ 13.7 14.0 + 0.3 3.35 3.07 — 0.28 4 „ 17.8 16.9 — 0.9 2.55 2.11 — 0.44 Total 50.6 46.2 — 4.4 14.45 10.46 — 3.99 London, Administrative County of 1 room 9.2 6.7 — 2.5 5.10 3.25 — 1.85 2 rooms 16.4 15.3 — 1.1 7.84 6.52 — 1.32 3 „ 15.8 16.5 + 0.7 4.57 4.13 — 0.44 4 „ 14.1 15.2 + 1.1 2.19 2.07 — 0.12 Total 55.5 53.7 — 1.8 19.70 15.97 — 3.73 It will be seen from tlie table that the percentage of the population inhabiting tenements of one room has declined in each sanitary area. In London, as a whole, the proportion has fallen in the ten years from 9.2 to 6.7 per cent. The proportion of the population occupying tenements of two rooms has declined in 23 districts and increased in 15 districts; the decline is most marked in the districts of St. Martin-in-the-Fields (from 18 1 to 11 "7 per cent.), the Strand (from 24.2 to 18.5 per cent.), and St. James's, Westminster (from 23.8 to 20.2 per cent.), while of the districts showing an increased percentage, St. George-in-the-East is most notable, the proportion of the population occupying tenements of two rooms having risen from 21.2 to 24.6 per cent. In London as a whole, however, the proportion of the population in tenements of two rooms declined from 16.4 to 15.3 per cent. The proportion of the population in tenements of three and four rooms shows a slight increase in the majority of districts, and the figures for London as a whole show that the proportion of the population in these tenements has risen from 15.8 to 16.5 per cent, in the case of tenements of three rooms, and from 14.1 to 15.2 per cent, in the case of tenements of four rooms. The term "overcrowding" used in the table is applied to those tenements of less than five rooms which, at the respective census years, were occupied to the extent of more than two persons per room. Using the term in this sense, it will be seen that in London as a whole the proportion of the population occupying "overcrowded" tenements declined from 19.70 per cent, to 15.97 per cent, in the ten years. This decline is shared by the populations occupying each class of tenement, but the decline is most marked in the case of occupants of tenements of one and two rooms. Referring to the several sanitary areas, it will be seen that the proportion of the total population occupying overcrowded tenements of one room declined in each sanitary area; the proportion of the population occupying overcrowded tenements of two rooms declined in each sanitary area with the exception of Limehouse, Mile-end Old Town, St. George-in-theEast, St. Margaret and St. John, Westminster, St. Saviour, and Whitechapel. In the case of tenements of three rooms there are nine exceptions to the general decline, and in the case of the tenements of four rooms 15 exceptions. Thus a marked improvement has taken place in the manner in which persons occupying tenements of less than five rooms are housed in London. The shifting of the population in the last ten years from the tenements of one and two rooms to the more ample accommodation provided in tenements of three and four rooms is conspicuous. Moreover, only in the sanitary areas of Whitechapel, St. George-in-the-East, and Mile-end Old Town, which have been specially affected by "alien" immigration has there been increase in the proportion of the total population occupying overcrowded tenements of less than five rooms, and even in these areas the proportion of the population occupying overcrowded tenements of one room has declined. Diagram I. Marriages. Births. Diagram II 11 Marriages. The number of marriages in the administrative county of London in 1902 (53 weeks) was 40,817, giving an annual rate of persons married of 17.8 per 1,000 living. The marriage rate in successive periods has been as follows— 1851-60 20.6 1893 17.2 1898 18.8 1861-70 20.3 1894 17.0 1899 18.6 1871-80 19.0 1895 17.2 1900 18.0 1881-90 17.5 1896 18.0 1901 17.6 1891 17.7 1897 18.5 1902 17.8 1892 17.4 The accompanying diagram (I.) shows the marriage rate in each year since 18-50 in relation to the mean marriage rate of the period 1851-1902. In the year 1902, among the males 40 per cent, married were under 21 years of age, and among the females 141 per cent.; the figures for previous years are shown in the following table; the proportions in England and Wales are also given for the purpose of comparison— Marriages of minora 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 1901 4.4 15.0 5.0 16.0 Of the 1,019 husbands who were under 21 years of age at the date of their marriage 1,615 were bachelors who married spinsters, and 4 were bachelors who married widows. Of the 5,738 wives who were under 21 years of age at the date of their marriage 5,659 were spinsters who married bachelors, 77 were spinsters who married widowers, and two were widows who married bachelors. Births. The number of births registered in the administrative county of London in 1902 (53 weeks) was 132,810, giving a birth-rate of 28-5 per 1,000 living per annum. The steady decline in the London birth-rate noted in previous reports has continued, and the birth-rate for 1902 is the lowest recorded rate in London since the institution of civil registration. The birth-rate in successive periods has been as follows— 1851-60 33.6 1893 31.0* 1898 29.7* 1861-70 35.4 1894 30.1* 1899 29.7* 1871-80 35.4 1895 30.6* 1900 29.1* 1881-90 33.2 1896 30.2* 1901 29.0* 1891 31.8* 1897 30.1* 1902 28.5* 1892 30.9* * The rates for these years relate to the Administrative County of London; the rates shown (or the periods previous to 1801 relate to the Registration County of London. 12 The corresponding figures for England and Wales are as follows— 1851-60 34.2 1893 30.7 1898 29.3 1861-70 35.2 1894 29.6 1899 29.1 1871-80 35.5 1895 30.2 1900 28.7 1881-90 32.5 1896 29.6 1901 28.5 1891 31.4 1897 29.5 1902 28.6 1892 30.4 The accompanying diagram (II.) shows the London hirth-rate in each year since 1850 in relation to the mean birth-rate of the period 1851-1902. The following table shows the birth-rate in the several metropolitan boroughs in 1902 per 1,000 persons, and per 100 married females aged 15-45— Metropolitan Boroughs. Births. Birth rate per 1,000 living. Births per 100 married females aged 15-45. Paddington 3,304 22.4 19.6 Kensington 3,488 19.3 18.8 Hammersmith 3,192 27.5 22.1 Fulham 4,789 32.9 23.8 *Chelsea 1,685 22.4 20.7 Westminster, City of 3,286 17.9 16.6 St. Marylebone 3,976 29.6 26.4 Hampstead 1,549 18.2 17.8 St. Pancras 6,452 27.0 21.2 Islington 9,217 26.9 21.1 Stoke Newington 1,154 22.0 18.7 Hackney 6,382 28.3 23.4 *Holborn 1,647 27.7 23.3 *Finsbury 3,697 36.2 27.9 London, City of 340 13.1 14.6 Shoreditch 4,069 33.9 26.5 Bethnal-green 4,589 34.8 27.5 *Stepney 11,590 37.9 29.9 Poplar 5,890 34.2 27.6 Southwark 6,897 32.8 24.5 Bermondsey 4,346 32.8 26.2 *Lambeth 9,067 29.2 23.2 Battersea 4,944 28.4 21.3 Wandsworth 6,380 26.0 22.0 Camber well 7,487 28.0 23.1 Deptford 3,391 29.9 23.2 Greenwich 2,802 28.1 24.1 Lewisham 3,466 25.7 21.8 Woolwich 3,734 30.7 23.3 London 132,810 28.5 23.3 Deaths. The mimber of deaths in the administrative county of London in 1902 (53 weeks) was 80,105, giving an annual death-rate of 17.2 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 17.4' 1900 18.61 1871-80 22.5 1895 19.51 1901 17.11 1881-90 20.5 1896 18.21 1902 17.21 1891 21.01 1897 17.81 The death-rate in each year since 1840, in relation to the mean death-rate of the period 1841-1902, 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. * Lying-in hospitals arc situated in tlie-e district*. 1 These dealb rates are fully corncted for institutions, i.e., by the exclusion of deaths of persons not belonging to but occurring in institutions situated within London, and by the inclusiun of d-atlis of persons belonging to London but occurring in London institutions situated outs'de the administrative county. Diagram. III Deaths (All Causes) 13 The columns showing "death-rates corrected for age and sex distribution" have been obtained by multiplying the crude death-rates by the "factor for correction,"* published by the Registrar-General in the Annual Summary for 1902— Towns. Estimated population middle of 1902. Crude death-rate per 1,000 living. Death-rate per 1,000 living (corrected for age and sex distribution). 1892-1901. 1902. 1892-1901. 1902. London 4579,110 19.21 17.71 20.2 18.6 Manchester 549,170 23.5 20.0 26.3 22.3 Liverpool 692,495 24.1 22.5 25.8 24.1 Birmingham 528,181 20.7 18.6 22.3 20.0 Leeds 437,037 19.9 17.6 21.7 19.2 Sheffield 418,177 20.4 17.1 22.0 18.4 Bristol 334,632 17.8 17.4 18.3 17.9 Nottingham 243,191 18.7 16.7 19.7 17.6 Bradford 281,771 18.4 15.8 20.3 17.5 Hull 245.449 19.4 17.2 19.9 17.6 Salford 224,007 23.7 19.3 26.2 21.3 West Ham 275,408 18.6 17.1 19.9 18.3 Leicester 216,389 17.7 14.9 18.9 15.9 Newcastle 219,150 21.1 19.9 22.8 21.5 London had, therefore (comparing the corrected death-rates), in 1902 a lower death-rate than Manchester, Liverpool, Birmingham, Leeds, Salford, and Newcastle, and in the decennium 1892-1901 had a lower death-rate than any of these towns except Bristol, Nottingham, Hull, West Ham, and Leicester. The following table enables comparison to be made of the death-rates of London with the death-rates of several foreign cities2— All causes—Death-rate? per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 19.21 17.71 St. Petersburg 27.8 23.0 Paris 20.2 18.4 Berlin 18.7 16.1 Brussels 18.0 16.1 Vienna 21.7 19.4 Amsterdam 17.1 15.4 Rome 19.4 21.9 Copenhagen 18.5 15.4 New York 20.7 18.7 Stockholm 17.8 14.3 It will be seen that both in the period 1892-1901 and in 1902 the London death-rate exceeded that of any of these towns except Paris, St. Petersburg, Vienna, Rome, and New York. 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 vear 1902— Crude and corrected death-rates,3 per 1,000 persons living, in the County of London and the several metropolitan boroughs. District. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate, 1902. Corrected death rate, 19U2. Comparative mortality figure, 1902 (London, 1,000). England and Wales 18.19 — — — — London 17.31 1.05107 17.2 18.1 1,000 Paddington 17.10 1.06398 14.6 15.5 856 Kensington 17.05 1.06710 15.3 16.3 901 Hammersmith 17.47 1.04144 16.3 17.0 939 Fulham 17.39 1.04623 17.1 17.9 989 Chelsea 17.57 1.03552 18.0 18.6 1,028 Westminster, City of 15.97 1.13926 16.1 18.3 1,011 * These factors are based upon the age and sex constitution of the respective populations at the census of 1901. 1 Including deaths of Londoners in the Metropolitan Workhouses, Hot-pital* and Lunatic Asylums, outside the County of London, but excluding deaths of non-Londoners in the Willesden Workhoute, the London Fever Hospital, the Metropolitan Asylums Board's Hospitals and the Middlesex County Lunatic Asylum, within the County of London. 1 All death-rates in this report relating to foreign cities are calculated anon figures published by the Registrar-General. * All death-rates in tbis report relating to Metropolitan Boroughs are fully corrected for institutions; (see footnote (') page 12. 14 District. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate, 1902. Corrected death-rate, 1902. Comparative mortality figure, 1902 (London, 1,000). St. Marylebone 16.93 1.07466 18.3 19.7 1,088 Hampstead 16.19 1.12378 10.8 12.1 669 St. Pancras 17.40 1.04563 18.6 19.4 1,072 Islington 17.53 1.03788 16.4 17.0 939 Stoke Newington 17.42 1.04443 13.4 14.0 773 Hackney 17.45 1.04264 15.0 15.6 862 Holborn 16.39 1.11007 21.3 23.6 1,304 Finsbury 17.40 1.04563 22.9 23.9 1,320 City of London 16.56 1.09867 20.4 22.4 1,238 Shoreditch 17.29 1.05228 20.7 21.8 1,204 Bethnal-green 17.98 1.01190 20.8 21.0 1,160 Stepney 17.40 1.04563 20.6 21.5 1,188 Poplar 17.61 1.03316 19.3 19.9 1,099 Southwark 17.38 1.04684 21.4 22.4 1,238 Bermondsey 17.60 1.03375 20.8 21.5 1,188 Lambeth 17.63 1.03199 17.4 18.0 994 Battersea 16.94 1.07403 15.0 16.1 890 Wandsworth 17.29 1.05228 13.5 14.2 785 Camberwell 17.53 1.03788 16.3 16.9 934 Deptford 17.31 1.05107 16.5 17.3 956 Greenwich 17.84 1.01984 15.4 15.7 867 Lewisham 17.64 1.03141 13.6 14.0 773 Woolwich 17.00 1.07024 15.1 16.2 895 A few of the " age and sex factors " shown in the above table differ materially from the corresponding factors published in my last annual report. This is due to the fact that since the publication of my last report I have been able to obtain from the General Register Office the age and sex distribution of the population of several large workhouses and infirmaries which are situated outside the area from which their inmates are drawn, and the populations of these institutions have been added to the populations to which they properly belong, and the factors recalculated. The following table shows the number of deaths1 occurring at several ages in each of the metropolitan boroughs of the Administrative County of London during the year 1902 (365 days)— Age-period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65— 75- 85 and up. All ages. Paddington 429 123 38 25 17 632 36 26 41 47 127 173 197 254 284 211 80 2,108 Kensington 511 170 60 27 23 791 48 26 32 65 140 217 293 366 347 302 89 2,716 Hammersmith 446 118 41 30 17 652 25 21 27 38 104 159 168 208 225 182 49 1,858 Fulham 701 222 85 59 39 1,106 78 30 46 47 120 199 221 209 208 145 41 2,450 Chelsea 236 78 27 28 13 382 28 15 12 18 76 101 138 174 199 147 37 1,327 W estminster, Citv of 444 115 50 23 19 651 40 32 47 68 199 319 369 399 378 301 77 2,880 St. Marylebone 418 132 50 39 12 651 43 21 20 53 156 236 261 293 340 247 67 2,388 Hampstead 133 29 16 11 10 199 15 4 17 32 64 76 97 99 131 130 42 906 St. Pancras 921 297 103 97 62 1,480 116 52 62 94 266 396 458 471 520 369 86 4,370 Islington 1,206 365 142 85 68 1,866 132 68 94 119 338 476 555 661 635 473 132 5,549 Stoke Newington 129 29 10 4 6 178 21 12 13 23 40 42 71 79 109 78 21 687 Hackney 739 225 73 61 45 1,143 87 52 60 79 210 231 299 371 414 286 83 3,315 Holborn 214 80 22 18 12 346 19 6 14 24 86 150 161 193 150 93 18 1,260 Finsbury 563 184 88 43 31 909 50 29 34 47 120 217 232 235 228 160 31 2,292 London, City of 44 24 7 7 3 85 8 2 10 16 22 45 67 80 99 68 16 518 Shoreditch 699 188 87 42 36 1,052 56 34 37 60 123 227 232 245 230 132 24 2,452 Bethnal-green 692 240 78 61 42 1,113 76 33 56 58 159 190 253 262 263 179 47 2,689 SteDnev 1,683 526 202 131 82 2,624 166 95 101 152 406 499 574 570 561 339 80 6,167 Poplar 884 246 99 61 43 1,336 85 47 54 79 216 245 318 324 299 210 45 3,258 Southwark 1,132 387 137 65 61 1,782 94 49 69 101 251 428 464 462 410 264 50 4,424 Bermondsey 662 251 95 58 26 1,092 61 33 52 50 168 215 270 282 278 153 34 2,688 Lambeth 1,139 311 136 70 38 1,694 122 61 88 118 311 465 547 674 669 446 116 5,311 Battersea 613 188 69 39 27 935 75 41 59 72 159 194 242 271 254 212 37 2,552 Wandsworth 795 190 73 49 40 1,147 98 51 56 82 196 252 262 360 386 296 85 3,271 Camberwell 1,016 288 123 82 57 1,566 128 59 67 106 249 312 405 469 473 353 94 4,281 Deptford 450 138 55 27 16 686 45 25 35 29 92 124 154 199 208 174 45 1,816 Greenwich 382 80 38 17 15 532 28 23 31 39 91 113 152 153 163 152 46 1,523 Lewisham 420 101 37 34 24 616 56 28 36 45 82 139 123 200 222 192 55 1,794 Woolwich 456 83 38 21 22 620 40 17 40 55 119 158 200 183 195 132 33 1,792 London 18,157 5,408 2,079 1,317 906 27,867 1,876 992 1,310 1,816 4,690 6,598 7,783 8,746 8,878 6,426 1,660 78,642 1 See footnote (1) page 12. 15 London mortality in 1902 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 1902. The figures for the year 1902 are fully corrected for institution deaths (see footnote (1) page 12), 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 London life table appended to my report for the year 1901. Age-period. Males. Females. Mean death-rate 1891-1900. Mean death-rate 1902. Difference per cent. Mean death-rate 1891-1900. Mean death-rate 1902. Difference per cent. 0— 71.97 60.53 —15.9 61.99 50.88 —17.9 5— 4.97 4.14 —16.7 5.17 4.25 —17.8 10— 2.46 2.36 — 4.1 2.48 2.33 — 6.0 15— 3.47 3.34 — 3.7 2.94 2.57 —12.6 20— 4.59 4.35 — 5.2 3.46 3.27 — 5.5 25— 7.36 6.69 — 9.1 5.65 4.94 —12.6 35— 14.22 12.88 — 9.4 10.68 9.41 —11.9 45— 23.14 22.14 — 4.3 17.12 15.52 — 9.3 55— 40.68 38.68 — 4.9 31.01 28.89 — 6.8 65— 77.78 75.25 — 3.3 63.44 59.87 — 5.6 75— 154.13 146.62 — 4.9 134.56 129.77 — 3.6 85 and upwards 284.10 296.36 + 4.3 265.77 275.85 + 3.8 All ages 20.88 18.78 —10.1 17.88 15.74 —120 It will be seen from this table that the rate of mortality in 1902 was considerably lower than that of the period 1891-1900 at each age-period of life and for each sex, with the exception of the age-period 85 and upwards. 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 formulae used are set out in some detail in the London life table appended to the annual report for 1901. 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 life time 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 the London life table, 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 1902, 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 1902. 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. 16 Table II. Age-groups. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1902. Gain (+) or loss (—) of lives in the year 1902 by fluctuations of mortality. Gain ( +) or loss (—) of " life capital" in the year 1902 by fluctuations of mortality. Males. 0— 18,010 15,147 + 2,863 + 143,608 5— 1,105 921 + 184 + 9,180 10— 516 494 + 22 + 1,003 15— 732 705 + 27 + 1,114 20— 1,007 955 + 52 + 1,927 25— 2,759 2,508 + 251 + 7,794 35— 4,029 3,649 + 380 + 9,112 45— 4,560 4,364 + 196 + 3,479 55— 4,875 4,635 + 240 + 2,964 65— 4,318 4,178 + 140 + 1,117 75— 2,650 2,521 + 129 + 633 85 and upwards 499 521 — 22 — 66 All ages 45,060 40,598 + 4,462 + 181,997 Females. 0— 15,499 12,720 + 2,779 + 149,121 5— 1,161 955 + 206 + 11,017 10— 530 498 + 32 + 1,578 15— 691 605 + 86 + 3,865 20— 910 861 + 49 + 1,990 25— 2,497 2,182 + 315 + 10,833 35— 3,346 2,949 + 397 + 10,675 45— 3,772 3,419 + 353 + 7,074 55— 4,413 4,111 + 302 + 4,207 65— 4,980 4,700 + 280 + 2,492 75— 4,049 3,905 + 144 + 773 85 and upwards 1,097 1,139 — 42 — 134 All ages 42,945 38,044 + 4,901 + 203,759 Total 88,005 78,642 + 9,363 + 385,756 It will be seen from the preceding table that during the year 1902, compared with the decennium 1891-1900, there has been a saving of 9,363 lives, representing a gain to the community of 385,756 years of life capital. Comparison of " life expectation " in two selected London districts. The foregoing tables relate to London as a whole, and on that account can be regarded as exhibiting the facts for a collection of hypothetical units, each of which may be described as an " average Londoner." In a vast community like that of London, comprising persons of every social condition, the rates of mortality of the component parts of the population exhibit wide variations. Some indication of the extent of these variations is afforded by the figures showing the corrected death-rates for each of the metropolitan boroughs (see table on page 13), where it will be seen, for instance, that the death-rate of Finsbury was 32 per cent. in excess of that of London, while the death-rate of Hampstead was 33 per cent. below that of London. Even wider divergencies from the average death-rate of the community are found when smaller areas than metropolitan boroughs are selected ; thus the death-rate in what is known as the Boundary-street area, Bethnal-green, which was cleared by the Council under the Housing of the Working Classes Act, was shown to be over 40 per 1,000, a figure considerably more than twice the London death-rate for the corresponding period of time. If the facts could be arithmetically stated it is probable that a close relation could be established between these variations in rates of mortality and variations in the " social condition " of the constituent parts of the community. Some indication of this is to be found in the figures published in previous annual reports showing the relation existing between " overcrowding," and all that this term connotes, and mortality. The amount of " overcrowding " in a community is probably the best index of its " social condition " ; in any case, it is the one which most readily lends itself to arithmetical statement. The inability to secure adequate house-room is in most cases associated with the inability to secure adequate food, clothing, and other necessaries. In view of these facts, two of the metropolitan boroughs have been chosen for comparison whose populations, broadly speaking, differ widely in respect of " social condition," viz., Hampstead and Southwark, and short life tables have been constructed for each for the purpose of comparing the expectation of life in the two communities. 17 It. is unnecessary to adduce a large amount of statistical evidence in order to show the wide differences obtaining in the general character of the two populations selected, as these must be evident to those whose knowledge of London is of the slightest ; and a few facts from the recent census report relating to the population inhabiting tenements of less than five rooms, and the proportion of domestic servants per family in the two communities will probably be amply sufficient to give broad indications of the differences in the two populations. The following table (I.) shows the number of persons occupying tenements of less than five rooms in the two districts and the manner of such occupation, from the census report of 1901. Table I. Southwark—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 per room. No. of occupants 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 14.7 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 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 1.13 61 586 0.72 Total 7,178 42.2 24,211 29.6 __ 864 5,215 6.37 It will be seen from the table that over 70 per cent. of the Southwark population were living in tenements of less than five rooms, while less than 30 per cent. of the Hampstead population were thus housed, nearly 10 per cent. of the Southwark population were living in one-roomed tenements, while in Hampstead this proportion was little more than 2 per cent. The contrast presented by the figures relating to overcrowded tenements is also most marked. Thus some 22 per cent., or nearly one-fourth of the Southwark population, were living in tenements of less than five rooms, occupied to the extent of more than two persons per room; while in Hampstead the proportion of the population thus housed was little more than 6 per cent. The proportion of domestic servants employed in the two communities, as shown by the recent census, affords further indication of the difference in social condition between the two populations; thus the proportion per cent. of domestic indoor servants to families or separate occupiers was 81'4 in Hampstead, compared with 7.8 in Southwark. The short life tables which follow have been based on the mortality figures for the period 1897-1900, and have been constructed on the modification of Dr. Farr's short method, introduced by Dr. Hay ward, medical officer of health of Haydock, and described by him in the "Journal of the Royal Statistical Society," vol. lxii., Part III. The chief difficulty in preparing tables of this kind relating to sanitary areas in London has been the absence of reliable mortality figures at the required age-periods in which due correction has been made for deaths of persons belonging to the district occurring in public institutions outside the district, and the deaths of persons not belonging to the district occurring in public institutions within the district. Since the year 1896, however, by reason of the opportunities which the Council has afforded me, I have been able to obtain from the records of the Registrar-General the number of deaths at each age-period, fully corrected for deaths occurring in institutions in each of the sanitary areas comprised in the administrative county. It has been the usual practice in recently constructed life tables to base them on the figures relating to a decennium, but being thus in possession of reliable mortality figures for the four years 1897-1900, it has been thought preferable to base the life tables on the data relating to these years rather than on the less reliable data obtainable for the whole of the decennium 1891-1900. The following table (II.) shows the mean annual death-rate* at each age-period obtaining in the two communities selected, for the four years 1897-1900. * The population of the Southwark infirmary, which is situated in the metropolitan borough of Camberwell, is not included in the population of Southwark on which these rates are calculated ; on the other hand, the population of Guy's Hospital, containing a large number of persons not usually resident in Southwark, has not been excluded. [3] 18 Table II. Age-period. Males. Death-rates per 1,000 living. Females. Death-rates per 1,000 living. Hampstead. Southwark. Comparative mortality figure for Southwark. (Hampstead taken as 100.) Hampstead. Southwark. Comparative mortality figure for Southwark. (Hampstead taken as 100.) 0— 45.54 86.92 190.9 37.45 74.75 199.6 5— 3.28 5.33 162.5 3.36 5.59 166.4 10— 1.62 2.85 175.9 1.35 2.48 183.7 15— 2.35 4.31 183.4 1.18 3.61 305.9 20— 2.57 5.61 218.3 1.19 4.30 361.3 25— 4.27 9.17 214.8 2.69 7.33 272.5 35— 9.04 17.78 196.7 5.07 14.41 284.2 45— 15.54 28.83 185.5 11.27 22.78 202.1 55— 31.60 49.34 156.1 20.45 36.07 176.4 65— 59.72 89.74 150.3 46.57 71.47 153.5 75 and upwards 134.23 202.26 150.7 133.67 181.46 135.8 All ages 14.41 25.12 174.3 9.83 21.97 223.5 It will be seen from this table that the high mortality which obtains in Southwark in comparison to that which obtains in Hampstead is not restricted to any particular age-period, although, as the comparative mortality figures show, the excess is greater at some ages than others. The difference in the figures shown for the two districts at ages 0-5 is striking, and in this connection it may be pointed out that the infant mortality (deaths under one year of age per 1,000 births) in Hampstead during the period 1897-1900 was 136 for males, while that of Souths wark was 203 ; the corresponding figures for females in the two districts were 104 and 170 respectively. It will be seen that the comparative mortality figures for females aged 15-35 in Southwark are particularly high—this is no doubt due in some measure to the large proportion of female domestic servants employed in Hampstead at these ages. The fact that many of these servants are drawn from areas outside London, to which many of them return when they become the subjects of a chronic disease such as phthisis, probably leads to some under-statement of the mortality among females in Hampstead at these ages, and the figures shown for males must be regarded as more trustworthy for comparative purposes. The following Table III. shows the expectation of life at certain ages in Hampstead and Southwark, the figures for London are also shown ; the latter, however, relate to the decennium 1891-1900, and are taken from the extended life table for London appended to the last annual report. Table III. Age. X Males. Females. Taking Hampstead Ex as 100, Southwark expectation of life is represented by- Expectation of life, Ex. Excess in Hampstead compared with Southwark Expectation of life, Ex. Excess in Hampstead compared with Southwark. London, 1891-1900. Hampstead, 1897-1900. Southwark, 1897-1900. London, 1891-1900. Hampstead. 1897-1900. Southwark, 1897-1900. Males. Females. At birth 40.98 50.80 36.52 14.28 45.33 56.56 40.70 15.86 71.9 72.0 At age 5 51.60 57.38 48.73 8.65 55.12 62.10 51.92 1018 84.9 83.6 „ 10 47.84 53.29 44.97 8.32 51.49 58.11 48.32 9.79 84.4 83.2 „15 43.40 48.70 40.58 8.12 47.10 53.48 43.89 9.59 83.3 821 „ 20 39.13 44.23 36.41 7.82 42.77 48.71 39.61 910 82.3 81.3 „ 25 34.96 39.80 32.39 7.41 38.46 44.06 35.46 8.60 81.4 80.5 „ 30 30.94 35.47 28.58 6.89 34.30 39.53 31.50 8.03 80.6 79.7 „ 35 27.25 31.31 25.03 6.28 30.42 35.13 27.78 7.35 79.9 79.1 „ 40 23.87 27.46 21.85 5.61 26.80 30.81 24.43 6.38 79.6 793 „ 45 20.65 23.81 18.93 4.88 23.29 26.69 21.31 5.38 79.5 79.8 „ 50 17.60 20.27 16.16 4.11 19.91 22.88 18.33 4.55 79.7 801 „ 55 14.76 16.99 13.60 3.39 16.72 19.29 15.49 3.80 800 80.3 „ 60 12.14 14.10 11.26 2.84 13.74 15.80 12.70 310 79.9 80.4 „ 65 9.76 11.51 9.10 2.41 11.01 12.56 10.09 2.47 791 80.3 „ 70 7.66 9.17 7.04 2.13 8.59 9.64 7.72 1.92 76.8 80.1 „ 75 5.91 7.14 5.21 1.93 6.57 7.22 5.70 1.52 73.0 78.9 The translation of the population and mortality figures into terms of " life expectation " brings into striking prominence the disparity in the viability of the two populations compared. The fact that the average unit of male population of Southwark has more than 14 years less 19 expectation of life at birth than the average unit of the male population of Hampstead shows the different degree to which causes of mortality, which must be regarded as more or less preventible, operate among the two populations selected. The following table (IV.) shows the number surviving at certain ages out of 100,000 born in Hampstead and in Southwark according to the mortality experience of the four years 1897.1900. Table IV. Number surviving at certain ages out of 100,000 born in Hampstead and Southwark, 1897-1900. Age. Males. Females. Hampstead. lx: Southwark. 1x Hampstead. lx Southwark. lx 0 100,000 100,000 100,000 100,000 5 81,147 67,374 84,029 70,945 15 79,182 64,677 82,076 68,142 25 77,251 61,551 81,107 65,500 35 74,025 56,160 78,955 60,877 45 67,627 47,039 75,053 52,727 55 57,893 35,337 67,052 42,033 65 42,208 21,843 54,650 29,412 75 23,226 9,441 34,300 14,598 This table shows that the average unit in Southwark begins life under more adverse conditions than the average unit in Hampstead, but whether those who survive the greater risks to infant life which obtain in Southwark 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 (V.), which shows the numbers surviving given age-periods out of 1,000 entering them ; by this method of comparison, the effect of 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 clearly appreciated. Table V. Of 1,000 entering given age-periods, the number surviving through the period. Age-period. Males. Females. Hampstead. Southwark. Hampstead. Southwark. 0—5 811 674 840 709 5—15 976 960 977 960 15—25 976 952 988 961 25—45 875 764 925 805 45—65 624 464 728 558 The conditions which adversely affect longevity in Southwark are, therefore, operative at each age-period shown in the table, although the effect of these conditions varies with the ageperiod. Thus, comparing males in the two communities, out of 1,000 born in Southwark, 326 die before reaching five years of age, while in Hampstead, out of 1,000 born, only 189 die before reaching the age of five years. Again, out of 1,000 children aged five in Southwark, 40 die before reaching the age of 15, while in Hampstead the corresponding number is 24. At ages 25-45, when probably, so far as the community is concerned, the economic value of life is at a maximum, the differences in the two communities is most marked. Thus, of 1,000 males aged 25 living in Southwark, 236 die before reaching the age of 45 years, while the corresponding figure for Hampstead is only 125. Another interesting comparison between the two districts which can be instituted from the material supplied by the life table is that shown in the following table (VI.). This table shows how much of the total expectation of life at birth is lived in infancy, in the school-age period of life, in the working-period of life, and in the period of decline. The age groups which approximately represent these periods of life are shown in the first column of the table. 20 Table VI. Mean lifetime in years, divided into infancy, school age, working period and decline. Life-period. Males. Females. Hampstead. Southwark. Hampstead. Sonthwark. Infancy (0-5 years) 4.24 369 4.38 386 School age (5-15 years) ... 8.00 658 8.28 6.93 Working period (15-65 years) ... 3370 24.26 3703 26.94 Decline (65 years and upwards) 4.86 1.99 6.87 2.97 Total 50.80 36.52 56.56 40.70 From this table it appears that, adopting the Hampstead figures as a standard, Southwark males lose 13.0 per cent. of the period of infancy, 17.7 per cent. of the school-age period, 28'0 per cent. of the working-period, and 59.1 per cent. of the period of decline. If the figures relating to females be compared on similar lines, it will be seen that Southwark females, compared with Hampstead females as a standard, lose 11.9 per cent. of the period of infancy, 16'3 per cent. of the school-age period, 27.2 per cent. of the working-period, and 56.8 per cent. of the period of decline. As long ago as 1841, Dr. Farr, in the fifth annual report of the Registrar-General, published short life tables for St. George, Hanover-square and Whitechapel, two metropolitan districts, the resident populations of which at that time were, and at the present day are, in marked contrast with respect to social condition. The data upon which these tables are based are probably much more imperfect than those at present obtainable, and the method of construction of the tables also differs from that adopted for the purposes of this report in the case of Hampstead and Southwark, but the "expectations of life" obtained by Dr. Farr for the first two districts in 1841 differ so widely from those obtained for the last two districts for the period of 1897-1900 that, even allowing a wide margin for differences in method of construction and imperfect data, a rough comparison may be made between the four districts. The results obtained by Dr. Farr in 1841 are as follows, and the figures for Hampstead and Southwark are inserted for comparison— Table VII. Table showing the expectation of life at certain ages in St. George, Hanover-square and Whitechapel in 1841, and in Hampstead and Sovthwark in 1897-1900. Age. Males. Females. Ex, Expectation of life. Ex, Expectation of life. St. George, Hanoversquare, 1841. Hampstead, 1897-1900. Excess in years. Whitechapel, 1841. Southwark, 1897-1900. Excess in years. St. George, Hanoversquare, 1841. Hampstead, 1897-1900. Excess in years. Whitechapel, 1841. Southwark, 1897-1900. Excess in yean. At birth 37.4 50.8 13.4 31.0 36.5 5.5 39.7 56.6 16.9 34.3 40.7 6.4 At age 10 470 53.3 6.3 41.6 45.0 3.4 50.2 58.1 7.9 45.6 48.3 2.7 „ 20 39.5 44.2 4.7 33.5 36.4 2.9 42.5 48.7 6.2 37.5 39.6 21 „ 30 32.1 35.5 3.4 26.7 28.6 1.9 34.0 39.5 5.5 29.8 31.5 1.7 „ 40 25.2 27.5 2.3 211 21.9 0.8 26.2 30.8 4.6 231 24.4 1.3 „ 50 18.7 20.3 1.6 159 16.2 0.3 190 22.9 3.9 16.7 18.3 1.6 „ 60 12.2 14.1 1.9 10.9 11.3 0.4 131 15.8 2.7 12.8 12.7 — 0.1 A comparison which is of interest is that showing the relative positions of the four districts with regard to life expectation; this may be best seen by comparing each with Hampstead taken as a standard. The following table (VIII.) shows the " comparative expectation of life " at each age in Southwark, 1897.1900 ; St. George, Hanover-square, 1841 ; and Whitechapel, 1841, taking the expectation of life in Hampstead, 1897-1900, as 100 at each age— 21 Table VIII. Comparative expectation of life figure (Hampstead, 1897-1900, Ex being taken as 100). Age. Males. Females. Hampstead, 1897-1900. St. George, Hanoversquare, 1841. Southwark, 1897-1900. Whitechapel, 1841. Hampstead, 1897-1900. St. George, Hanoversquare, 1841. Southwark, 1897-1900. Whitechapel, 1841. At birth 100 74 72 61 100 70 72 61 At age 10 100 88 84 78 100 86 83 78 „ 20 100 89 82 76 100 87 81 77 „ 30 100 90 81 75 100 86 80 75 „ 40 100 92 80 77 100 85 79 75 „ 50 100 92 80 78 100 83 80 73 „ 60 100 87 80 77 100 83 80 81 Although, it is probable that the mortality among the better circumstanced class will always, cceteris paribus, be lower than that among the poorer class, it would appear from these figures that a closer approximation to equality in this respect than that at present obtaining is possible. Notwithstanding the fact that economic conditions must influence mortality to a considerable) extent, the fact that the figures at the earlier relating ages to the Southwark population to-day approximate to those relating to St. George, Hanover-square, sixty years ago is significant, and distinctly encouraging to further efforts in the direction of improving the standard of public health. Infant mortality. The deaths of children under one year of age in the administrative county of London during 1902 (53 weeks) numbered 18,478, being in the proportion of 139 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 1902 1391 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. 1892-1901. 1902. Towns. 1892-1901. 1902. London 1592 1412 Nottingham 185 159 Manchester 191 152 Bradford 170 139 Liverpool 191 163 Hull 179 137 Birmingham 189 157 Salford 205 157 Leeds 180 159 West Ham 169 149 Sheffield 188 150 Leicester 191 153 Bristol 146 131 Newcastle 174 139 1 See footnote (1), page 12. 2 See footnote (2), page 13. 22 London had therefore in the period 1892-1901 a lower infant mortality than any of these towns except Bristol, and in 1902 a lower infant mortality than any except Bristol, Bradford, Hull and Newcastle. 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 age, 1902. Deaths under one year of age per 1,000 births, 1902. Paddington 438 133 Kensington 519 149 Hammersmith 455 143 Fnlham 709 148 Chelsea 244 145 Westminster 446 136 St. Marylebone 427 107 Hampstead 135 87 St. Pancras 946 147 Islington 1,222 133 Stoke Newington 133 115 Hackney 757 119 Holborn 213 129 Finsbnry 571 154 London, City of 43 126 Shoreditch 707 174 Bethnal-green 713 155 Stepney 1,702 147 Poplar 905 154 Southwark 1,144 166 Bermondsey 674 155 Lambeth 1,152 127 Battersea 626 127 Wandsworth 811 127 Camberwell 1,033 138 Deptford 468 138 Greenwich 386 138 Lewisham 432 125 Woolwich 467 125 London 18,478 139 It will be seen from the foregoing table that the rate of infant mortality was highest in Shoreditch (174) and lowest in Hampstead (87). The infant mortality in London during each of the four quarters of the year 1902 was as follows—first quarter 132 ; second quarter 119 ; third quarter 149 ; and fourth quarter 155 per 1,000 births. With a view to reducing infant mortality the corporation of St. Helens established in 1899 a milk depot for the supply of sterilised humanised milk for the feeding of infants. This example was followed by one or two other authorities, and more recently the Borough Council of Battersea has adopted the same course. Dr. McCleary's annual report contains some interesting figures which may be referred to here. Comparing the mean infant mortality of Battersea, Fulham, Lambeth, and Camberwell in the last six months of the period 1897-1901 with that in the last six months of 1902, during which milk from the depot of the borough council was supplied in Battersea, he shows that the reduction in the later period was more marked in Battersea than in any of the other districts, and to this reduction he thinks the milk from this depot has contributed. Again, he compares the mortality of 394 children thus fed, with the infant mortality of Battersea, and he finds a marked difference between the two populations in favour of the children supplied from the depot. For the purpose of more precise comparison he excludes from both populations the figures relating to a sub-district in which the infant mortality is low, and in which few children lived who were supplied with milk, and obtains wider differences in the mortality figures, again, in favour of the children thus supplied; and, finally, he excludes from his depot-fed children the deaths of those who died within one week of the beginning of the supply, and from the other children the deaths of those who died within a week of birth, with a like result. Dr. McCleary states that a contention that children thus fed are the offspring of parents of more than average carefulness is not without an element of truth, but against this may be set the fact that by far the greater number of these children were in ill-health. The experience of a longer period and of varying meteorological conditions in this connection will be of much interest. Deaths from certain diseases and groups of diseases. The following table from the annual summary of the Registrar-General shows in a summary form the excess and defect in the year 1902 under certain of the more important headings in the list of causes of death as compared with the corrected average in the previous ten years— 23 Cause of death. Diminution in 1902. Excess in 1902. Smallpox — 1,245 Measles 349 — Scarlet fever 302 — Typhus 5 — Influenza 358 — Whooping cough 291 — Diphtheria 1,107 — Pyrexia (origin uncertain) 6 — Enteric fever 72 — Diarrhoea 1,253 — Phthisis and other tuberculous diseases (including scrofula) 1,439 — Cancer — 608 Premature birth — 59 * Diseases of nervous system ... 743 — *Diseases of circulatory system †Diseases of respiratory system 1,242 — Diseases of urinary system — 214 Childbirth and puerperal septic diseases 88 — Accident 280 — Homicide — 2 Suicide — 52 All other causes 1,378 — Net diminution or excess 6,733 — Comparison can be made of certain causes of death in London sanitary areas by reference to the following table. The death-rates shown in the table are fully corrected for deaths in institutions. (See footnote (1), p. 12), and in the case of phthisis and cancer " factors for correction for differences in age and sex constitution " have been calculated, and these factors and the corrected death-rates are shown on pp. 66 and 69. Death-rates per 100,000 living from all causes, and from various causes, in each of the metropolitan boroughs, 1902 (365 days). Metropolitan Boroughs. Measles. Rheumatic fever. Carcinoma. Sarcoma. Cancer. Tabes mesenterica. Tubercular meningitis. Phthisis. Other tubercular diseases. Pneumonia. Other respiratory diseases. All other causes. All causes. Paddington 56 7 50 6 40 11 17 107 12 125 170 852 1,453 Kensington 52 8 41 7 41 5 21 122 20 157 175 880 1,529 Hammersmith 67 4 39 5 41 9 18 143 14 151 164 972 1,627 Fulham 117 8 43 2 30 13 28 140 19 206 167 939 1,712 Chelsea 92 5 53 8 45 5 18 145 20 212 193 997 1,793 Westminster, City of 23 8 48 8 51 8 16 178 14 171 175 893 1,593 St. Marvlebone 74 11 53 6 51 15 17 187 18 154 213 1,008 1,807 Hampstead 17 4 69 13 29 6 16 90 7 75 106 650 1,082 St. Pancras 46 8 56 6 41 15 23 191 22 203 158 1,086 1,855 Islington... 32 8 52 6 40 14 23 149 12 159 188 962 1,645 Stoke Newington 8 12 35 2 48 12 21 124 21 118 141 787 1,329 Hackney 33 9 32 5 51 17 25 144 26 141 132 879 1,494 Holborn 53 7 53 7 48 19 24 301 19 251 260 1,111 2,153 Finsbury 81 7 40 3 38 25 27 228 26 201 315 1,290 2,281 London. City of 39 — 70 12 74 4 31 156 16 234 207 1,181 2,024 Shoreditch 73 12 50 6 48 11 37 181 31 167 236 1,226 2,078 Bethnal-green 45 5 58 7 18 22 26 199 28 223 276 1,164 2,071 Stepney 55 6 41 5 21 20 32 188 34 232 207 1,211 2,052 Poplar 40 9 48 5 32 24 24 174 17 154 234 1,164 1,925 South wark 79 9 58 6 20 22 28 260 28 258 203 1,168 2,139 Bermondsey 117 16 55 9 31 18 36 181 26 256 201 1,118 2,064 Lambeth 25 8 45 10 46 14 26 169 21 200 170 1,006 1,740 Battersea 59 11 42 5 39 13 15 130 13 128 183 851 1,489 Wandsworth 41 8 46 5 42 11 16 94 13 115 108 854 1,353 Camberwell 46 7 44 8 43 11 25 154 15 150 170 956 1,629 Deptford 63 5 49 9 38 10 25 107 19 117 163 1,023 1,628 Greenwich 39 7 44 9 33 23 16 120 14 134 163 952 1,554 Lewisham 20 11 59 4 35 11 17 107 18 98 112 863 1,355 Woolwich 32 3 40 3 43 12 20 150 12 100 136 948 1,499 London 51 8 48 6 39 14 23 160 20 170 180 993 1,717 * For purposes of comparison deaths from infective endocarditis are included under this heading, † For purposes of comparison deaths from epidemic pneumonia are included under this heading. 24 Principal Epidemic Diseases. The number of deaths in the administrative county of London from the principal epidemic diseases, viz.—smallpox, measles, scarlet fever, diptheria, whooping-cough, typhus, enteric, and ill-defined fevers and diarrhoea during 1902 (53 weeks) was 10,280, giving an annual death-rate of 2.21 per 1.000 living. 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 1902 2.211 It will be seen from the following table that London in the period 1892-1901 had a lower death-rate from these diseases than any of the undermentioned towns except Bristol, Nottingham, Bradford and Newcastle, and in 1902 a higher death-rate from these diseases than any except Liverpool, Birmingham, Bristol, Hull, Salford, and "West Ham. Principal epidemic diseases—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 2.702 2 232 Nottingham 2.62 1.32 Manchester 3.41 1.99 Bradford 2.16 1.43 Liverpool 3.40 3.08 Hull 3.18 2.27 Birmingham 3.01 2.53 Salford 4.38 2.67 Leeds 2.79 1.99 West Ham 3.53 3.20 Sheffield 3.48 1.69 Leicester 3.11 1.54 Bristol 1.93 2.82 Newcastle 2.29 1.75 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 both in the period 1892-1901 and in 1902 higher than that of any of these towns except St. Petersburg. Six principal epidemic diseases—Death rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 1.892 1692 St. Petersburg 3.34 2.30 Paris 1.03 0.91 Berlin 1.29 0.76 Brussels 0.85 0.57 Vienna 1.43 1.00 Amsterdam 0.76 1.31 Rome 1.08 1.61 Copenhagen 1.24 0.75 New York 1.58 1.47 Stockholm 1.45 0.49 The following table shows the deaths from the principal epidemic diseases and the deathrates per 1,000 living in each of the metropolitan boroughs in 1902— Metropolitan borough. Deaths in 1908. Death-rate per 1,000 living. Metropolitan borongh. Deaths in 1902. Death-rate per 1,000 living. Paddington 256 1.74 Shoreditch 425 3.53 Kensington 265 1.49 Bethnal-green 339 2.56 Hammersmith 222 1.90 Stepney 1,009 3.31 Fulham 454 3.13 Poplar 476 2.77 Chelsea 155 2.06 Southwark 653 3.10 Westminster, City of 234 1.28 Bermondsey 405 3.06 St. Marylebone 267 1.98 Lambeth 581 1.86 Hampstead 68 0.81 Battersea 346 1.98 St. Pancras 590 2.46 Wandsworth 402 1.62 Islington 614 1.80 Camberwell 596 2.23 Stoke Newington 61 1.17 Deptford 277 2.44 Hackney 443 1.98 Greenwich 159 1.59 Holborn 146 2.44 Lewisham 241 1.79 Finsbury 325 3.18 Woolwich 235 1.93 London, City of 36 1.38 London 10,280 2211 1 See footnote (1), page 12. 2 See footnote (2), page 13. 25 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases was highest in Shoreditch (3.53) and lowest in Hampstead (0.81). The death-rates from these diseases in London during each of the four quarters of the year 1902 were as follows— first quarter 2.34; second quarter 2.08; third quarter 2.67, and fourth quarter 1.76 per 1,000 living. Smallpox and Vaccination. The deaths from smallpox in the administrative county of London numbered 1,314 in 1902 (53 weeks), and 4 deaths were attributed to cow pox 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 0.0001 1891 — 1899 0.0011 1892 0.0071 1900 0.0011 1893 0.0401 1901 0.0511 1894 0.0201 1902 0.2821 In this table where — is inserted no deaths occurred. The smallpox death-rate in each year since 1840 in relation to the mean smallpox deathrate of the period 1841-1902 is shown in diagram IY. During the complete years in which the notification of infectious diseases has been obligatory, the number of cases of smallpox notified to the medical officers of health in the various sanitary districts comprised in the administrative county has been as follows— Year. Cases notified. Case rate per 1,000 living. 1890 60 0.014 1891 114 0.027 1892 425 0.100 1893 2,815 0.653 1894 1,193 0.274 1895 980 0.223 1896 225 0.050 1897 104 0.023 1898 33 0.007 1899 29 0.006 1900 86 0.019 1901 1,700 0.375 1902 7,796 1.675 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 1892-1901 the London death-rate was exceeded by the death-rates of Liverpool, Birmingham, Bristol, Bradford, Hull and West Ham, while in 1902 it was considerably higher than the death-rates of any of the undermentioned towns except West Ham. Smallpox death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.012 0.282 Nottingham 0.00 — Manchester 0.01 — Bradford 0.07 — Liverpool 0.02 0.03 Hull 0.08 — Birmingham 0.05 0.01 Salford 0.01 — Leeds 0.01 0.01 West Ham 0.05 0.54 Sheffield 0.00 — Leicester 0.01 0.02 Bristol 0.02 0.00 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 death occurred — is inserted. 1 See footnote (1), page 12. 2 See footnote (2), page 13. [4] 26 From the following table it will be seen that the London smallpox death-rate in the period 1892-1901 exceeded that of any of the following large foreign towns except Paris, Brussels, St. Petersburg, Vienna, and New York, and in 1902 was considerably in excess of that of any of these towns. Smallpox death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.01 0.28 St. Petersburg 0.11 0.04 Paris 0.05 0.03 Berlin 0.00 0.00 Brussels 0.01 0.02 Vienna 0.01 — Amsterdam 0.00 — Rome 0.00 0.02 Copenhagen 0.00 — New York 0.03 0.08 Stockholm 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005 ; where — is inserted no death occurred. In the annual report for the year 1901 account was given of the progress of smallpox in that year. The cases of this disease, which had increased in November and December, 1901, continued to increase during the first three months of 1902, attaining a maximum in March, after which there was decline until the beginning of September, subsequent to which the number of cases notified in any week did not exceed eight. This will be seen by reference to the following table— Smallpox—Notified cases, 1902. Week ended No. of cases notified. Week ended No. of cases notified. Week ended No. of cases notified. January 4 249 May 10 219 September 6 13 „ 11 297 „ 17 181 „ 13 8 „ 18 230 „ 24 271 „ 20 4 „ 25 184 „ 31 254 „ 27 3 February 1 422 June 7 206 October 4 3 „ 8 305 „ 14 165 „ 11 4 „ 15 368 „ 21 101 „ 18 3 „ 22 417 „ 28 127 „ 25 2 March 1 350 July 5 77 November 1 5 „ 8 466 „ 12 47 „ 8 3 „ 15 430 „ 19 47 „ 15 2 „ 22 418 „ 26 21 „ 22 6 „ 29 340 August 2 46 „ 29 3 April 5 351 „ 9 25 December 6 7 „ 12 278 „ 16 22 „ 13 1 „ 19 272 „ 23 26 „ 20 2 „ 26 279 „ 30 12 „ 27 1 May 3 212 • January 3, 1903 1 By the end of 1901 cases of this disease had occurred in every district of London, and in St. Pancras (in which smallpox first assumed serious proportions), in Westminster, and in Holboru, the number of cases had either attained or had nearly approached the maximum reached in these districts during the epidemic. In the first thirteen weeks of 1902 the chief incidence of the disease was on the eastern districts (10-3 cases per 1,000 population) comprising Stepney, Shoreditch, Bethnal Green and Poplar. Of these districts Stepney suffered most in this quarter (12'4 cases per 1,000). Smallpox had, in the last month of 1901, begun seriously to invade the numerous common lodging-house population of Stepney, and in each of the first three months of 1902 the disease made progress in this as well as in the rest of the population, attaining a high maximum in February and March, and lasting into August. Next to Stepney in the first quarter the greatest incidence was on Shoreditch (10-6 cases per 1,000). The common lodging-house population of Shoreditch, however, which is about one-tenth of that of Stepney, almost entirely escaped attack. Indeed, until the last week of January, 1902, the number of cases in the general population of Shoreditch had been relatively few, but in that week there was a marked increase. Dr. Bryett states in his annual report that "between 25th January and 3rd February some sixty-two houses were invaded, the majority during the four days ending 30th January." These houses were mostly situate, towards the western boundary of the district, in streets leading from or in the near neighbourhood of Nile-street. From 8th to 21st February a fresh series of houses was invaded, these houses being not so much limited to the neighbourhood of Nile-street; and later the disease appeared in a third series of houses which were scattered over the borough. The prevalence attained a high maximum in this district in February and March, and lasted until the end of June. After Shoreditch, the greatest incidence in the first quarter was on Bethnal Green (8.5 cases per 27 1,000). Smallpox, which had not made much progress in the general population of this district in 1901, increased in amount during the first quarter of 1902, and lasted to the end of August, the greatest number of cases in common lodging-houses occurring in the second quarter of 1902. The incidence on the remaining eastern district, Poplar (7.8 cases per 1,000), was nearly that of Bethnal Green. Smallpox had appeared among the general population of this district in the latter part of 1901, and after the first month of 1902 became much more prevalent, continuing in considerable proportion until the latter part of June, after which it declined. The common lodging-house population of this district had remained free from smallpox during 1901, but some nineteen cases occurred among inmates of these houses in the first quarter of 1902. During the first quarter of 1902, next to the eastern group of districts, the central group of districts suffered most (7'3 cases per 1,000). This group comprises the districts of Holborn, Finsbury, and the City. In Holborn (12.7 cases per 1,000), in which the common lodginghouse population had been severely attacked in the last quarter of the year 1901, the disease attained its maximum in the last week of that year, and after the next two or three weeks rapidly declined, increasing a little at the latter part of the quarter and then further declining. In Finsbury (5.2 cases per 1,000), the disease never attained the same prevalence as in Holborn. Finsbury had been invaded in September of 1901 as the result of the return of hoppers from Sussex while suffering from smallpox, but the outbreak was promptly dealt with, and, although a few cases of smallpox still occurred week by week during the last quarter of that year, the disease did not attain its maximum prevalence until February and March, 1902. In the latter month the disease declined, but cases continued to occur into May, and in J uly and August there was further prevalence arising from a child whose illness was certified erroneously to be chicken-pox, and from a man who suffered from the disease as a result of visiting the smallpox hospital. The City, which is also included in the central districts, was but little affected by the epidemic at any time. The north, south and west groups of districts suffered much in the same proportion, the incidence in the north being, in the first quarter of the year, 2.7 per 1,000 of population, in the south 2.6, and in the west 2.0 per 1,000. The northern group comprises St. Pancras, Islington, St. Marylebone, Hackney, Stoke Newington, and Hampstead. In St. Pancras the common lodginghouse population was but little attacked, but the disease maintained its prevalence in this district until the summer of 1902, notwithstanding that it was the first district in London seriously invaded during the preceding year. In Islington, which borders on St. Pancras in the east, although invaded soon after St. Pancras, the disease did not attain its maximum until towards the close of the first quarter, and then not a high one. In St. Marylebone, which borders on St. Pancras in the west, cases of smallpox occurred early, and continued into 1902, when the disease appeared in the common lodging-houses and in a Salvation Army shelter. The number of cases, however, never attained great proportions. There were only a few cases in Hackney during 1901. Twenty-four cases, however, occurred at the beginning of the year 1902 as the result of infection from an unrecognised case of the disease, after which the disease began to assume serious proportions, the common lodging-house population remaining nearly free. Stoke Newington and Hampstead were but little affected. The southern group of districts comprises Southwark, Bermondsey, Lambeth, Battersea, "Wandsworth, Camberwell, Deptford, Greenwich, Lewisham, and Woolwich. Of these districts, Southwark, which contains a large common lodging-house population, had been invaded early in the epidemic, the infection being received from Holborn. Cases of the disease occurred in each of the last ten weeks of 1901, appearing in the common lodging-house population in November, and in subsequent months attaining considerable proportions in this class. Notwithstanding the efforts which were made, the common lodging-house population furnished many cases until after June, 1902. In Bermondsey there was a considerable localised outbreak in the latter part of October and in November, 1901, after which the number of cases diminished, but some prevalence in the borough was maintained until June, 1902. It was only in February, 1902, and the subsequent three months that cases occurred in the common lodging-house population. In Wandsworth the disease appeared in July, 1901, and was promptly dealt with, but the district was again invaded towards the latter part of the year, and cases continued to occur until the beginning of August, 1902. The common lodging-house population, which is small, was but little affected. Battersea suffered about twice as much as Wandsworth, but less proportionately than London as a whole. Cases began to occur at the end of October, and continued almost without intermission until the beginning of August. The common lodging-house population, which is small, was but little affected. Camberwell was invaded in October, 1901. The disease did not make much progress until the end of March, 1902, when much greater prevalence occurred; the cases began to decline in May, 1902, but the disease continued until the end of July. The common lodging-house population in this district was not much affected. In Lambeth cases of smallpox occurred in August and September, 1901, and continued in small proportions until the last week of the year, when the numbers considerably increased; the major prevalence lasted until May, 1902, after which the number of cases declined, but continued in some degree until August. A few cases occurred in the common lodging-house population. In Deptford, Greenwich and Lewisham, although occasional cases occurred in the latter part of 1901. there was no constant succession of cases until the early part of 1902. In Lewisham the succession of cases week by week began later, and terminated earlier than in Deptford and Greenwich, and only a few cases occurred in any of these districts after the end of July, 1902. The common lodging-house population of these three districts practically escaped. In Woolwich cases of smallpox occurred in small numbers in every week from November, 1901, to the end of the year, after which there was some increase, which attained greater magnitude in March and April, 1902. Woolwich suffered more severely than any any of the southern districts, except Southwark. The common lodging-house population is much 28 smaller than that of Southwark, and slightly larger than that of Bermondsey. It was not much affected by attacks of smallpox. The western group of districts, comprising Paddington, Kensington, Hammersmith, Fulham, Chelsea and Westminster was, as a whole, less affected by smallpox than the other groups, and had it not been for the special incidence in Westminster, owing largely to the considerable number of persons of the common lodging-house class in that district and to an outbreak of smallpox in a Rowton House in Hammersmith, this difference would have been much more marked. In Westminster, which suffered most, few cases of smallpox were notified until the latter part of October, when a number of cases occurred due to infection from a woman suffering from smallpox, of whom account is given in the last annual report, who remained at large for four days, infecting especially the inmates of common lodging-houses and the frequenters of publichouses. In December the number of cases declined, but in January, 1902, there was an. accession of cases largely occurring among the inmates of common lodging-houses. In February there was less prevalence, but the number of cases was still considerable; in subsequent months fewer cases occurred, but a weekly succession of cases was maintained until the beginning of July. In Hammersmith there was little smallpox until the latter half of November, 1901, when the outbreak in Rowton House occurred to which reference has been made; cases continued to occur in the district, but not in great numbers until August, 1902, workers in laundries being conspicuous among the sufferers. In Paddington, Kensington, Chelsea and Fulham the prevalence of the disease began late and never attained any great magnitude. In summary it may be stated that during 1900 and 1901 smallpox had been frequently introduced into London from abroad, especially from Paris, where smallpox was prevalent.* In the beginning of August, 1901, two women living in a house in Tottenham-street, St. Pancras, were attacked. Their illness had been preceded a fortnight before by that of their sister, who was employed at a laundry as a sorter of dirty linen received from hotels and boarding-houses in the W.C. district. This girl's illness had been regarded as chicken-pox. Then followed another case in this house and four cases in the house next door. The illness of these four persons had been preceded by that of a child who died, and whose illness had been regarded as chicken-pox. The laundry girl's attack was apparently the first of the series. The disease spread in this neighbourhood and in that of Sandwich-street, Gray's Inn-road, into which it was introduced by a sister of the child in Tottenham-street previously mentioned. Smallpox then appeared in Holborn, especially in the common lodging-house population. In October a woman who frequented common lodging-houses in Holborn and Westminster, remained at large for four days, having, while suffering from smallpox, escaped from the Endell-street Infirmary, where her disease had been recognised. As a direct result, a very large number of persons were infected in the two districts ; " she visited nearly every public-house in the district, and from each one into which she had been one or more of the inmates or customers took smallpox."t The disease continued to extend in this class of the population, the common lodging-houses of Holborn, St. Pancras, Westminster, Stepney and Southwark being especially affected in the last quarter of the year 1901. Another factor in the spread of the disease became operative in the early part of 1902, and may be here referred to. A number of men employed in the erection of additional smallpox hospital accommodation in Essex, for the use of the London population, contracted the disease. Thus, from returns which are no doubt incomplete, it is found that in London 23 persons were attacked in January, 1902, 26 in February, 30 in March, and 13 in April, all infected in that locality, and the great majority of whom had been employed in hospital construction. Cases thus occurred in 22 of the 29 sanitary areas of London, the majority occurring in the southern districts. The occurrence of cases of the disease in common lodging-houses will be referred to in more detail later. With respect to hospitals, workhouses and workhouse infirmaries, it may be said that while no extension of the disease of any magnitude is recorded in hospitals during the epidemic a considerable number of the inmates of poor-law institutions were attacked. In December, 1901, one of the inmates of a common lodging-house in Westminster was admitted with malignant smallpox into the St. George's Infirmary, and a number of the inmates were thus infected. Eleven cases also occurred in the Shoreditch Workhouse and Infirmary and 32 in the Holborn Union Workhouse. The Mile-end Infirmary suffered especially, 91 of the inmates being infected. In the Whitechapel Infirmary 24 cases, in St. George's Infirmary 7, and in Ratcliff Infirmary 2 cases occurred. Dr. Priestley reports that in Lambeth " on eight separate occasions a workhouse or infirmary was infected, but in no single instance did the disease spread, on account of strict isolation by removal to hospital, disinfection, and medical inspection (together with re-vaccination of ' contacts.') The staffs at the workhouse and infirmary were all re-vaccinated as required." In Southwark 12 cases occurred in the workhouses. The behaviour of the disease in each of the metropolitan boroughs during the whole of the period in which smallpox was epidemic in London will be seen on reference to Diagram V. This diagram is based upon the number of cases of smallpox notified in each week, each square of the diagram representing two cases. The diagram does not show the relative incidence of the disease on each district as only the actual cases notified are shown, and no allowance is made for the varying size of the populations concerned ; the progress of the epidemic with regard to time, and the period of maximum and minimum prevalence in each district are, however, well' illustrated. The incidence of the disease on the populations of the several boroughs in the period 1892-1901, in the year 1902, and also in the two years 1901-2 (the latter period covering the whole time during which the disease was epidemic in London) will be seen on reference to the following table— * The deaths from smallpox in Paris numbered in 1899, 4; in 1900 211; in 1901, 417 ; and in 1902, 90. † Annual report of the medical officer of health of Westminster, 1902. 20 Metropolitan borough. Cases, 1902. Case-rate per 1,000 living. Deaths, 1902. Death-rate per 1,000 living. 1902. Bates* per 1,000 living, 1901-2. 1892-1901. 1902. Cases. Deaths. Paddington 113 0.1 0.8 20 0.14 0.4 0.07 Kensington 99 0.1 0.5 11 0.06 0.3 0.03 Hammersmith 100 0.1 0.9 13 0.11 0.6 0.12 Fulham 94 0.1 0.6 13 0.09 0.4 0.06 Chelsea 39 0.1 0.5 7 0.09 0.3 0.05 Westminster, City of 232 0.2 1.3 39 0.21 0.8 0.15 St. Marylebone 155 0.5 1.2 24 0.18 0.7 0.12 Hampstead 20 0.1 0.2 3 0.04 0.2 0.03 St. Pancras 360 0.2 1.5 81 0.34 1.2 0.26 Islington 302 0.1 0.9 54 0.16 0.5 0.09 Stoke Newington 51 0.1 1.0 8 0.15 0.7 0.11 Hackney 424 0.1 1.9 70 0.31 1.0 0.17 Holborn 219 0.6 3.7 46 0.77 3.5 0.65 Finsbury 211 0.2 2.1 36 0.35 1.4 0.21 London, City of 39 0.2 1.5 7 0.27 0.8 0.17 Shoreditch 442 0.1 3.7 76 0.63 1.8 0.34 Bethnal-green 515 0.3 3.9 64 0.48 2.0 0.25 Stepney 1,387 0.3 4.5 260 0.85 2.4 0.47 Poplar 630 0.3 3.7 93 0.54 2.0 0.30 Southwark 517 0.2 2.5 78 0.37 1.4 0.22 Bermondsey 224 0.2 1.7 31 0.23 1.2 0.17 Lambeth 362 0.1 1.2 60 0.19 0.7 0.11 Battersea 189 0.1 1.1 27 0.15 0.7 0.09 Wandsworth 131 0.0 0.5 25 0.10 0.3 0.06 Camber well 356 0.1 1.3 63 0.24 0.7 0.13 Deptford 145 0.1 1.3 33 0.29 0.7 0.15 Greenwich 102 0.2 1.0 22 0.22 0.6 0.13 Lewisham 88 0.0 0.7 12 0.09 0.4 0.05 Woolwich 236 0.2 1.9 38 0.31 1.0 0.16 Port of London 14 - - - - - - London 7,796 0.2 1.7 1,314 0.28 1.0 0.17 Administrative measures adopted for the limitation of the spread of smallpox. (a) The diagnosis of smallpox.—When smallpox first appeared in London, 1901, there were many medical practitioners who had not had experience of the appearances of the disease, and quite early in the epidemic cases of smallpox were mistaken for chicken-pox. In October, 1901, in St. Pancras, and in the beginning of 1902, in certain other districts, the requirement of notification was extended to chicken-pox, and on 28th January, 1902, the County Council, with the consent of the Local Government Board, made an Order extending this requirement to the whole of London. This requirement was continued in force until January, 1903, by subsequent Orders made in April and October. The Council, moreover, in the early part of February, 1902, appointed medical men who had had experience of smallpox to consult with medical practitioners who desired a further opinion on any suspected case of the disease. Under this arrangement medical practitioners availed themselves of this opportunity in 1,153 cases in 1902. Medical officers of health express different opinions as to the value of notification of chicken-pox in bringing to their knowledge cases of smallpox which would otherwise have remained unknown to them. Some are of opinion that it was not of practical value ; on the other hand, Dr. Bate, the medical officer of health of Bethnal-green, states that sixteen persons who were reported to have chicken-pox were found on examination to be suffering from smallpox, and he adds that " undoubtedly these persons would have remained at home distributing infection had chicken-pox not been reportable." In Hackney twenty-two cases of smallpox were mistaken for chicken-pox, and Dr. Warry, the medical officer of health, states that notification of chicken-pox was a measure of great value. A smaller number of such cases is also reported by some other medical officers of health as occurring in their districts. Thus, there were two cases in Paddington, three cases in Woolwich, three cases in Finsbury, as well as two cases in Wandsworth, which would not otherwise have become known. From returns furnished by medical officers of health, relating to some 4,000 cases, it is recorded in more than 100 instances that infection was traceable to a previous case, erroneously regarded as chicken-pox. The use of notification of chicken-pox cannot, however, be fully estimated bv such occurrences, for not the least of its value must undoubtedly have been the direction of public attention to the possibility that cases of smallpox might be mistaken for chicken-pox, and to the need for more critical examination of all persons suffering from eruptions presenting the appearance of chicken-pox. Notwithstanding the efforts made to secure correct diagnosis, the reports of the Metropolitan Asylums Board show that in 1901 13.3 per cent, of persons who were removed to the wharves, with a view to transmission to the hospitals, were not, after removal, deemed to be suffering from smallpox, and in 1902 in 8 8 per cent. of those thus removed the diagnosis was regarded as erroneous. (b) Removal to hospital.—With very few exceptions, the whole of the cases of smallpox which became known to the medical officers of health were promptly removed to hospital by the * These rated are calculated upon the number of cases notified during the two years after correction for errors in diagnosis. This correction reduces the total notified cases by 6 per cent., a percentage which would probably have been much larger but for the fact that notification was frequently delayed until after the diagnosis had been confirmed at the South Wharf. 30 Metropolitan Asylums Board. In a few instances the nature of the malady was not recognised until the sufferer was found to be dying from a malignant type of the disease. In certain other cases the disease was not recognised until after recovery. In no single instance was failure reported to remove to hospital cases of the disease for which application was made, and testimony to the promptitude with which removals were effected is found in many of the reports of medical officers of health. (c) The supervision of persons exposed to infection.—The system of keeping under observation persons who had been exposed to infection was largely adopted during the epidemic. This, indeed, was a course followed in every district, and early in 1902 the Council's Public Health Department was utilised for immediate daily distribution to every medical officer of health in London of particulars as to cases of smallpox occurring, and also of the addresses of persons who had been exposed to infection, this information being transmitted by medical officers of health for this purpose. In this way, medical officers of health obtained information of the addresses of persons residing in their districts who had been exposed to infection in other districts, and such " contacts " were able to be visited, offered vaccination, and removed to hospital in an early stage of the disease if they subsequently sickened with smallpox. It was a frequent practice, especially in the early part of the epidemic, to endeavour to limit the extension of disease by informing employers whenever any of their staff were found to have been living in a house in which a case of smallpox occurred. The result was, in many cases, that the employee was suspended from work, and where no allowance was made for his maintenance or that of his family by his employer, or by the sanitary authority, hardship was often suffered. Dr. Warry gives his experience in Hackney of this procedure. "The result, in the majority of cases, was that many persons were reduced to the brink of starvation, for a large number, although in great want, would not apply for parish relief ; and as a matter of fact, the Guardian officials did not like persons coming from infected houses and applying for relief, neither did they like visiting the unfortunate contacts in their houses." Nor does the result of such action always appear to have been of sufficient value to compensate for the disturbance of wage earning. Dr. Harris, medical officer of health of Islington, found that " these employees were thrown on their own resources to fill in their time, and although they might stay at home for a few days, they would then generally go into the streets, loiter at the hall doors, or find their way to the nearest public-house." Question, therefore, arose in a number of districts whether steps should be taken to prevent the extension of disease by inducing the inmates of infected houses to remain within doors, a course which involved the abandonment of work and wage earning, and the maintenance of the household at the cost of the rates. In February, 1902, the Local Government Board addressed a circular letter to London sanitary authorities on the question of the quarantining of persons living in dwellings invaded by smallpox. The letter stated that the Board " are advised that under ordinary circumstances the quarantining at their homes of inmates of such dwellings is not necessary in districts in which sanitary matters are properly administered and vaccination and re-vaccination are properly carried out. If, on a dwelling becoming invaded by smallpox, the actual patients are at once removed to hospital, the dwelling, and all articles in it that have been exposed to infection, including the clothes worn by the other inmates, are properly disinfected, and the other inmates of the house are immediately vaccinated or re-vaccinated (as the case may be), there is no material advantage to be gained by keeping these other inmates at home. They are not likely to infect other people unless they themselves develop smallpox ; and all that is required is to keep such persons under medical observation for a fortnight, and particularly to examine them carefully day by day towards the end of the second week from their exposure to infection, in order to ascertain whether any of them are developing smallpox. If none of them do so by the beginning of the third week from exposure, the re-vaccination (or vaccination) to which they were submitted on the occurrence of the first case in the invaded house should secure them from attack by the disease. The Board considers that in ordinary circumstances the course of action indicated above is the correct one. Occasions, however, may arise in which additional precautions may be necessary, as, for example, when laundries are in question, or where the business or habits of the members of the invaded house are such as to make it difficult for medical observation of them to be maintained. In exceptional cases of this kind, in which the Council are advised by their medical officer of health that in the special circumstances it is essential that the inmates should remain in their own houses, the Board would be prepared to sanction a reasonable expenditure in securing such a result." The impracticability of the wholesale quarantining of all persons exposed to infection when smallpox is widely distributed is, of course, obvious. The actual number of such persons during the recent epidemic cannot be shown, but some idea of the magnitude of this number can be formed by reference to the annual reports of a few of the medical officers of health. Thus in Westminster, where there were 301 cases of smallpox, there were 2,677 persons living in houses in which cases of smallpox occurred, and there were 3,108 additional "contacts" who had otherwise been exposed to smallpox bv visiting: persous suffering from the disease, or working with such persons, or in other ways. In Woolwich, in which 245 cases of smallpox occurred, there were 1,673 " contacts." In Lambeth, where 404 cases of smallpox occurred, there were 4,182 " contacts " exposed to infection in the district, and 739 " contacts " exposed to infection elsewhere. In Wandsworth, in which 143 cases of smallpox occurred, there were 880 " contacts." In these districts there were, therefore, 1,093 cases of smallpox and 13,259 " contacts." Only in Poplar was money expended on a large scale in providing for " contacts " in their own homes. Thus between the 4th December, 1901, and the 12th September, 1902, in which period some 660 cases of smallpox occurred, £1,089 was expended on the supply of food to persons whom 31 it was desired to retain in their homes. The sums expended in other districts were much smaller. Thus in Hackney, in which 467 cases of smallpox occurred, £74 11s. was expended in payments to contacts," and in Lambeth, in which 404 cases occurred, £53 8s. was so expended; in Paddington, in which 117 cases of smallpox occurred, £93 was paid to persons working in laundries, at dressmakers, and in a few other cases ; and in Stoke Newington, in which 67 cases occurred, £43 13s. 11d. was expended on " contacts." In Bermondsey, in which there were 297 cases in the period October 12th, 1901, to September, 1902, a sum of £89 7s. 8d. was expended in compensation for loss of work. Large use was made of the shelters provided by sanitary authorities for the accommodation of persons during the period in which their houses were undergoing disinfection, and sometimes for the better observation of such persons. In certain districts in which there had been omission to establish a shelter as part of the permanent provision for dealing with infectious disease, accommodation for this purpose was sought. In Bethnal-green a house was obtained and furnished; in Poplar two houses in the Bromley depot were utilised for this purpose; in Holborn, in addition to the existing shelter, a house belonging to the Borough Council was made available; and in Stepney three additional shelters were acquired, two at Hose-lane and one at Emmott-street. The extent to which shelters were used varied in different districts. In Southwark effort was made to induce the members of all infected families to enter the shelter, and thus as many as 135 persons in 1901 and 678 persons in 1902 up to the 21st June were accommodated. Large use was made of this opportunity to secure the vaccination of the inmates, and as many as 550 persons were thus vaccinated or re-vaccinated. (d) Vaccination or re-vaccination of persons exposed, to smallpox infection.—The accumulation of a large number of unvaccinated children in London rendered of especial importance during the recent epidemic the promptitude with which vaccination was offered to the inmates of invaded houses and the willingness of the inmates to accept the services of the vaccinator. The reports of a few of the medical officers of health tell of the actual results obtained under the circumstances which existed. Thus Dr. Davies gives account of 1,673 persons known to have been exposed to infection of smallpox in Woolwich. Of these, 1,171 were vaccinated within three days of exposure to infection, or had been vaccinated in the previous ten years, and only one of these persons contracted smallpox; 420 " contacts " refused vaccination or were otherwise unprotected by vaccination in the ten years before or within three days after exposure to infection, and 45 of these persons contracted smallpox; eight contacts had never been vaccinated before exposure to infection and not vaccinated within three days of exposure, and of these 2 were attacked. Dr. Priestley gives the result of his experience in Lambeth. He does not, as does Dr. Davies, distinguish in his figures between a vaccination within three days of exposure to infection and a vaccination after a longer interval, but he gives the results of exposure of Lambeth residents to infection. Of persons over 10 years of age, 1,254 previously vaccinated persons were re-vaccinated after exposure and 11 sickened; of 2,184 previously vaccinated persons who were not re-vaccinated, 88 sickened; of 568 persons who had been previously re-vaccinated or had had smallpox, 5 sickened; of 37 unvaccinated persons who remained unvaccinated, 9 sickened, and of 3 unvaccinated persons who were vaccinated after exposure, all sickened. So again, with children under 10 years of age, 99 were re-vaccinated after exposure and 1 sickened; of 727 previously vaccinated children who were not re-vaccinated, 6 sickened; of 109 previously unvaccinated children vaccinated after exposure, 6 sickened ; and of 73 unvaccinated children who remained unvaccinated, 12 sickened. Dr. Priestley's figures show that the attack rate of persons previously vaccinated and re-vaccinated after exposure was nearly .9 per cent.; of persons previously vaccinated but not vaccinated after exposure, 3.2 per cent.; of persons re-vaccinated or who had smallpox before exposure, 9 per cent.; of persons previously unvaccinated but vaccinated after exposure, 8'0 per cent.; and of persons who were neither vaccinated before or after exposure, 19 per cent. Some information under this heading is supplied by a few other reports, but it is less detailed in its character. Dr. Bond reports that in Holborn, in all houses in which a case of smallpox was notified on the first day of the rash, and all the people in the house were vaccinated or re-vaccinated who had not been vaccinated within five years, no further case of smallpox arose. Dr. Jackson states that in Fulham no case occurred among those who were vaccinated within four days of exposure, while eleven cases occurred among those who refused to be at once vaccinated. In Wandsworth, Dr. Caldwell Smith says, only four cases occurred among persons vaccinated or re-vaccinated in the incubation period. Dr. Allan writes that in Westminster " a certain proportion of persons who had been in contact with cases of smallpox were found to be unvaccinated ; as promptly as possible they were vaccinated if they would permit it to be done, and a considerable number of persons must have been protected thereby, as in no case did an unvaccinated person who had been exposed to infection escape." There is no doubt that resort to vaccination or re-vaccination of persons after exposure to smallpox has been largely instrumental in limiting the spread of the disease in London. The value of this measure in affording protection, however, altogether depends upon the interval of time elapsing between the infection and the subsequent operation. Mr. Marson, who was many years resident medical officer of the London Smallpox Hospital at Highgate, wrote— " Suppose an unvaccinated person to inhale the germ of variola on a Monday: if he be vaccinated as late as on the following Wednesday the vaccination will be in time to prevent smallpox being developed ; if it be put off until Thursday, the smallpox will appear but will be modified ; if the vaccination be delayed until Friday, it will be of no use, it will not have had time to reach the stage of areola, the index of safety, before the illness of smallpox begins ; this we have seen over and over again, and know it to be the exact state of the question. Re-vaccination will have effect two days later than will vaccination that is performed for the first time, because 32 re-vaccinated cases reach the stage of areola two or three days sooner than in those persons vaccinated for the first time." (Reynold's System of Medicine.) The Lambeth figures show that re-vaccination after exposure of previously vaccinated persons was able to reduce the proportion of attacks more largely than the vaccination after exposure of previously unvaccinated persons. The difference is probably due to the fact that a re-vaccination, as Marson points out, runs a more rapid course than a primary vaccination. Reports of other medical officers of health supply further information as to the importance of limiting the interval of time elapsing between infection and subsequent vaccination. Thus Dr. Caldwell Smith writes that in Wandsworth "no case occurred in a re-vaccinated person, and only four among persons vaccinated or re-vaccinated in the incubation period. One of these was re-vaccinated within three days, but the re-vaccination was unsuccessful. Another was revaccinated on the fifth day, a third on the sixth, and a fourth, an unvaccinated infant, was not vaccinated until nine days after exposure to infection." Dr. Jackson states that in Fulham " on case occurred among those who were vaccinated within four days of their exposure to infection, while eleven cases occurred among those who refused to be at once vaccinated." Dr. Bryett mentions the attack of a disinfecting officer in Shoreditch who was not re-vaccinated until 48 hours after beginning his work. He suffered, however, from a very slight attack of smallpox. Dr. Allan writes that in Westminster "twelve persons [who subsequently suffered from smallpox] had been re-vaccinated within the infected period (twelve days); of these, three were less than four days before the patient began to feel ill, and probably, therefore, eight days after receiving the smallpox infection ; six were between four and six days ; and three were between eight and ten days. With one exception, all these were modified cases ; the exception was a female with one mark, who developed confluent smallpox, caught from her husband who had the hsemorrhagic type, in which possibly the incubation period is shorter than in ordinary smallpox." Through the courtesy of the Metropolitan Asylums Board I am able to show in the following table the interval which occurred between the vaccination after exposure to infection and the appearance of the eruption of smallpox of those persons in London who subsequently suffered from that disease. Interval between vaccination after exposure to infection and subsequent appearance of eruption of smallpox. Total cases. Interval in days. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 More than 14 Previously vaccinated 262 13 20 26 30 25 33 41 31 16 17 4 4 1 - 1 Not previously vaccinated 344 14 17 19 22 25 36 44 72 51 23 14 4 - 1 2 The incubation period of smallpox is usually stated to be twelve days and the eruption appears on the third day of the illness, i.e., on the fourteenth or fifteenth day after infection. In all infectious diseases there are variations in the actual period of incubation, as well as variations in the period which elapses between the first symptoms and the appearance of the eruption. Assuming, however, that the periods above mentioned are in the case of smallpox fairly constant, it will be seen that the behaviour of the disease was in very few cases different from that observed by Marson, i.e., very few cases of smallpox occurred in which the sufferer had been vaccinated or re-vaccinated within 48 hours after infection, or, in other words, who had been vaccinated or re-vaccinated more than 12 days before the appearance of the eruption. The further point will be noticed that the average interval between a re-vaccination and the appearance of the eruption of smallpox was less than the average interval between a primary vaccination and the eruption, in the former (if cases with a longer interval than 14 days be excluded) the interval was 5.8 days, in the latter 6 8 days; i.e., assuming the interval between infection and the appearance of the eruption to be fourteen days, the average interval between the infection and the re-vaccination was 8'2 days, and between the infection and the primary vaccination was 7.2 days, or, in other words, the interval during which the re-vaccination afforded protection was a day longer than the interval during which primary vaccination protected. As already stated, the early vaccination of persons known to have been exposed to smallpox must have largely limited the spread of the disease. Necessarily, however, in numerous cases the sufferers did not know that they had been exposed to infection. Indeed, averaging the results obtained by several medical officers of health, it may be stated that it was impossible to discover the source of infection in more than one-third of the cases which occurred, and no doubt in many cases the source of infection, even when discovered, was unknown until after the attack of the persons whose illness led to the inquiry. In many cases, moreover, a person attacked by smallpox was not recognised to be suffering from this disease until the period had elapsed in which the vaccination or re-vaccination of other persons he was infecting would have protected them from smallpox. Some estimate can be formed of the period of illness at which the nature of the disease was recognised, bv the information contained in several reports as to the day of illness on which the patient was removed to hospital, for so prompt was the administration of the Metropolitan 33 Asylums Board, that within one or two hours of the receipt at the Board's offices of the necessary intimation, the ambulance usually had arrived at the invaded house. The following statement of the period of disease at which the patient was removed must, therefore, show very nearly the period which had elapsed before the nature of the malady was recognised— Day of removal, the day of onset being numbered 1.* 1 2 3 4 5 6 7 8 9 10 11 12 13 or more. Shoreditch 2 27 82 84 76 42 23 9 2 1 ... 1 3 Chelsea ... 1 8 9 11 7 3 1 1 ... 1 ... Southwark ... 5 12 33 25 9 11 2 2 ... ... ... 1 Fulham 1 9 22 39 8 6 ... ... 1 ... ... ... 2 Stepney 1 9 16 24 25 12 8 4 ... ... ... ... 1 It will be seen, therefore, that a considerable proportion of the persons attacked must have been a source of infection to others for several days before the risk to the exposed persons was recognised and the protection of vaccination could be sought. Having regard to all these facts, it is obvious, therefore, that to postpone vaccination or re-vaccination until the fact of exposure to smallpox is known, is for the individual to incur considerable risk at times of prevalence of the disease. As an administrative measure applied to a large population, the resort to vaccination and re-vaccination only at such times is for the community but an imperfect substitute for routine vaccination and re-vaccination irrespective of exposure to infection. (e) Measures adopted for the prevention of smallpox in children.—In previous reports I have referred to the large proportion of children born in London appearing in recent years 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 1900 are not yet available. London vaccination returns. Year. Children not finally accounted for (including cases postponed, and for which "certificates of exemption " were granted) per cent. of total births. Year. Children not finally accounted for (including cases postponed, and for which " certificates of exemption" were granted) percent. of total births. 1872 8.8 1887 9.0 1873 8.7 1888 10.3 1874 8.8 1889 11.6 1875 9.3 1890 13.9 1876 6.5 1891 16.4 1877 7.1 1892 18.4 1878 7.1 1893 18.2 1879 7.8 1894 20.6 1880 7.0 1895 24.9 1881 5.7 1896 26.4 1882 6.6 1897 29.1 1883 6.5 1898 33.0 1884 6.8 1899 27.7 1885 7.0 1900 25.8 1886 7.8 It will thus be seen that at the beginning of the epidemic a large proportion of the child population of London was unprotected by vaccination, hence attention was early directed to the risk from smallpox to which these children were exposed. With a view to securing as far as practicable the early vaccination of children who had up to that time remained unvaccinated, leave was sought for the examination of the arms of children in the elementary schools. After receiving a letter from the Local Government Board in September, 1901, the London School Board adopted the following resolution— " That facilities be given to the public vaccination officers of the metropolis, on the application of the proper 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 figures for Shoreditch and Chelsea are extracted from the reports of the medical officers of health ; those for Southwark and Stepney are based upon information contained in the reports as to each case, the first 100 beiug taken as a sample. The Stepney and Southwark cases do not include any which occurred in common lodging-houses. [5] 34 the parents asking if they have any objection to their 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." The results of examination of the arms of school children are given in some of the reports of medical officers of health. In Hackney there were 30,990 children on the rolls; in the case of 15,016 children there were refusals of parents to permit examination, and of 12,890 children examined 3,461 were found to be unvaccinated. In Finsbury there were 15,652 children on the rolls; for one-third there were refusals, but among the remaining two-thirds examined 2,617 were found to be unvaccinated. In Wandsworth there were 16,142 children on the rolls ; for 5,212 there were refusals, and of 8,967 children examined 1,138 were found to be unvaccinated. In Fulham, of 21,121 children on the rolls, 12,487 were examined, and of these 870 were unvaccinated. The number subsequently vaccinated was 367. In the St. Giles and Bloomsbury division of Holborn there were 2,920 children on the rolls ; for 263 there were refusals, 2,657 were examined, and 568 found to be unvaccinated. In the Holborn division there were refusals for about one-third of the children on the rolls, and about another third were found to be unvaccinated. As the result of the examination, fully 1,000 children in this division were vaccinated, and more than another 1,000 re-vaccinated. In Westminster, in St. George's Union, 780 unvaccinated school-children were found, in Westminster Union 738 unvaccinated children were found among 2,994 examined. In this Union in 168 instances the parents refused to allow their children to be examined, but 76 of these children were subsequently vaccinated. In the Strand Union, of the children examined, 88 were found to be unvaccinated, but the arms of 116 children were not permitted to be examined. In Chelsea 6,779 children were examined, but the results are not stated. Altogether the arms of children were examined in the City and in Kensington, Fulham, St. Marylebone, Westminster, Islington, Bermondsey, Wandsworth, Greenwich, Lewisham, Woolwich, Hackney, Holborn and Finsbury. Notwithstanding the large number of parents who refused to allow their children to be examined, great impetus was given to the vaccination of children, and in some degree the arrears of vaccination in recent years was overtaken. It is interesting to note that only two instances are mentioned in the annual reports of the closure of schools on account of the: occurrence of smallpox among the scholars. These schools were situated in Bermondsey. In the annual report for the year 1900 it was stated— Estimates may, however, be made of the proportion of children under ten years of age in the London population who in 1898 were unvaccinated, assuming that the general rate of mortality has been the same among vaccinated and unvaccinated, and that those who in the vaccination returns are described as " unaccounted for" were not subsequently vaccinated. By applying the figures of the English life table of 1881-90 to the number of children " unaccounted for " in respect of vaccination in each year of the period 1889-1898, it is found that approximately 25 per cent, of the children born during that period and surviving to 1898 were unvaccinated. If these populations are applied to cases of smallpox properly belonging to them received into the hospitals of the Metropolitan Asylums Board, of which 16 cases had vaccination cicatrices and 428 had no vaccination cicatrices, the attack rates are 21 per million and 1,715 per million respectively. In other words, for every child attacked among those having vaccination cicatrices, 82 children were attacked who had no such cicatrices. The number of deaths among the former class was nil, among the latter class 131, giving death-rates of 0 and 525 per million. In similar way, if the cases and deaths under ten years of age in the ten years 1893-1902 are applied to two populations, viz., about 75 per cent, vaccinated and about 25 per cent, unvaccinated, thus including the epidemic years of 1901 and 1902, a very different result is obtained. Instead of 82 unvaccinated children being attacked to one vaccinated child, only 29 unvaccinated children were attacked to one vaccinated child, and instead of 131 unvaccinated children dying to 0 vaccinated, 912 unvaccinated children died to one vaccinated.* The annual report of the medical officer of the Local Government Board for the year 1901-2 shows an increase in the number of primary vaccinations at " all ages " in 1901 of more than 29 per cent, over the number in 1900. The return of the vaccination officers for the years 1901 and 1902 are not vet published, but through the courtesy of the clerks of the Boards of Guardians I have been supplied with information as to the number of primary vaccinations in that year in 21 unions. This information shows that in these Unions the number of primary vaccinations at all ages was in 1902 over 60 per cent, more than the number in 1900. If this increase has been maintained throughout the whole of London, and such vaccinations had been solely among children under 10 years of age, it would not, as an arithmetical statement, suffice to explain the whole of the fall in the proportion of attacks in unvaccinated children as compared with the attacks in vaccinated children, but it needs to be recollected that this larger number of vaccinations in 1901 and 1902 would necessarily have taken place especially in infected houses and areas, and would thus have determined the alteration in the proportions noted in much greater degree than if they had been evenly distributed throughout the population. Nevertheless, the neglect of vaccination in years preceding 1901 and 1902 has not been without its influence in determining the relative incidence in the several Unions of attack by smallpox of children under 10 years of age in proportion to the attacks at all ages.t This will be seen by reference to diagram VI. which is based upon the London cases admitted during the epidemic into the hospitals of the Metropolitan Asylums Board. (/) Measures adopted for the prevention of the spread of smallpox in common lodging-houses. In the period August, 1901, to August, 1902, about 800 residents in common lodging-houses were attacked by smallpox, the first case occurring on the 28th August, 1901. The distribution of cases in these houses in London is shown in the following table— * It has been stated that one of the children who died, and who was included among the unTaccinated, had been vaccinated. In such event, this would reduce the proportion to one death among the vaccinated to 459 deaths among the unvaccinated. † As the figures relating to infants " not finally accounted for " in the vaccination returns in the epidemic years 1941 and 1902 are not yet available, the number of cases of smallpox occurring among children aged 0-1 has been excluded from the figures upon which the diagram is based. — Smallpox, ( London) 1901-2.— Diagram showing the proportion of cases of smallpox at ages 1-10 of total cases in each poor law union in relation to Vaccination Default. 35 Number of common lodginghouses. Authorised number of lodgers. Borough. 1901. 1902. Totals. Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. April May June July Aug. Aug., 1901, to Aug., 1902 9 508 Battersea - -- -1 - 1 - - - - - 2 6 930 Bermondsey - - - - - - - 2 2 1 6 - - - 11 18 781 Bethnal-green - 1 - - 1 - 2 1 6 1 1 — — 13 9 609 Camberwell - - - - - - - - - - 7 - - - 7 9 479 Chelsea - - - - - 1 2 - - - - - 3 9 545 Deptford - - 1 - - - - - - - -- - - 1 10 686 Finsbury - -1- - - 3 - - 1 - - - 5 3 93 Fulham - - - - - 4 - - - - - - - - - 4 7 228 Greenwich - - - - - - - - - - - - - - - - - - -- 8 426 Hackney - - -- - - - 4 - - - - - - 4 9 550 Hammersmith - - - 1 - - - — — 1 — — — 2 1 35 Hampstead - - - - - - - - - - - - - - 44 2,647 Holborn - - 8 14 25 10 6 7 5 1 2 1 - 79 43 1,432 Islington - - - - - 1 - 1 3 - - - — 5 34 1,062 Kensington— — — 1 — 1 3 1 2 - - - - 8 10 696 Lambeth — — — 1 — 2 1 - 2 - - — — 6 1 30 Lewisham - - - - — - — — — — — — — - 9 304 Paddington — — — - - - - - - - 12 1,450 Poplar - - - - - 3 14 2 3 14 1 - - 37 22 1,739 St. Marylebone 1 - 1 - - 6 11 6 1 4 2- - 32 16 1,085 St. Pancras - - - 1 4 1 1 - - 2 1 - - - 19 13 761 Shoreditch - - - - - 2 - 1 3- - - - 6 59 4,388 Southwark - 1 - 6 11 4 11 18 24 37 10 - - 122 96 7,863 Stepney - - 1 4 28 50 64 91 37 15 17 - 2 309 1 37 Stoke Newington - 1 2 1 — - — - — 4 10 231 Wandsworth - - - 3- -- - 3 27 2,102 Westminster - - 6 2 3 34 22 12 4 7 7 1 - 98 33 797 Woolwich - - - - - 1 1 1 - - 1 - - - 4 528 32,494 County of London. 1 2 18 43 71 120 144 149 96 96 40 2 2 784 The Council's administration aimed at the early detection of cases of smallpox in common lodging-houses with a view to their removal. For this purpose the houses were kept under close inspection, especial attention being given to houses in which a case of smallpox was known to have occurred. In such houses systematic inspection was made of the inmates, the houses being visited in the early morning, when the lodgers were most likely to be within doors, by officers who, for this purpose, were relieved of other inspectorial duties. Effort was made to induce lodgers, who had been living in houses in which smallpox had appeared, to continue to reside in such houses so as to prevent the infection of other houses which would result if they were to remove while incubating the disease. With a view to insuring, as far as possible, the continued residence of such lodgers where they could be kept under observation, the inducement of a free bed and, when necessary of small sums of money for the purchase of food was offered to them, and this was doue with much success. The money thus expended by the Council during the whole of the epidemic amounted to £35. The keepers of common lodging-houses, who co-operated largely with the Council in this matter, were able to learn when particular lodgers who had been indicated to them by the Council's officers were likely to leave their houses, and thus, without any general offer of bed and money to the lodgers as a whole, which would have involved a large expenditure, by dealing with particular persons the officers were able to secure the object in view at trifling cost. Lodgers who had been especially associated with any person attacked by smallpox were in their sleeping arrangements kept together in a particular room. Persons showing any ailment which raised suspicion of smallpox were, as far as practicable, kept from other lodgers and from the population outside until it was possible to determine the nature of their malady. It was, of course, impracticable when numerous houses were invaded to proceed in the same way as in the beginning of the outbreak when the Council rented the common lodging-house, 8 and 10, Parkerstreet, Drury-lane, and maintained the whole of the inmates, keeping them in quarantine; but much was done by the early detection of cases of smallpox to prevent the continued residence of infectious persons in these houses. Moreover, the Council obtained the sanction of numerous Boards of Guardians for the poor-law medical officer to examine, without previous order of the relieving officer, the inmates of common lodging-houses whose condition created suspicion of smallpox, and in certain localities where the common lodging-house population was much involved the Council appointed medical men to examine the inmates at a time in the morning before they had left the house so as to ensure the early detection and removal of infectious persons. It is difficult to estimate the extent to which this procedure limited the spread of smallpox in this class of the population, although there cannot be doubt that it was of considerable value. The inmates of common lodging-houses do not appear to have been especially susceptible to smallpox ; indeed, the results of inquiries made by the Council's officers showed that a considerable proportion had been re-vaccinated or had previously suffered from smallpox. Even, however, allowing for this, the attack rate, which was only about 3 per cent, of the population residing in these houses, must be regarded as low when the frequency of invasions of common lodging-houses and the condition of aggregation in which the inmates live, is considered. When a common lodging-house was involved to the extent of several lodgers being attacked, only the 36 vaccination of the inmates on a large scale can be pointed to as at once bringing the outbreak to an end; but the speedy detection and removal of infectious cases must have limited the exposure of other inmates to infection and reduced the number of cases which otherwise would have occurred among persons associating with the lodgers, whether within or outside the lodging-house. As a rule, comparatively little success attended efforts to induce the inmates of common lodging-houses to submit to vaccination. The Council exhibited a notice in all common lodging-houses advising the inmates to seek this means of protection against smallpox, and the Council's officers exercised such influence as tbey had over the lodgers, but the only inducement which was successful on a large scale was the course adopted in a few instances by the sanitary authority, viz., the offer of a small sum of money which would enable the lodger to live for a few days without work if the effect of the vaccination was such as to prevent him from following his employment. The behaviour of smallpox among the inmates of common lodging-houses was, as far as practicable, studied during the epidemic, and Dr. Hamer has summarised the experience gained in a report which is appended. (See appendix I.) (g) General administrative measures.—The action of London sanitary authorities in dealing with smallpox may be thus summarised. Notice of the occurrence of smallpox in any house was at once given by the medical officer of health to the vaccination officer, and usually to the public vaccinator, in order that the invaded house might be visited and the inmates who had been exposed to smallpox might be vaccinated or re-vaccinated. Lists of the inmates were made, and tne names and addresses of persons who had been exposed to infection, and who were resident in other districts were frequently communicated directly to the respective medical officers of health. Particulars as to cases of smallpox and of the persons who were exposed to infection were, as has been previously mentioned, sent to the County Council's medical officer, and through him communicated daily to every medical officer of health in London. Persons who had been exposed to infection were kept under observation until the expiration of the period of incubation so as to secure the speedy removal to hospital of any of them who developed smallpox. House-to-house inquiry in invaded areas for the purpose of securing the vaccination or re-vaccination of susceptible persons was made. Particulars as to the course adopted in each district, especially in connection with the steps taken to secure the vaccination and re-vaccination of susceptible persons, may here be given— Paddington.—Letters were addressed by the Public Health Department to all public elementary schools other than those under the School Board and to all private schools recommending vaccination, and asking for information as to unvaccinated children. In September, 1901, a vaccination station was opened. In the same month the public vaccinator was authorised to have the assistance of his deputy, and in January, 1902, a second assistant was appointed. Circulars were delivered at the instance of the Board of Guardians at each house in the borough, recommending vaccination and re-vaccination, and describing the arrangements which had been made. In February, 1902, a house-to-house visitation was made by two of the district medical officers in the " Clarendon-street area " to offer vaccination and re-vaccination to the inhabitants. Children in elementary schools were not inspected. An assistant vaccination officer was appointed. Kensington.—Notices were exhibited by the Board of Guardians giving the necessary information and the names and addresses of the public vaccinators. Children in elementary schools were inspected. No assistant vaccination officers were appointed. Under a system which has been in operation in Kensington since 1887 medical practitioners notifying cases of smallpox took the necessary steps for securing the patient's removal, receiving for this purpose a small fee from the Borough Council. Hammersmith.—Posters were exhibited by the Board of Guardians. No house-to-house inspections were made. No assistant vaccination officers were appointed. No vaccination station was opened. The arms of children in schools were not examined. Chelsea.—The Board of Guardians appointed three assistant vaccinators for a period of four months. To each of these additional vaccinators a district was assigned. The Board of Guardians exhibited notices on the church and other public notice boards as to the arrangements made for vaccination, and the Borough Council printed and circulated a leaflet recommending vaccination and re-vaccination, which was left at every house in the borough. At the request of the Public Health Committee the Board of Guardians authorised their public vaccinator and vaccination officer to inspect the children in the elementary schools. No assistant vaccination officers were appointed. Fulham.—The Board of Guardians issued notices on the subject of vaccination. Inquiries were made by the medical officer of health and the vaccination officer in invaded areas, and children in elementary schools were inspected by the public vaccinator on the application of the Board of Guardians. No assistant vaccination officers were appointed. Westminster.—The City Council issued notices to employers, hotels and clubs throughout the City, recommending re-vaccination. The Strand and Westminster Guardians took early steps in the matter of vaccination. The St. George's Guardians eventually fell into line with the other two Boards. The St. Clement Danes Hall was opened by the Strand Guardians as a vaccination station from the 29th October to the 23rd December, 1901, and from the 24th January to the 11th April, 1902, and three deputy vaccinators were appointed. Children in schools were inspected in each Union. St. Marylebone.—Posters were exhibited and communications sent to all employers and to all schools. Three assistant public vaccinators were appointed, two public vaccination stations were opened. Children in schools were inspected, a house-to-house visitation was made except in "well-to-do" streets, and children inspected where possible. Hampstead.—Posters were exhibited and a house-to-house inquiry made. Two additional vaccinators were appointed and two stations opened. No additional vaccination officers were appointed. 37 St. Pancras.—The guardians exhibited posters and distributed handbills throughout the borough, and instructed the vaccination officers to make inquiries from house to house in infected ureas. The sanitary authority obtained permission for the public vaccinator to examine children's arms in schools, and the public vaccinator examined the arms of children in both public and private schools and advised the parents as to vaccination and re-vaccination. An additional public vaccinator and two additional vaccination officers were appointed and a vaccination station opened. A public vaccinator visited various common lodging-houses with a view to re-vaccinating the inmates. All applicants for admission to the casual wards were vaccinated, and applicants for admission to the workhouse were quarantined and offered vaccination. Islington,.—A few notices giving the names and addresses of the public vaccinators and vaccination officers were issued by the Board of Guardians. Additional vaccination officers were not appointed. The sanitary authority exhibited posters, and a copy was delivered at every factory and workshop. A handbill was delivered to every householder. Children attending the public schools were examined as to their state of vaccination, and house-to-house visitation was made in several instances, particularly in the case of large artisans' dwellings. The sanitary authority recommended the guardians to appoint assistants to the vaccination officers, but their recommendation was not adopted. The medical officer of health states that the opening of vaccination stations did not appear to be required. Stoke Newington.—The Borough Council exhibited posters and distributed handbills recommending vaccination and re-vaccination. The arms of children in schools were not inspected. Special vaccination stations were not found necessary, but the public vaccinator found it necessary to have the assistance of a medical colleague. Hackney.—No special action appears to have been taken by the Board of Guardians. The Borough Council exhibited posters, and handbills were left at every house in the district. The Borough Council employed three medical men to examine the arms of children in schools. House-to-house inspection was made in specially infected areas. Holborn.—The Board of Guardians of St. Giles and Bloomsbury took prompt action. A house-to-house visitation was instituted. Placards respecting smallpox and vaccination were exhibited and handbills distributed. The arms of children in elementary schools were examined. An assistant vaccination officer was appointed. In the Holborn division house-to-house visitation was made by the vaccination officer in the neighbourhood of infected houses. The arms of children in elementary schools were examined. The Borough Council caused large posters to be exhibited throughout their district. Slips, with the address of the public vaccinator, were freely distributed. Finsbury.—Three vaccination stations were opened, one in each vaccination district. Bills were posted at each vaccination station and handbills provided. By order of the guardians each public vaccinator was required to appoint a deputy, hence six medical men were employed in public vaccination. One assistant vaccination officer was appointed for three months. The vaccination officers visited houses in proximity to invaded houses. The vaccination officers, accompanied by medical men, examined the arms of children in elementary schools. The Borough Council exhibited posters and distributed handbills to each house in the borough. House-to-house inquiry was instituted in each street in which smallpox occurred. City.—Vaccination stations were opened by the Board of Guardians, and extra public vaccinators were appointed. Posters were exhibited. The sanitarv authority addressed a letter to numerous firms in the City. The arms of children in the whole of the ward schools, infant schools and parochial schools were inspected by the medical officer of health. Children were also inspected in the Board Schools. Medical men were engaged by the Corporation to assist in the work of re-vaccination. Shoreditch.—Posters were not exhibited (except, perhaps, in the workhouse and infirmary) nor handbills distributed by the Board of Guardians or the sanitary authority. Vaccination stations were not opened nor assistant vaccination officers appointed. Children in schools were not inspected. Bethnal-green.—Posters were exhibited by the Board of Guardians setting forth the value of vaccination and the names and addresses of the public vaccinators. No assistant vaccination officers were appointed and the arms of children in elementary schools were not examined. Stepney.—Towards the latter end of 1901 the Whitechapel Guardians appointed two officers to assist the vaccination officer in visiting infected houses, and this action was followed by the Guardians of St. George-in-the-East, by the Stepney Guardians, and later by the Guardians of Mile-end Old Town. A vaccination station was opened in each of the four unions. In January, 1902, placards were posted throughout the borough giving the names and addresses of the public vaccinators and the hours of attendance at the vaccination stations. The arms of children in elementary schools were not examined except in the case of one school ; this was done by the medical officer of health. Poplar. Vaccination stations were opened in 1902, and assistants to the public vaccinators appointed. Notices were issued as to the vaccination stations. Handbills, etc., were distributed by the Guardians. The arms of school children were not examined. Southwark.—The Board of Guardians distributed a circular giving the names and addresses of the public vaccinators. House-to-house inquiry was not made by the vaccination officers. Additional vaccination officers were not appointed and vaccination stations were not opened. The arms of children were not examined in schools. The Borough Council distributed papers containing information as to smallpox, and two female inspectors were employed in making a house-to-house inquiry for unvaccinated persons in streets in which cases of smallpox occurred. A circular letter was sent by the medical officer of health to employers informing them that if they wished it the public vaccinator would attend and vaccinate persons in their employ. The medical officer of health himself vaccinated or re-vaccinated 2,269 persons. As many as 819 38 persons, who had been in contact with cases of smallpox, were lodged and maintained in the reception house of the Borough Council for an aggregate of 3,022 days. Bermondsey.—Posters were exhibited and handbills distributed by the sanitary authority. Vaccination stations were not opened, and assistants to vaccination officers were not appointed. The arms of children in schools were examined by the public vaccinator and vaccination officers. House-to-house inquiry was made when necessary by the officers of the Borough Council. Lambeth.—The arms of children in schools were not inspected. No vaccination station was opened, and the medical officer of health did not regard this as necessary. Assistant vaccination officers were not appointed. The vaccination officers made house-to-house inquiry in infected streets. The Guardians exhibited posters advising vaccination and giving addresses of public vaccinators. No other notices were issued by the Guardians or Borough Council. Battersea.—Assistants to the vaccination officers were not appointed, a vaccination station was not opened. No notices as to vaccination were issued by the Board of Guardians or the Borough Council. The arms of children in schools were not examined. A house-to-house inquiry was made by the vaccination officer in infected areas. Wandsworth.—Assistants to the vaccination officers were not appointed, and a vaccination station was not opened. The sanitary authority issued posters and handbills advising vaccination and re-vaccination, and the arms of children in schools were examined by two medical men appointed by them. Camberwell.—An assistant vaccination officer was appointed. The vaccination officers made house-to-house inquiry in streets in which smallpox occurred. The sanitary authority exhibited posters. Children's arms were not inspected in schools. Deptford.—No assistant to the public vaccinator or vaccination officer was appointed. A vaccination station was not opened. Posters were exhibited and the officers of the Borough Council made house-to-house inquiry in invaded areas. The arms of children in schools were not examined. Greenwich.—No assistant to the vaccination officer was appointed, and a vaccination station was not opened. The Borough Council exhibited posters and distributed leaflets advising vaccination. House-to-house inquirv in invaded areas was in the main made by the vaccination officer, and on occasion by the medical officer of health and sanitary staff. The arms of children attending the whole of the public schools and many private schools were inspected by the medical officer of health, accompanied by the vaccination officers. Large employers of labour were advised as to the desirability of the vaccination of their staff, and several arranged for the attendance of the public vaccinator for the purpose. Lewisham.—A vaccination station was not opened. The arms of children in schools were examined by order of the Board of Guardians. Special circulars were issued and bills were exhibited. No assistant vaccination officers were appointed. The medical officer of health vaccinated persons in a number of houses. A stock of iymph was kept available for all practitioners free of charge. Woolwich.—An assistant vaccination officer was appointed and the public vaccinator obtained the services of other medical men. A vaccination station was opened at the Royal Arsenal. The arms of children in schools were examined by the public vaccinator and vaccination officer. When smallpox first occurred in London posters were printed recommending re-vaccination. Later, a bill was delivered at each house in the borough. Social condition of persons attacked by smallpox. In Appendix II. will be found an analysis by Dr. Hamer of the returns relating to some 4,000 cases in which particulars were given of the occupation of the persons attacked by smallpox. It will be sufficient here to refer to two classes, (a) persons employed in laundries, and (6) persons employed by local authorities who were especially exposed to smallpox infection. In several instances reference is made by medical officers of health to the infection of persons employed in laundries. Thus 13r. Collier, the medical officer of health of Hammersmith, states that between 16th July, 1901, and 19th June, 1902, 91 cases were notified as occurring in private dwelling-houses in Hammersmith. "Of this number, 22 of the patients were either employed at laundries, or there was evidence that they had contracted the disease from persons who were employed at laundries, and who were suffering from the disease." A tabular statement in the report of Br. Allan shows that in Westminster two laundry-women were attacked by smallpox. In Shoreditch three laundry-women were attacked. In Kensington six were attacked, five of these cases being secondary. In Wandsworth, the linen from an infected house was sent to a laundry in which two laundry-maids were subsequently infected, two other persons being infected by one of these maids. * In Woolwich a laundry-man was attacked. This, probably, is not a complete record, but such information as is available, while pointing to the infection of the workers in the laundry by infected linen, does not give any indication of attack of persons who received linen from the infected laundries. It needs, however, to be stated that much care was taken to disinfect linen from such laundries. In connection with the occurrence of smallpox among persons employed by the sanitary authorities, the following information is supplied by the reports of medical officers of health— In St. Pancras, at the beginning of the outbreak, an inspector and a disinfector were attacked, as well as several of the cleansers of infected rooms. In Holborn all the permanent staff of the Public Health Department were re-vaccinated (except one who had been re-vaccinated 18 months before), and all escaped smallpox, but of men who were employed temporarily in disinfection, and who were not re-vaccinated (except one who was. re-vaccinated five days after his work began) six suffered from smallpox, including the man re-vaccinated too late. 39 In Islington, every member of the staff of the Public Health Department had been re-vaccinated at the beginning of the epidemic, except one. This was the only one who contracted smallpox, although 42 persons were exposed to direct and 7 to indirect infection. In Stoke Newington all the members of the staff whose duty brought them into contact with smallpox infection were re-vaccinated, and escaped attack, but a servant in the surveyor's department who had not been re-vaccinated, on one occasion, against orders, assisted a disinfector, and contracted smallpox and died. In Shoreditch the members of the sanitary staff who had not had smallpox, or been recently re-vaccinated, 18 in number, were re-vaccinated, except one who was not re-vaccinated until 48 hours after beginning his work ; all escaped but this man, who suffered from a slight attack of smallpox. In Bethnal-green only some of the staff were re-vaccinated. Nine sufEered from smallpox, only one of whom was re-vaccinated, and his re-vaccination took place only six days before his removal to hospital, and therefore too late to protect him against attack. In Stepney, at the beginning of the outbreak, all the sanitary inspectors, clerks, and disinfectors were re-vaccinated. During the height of the epidemic 21 men were employed in the removal of infected clothing and in disinfecting rooms. The driver of the disinfecting van was employed by the contractor, and he was the only man who was not re-vaccinated, and the only one who contracted smallpox. In Lambeth the staff (including disinfecting men, inspectors, strippers, sanitary clerks, and others) who had not been sufficiently protected by re-vaccination or otherwise were re-vaccinated, and no single official was attacked. In Battersea 29 members of the staff were re-vaccinated, and not one of these contracted smallpox; 11 refused re-vaccination and 5 of them were attacked. In Wandsworth all the staff (23 in number) had been re-vaccinated at the beginning of the outbreak, and not one of them was attacked. In Greenwich all the staff likely to come in contact with cases of smallpox were revaccinated, except one who had had smallpox. None of them were attacked. To these cases may be added three medical officers and 18 inspectors of common lodginghouses iu the service of the London County Council, who were re-vaccinated and all of whom escaped smallpox. Thus the information supplied shows that all those persons stated to have been re-vaccinated before beginning their work escaped attack by smallpox, while numerous other persons, in whom this precaution was delayed or neglected, suffered from the disease. No member of the staff employed in the smallpox hospitals of the Metropolitan Asylums Board contracted the disease in 1901, among the 578 persons so employed. In the year 1902, however, out of 989 persons employed in the smallpox hospitals of the Board, two nurses were attacked by smallpox. One of these nurses, who was attacked in April, had, in the preceding December, sufEered from smallpox, and in consequence was not re-vaccinated on taking up her duties at the hospital, the other nurse, who was also attacked in April, had not been re-vaccinated on taking up her duties at the smallpox hospital owing to the fact that she had been re-vaccinated five months before in one of the fever hospitals. Concerning this case, Dr. Ricketts, the medical superintendent reports," With regard to the question whether or not the re-vaccination performed five "months before was really successful, I have no direct evidence. All my own experience tells "against the former view. The medical officer who vaccinated her at the other hospital was "satisfied at the time." Age and sex incidence of smallpox. The following table shows the case-rates, death-rates, and fatality of smallpox at certain aere-periods, and for each sex during the year 1902— Smallpox,* 1902. 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 4,443 745 16.8 205 34 3,353 569 17.0 139 24 0— 89 56 62.9 160 101 87 49 56.3 158 89 1— 45 16 35.6 92 33 56 34 60.7 114 69 2— 55 19 34.5 111 38 47 21 44.7 95 42 3— 76 23 30.3 157 48 75 31 41.3 153 63 4— 80 23 28.7 169 49 71 15 21.1 151 32 5— 334 42 12.6 150 19 313 46 14.7 139 20 10— 272 31 11.4 130 15 333 44 13.2 156 21 15— 465 37 8.0 221 18 399 39 9.8 170 17 20— 702 63 9.0 320 29 484 47 9.7 184 18 25— 1,132 128 11.3 302 34 802 100 12.5 182 23 35— 683 161 23.6 241 57 407 70 17.2 130 22 45— 332 104 31.3 168 53 160 46 28.7 73 21 55 and upwards 178 42 23.6 92 22 119 27 22.7 47 11 * See footnote (*), page 51. 40 It will be seen that the case-rate at "all ages" was much greater among males than among females, as was also the death-rate, especially in the case of the older ages. The case mortality was, however, slightly lower 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 aged 20-25, and the greatest incidence of death was upon males and females under one year of age. The case mortality was greatest among males under one year of age, and among females aged 1-2 years of age. The marked incidence of the disease on males of the later ages was equally conspicuous in the outbreak 1893-4-5, and is no doubt due in large degree to the fact that the inmates of common lodging-houses furnished a large number of cases in both epidemics. These houses are principally occupied by males, the approximate numbers of male and female lodgers living in these houses in London being 25,000 and 2,500 respectively. There is, however, a difference observable between the two epidemics as regards the age distribution of cases of the disease, the relative incidence of smallpox being smaller on the younger ages in 1901-2 than in 1893-4-5. This will be seen by reference to the following table— Cases of smallpox at ages per cent, of total cases. Ages. 1893-4-5. 1901-2. 0—5 7.7 7.8 5—10 8.4 7.6 10—15 10.7 8.1 15—25 31.4 26.7 25 and above 41.8 49.8 The percentages in the period 1893-5 are obtained from the tabular statements in the reports of the Statistical Committee of the Metropolitan Asylums Board, which include all the cases admitted into the hospitals, about three per cent, were not London residents. If the age distribution of the cases of smallpox in the two periods be considered in relation to vaccination, the following results are obtained— Ages. Vaccinated. Unvaccinated. Doubtful. 1893-4-5. 1901-2. 1893-4-5. 1901-2. 1893-4-5. 1901-2. 0—5 .4 .3 32.2 31.1 1.3 2.0 5—10 2.8 1.6 25.6 25.2 7.1 6.6 10—15 9.2 5.0 15.2 17.3 10.9 6.9 15—25 37.9 30.5 16.2 16.6 20.0 21.3 25 and above 49.7 62.6 10.8 9.8 60.7 63.2 In answer to the possible suggestion that the smaller relative incidence in the later period on the younger ages of the vaccinated is explicable on the ground that fewer children were vaccinated in recent years than before, it may be pointed out that there is absence of corresponding increase of incidence on the younger ages of the unvaccinated, and this leads to the conclusion that other explanation is required. Such explanation is probably to be found in the more complete search made in the later period for cases of smallpox which would otherwise have remained undiscovered and the various measures taken thereupon, tending to the more complete limitation of the disease to the class in which it first attained marked prevalence. Analysis of London cases of smallpox in respect of age and vaccination. I am able, through the courtesy of the Metropolitan Asylums Board, to show in the following table particulars of the condition as to vaccination of London inhabitants who were admitted into the hospitals of the Board on account of attack by smallpox, and the case mortality of each class at several ages. The deaths in this table, whether occurring in 1901 or 1902, are shown in relation to the cases admitted during each of the two years. The table shows, as such tables always do, the great difference between the fatality of the vaccinated and unvaccinated who are attacked by smallpox ; it shows the difference in the age incidence of attack by smallpox of these two classes of the population, the unvaccinated having the greater proportion of their attacks in the first ten years of life, the vaccinated having the greater proportion of their attacks after 20 years of age ; and it shows further the extent to which the fatality of the unvaccinated and those " without evidence of vaccination " was reduced by vaccination after infection by smallpox. 41 Vaccinated cases. Ages. 1901. 1902. Totals. Case mortality. Cases. Deaths. Cases. Deaths. Cases. Deaths. 0—10 20 - 95 1 115 1* 0.9 10—20 220 4 838 18 1,058 22 2.1 20—35 566 49 2,494 177 3,060 226 7.4 35 and upwards 360 62 1,527 317 1,887 379 20.1 Total 1,166 115 4,954 513 6,120 628 10.3 Unvaccinated cases. A B Age. 1901. 1902. Totals A. Case mortality 1901. 1902. Totals B. Case mortality. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths Cases. Deaths 0—10 37 9 227 57 264 66 25.0 140 49 771 283 911 332 36.4 10—20 15 1 67 8 82 9 11.0 99 30 390 98 489 128 26.2 20—35 4 1 24 3 28 4 14.3 44 15 197 76 241 91 37.8 35 and upwards - - 4 - 4 - - 15 8 56 34 71 42 59.2 Total 56 11 322 68 378 79 20.9 298 102 1,414 491 1,712 593 34.6 No evidence of vaccination. A B 0—10 1 1 6 - 7 1 14.3 4 1 24 5 28 6 21.4 10—20 - - 9 2 9 2 22.2 9 1 49 11 58 12 20.7 20—35 1 - 10 3 11 3 27.3 26 12 99 41 125 53 42.4 35 and upwards 3 1 9 - 12 1 8.3 38 22 120 54 158 76 48.1 Total 5 2 34 5 39 7 17.9 77 36 292 111 369 147 39.8 The unvaccinated and doubtful cases are divided as follows— A.—Successfully vaccinated after infection. 13.—Not successfully vaccinated after infection. Percentage of deaths. Age. Vaccinated. Unvaccinated. No evidence. Successfully vaccinated after infection. Not vaccinated after infection. Successfully vaccinated after infection. Not vaccinated after infection. 0—10 0.9 25.0 36.4 14.3 21.4 10—20 2.1 11.0 26.2 22.2 20.7 20—35 7.4 14.3 37.8 27.3 42.4 35 and upwards 20.1 — 59.2 8.3 48.1 All ages 10.3 20.9 34.6 18.0 39.8 The report of the Metropolitan Asylums Board for the year 1902 shows that of the 7,951 cases of smallpox admitted to the hospitals of the Board during the year from the London and elsewhere, 20 were those of persons who were stated to have previously suffered from smallpox, and 11 of these presented appearances which afforded presumptive evidence of their previous attack. Again, there were 276 persons admitted to these institutions who were stated to have been revaccinated of whom it is reported that the vaccination cicatrices of 93 afforded presumptive evidence of re-vaccination; concerning 47 the evidence of re-vaccination was uncertain, but was capable of interpretation in the affirmative; while of the remaining 136 no evidence of * See footnote (*) page 34. [6] 42 re-vaccination existed. In the absence of any precise knowledge as to the proportion of the London population who have been re-vaccinated, it is impossible to compare the incidence of the disease on this class of the population with that on those who have only been vaccinated in infancy. But even if it be assumed that the whole of the 276 persons mentioned had been successfully re-vaccinated, which no doubt was not the case, this number must stand in very small proportion to the total number of re-vaccinated persons in the London population, 351,481 of whom were re-vaccinated at the expense of the rates during the one year ended September, 1902. There cannot be doubt that the administrative measures adopted during the years 1901-2 were largely instrumental in limiting the prevalence of smallpox. This is shown by the smaller relative incidence of the disease upon the population at younger ages in 1901-2 as compared with 1893-4-5, a circumstance which is especially noteworthy in view of the increase in the number of children unprotected by vaccination. When, moreover, it is recollected that the administration for the one community of London was vested in 29 separate sanitary authorities, and in 31 vaccination authorities, and the attitude of all these authorities to the subject of vaccination was by no means the same, it is matter for congratulation that the four and a-half millions of the population escaped with not more than some 10,000 cases of, and not more than 1,600 deaths from, smallpox. As yet it is impossible to give particulars of the vaccinations performed during this period, and it will never be possible to state the total number of the London population who were revaccinated, but inasmuch as during the year endiug September, 1902, as many as 351,481 persons were re-vaccinated at the cost of the rates, and that large numbers of other re-vaccinations took place, the cost of which did not fall on the rates, the susceptibility of the population to smallpox must have been materially altered as the result. The matter for regret is that with all the willingness which the London population shows to resort to vaccination for protection against smallpox, no system exists which provides for re-vaccination, as a matter of routine, at an age when the protection afforded by the primary vaccination of infancy is waning, aud before there is exposure to smallpox infection. That such a system would largely reduce the mortality from smallpox, there is no question, and indeed, it is the more necessary since the State has provided for the exemption from the requirement of the vaccination law of the children of the "conscientious objector." The interests of these children especially require that they should not be exposed tothe infection of cases of smallpox. Many of these cases now occur among persons who, while they are not themselves objectors to vaccination, in the absence of any statutory incentive do not renew the state of insusceptibility to smallpox which is for a time conferred upon them by their vaccination in infancy. Chicken-pox. On the 28th January, 1902, the Council made an order that section 55 of the Public Health (London) Act, 1891, relating to the notification of infectious disease should apply to the disease known as chicken-pox. The effect of this Order was to make compulsory the notification of chicken-pox in the county of London for a period of three months dating from the 7th February, 1902. This period was subsequently extended, and the Order remained in force until January 6th, 1903. The course adopted by the Council was recommended in a report of the Public Health Committee dated 21st January, 1902, in which it was pointed out that in the course of the smallpox outbreak in London, which began in the middle of the year 1901, the failure to distinguish between chicken-pox and smallpox had led to the spread of the latter disease. The compulsory notification of cases of chicken-pox occurring among the population of London for a period of nearly twelve months provides sufficient statistical material for discussing some points of interest in the behaviour of this disease. It is common knowledge that chickenpox is rarely fatal. Only a few deaths from this disease are recorded each year in the returns of the Registrar-general, and probably some of these may be deaths from unrecognised smallpox. The mortality records, therefore, even over a long series of years, supply no answer to questions concerning seasonal variations in the prevalence of the disease, age and sex incidence, differences in the distribution of the disease in regard to locality, etc. During the time that the Order of the Council was operative, 25,009 cases of chicken-pox were notified in London, this number giving a case-rate of 5.9 per 1,000 living per annum. This rate is considerably greater than the mean case-rate obtaining for the other notifiable diseases. Thus the mean case-rates obtaining in the decennium 1891-1900 were—for scarlet fever, 4.8; diphtheria, 2.65; enteric fever, 0.8; and erysipelas 1.4 per 1,000 living. The following table shows the number of cases notified in each week of the period during which the disease was notifiable, and the accompanying diagram (VII.) shows the weekly notifications in relation to the mean of the whole period. For the purpose of comparison the curve formed by the weekly number of notified cases of smallpox is also shown. So far as the figures for such a limited period as 48 weeks can be trusted to indicate the relation between chicken-pox prevalence and season, the diagram suggests a close similarity between chicken-pox and measles in this connection. It will be seen that the curve exhibits two distinct maxima, one in June and the other at the end of November and beginning of December. The measles curve, based on the mortality in London during the 60 years 1841-1900, which was published in the annual report for the year 1900, also exhibits two maxima—one in June and the other in December. It is, no doubt, unsafe to draw precise conclusions as to the character of the seasonal curve of chicken-pox on the figures furnished by the limited period during which notification was compulsory in London, but the close resemblance between the chicken-pox and measles curves is noteworthy although the possibility of coincidence must not be overlooked. London. Notified Cases, 1902. Diagram VII. 43 Weekly notifications. No. of week. Cases notified. No. of week. Cases notified. No. of week. Cases notified. 1 Notifications not complete for these weeks. 20 636 39 164 2 21 569 40 251 3 22 980 41 203 4 23 1,002 42 381 5 24 878 43 404 6 349 25 786 44 547 7 519 26 686 45 669 8 471 27 981 46 603 9 610 28 658 47 683 10 597 29 464 48 607 11 572 30 360 49 765 12 608 31 323 50 698 13 420 32 341 51 600 14 514 33 301 52 526 15 502 34 313 53 714 16 358 35 268 17 567 36 205 18 569 37 188 19 418 38 181 Total 25,009 The objection against the use of a single year's figures, previously referred to in discussing the character of the seasonal curve of chicken-pox, cannot be urged when these figures are used to show the age and sex incidence of the disease, as the number of cases (over 25,000) is sufficiently large to give reliable results, and to indicate with sufficient accuracy the normal age-incidence of the disease on the London population. The following table shows the age and sex distribution of the 25,009 cases of the disease notified in London during the period in which the disease was compulsorily notifiable. Case-rates in certain age groups, 1902. Age period. Males. Females. Cases. Annual case-rate per 100,000 living. Cases. Annual case-rate per 100,000 living. 0— 1,249 2,481 1,202 2,406 1— 1,218 2,735 1,201 2,696 2— 1,199 2,663 1,167 2,602 3— 1,492 3,403 1,467 3,306 4— 1,704 3,972 1,649 3,862 5— 4,490 2,230 4,710 2,317 10— 616 324 768 397 15— 192 101 183 86 20— 89 45 122 51 25 and upwards 133 14 158 14 All ages 12,382 632 12,627 577 The table shows that the incidence of the disease was greater upon males than upon females at "all ages," and this greater incidence was manifest at the age-periods which are especially liable to attack from this disease, viz., ages 0—5. The greatest incidence of attack in the case of both males and females was upon age 4—5, and in this respect a parallel may be found in scarlet fever and diphtheria, although the incidence of attack upon the higher ages in the case of the two latter diseases is proportionately greater. One feature in the age incidence of chicken-pox which markedly distinguishes it from the other notifiable diseases is the high case-rate which obtains at age 0—1. It is a well-known fact that children of this age enjoy comparative immunity from attack by scarlet fever and diphtheria, and various reasons have been advanced to account for this. The figures shown in the table relating to children of this age are in such marked contrast to those of the other notifiable diseases that they are of special interest. The following table shows the case-rates obtaining in each of the metropolitan boroughs. It will be seen that the incidence of the disease varied considerably in different parts of London. The highest case-rate obtained in Deptford (12.3 per 1,000 living), and the lowest in Chelsea (3.1). The variations shown in the table would, however, probably be within narrower limits if the case-rates for ages 0—10 were shown instead of the case-rates at "all ages." 44 Case-rates per 1,000 living, 1902. Metropolitan borough. Estimated population middle of 1902. Cases, 1902 (48 weeks). Annual case-rate per 1,000 living. Paddington 145,107 457 3.4 Kensington 177,605 671 4.1 Hammersmith 114,210 637 6.1 Fulham 143,102 472 3.6 Chelsea 74,018 212 3.1 City of Westminster 180,800 723 4.3 St. Marylebone 132,145 463 3.8 Hampstead 83,743 388 5.0 St. Pancras 235,521 1,106 5.1 Islington 337,270 1,846 5.9 Stoke Newington 51,700 362 7.6 Hackney 221,926 1,327 6.5 Holborn 58,535 198 3.7 Finsbury 100,487 702 7.6 City of London 25,598 85 3.6 Shoreditch 118,004 754 6.9 Bethnal-green 129,865 767 6.4 Stepney 300,551 1,563 5.6 Poplar 169,214 846 5.4 Southwark 206,825 1,254 6.6 Bermondsey 130,218 904 7.5 Lambeth 305,102 1,613 5.7 Battersea 171,401 1,223 7.8 Wandsworth 241,810 1,440 6.5 Camberwell 262,775 1,533 6.3 Deptford 111,577 1,260 12.3 Greenwich 98,013 733 8.1 Lewisham 132,432 824 6.8 Woolwich 117,556 645 5.9 Port of London — 1 — London 4,579,110 25,009 5.9 In considering the incidence of the disease in respect to locality the following table is of interest. This table shows the number of cases of chicken-pox notified in successive four-weekly periods in each of the metropolitan boroughs. The periods in which the maximum and minimum number of cases were recorded are specially indicated, and it will be seen that the figures for each borough exhibit considerable uniformity in this respect. 45 Chicken-pox, 1902 (48 weeks). Period. London. Paddington. Kensington. Hammersmith. Fulham. Chelsea. City of Westminster. St. Marylebone. Hampstead. St. Pancras. Islington. Stoke Newington. Hackney. Holborn. Finsbury. City of London. Shoreditch. Bethnal-green. Stepney. Poplar. South wark. Bermondsey. Lambeth. |Battersea. Wandsworth. Camberwell. Deptford. Greenwich. Lewisham. Woolwich. Port of London. Weeks. 6—9 1,949 60 77 45 40 13 77 70 37 122 138 18 131 18 61 10 33 59 116 43 69 52 119 76 112 150 73 41 65 24 — 10—13 2,197 45 42 27 45 18 98 63 44 135 152 31 146 12 83 8 31 85 120 43 113 58 139 86 133 122 109 48 95 66 — 14—17 1,941 31 25 46 28 32 76 40 26 111 126 46 149 14 29 6 58 60 97 50 113 62 126 80 96 118 103 53 70 69 1 18—21 2,192 46 20 57 26 18 61 16 31 113 136 34 149 7 63 8 59 83 144 114 109 110 116 102 103 151 145 65 60 46 — 22—25 3,646 53 70 146 61 11 119 44 41 120 260 49 193 14 120 10 127 100 254 200 148 234 216 169 153 227 228 81 121 77 — 26—29 2,789 69 87 106 46 14 100 40 32 114 174 49 127 18 80 11 88 61 198 145 119 122 150 128 115 210 175 76 56 79 — 30—33 1,325 27 51 31 25 9 59 27 5 54 92 18 49 15 22 6 44 40 137 37 59 36 72 102 50 86 64 38 29 41 — 34—37 974 11 27 14 22 7 24 34 12 41 61 7 46 17 22 3 40 34 106 36 32 14 63 58 54 61 47 23 41 17 — 38—41 799 13 26 9 17 3 13 26 17 49 58 8 36 9 21 2 21 27 78 32 40 23 63 36 29 52 39 28 10 14 — 42—45 2,001 19 71 31 29 24 21 25 55 74 173 43 74 20 69 1 85 75 120 41 123 64 160 86 114 96 108 86 53 51 — 46—49 2,658 36 104 53 62 25 33 43 54 83 238 32 111 32 58 6 90 80 107 60 171 70 227 141 220 143 93 94 112 80 — 50—53 2,538 47 71 72 71 38 42 35 34 90 238 27 116 22 74 14 78 63 86 45 158 59 162 159 261 117 76 90 112 81 — Total (48 weeks) 25,009 457 671 637 472 212 723 463 388 1,106 1,846 362 1,327 198 702 85 754 767 1,563 846 1,254 904 1,613 1,223 1,440 1,533 1,260 733 824 645 1 Maxima shown in clarendon type, thus—3,646. Minima shown in italics, thus—799. 46 Measles. The deaths from measles in the administrative county of London during 1902 (53 weeks) numbered 2,360, as compared with 1,952 in 1901. The death-rates from this disease per 1,000 living in 1902 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 1902 0.511 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1902 is shown in diagram VIII. If the London death-rate be compared with the death-rates of the following large English towns it will be seen that in the period 1892-1901 the London death-rate exceeded the deathrate of all except Manchester, Salford and "West Ham, and in 1902 it exceeded all except Bristol, Bradford, Hull, Salford and Newcastle. Measles—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.582 0.512 Nottingham 0.40 0.02 Manchester 0.78 0.44 Bradford 0.33 0.56 Liverpool 0.54 0.48 Hull 0.52 0.83 Birmingham 0.48 0.34 Salford 0.94 0.69 Leeds 0.51 0.42 West Ham 0.66 0.50 Sheffield 0.56 0.45 Leicester 0.39 0.34 Bristol 0.38 1.22 Newcastle 0.55 0.63 The following table shows that the measles death-rate in London exceeded that of any of the undermentioned foreign towns in the period 1892-1901, and in 1902 was only exceeded by that of Amsterdam, St. Petersburg and Rome. Measles—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.582 0.512 St. Petersburg 0.57 0.52 Paris 0.32 0.25 Berlin 0.20 0.19 Brussels 0.30 0.20 Vienna 0.53 0.44 Amsterdam 0.17 0.88 Rome 0.28 0.94 Copenhagen 0.23 0.21 New York 0.25 0.20 Stockholm 0.17 0.08 The following table shows the deaths and death-rates from measles in 1902 in each of the metropolitan boroughs— Metropolitan borough. Deaths in 1902. Death-rate per 1,000 living, 1902. Metropolitan borough. Deaths in 1902. Death-rate per 1,000 living, 1902. Paddington 83 0.56 Shoreditch 88 0.73 Kensington 93 0.52 Bethnal-green 59 0.45 Hammersmith 77 0.66 Stepney 164 0.54 Fulham 168 1.16 Poplar 69 0.40 Chelsea 67 0.89 Southwark 164 0.78 Westminster, City of 42 0.23 Bermondsey 155 1.17 St. Marylebone 97 0.72 Lambeth 83 0.27 Hampstead 15 0.18 Battersea 101 0.58 St. Pancras 113 0.47 Wandsworth 97 0.39 Islington 116 0.34 Camberwell 121 0.45 Stoke Newington 5 0.10 Deptford 74 0.65 Hackney 78 0.35 Greenwich 41 0.41 Holborn 30 0.50 Lewisham 27 0.20 Finsbury 83 0.81 Woolwich 40 0.33 London, City of 10 0.38 London 2,360 0.511 1 See footnote (1), page 12. 2 See footnote (1), page 13. Diagram VII Measles. 47 In the distribution of measles mortality in London throughout the year 1902 the highest death-rate obtained in Bermondsey (117) and the lowest in Stoke Newington (0.10). The measles death-rates in London in the four quarters of the year were as follows—first quarter 0.64; second quarter 0.62 ; third quarter 0.30, and fourth quarter 0'4G 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 previously resided. Measles (365 days). Age-period. 0— 1— 2— 3— 4— under 5 5— 10-- 15 and upwards. All ages. Paddington 20 32 13 8 6 79 3 — — 82 Kensington 21 40 17 6 5 89 4 — — 93 Hammersmith 37 23 5 8 2 75 2 — — 77 Fulham 29 65 28 23 17 162 5 1 — 168 Chelsea 11 28 12 9 2 62 5 — 1 68 Westminster, City of 13 17 6 4 — 40 — — 1 41 St. Marylebone 26 32 15 9 5 87 10 1 — 98 Hampstead 6 4 3 1 — 14 — — — 14 St. Pancras 22 49 20 6 7 104 5 — — 109 Islington 20 51 18 7 7 103 5 1 — 109 Stoke Newington — 2 1 1 — 4 — — — 4 Hackney 15 38 10 7 2 72 2 — — 74 Holborn 6 16 6 2 1 31 — — — 31 Finsbury 19 36 17 4 2 78 3 — — 81 London, City of 2 6 1 1 — 10 — — — 10 Shoreditch 21 26 24 9 4 84 2 — — 86 Bethnal-green 13 22 12 4 7 58 1 — — 59 Stepney 50 72 21 13 4 160 4 — — 164 Poplar 12 35 8 6 4 65 1 1 — 67 Southwark 36 75 25 10 13 159 4 — — 163 Bermondsey 26 65 38 14 6 149 4 — — 153 Lambeth 15 24 15 10 5 69 5 1 2 77 Battersea 17 47 13 8 6 91 9 — 1 101 Wandsworth 22 37 15 10 6 90 6 1 1 98 Camberwell 33 43 21 10 8 115 5 — — 120 Deptford 10 35 16 2 3 66 4 — — 70 Greenwich 10 13 9 — 2 34 3 — 1 38 Lewisham 3 11 2 2 5 23 2 — 1 26 Woolwich 10 11 7 3 5 36 2 — — 38 London 525 955 398 197 134 2,209 96 6 8 2,319 The fact that measles is highly infective for some three days before the eruption manifests itself militates seriously against the success of efforts made to limit the spread of the disease. Medical officers of health receive from school teachers information of any cases of measles occurring in the families of children attending schools, and such scholars are excluded from school attendance for a period of three weeks. The number of cases which thus became known in 1902 to medical officers of health is stated in some of the annual reports thus—In Paddington information was given of 559 cases, in Hammersmith of 293 cases, and in Westminster of 294 cases. In Shoreditch 776 children were excluded from the Board Schools, either because the scholars suffered from measles, or because the disease was present in the houses in which the scholars dwelt. The disease rapidly spread in the infant classes of schools, and in particular instances the class or department was temporarily closed for this reason. In Deptford the infants' departments of four schools were closed for three weeks in December. In Woolwich, class-rooms for the whole infants' department were closed in three schools in February, in one in March, in two in April, in three in May, in one in June, in one in October, and in one in December. In Lambeth the attention of the medical officer of health was directed to the prevalence of measles in two schools, but it was found that the number of cases occurring was declining, and it was not, therefore, thought necessary to close the schools. With a view to obtaining better knowledge of the value of school closure for the limitation of measles, Dr. Kerr, the medical officer of the London School Board, has arranged with Dr. Davies, the medical officer of health of Woolwich, for observation of all known cases of measles in the houses, which with the necessary observation of the behaviour of measles in the schools will be helpful in determining this question. Record is also being made of the number of children at different ages who have already been attacked, and Dr. Kerr finds that of 800 children at five years of age in seven schools 375 had been attacked before coming to school, and 207 subsequently ; while of 899 children at six years of age, 413 had had measles before coming to school and 303 subsequently. These proportions might be expected to vary in different years, for in London, every two or three years, measles attains increased prevalence, attacking the susceptible children who have accumulated in the interval. It is not probable that efforts made to limit the spread of measles will do more than postpone the age of attack, but it may be expected, if this result can be attained, that the mortality of measles would be diminished. In the decade 1851-60, and subsequent decades, the proportion of deaths under five years of age from measles has ranged from 92 5 per cent, of the measles deaths at "all ages" to 48 94.7 per cent. The deaths above five years of age from measles in London are less than 150 a year. The number of cases occurring below and above five years of age cannot be stated, but the fatality is no doubt much greater at the lower ages. Medical officers of health have frequently commented in their reports on the neglect of parents to recognise the infectious nature of measles, and to take such precautions as are possible to limit the spread of the disease. The County Council has now, with the consent of the Local Government Board, extended to measles certain provisions of the Public Health (London) Act, the principal of which, section 68, prohibits the exposure in a public place, without proper precautions, of any person suffering from a dangerous infectious disease, and the transmission, without proper precautions of infected articles. The other provisions are, section 60, which gives power to sanitary authorities to require the cleansing and disinfection of infected premises, and the disinfection or destruction of infected articles, and contains other provisions as to compensation and shelter during disinfection ; section 61 enables sanitary authorities to require infected bedding, clothing, etc., to be delivered up to them for disinfection, and requires them to pay compensation for any unnecessary damage ; section 62 prohibits the casting of infectious rubbish into ashpits without previous disinfection ; section 63 prohibits persons from knowingly letting houses who make false statements as to infectious disease ; section 65 provides for a penalty on persons ceasing to occupy houses without disinfection or notice to owner, or making false answer; section 69 prohibits infected persons from carrying on any occupation in such a manner as to be likely to spread disease ; section 70 prohibits the conveyance of infected persons in public conveyances ; section 72 prohibits, in certain cases, the retention of the body of a person who has died of any dangerous infectious disease ; section 73 requires that, in certain cases, the body of a person who has died in hospital of any dangerous infectious disease shall be removed only for burial ; section 74 prohibits, without previous notice to the owner or driver, the use of a public conveyance for carrying the body of a person who has died of any dangerous infectious disease, and requires the disinfection of the conveyance, if so used. In another direction effort might be made to reduce the mortality from this disease. Pulmonary complications are those which most frequently cause death in persons suffering from measles. Dr. Harris notes that of 114 deaths in Islington from measles in 1902 the "secondary causes of death" were pneumonia in 70 instances and bronchitis in 20 instances. Again, in Bermondsey, Dr. Brown records 154 deaths from measles in that year, and of these the "secondary causes of death" were broncho-pneumonia in 110 cases and bronchitis in 22 cases. The need of careful nursing and of warm, well-ventilated rooms for such cases is obvious. In the homes of the very poor the opportunities for the care of sick children are often wholly inadequate, and the want of proper nursing must militate strongly against the prospect of recovery. The provision of a sick nurse, and, in certain cases, the removal of the sick to a hospital, appear to be well worth trial on a limited scale, with a view to gaining experience of their value in reducing the fatality of cases of the disease in which there is risk of a fatal termination. Scarlet Fever. The cases of scarlet fever notified in the administrative county of London during 1902 (53 weeks) numbered 18,252, as compared with 18,381 in 1901. The number of deaths registered from this cause in 1902 was 500, as compared with 584 in 1901. The London rates in 1902 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 0.171 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 1902 0.121 3.9 3.1 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859-1902 will be seen on reference to diagram IX. The monthly case-rate and case-mortality in each of the years 1891-1902 in relation to the mean of the whole period is shown in diagram XI. It will be seen from the following table that in the period 1892-1901 the London scarlet fever death-rate was exceeded by the death-rates of Manchester, Liverpool, Nottingham, Bradford, Salford, and Leicester, and in 1902 was lower than that of any of the undermentioned towns except Leeds, Nottingham, Hull, and Leicester. (1) See footnote (1) page 12. * The Infectious Disease (Notification) Act came into force in 1889. Diagram IX. Scarlet Fever. Scarlet Fever. Diagram XI. 49 Scarlet fever—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.191 0.121 Nottingham 0.20 0.10 Manchester 0.23 0.26 Bradford 0.20 0.16 Liverpool 0.30 0.45 Hull 0.17 0.07 Birmingham 0.18 0.54 Salford 0.39 0.22 Leeds 0.17 0.12 West Ham 0.18 0.16 Sheffield 0.19 0.13 Leicester 0.21 0.06 Bristol 0.12 0.19 Newcastle 0.13 0.26 The following table shows that the London scarlet fever death-rate was lower than that of any of the undermentioned foreign towns except Paris, Brussels, Amsterdam and Rome in the period 1892-1901, while in 1902 it exceeded that of any except St. Petersburg, Berlin, Vienna and New York. Scarlet fever—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.191 0.121 St. Petersburg 0.62 0.37 Paris 0.06 0.05 Berlin 0.27 0.15 Brussels 0.05 0.01 Vienna 0.20 0.16 Amsterdam 0.03 0.00 Rome 0.02 0.02 Copenhagen 0.21 0.04 New York 0.25 0.26 Stockholm 0.34 0.04 The following table shows the death-rate from scarlet fever in 1902, and the case-rates in 1902 and the decennium 1892-1901 in the several metropolitan boroughs— Metropolitan Borough. Cases, 1902. Case-rate per 1,000 living. Deaths, 1902. Death-rate per 1,000 living. 1902. 1892-1901. 1902. Paddington 364 4.0 2.5 9 0.06 Kensington 378 3.6 2.1 21 0.12 Hammersmith 353 4.1 3.0 7 0.06 Fulham 553 5.4 3.8 19 0.13 Chelsea 204 4.3 2.7 8 0.11 Westminster, City of 475 3.6 2.6 15 0.08 St. Marylebone 414 3.9 3.1 14 0.10 Hampstead 254 3.8 3.0 7 0.08 St. Pancras 1,219 5.0 5.1 49 0.20 Islington 1,379 5.1 4.0 40 0.12 Stoke Newington 202 4.8 3.8 5 0.10 Hackney 883 5.9 3.9 15 0.07 Holborn 203 4.6 3.4 8 0.13 Finsbury 392 5.4 3.8 15 0.15 London, City of 83 4.6 3.2 1 0.04 Shoreditch 250 4.9 2.1 8 0.07 Betlmal-green 529 6.0 4.0 19 0.14 Stepney 1,069 5.8 3.5 30 0.10 Poplar 670 5.5 3.9 21 0.12 Southwark 1,099 5.5 5.2 42 0.20 Bermondsey 506 5.6 3.8 18 0.14 Lambeth 1,354 4.6 4.4 48 0.15 Battersea 893 6.0 5.1 24 0.14 Wandsworth 1,080 4.3 4.4 23 0.09 Camberwell 1,390 4.8 5.2 41 0.15 Deptford 648 6.2 5.7 19 0.17 Greenwich 463 5.0 4.6 6 0.06 Lewisham 662 3.8 4.9 19 0.14 Woolwich 279 6.1 2.3 9 0.07 Port of London 4 — — — — London 18,252 5.0 3.9 560 0.122 It will be seen from the foregoing table that the scarlet fever death-rate in 1902 was highest in St. Pancras and Southwark (0.20), and lowest in the City of London (0.04). The scarlet 1 See footnote (1), page 13. 2 See footnote (1), page 12. [7] 50 fever death-rates obtaining in London during the four quarters of the year were as follows—First quarter, 0-13; second quarter, 0-12; third quarter, 012; and fourth quarter, 0-11 per 1,000 living. During the year no outbreaks of scarlet fever of any considerable extent occurred. Mr. Jackson reports that in Fulham "the disease attained its maximum prevalence in the third week of August, a period when, owing to the schools being closed for the summer holiday, it is usually at its lowest. This was largely due to the occurrence of some unrecognised attacks of scarlet fever among children sent into the country by the managers of a children's holiday fund. In one instance, a child who was sent to a village in Berkshire developed the disease shortly after its arrival there, having probably been infected before leaving Fulham, and communicated it to three other children also from Fulham, but the nature of the illness was not recognised until after their return home, when, on the occurrence of several cases in their homes and some neighbouring houses, they were examined and found to be evidently recovering from mild scarlet fever. In another instance, a child who had been sent to a village in Middlesex, contracted scarlet fever while there, but it was not until her return home, and the occurrence there of some secondary cases, that the nature of her illness was recognised." Such evidence as is afforded by the reports of medical officers of health does not show that the disease during 1902 was spread in any other way than by infection from person to person. In Finsbury, Dr. Newntan was able to associate 103 cases among 381 cases notified in the borough with antecedent cases of the disease. In Bermondsey, however, the source of infection could only be definitely traced in 49 cases among 460 cases notified. It will be seen from Diagram X. that the number of admissions to the hospitals of the Metropolitan Asylums Board per cent, of the total cases of scarlet fever notified in London was greater in 1902 than in any previous year. In the annual reports relating to the following districts the number of cases is stated which followed the return home of a patient who had been discharged from a fever hospital, viz.— Fulham, 1G cases ; Stoke Newington, 3 cases; Finsbury, 11 cases ; Southwark, 46 cases ; Bermondsey, 10 cases; Wandsworth, 48 cases; Greenwich, 24 cases; Lewisham, 50 cases; Woolwich, 19 cases. Scarlet fever and elementary schools. The subject of scarlet fever in relation to school attendance is referred to only in a few reports. In the City a school was closed in October for 21 days on account of the prevalence of this disease among the pupils. In Stoke Newington the disease was in 9 cases attributed to exposure to infection at school, and in Finsbury 10 such cases occurred. The effect, however, of the summer holiday of the schools in causing a reduction in the number of cases of scarlet fever was, as usual, manifest. The summer holiday of the London School Board schools began in 1902 on Thursday, the 24th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 25th 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 following table are obtained. It will be seen that the decrease during the period of holiday influence is most marked at ages 3—13, ages 0—3, and 13 and upwards showing increase in this period, and the increase subsequent to the period of holiday influence is particularly marked at the school age, while the number of cases at other ages show decrease. Scarlet fever—Notified cases, 1902. 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) 186 1,143 257 — — — Four weeks of holiday influence (32nd to 35th) 203 884 270 + 9-1 — 22-7 + 51 Four weeks following weeks of holiday influence (36th to 39th) 180 1,086 234 — 11-3 + 22-9 — 13-3 Scarlet fever—Age and sex distribution. The following table shows the cases, deaths, case-rates, death-rates, and fatality of scarlet fever during the year 1902. It will be 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 of two and upon females of three years of age. The fatality, it will be observed, was greatest both among males and females under one year of age. Diagram, X77. Diphtheria Death occurring inn the hospitals of the Metropol. Asylums Board per cervt Diagram XIII. . of total deaths in London 1888-1902 Admissions to hospitals of the Metropolitan Asylums Board per cet of total cases notified in London . 1890-1902 51 Scarlet fever*, 1902. Age-period. Males. Females. Cases Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Cases. Deaths. All ages 8,835 288 3-3 409 13 9,417 274 29 390 n 0— 132 16 121 238 29 98 13 13-3 178 24 1— 363 40 110 738 81 313 34 109 636 69 2— 657 62 9-4 1,322 125 626 50 8-0 1,264 101 a— 874 50 57 1,805 103 886 51 5-8 1,808 104 4— 962 34 35 2,031 72 965 24 2-5 2,047 51 5— 3,292 60 1-8 1,481 27 3,680 72 2-0 1,639 32 10— 1,345 10 0-7 641 5 1,454 10 0-7 680 5 15— 586 9 1-5 278 4 566 4 07 241 2 20— 336 4 1-2 153 2 366 8 2-2 139 3 25— 215 3 14 57 1 355 7 2-0 80 2 35— 58 — — 20 — 77 — — 25 — 45— 11 — — 6 — 22 — — 10 — 55 and upwards 4 — — 2 — 9 1 Ill 4 0 An outbreak of scarlet fever in East London, due to milk received from a farm in the provinces, of which particulars were given in the last annual report, led the Council to include in their General Powers Bill of 1902 clauses to enable the Council to exercise for the whole county the power of prohibition of an infected milk supply, similar to that possessed by the sanitary authorities in respect of their several districts. The clauses further required milk vendors to supply, when required, lists of their customers and information as to the sources from which they derived their milk supplies. The clauses were not accepted by Parliament, and these powers are, therfore, still wanting for London. Diphtheria. The cases of diphtheria notified in the administrative county of London in 1902 (53 weeks) numbered 10,731, compared with 12,156 in 1901. The number of deaths registered from this cause in 1902 was 1,159, compared with 1,330 in 1901. The diphtheria case-rates and death-rates in 1902 and preceding periods are shown in the 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 2.0 22.2 1893 0.741 3.2 23.3 1894 0.611 2.6 23.6 1895 0.521 2.6 20.4 1896 0.591 3.1 19.3 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 1902 0.251 2.3 10.8 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591902 is shown for diphtheria and for diphtheria and croup combined in diagram XII. The monthly case-rate and case-mortality in each of the years 1891-1902 in relation to the mean of the whole period is shown in diagram XIV. If the London diphtheria death-rate be compared with the death-rates of the following large English towns it will be seen that in the period 1892-1901 the London rate exceeded the rates of all these towns except West Ham; while in 1902 it was lower than the rates of any except Manchester, Birmingham, Leeds, Nottingham, Leicester and Newcastle. * In the preparation of this table, the percentages are calculated on the number of cases notified in London, and the number of deaths occurring in London and the institutions belonging to London. t See footnote (*), page 48. 1 See footnote (!), p*ge 12. 53 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 1891-1902 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. 1902. Paddington 104 77 73 117 74 66 91 98 63 44 89 65 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 78 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 Islington 152 119 86 103 70 106 73 60 68 70 100 113 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 Holbom 52 89 79 61 66 61 104 102 46 70 104 87 Finsburv 118 82 130 81 86 112 170 163 93 74 107 100 City of London 59 130 60 49 51 74 71 60 68 89 96 161 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 Bethnal-green 154 230 181 168 143 114 144 100 89 115 133 104 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 r South wark 71 72 116 113 86 106 102 151 207 141 100 113 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 Le wish am 48 74 82 70 57 122 85 127 170 126 85 130 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 London 100 100 100 100 100 100 100 100 100 100 100 100 The annual reports for the year 1902 show a considerable advance of opinion as to the origin of notified cases of diphtheria, and as to the measures necessary for limitation of the spread of the disease. In much larger degree have unrecognised cases, and cases presenting no clinical symptoms, but in whose throats or noses the Klebs-Loeffler bacillus existed, been sought for, and bacteriological methods utilised for their detection. Dr. Brown, the medical officer of health for Bermondsey, thus found the bacilli in the throats of 32 persons who had been exposed to infection, 16 of whom subsequently developed clinical symptoms of diphtheria. He writes as follows— "During the year 1902 I visited 102 families in which diphtheria had occurred. Examinations were made of the members of the family who were in immediate contact with the patient, and these examinations were practically confined to 'contacts' of school age i.e., up to 15 years of age. The number of examinations made was 259, and swabs were taken from the throats and, in a few cases, from the noses of those examined. In 32 specimens, or 12 4 per cent? of the examinations, KlebsLoeffler bacilli, which constitute the immediate infective agent of diphtheria, were found ; 16 of these, or 50 per cent., later developed the clinical symptoms of diphtheria, and were removed to hospital. Those who had bacilli in their throats, but did not develop the clinical symptoms of diphtheria, were kept isolated, as far as possible, until they were considered to be free from infection, and were advised to go to their medical attendant for an antiseptic gargle. These latter did not, as far as I am aware, give rise to any further cases in the household. In all cases of children in which diphtheria bacilli were found, the parents were immediately notified that their child harboured diphtheria bacilli in its throat, and might either develop diphtheria later, or be a source of infection to others, and were advised to keep the child in question under the close observation of their medical attendant. By this method there is no doubt the 16 cases notified were placed under treatment and isolated much earlier than they would otherwise have been." An interesting account of an outbreak in which cases occurred which, under other circumstances, might probably have remained unrecognised, is contained in the annual report of Dr. Newman, the medical officer of health of Finsbury, who thus states the circumstances of this outbreak— "On April 17th M. L. returned to an institution in Finsbury from Bournemouth. She had been engaged at Bournemouth in nursing diphtheria patients for five weeks in an institution. She rested for one week previous to coming to London ; but the night before she left she went to take leave of hor diphtheria patients in Bournemouth. On April 18th—the day after her arrival in London—she went to a branch home in Finsbury, and there nursed a small boy—W. P., aged 2£ years. Two or 54 three days after he sickened with diphtheria, and on April 28th he was notified. Careful inquiry elicited no other possible source of infection than that which had been obtained from M. L. Further, there was now evidence of sore throats in several persons who had come into contact with M. L. Accordingly, the medical man and myself agreed that bacteriological examination should be made of the throats of the other inmates of the home. This was carried out on April 26th, 28th, 29th and 30th, with the result that the diphtheria bacillus was found in the sore throats of B. H., N. N., and N. V., and these three patients were notified and removed to hospital. It was also found in the throats of four other persons who showed no clinical symptoms. It was absent in the throats of six other persons in the home. Of all these, seven persons were at once inoculated with anti-toxin as prophylactic, and antiseptics applied to their throats. One of these (O. A.) having the diphtheria bacillus in her throat (on April 29th), but who showed no signs of illness, slept away from the home, and came into contact with Miss C., who slept in Poplar, and she apparently took infection from O. A. and sickened with diphtheria. Here, then, we have a history of one little boy in an institution contracting infection from a diphtheria nurse, and through him and through the nurse 15 other persons came into the way of infection. Five remained quite well. Six others had sore (diphtheritic) throats. Four others got true diphtheria. Prompt investigation, coupled with antiseptic applications to the throats and inoculation of anti-toxin, stamped out what, in all probability, would have been a considerable outbreak of diphtheria." As matter of course, diphtheria, due to infection transmitted from person to person, finds in schools the largest opportunity for spreading, and it is under these conditions that unrecognised and "carrier" cases are able to do the greatest mischief. Ur. Caldwell Smith gives account of three outbreaks of diphtheria among the children attending schools in Wandsworth. Among the children attending St. Anne's School, Wandsworth, 32 cases occurred, these cases being distributed throughout the year. The infants' department was most affected, but personal infection in school did not seem to be causing the spread of the disease, and there were ample opportunities of infection other than in school hours. In another school, the Swaffield-road Board School, 34 children were attacked in November and December. The first case was notified on the 9th October, the child having been at school last on the 3rd. Dr. Caldwell Smith writes—"This case, although the first notified, was not the first actual case, but it was not till the 27th October that the cause of the first series of cases was discovered. On that date, in consequence of inquiries as to school absentees, I received information that three children in one family were suffering from sore throat, and I ascertained that one of them had been ill since the 2nd, and that he had been at school in the infants' department on that date. His sister, however, was allowed to attend school till the 13th, and she had suffered from sore throat since October Gth. Another unrecognised case was the cause of a second series of cases, the girl having been taken ill on the 13th October, and although she was not at school from the 13th to the 20th, she returned on the latter date, and was at school while she was still in an infective condition till the 27th. A third unrecognised case was notified on the Gth November, having been taken ill on the 12th October; but this case only infected three children in the same house, as the child did not go to school after the first symptoms appeared." The third school outbreak occurred among the pupils of the Cavendish-road Board School, 70 of whom were attacked in 1902, 22 of the children attending the infants' department being attacked in November. The infants' department was closed from November 28th to December 15th; eight cases were notified after the closing of the school, but five of these were possibly infected previously. Dr. Caldwell Smith also comments on the continued prevalence of diphtheria since 1896 on the Hyde Farm estate on which this school is situated, and he states that the wetness of the soil is no doubt one of the chief causes of this undue prevalence of diphtheria. He writes: "I had come to the conclusion that in houses built upon a wet soil which contains a large portion of organic matter, cases of diphtheria may be looked for, the germ existing in the superficial layers of the soil. It is probable that the infection is conveyed to the mouth by the hands of the children playing with this soil, and consequent infection from person to person." He adds: "Unrecognised cases in this outbreak were responsible for a large proportion of the cases. In the house where eight cases occurred one unrecognised case infected the others, and it was only by a bacteriological examination after a second case occurred that the original case was detected. In several of the cases the diagnosis was made only after bacteriological examination." The occurrence of cases of diphtheria among the children attending the Ancona-road Board School, Woolwich, led Dr. Davies to communicate with the medical officer of the London School Board, and Dr. Thomas, assistant medical officer, forthwith examined all the children in two classrooms of the infants' department. Dr. Davies writes : " He picked out 16 cases for bacteriological examination, one of which had obvious diphtheria when I saw her, and one was found to have the diphtheria germs in a nasal discharge. Four others were found to have pseudo diphtheria germs in nasal discharges from which they suffered. In addition to these I found, on visiting the houses, three pupils of this school and one pupil at another school with undetected diphtheria not under medical treatment. Three of these were in attendance up to the day preceding my visit. With the exclusion of the children above mentioned, the outbreak at the Ancona-road School was abated." The measures described above had the desired effect, and during January of the current year there was only a total of 17 cases of diphtheria in the borough, and only one was a pupil of Ancona-road School. " Dr. Davies also records three outbreaks in families in Woolwich in which unrecognised cases played an important part. In the first, the attack of three children was obviously due to infection from an older brother, who was not suspected as the cause before Dr. Davies' inquirv. He found the boy to have soreness and running at the nose, but with a normal throat. Two weeks before, however, lie had a slight sore throat, for which he had stayed away from school for half a day. His nasal discharge was found to contain diphtheria bacilli. In the second outbreak, the second of a series of five cases was a similar case to that mentioned above. The discovery of this second case explained the interval between the first and subsequent cases. In the third outbreak the cause was a previously unsuspected case, that of a boy who had been attending a school in which cases of diphtheria had occurred among the pupils ; diphtheria bacilli were found to be present in his throat. 55 The only instances of closure of schools on account of diphtheria mentioned in the annual reports, other than those already referred to, were those of the Church-street Schools, Lee, in the Borough of Lewisham, and of a school in Westminster. Concerning the latter, Dr. Allan states that an outbreak occurred in one of the boarding-houses: "Every master, boy and servant was examined and the school was closed for fourteen days. No pupil was allowed to return without a certificate certifying that a bacteriological examination had been made and no infectious organism found." Dr. Kerr, medical officer of the London School Board, in referring in his report to the Board to the outbreak in the Ancona-road Board School in Woolwich and to another at Isleworth, states that: "Following the indications given by such instances, it has been decided to attempt the prevention of school dissemination of dlitheria." There is no subject with which the medical officer of health is concerned for which this attempt is more needed, and it is indeed one in which, if efforts are made on a systematic and comprehensive scale, there is in every way reasonable prospect of success. It will require the fullest co-operation of the medical officer of health of the district with the medical officer of the School Board, involving inquiry in the home as well as in the school and the unstinted use of the laboratory. Previous annual reports to the London County Council have contained a diagram showing the effect of the closing of the school for the summer holiday in reducing the prevalence of diphtheria in the London population, and especially among the children of school age. Dr. Kerr, in his annual report to the London School Board, has included a similar diagram showing the extent of this reduction in 1902 not only in the London children of school age, but among the children attending the Board schools. In this diagram the effects of the closing of the schools in August are conspicuous ; and, further, from this diagram it would appear that a similar, although necessarily a less marked, reduction attended the closing of the schools at the Easter, Coronation and Christmas holidays of that year.* The summer holiday of the schools of the London School Board began on Thursday, the 24th July, i.e., the latter part of the 30th week, and the schools reopened on Monday, the 25th 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 is most marked at the school age, while the increase in the subsequent period is confined to the school age. Diphtheria—Notified cases, 1902. 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) 141 570 189 Four weeks of holiday influence (32nd to 35th) 136 427 211 — 35 —25.1 + 11.6 Four weeks following weeks of holiday influence (36th to 39th) 100 443 161 —26.5 + 3.7 —23.7 The results of bacteriological examination of material from suspected cases of diphtheria are given in a number of the annual reports. In 12 districts material from over 1,500 cases was thus examined, and positive results were obtained in 23 per cent, of these cases. Proportion of cases of diphtheria removed to hospital. It will be seen from Diagram XIII. that the proportion of cases of diphtheria admitted to the hospitals of the Metropolitan Asylums Board was slightly less in 1902 than in the preceding year. In the reports relating to the following districts the number of cases is stated which followed the return home of a patient who had been discharged from hospital after attack of diphtheria— Paddington 10 cases, Finsbury 4 cases, Southwark 8 cases, Bermondsey 3 cases, and Wandsworth 8 cases. Diphtheria—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 1902. 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 * Dr. Kerr's report contains a similar diagram, showing the same effect of the holidays on the prevalence of scarlet fever. 56 adopted for the purposes of this table, the greatest incidence of attack, and also of death, was upon males of three and upon females of four years of age. The fatality was greatest both among males and females under one year of age. Diphtheria*, 1902. Age-period. Males. Females. Cases. Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Cases. Deaths. All ages 4,975 568 11.4 230 26 5,756 596 10.4 238 25 0— 145 48 33.1 261 86 81 33 40.7 147 60 1— 384 97 25.3 781 197 322 81 25.2 655 165 2— 461 64 13.9 927 129 444 96 21.6 897 194 3— 592 108 18.2 1,223 223 529 87 16.4 1,080 178 4— 570 66 11.6 1,203 139 632 100 15.8 1,341 212 5— 1,529 151 9.9 688 68 1,908 156 8.2 850 69 10— 563 17 3.0 268 8 671 19 2.8 314 9 15— 272 3 1.1 129 1 340 6 1.8 145 3 20- 173 2 1.2 79 1 291 2 0.7 111 1 25— 201 2 1.0 54 1 335 6 1.8 76 1 35— 51 4 7.8 18 1 143 5 3.5 46 2 45— 21 3 14.3 11 2 41 2 4.9 19 1 55 and upwards 13 3 23.1 7 2 19 3 15.8 7 I Whooping Cough. The deaths from whooping cough in the administrative county of London in 1902 numbered 1,876, compared with 1,604 in 1901. The death-rates from this disease 111 1902 and preceding periods Have been as loiiows— Whooping cough. Period. Death-rate per 1,000 living. Period. Death-rate per 1,000 living. 1851-60 0.88 1895 0.341 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 0.58' 1900 0.431 1893 0.541 1901 0.351 1894 0.491 1902 0.401 The death.rate in each year in relation to the mean death.rate of the period 1841-1901 is shown in diagram XV. 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 1892-1901, while in 1902 it was lower than that of any except Sheffield, Bristol, Nottingham, Bradford and Leicester. Whooping cough—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.473 0.402 Nottingham 0.37 0.15 Manchester 0.53 0.43 Bradford 0.35 0.12 Liverpool 0.52 0.57 Hull 0.39 0.44 Birmingham 0.50 0.50 Salford 0.65 0.52 Leeds 0.39 0.45 West Ham 0.50 0.41 Shelffield 0.46 0.17 Leicester 0.32 0.32 Bristol 0.43 0.32 Newcastle 0.45 0.45 * See footi.ote (*), page 51. 1 See footnote ('), page 12. See footnote ('), page 13. Diagram, Whooping Cough. 56 adopted for the purposes of this table, the greatest incidence of attack, and also of death, was upon males of three and upon females of four years of age. The fatality was greatest both among males and females under one year of age. Diphtheria*, 1902. Age-period. Males. Females. Cases. Deaths. CaBe mortality per cent. Rates per 1,000 living. Cases. Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Cases. Deaths. All ages 4,975 568 11.4 230 26 5,756 596 10.4 238 25 0— 145 48 33.1 261 86 81 33 40.7 147 60 1— 384 97 25.3 781 197 322 81 25.2 655 165 2— 461 64 13.9 927 129 444 96 21.6 897 194 3— 592 108 18.2 1,223 223 529 87 16.4 1,080 178 4— 570 66 11.6 1,203 139 632 100 15.8 1,341 212 5— 1,529 151 9.9 688 68 1,908 156 8.2 850 69 10— 563 17 3.0 268 8 671 19 2.8 314 9 15— 272 3 1.1 129 1 340 6 1.8 145 3 20— 173 2 1.2 79 1 291 2 0.7 111 1 25— 201 2 1.0 54 1 335 6 1.8 76 1 35— 51 4 7.8 18 1 143 5 3.5 46 2 45— 21 3 14.3 11 2 41 2 4.9 19 1 55 and upwards 13 3 23.1 7 2 19 3 15.8 7 I Whooping Cough. The deaths from whooping cough in the administrative county of London in 1902 numbered 1,876, compared with 1,G04 in 1901. The death-rates from this disease in 1902 and preceding periods have been as follows— Whooping cough. Period. Death-rate per 1,000 living. Period. Death-rate per 1,000 living. 1851-60 0.88 1895 0.341 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 0.431 1893 0.541 1901 0.351 1894 0.49' 1902 0.401 The death-rate in each year in relation to the mean death-rate of the period 1841-1901 is shown in diagram XY. . 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 1892-1901, while in 1902 it was lower than that of °any except Sheffield, Bristol, Nottingham, Bradford and Leicester. Whooping cough—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.472 0.402 Nottingham 0.37 0.15 Man chester 0.53 0.43 Bradford 0.35 0.12 Liverpool 0.52 0.57 Hull 0.39 0.44 Birmingham 0.50 0.50 Salford 0.65 0.52 Leeds 0.39 0.45 West Ham 0.50 0.41 Shefiels 0.46 0.17 Leicester 0.32 0.32 Bristol 0.43 0.32 Newcastle 0.45 0.45 » See footi-ote (,*), page 51. 1 Ste footnote ('), page 12. See footnote ('), page 13. DiagramXV Whooping Cough Diagrram XVl. Typhus Fever. 57 The following table shows that the London whooping cough death-rate exceeded the deathrates of all the undermentioned foreign towns both in the period 1892-1901, and in the year 1902— Whooping-cough—Death-rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.47' 0.401 St. Petersburg 0.23 0.16 Paris 0.14 0.18 Berlin 0.29 0.27 Brussels 0.15 0.10 Vienna 0.09 0.12 Amsterdam 0.28 0.23 Rome 0.06 0.08 Copenhagen 0.35 0.31 New York 0.18 0.16 Stockholm 0.19 0.18 The following table shows the deaths from whooping cough and the death-rates in the several metropolitan boroughs during the year 1902— Metropolitan borough. Deaths in 1902. Death-rate per 1,000 living. Metropolitan borough. Deaths in 1902. Death-rate per 1,000 living. Paddington 23 0.16 Shoreditch 76 0.63 Kensington 21 0.12 Bethnal-green 89 0.67 Hammersmith 27 0.23 Stepney 199 0.65 Fulham 65 0.45 Poplar 99 0.58 Chelsea 14 0.19 South wark 114 0.54 Westminster, City of 34 0.19 Bermondsey 69 0.52 St. Marylebone 23 0.17 Lambeth 118 0.38 Hampstead 10 0.12 Battersea 63 0.36 St. Pancras 113 0.47 Wandsworth 64 0.26 Islington 156 0.46 Camberwell 110 0.41 Stoke Newington 14 0.27 Deptford 41 0.36 Hackney 92 0.41 Greenwich 20 0.20 Holborn 27 0.45 Lewisham 65 0.48 Finsbury 75 0.73 Woolwich 51 0.42 London, City of 4 0.15 London 1,876 0.402 It will be seen from the foregoing table that the whooping cough death-rate was highest in Finsbury (0-73) and lowest in Kensington and Hampstead (0T2). The whooping cough deathrate in London in each of the four quarters of the year 1902 were as follows—first quarter 0'41; second quarter 0'47; third quarter 0-41; and fourth quarter 0-34 per 1,000 living. Typhus. No deaths from typhus in the administrative county of London occurred during the year 1902. The death-rates from this disease in 1902 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 .0012 1891 .0022 1898 .0012 1892 .0032 1899 .0002 1893 .0012 1900 .0012 1894 .0012 1901 .0012 1895 .0012 1902 In this table 000 indicates that the deaths were too few to give a rate of *0005. Where — is inserted no death occurred. The death-rate in each year since 1868 in relation to the mean death-rate of the period 18G9-1902 is shown in diagram XVI. Four persons were certified to be suffering from this disease during the year residing in the following districts—Stepney one case, Bermondsey one case, Wandsworth one case and Camberwell one case. 1 See footnote ('), page 13. 2 See footnote ('), page 12. [8] 58 Only the first of these cases was, after admission to hospital, regarded as a case of typhus. The patient was a boy aged 14. The case was notified in the first instance as one of enteric fever ; the patient was moved to the German Hospital, Dalston, where his malady was regarded as typhus. The source of his infection could not be ascertained. Enteric Fever. The number of cases of enteric fever notified in the administrative county of London during 1902 (53 weeks) was 3,407, compared with 3,194 in 1901 ; the number of deaths from this disease belonging to the administrative county was 537, compared with 497 in 1901. The rates per 1,000 living in 1902 and preceding periods were as follows— Period. Death -rate per 1,000 living. Case-rate per 1,000 living. Case mortality per cent. 1871-80 0.24 * * 1881-90 0.19 * * 1891 0.121 0.8 15.6 1892 0.101 0.6 17.2 1893 0.161 0.9 18.4 1894 0.141 0.8 18.1 1895 0.141 0.8 17.0 1896 0.131 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 0.0l1 0.7 15.6 1902 0.121 0.7 15.8 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1809-1902 is shown in diagram XVII. The monthly case-rate and case mortality in each of the years 1891-1902 in relation to the mean of the whole period is shown in diagram XIX. The following table shows the death-rate from enteric fever in 1902, and the case-rates in 1902, and the decennium 1892-1901 obtaining in each of the metropolitan boroughs— Metropolitan borough. Cases, 1902. Case-rate per 1,000 living. Deaths, 1902. Death-rate per 1,000 living, 1902. 1892-1901. 1902. Paddington 83 0.5 0.6 13 0.09 Kensington 83 0.6 0.5 19 0.1l Hammersmith 51 0.6 0.4 11 0.09 Fulham 74 0.6 0.5 9 0.06 Chelsea 35 0.7 0.5 6 0.08 Westminster, City of 132 0.6 0.7 20 0.11 St. Marylebone 96 0.7 0.7 15 0.11 Hampstead 46 0.6 0.5 11 0.13 St. Pancras 197 0.9 0.8 44 0.18 Islington 263 0.8 0.8 46 0.13 Stoke Newington 22 0.7 0.4 4 0.08 Hackney 184 1.1 0.8 31 0.14 Holborn 40 0.8 0.7 6 0.10 Finsbury 82 0.8 0.8 9 0.09 London, City of 15 1.0 0.6 2 0.08 Shoreditch 150 0.9 1.3 22 0.18 Bethnal-green 132 1.0 1.0 14 0.11 Stepney 296 0.9 1.0 34 0.11 Poplar 209 1.3 1.2 27 0.16 Sonthwark 193 0.7 0.9 23 0.11 Bermondsey 130 0.9 1.0 13 0.10 Lambeth 218 0.7 0.7 38 0.12 Battersea 96 0.8 0.6 16 0.09 Wandsworth 145 0.6 0.6 29 0.12 Camberwell 146 0.6 0.5 31 0.12 Deptford 76 0.8 0.7 13 0.1l Greenwich 68 0.8 0.7 9 0.09 Lewisham 60 0.5 0.4 9 0.07 Woolwich 61 0.7 0.5 13 0.11 Port of London 24 — — — — London 3,407 0.8 0.7 537 0.121 * See footnote (*), page 48. 1 See footnote (';, page 12. Diagram XVII. Enteric Fever. DiagramXVIII Enteric Fever. 12ZZ52 Month Vi% 104! G 43 44 45 *47 to 10 S0 Diagram XIX . Enteric Fever. 59 It will be seen from the foregoing table that among the several metropolitan boroughs the enteric fever death-rate was highest in St. Pancras and Shoreditch (0-18) and lowest in Fulham (0 06). The enteric fever death-rates in London in each of the four quarters of the year 1902 were as follows—first quarter 0'09 ; second quarter 0-06; third quarter 0-15 ; and fourth quarter 0-16 per 1,000 living. The behaviour of enteric fever in Loudon in 1902 was characterised by some prevalence, abnormal in point of time, in the period 25th-30th week, more especially marked in the 29th and 30th week (see diagram XVIII). This increase was not limited to any one locality, but was widely distributed throughout London. Corresponding in point of time with this prevalence an outbreak of enteric fever occurred in Southend, which was attributed by Dr. Nash, the medical officer of health, to the consumption of contaminated shellfish. Such information as I was able to obtain from London medical officers of health relating to cases of enteric fever in London associated with shellfish eating did not explain the abnormal prevalence referred to, although its coincidence in point of time with that of Southend is noteworthy. A further condition requiring consideration in relation to the more marked prevalence in the 29th and 30th week, is the occurrence of floods in the Thames in the 25th week, and in the Lee in the 24th and 25th week, which caused in the filtered water of the several companies a notable increase in the organic matter beginning either in the 25th or 26th weeks. This condition, however, could not have been concerned in causing the increase in the number of cases notified in the earlier weeks. In discussing the causes of cases of enteric fever in London, the subject most frequently referred to in the annual reports is that of infection from the consumption of shellfish. Large quantities of shellfish, especially cockles, came to London from the neighbourhood of Southend, and many London inhabitants visited Southend during the summer months, some limiting their stay there to a single day, others residing there for longer periods, and many of these visitors ate shellfish. There is no reason for doubting that many cases of enteric fever in London were caused in this way, and it is highly probable that the consumption of shellfish from other places has had a similar result. Many occurrences of enteric fever in this connection are described in the annual reports of medical officers of health, of which the following deserve especial reference. Thus Dr. Allan, the medical officer of health of Westminster, writes— "Thirty persons are believed to have contracted the disease from eating shellfish; twenty-two of these were persons in the Strand and Covent-garden wards who had been to Southend and Southwick, at one or other of which places they had eaten cockles or mussels from sources known to have been sewage polluted. Another had eaten oysters while yachting off Poole, the oysters having been gathered by himself. Six others had eaten shellfish from stalls in London, or on day trips to seaside places on dates which would correspond with the periods of infection. In some instances the patients themselves attributed the attack to such cause, as they had had some stomach or bowel trouble soon after eating the shellfish." With reference to the persons who went to Southend and Southwick, the report of Dr. Allan for the mouth of September contains the following statement— " The marked decline which took place in enteric fever cases in London in August was not maintained, the cases rising from 287 to 473, a figure in excess of that recorded last year. In Westminster there have been no less than 26 cases, and the manner in which a number of these contracted the disease suggests a possible explanation of the increase in London generally. It will be observed that 14 of the cases were notified in the wards of Covent-garden and Strand. Two other cases were notified at the end of the month subsequent to the date of this report, and I am informed that a case has also occurred in the Borough of Holborn, and is connected with this group; a fourth case of bowel complaint in a brother of one of the above patients came to my knowledge, but the medical men in attendance did not feel justified iu notifying it as a case of typhoid fever." " All those attacked were young persons, and on inquiry it was elicited that all of them had been to Southend-on-Sea or Southwick (a small seaside village between Brighton and Worthing) for a fortnight. Of these eighteen cases, seven had been to the former place only, one to Southwick only, and ten to both places. All those who went to Southend bought and ate cockles from itinerant vendors, and, with one exception (a boy who went to Southend also), those who went to Southwick picked up mussels and ate them, in some cases taking them to their lodgings to be cooked, but in a good many instances the mussels were eaten raw. In the one exception, although the boy did not eat mussels at Southwick, he had eaten cockles at Southend, and the interval between so doing and falling ill was not too long to preclude the cockles as the source of the disease, but he had been constantly in the water bathing or paddling at Southwick, and had assisted other boys in collecting mussels. From inquiries I have made, there is no doubt that infection through the medium of infected shellfish might be contracted at both the> places mentioned." Dr. Bond, the medical officer of health of Holborn, states that in four cases " there was strong evidence that the disease was caused by eating shellfish. One of them was a boy aged 13, who had been at a school outing at Southwick for a fortnight, and had also visited Southend-onSea. Of the boys who went to this outing eighteen were attacked with enteric fever, and all of them had eaten cockles, or mussels, or both." Dr. Caldwell Smith found that of three cases of enteric fever occurring in one house in Wandsworth, two were attacked simultaneously a fortnight after eating cockles which had come from Leigh-on-Sea, the third case, who ate cockles a week after the other two, being attacked a week later. A fourth case occurred a few days later in 60 another house, the patient having eaten cockles purchased from the same dealer. In the reports relating to the following districts cases of enteric fever occurred which followed the eating of shellfish. In Paddingtou, the eating of oysters in four cases and of cockles in one case was followed within the period of incubation by attack by enteric fever. In Kensington there was ground for suspicion in twelve cases that enteric fever had been caused by eating oysters. In. Fulham there were five cases in which shellfish had been eaten at a time which corresponded with the period of incubation, viz., at Ramsgate (oysters), at Brighton and Southend (oysters and cockles), at Littlehampton (oysters), at Dublin (cockles), in London (oysters). In Chelsea there was one case in which cockles and oysters had been eaten at Southend. In St. Pancras eleven cases occurred in July, September and October, cockles, or oysters, or other shellfish having been eaten in each case at Southend. In Islington there were three cases after eating oysters. In Stoke Xewington, one case occurred after eating oysters, and two cases after eating cockles. In Hackney, nine cases were attributed by the relatious to the eating of shellfish. In Finsbury, ten cases occurred after the eating of shellfish, in five shellfish had been purchased at a stall (in one case, oysters), in one case oysters had been eaten at Jersey, in one case oysters and other shellfish at Margate, in two cases shellfish had been eaten at Southend, and in another case the shellfish had come from Southend. In Shoreditch, in twelve cases occurring in July, August, and September, the attack followed the eating of cockles at Southend. The interval between the visit to Southend and the subsequent attack in eleven cases ranged between seven and sixteen days, and in one case was twenty-six days. In Poplar, in July, August, and September, in seven cases cockles had been eaten at Southend, in four cases cockles which came from Southend, and in one case cockles which came from Margate had been eaten. In two cases oysters had been eaten, in one case three weeks and in the other a month before attack. In Southwark, in seven cases cockles had been eaten at Southend, in one cockles from an unknown source, in seven cases mussels, in seven cases oysters, in four whelks, and in two crabs, all from unknown sources. In Battersea, at a time corresponding with the date of infection, cockles had been eaten in five cases, mussels in five, and oysters in two cases. In two of these cases the cockles came from Leigh-on-Sea. Dr. Smith is of opinion that 22 cases in the borough of Wandsworth were due to the consumption of shellfish two or three weeks before this attack, viz., mussels in one case, winkles in one case, cockles in six cases, and oysters in fourteen cases. In only one of the last cases was the source of the oysters definitely traced, viz., Emsworth. This case occurred about the same time as an outbreak of enteric fever at Southampton, due to eating oysters from this source. In Camberwell, in two cases oysters had been eaten at Southend, in one case oysters had been eaten at Brixton, and in a fourth case winkles had been eaten at Southend some four weeks before attack; in other cases the patients occasionally partook of shellfish. In Greenwich, in seventeen cases shellfish had been eaten within three weeks of attack; in two of these cases cockles had been eaten at Leigh; in five cases cockles, in one case oysters at Southend, and in nine cases shellfish had been eaten at home. The Southend and Leigh cases occurred in September and October. In Woolwich, in twelve cases shellfish had been eaten within three weeks of attack, and one of these was a case in which cockles had been eaten at Southend. How many of the cases mentioned above were actually due to the eating of shellfish cannot be stated, but the fact that in numerous instances the shellfish was known to come from polluted sources, and that in respect of some of these, notably Southend and Leigh, cases of enteric fever had occurred locally, apparently from the eating of shellfish, creates a strong presumption that in 1902 many cases of this disease were caused in London in this manner. On the occurrence of the four cases of enteric fever in Wandsworth, mentioned above, Dr. Caldwell Smith communicated with Dr. Collingridge, who found that the cockles in question had come from Leigh-on-Sea. Samples of cockles taken at Leigh—some boiled, some unboiled— were submitted by Dr. Collingridge to Dr. Klein for bacteriological examination, with the result that Dr. Klein reported that they showed evidence of sewage pollution. Dr. Collingridge reports that the Fishmongers' Company at once put their powers into force, and prohibited the Leigh cocklers from sending to the London market any more cockles which had been relaid in the Leigh estuary other than those which were actually ready for market and had been boiled, but that cockles taken from the parent beds on the Maplins and elsewhere and boiled directly they were landed, without allowing them to be contaminated with sewage, might be sold in London. Later, however, after examination by Dr. Klein, Dr. Collingridge reported that samples of cockles taken from the Maplins and Blyth were also contaminated with sewage. The occurrence of numerous cases of enteric fever among the guests at a mayoral banquet at Winchester in November, due to the consumption of oysters taken from the Emsworth pits, led the Fishmongers' Company to prohibit the sale in London of oysters from this source. Dr. Collingridge gives the results of Dr. Klein's examination of oysters from five places, and he states that the conclusions arrived at were that one Emsworth sample examined was contaminated, that of two Bosham samples both were contaminated, that of five Mumbles samples four were contaminated, that of two Southwick samples both were contaminated, and that of eight Whitstable samples two were contaminated. It is important to observe that evidence of the contamination of particular shellfish layings appears in some instances to include that of a clinical and topographical nature, while in other cases the evidence appears to have been of a bacteriological nature only. In 1898, the County Council joined in a deputation from the authorities of 27 large towns to the. President of the Local Government Board, which urged the necessity of legislation in order to minimise the dangers to which the public are exposed through the consumption of sewage contaminated ovsters and other shellfish. A Bill for the purpose of dealing with oysters was in 1899 introduced into Parliament, and submitted to a select committee of the House of Lords. This- 61 Bill authorised county councils to enter upon any oyster laying and take samples, and to prohibit the sale of oysters from polluted layings, unless the oysters were before sale laid down for a specified period in a laying free from contamination. The select committee, however, substituted the sea fishery boards for county councils, and the President of the Local Government Board in consequence withdrew the Bill. In view of the occurrences of enteric fever due to contaminated shellfish, the County Council on the 3rd February, 1903, on the recommendation of the Public Health Committee, adopted the following resolution : " That a letter be addressed to the Local Government Board expressing the Council's hope that, in the interests of the public health, the Board will, as soon as possible, take steps to obtain an amendment of the law so as to prohibit under heavy penalties the laying down of all edible forms of shellfish in sewage-polluted creeks or other dangerous localities, and the sale of such shellfish for human consumption; and that all unpolluted layings, fattening beds and storage ponds at present in use may be protected from pollution by sewage by any person or sanitary authority." The subject is now being considered by the Royal Commission on Sewage Disposal. It will be recollected that in the year 1900 Dr. Hamer, as the result of an inquiry on behalf of the Council into certain local prevalences of enteric fever in London, came to the conclusion that a localised outbreak of some magnitude in the parish of St. George-the-Martyr was due to the consumption of fish from a particular fried fish shop. During 1902 Dr. Allan observed in Westminster the occurrence of certain cases which appeared to be attributable to a similar cause. He writes:" It is now known that infection may sometimes be communicated through fish where not thoroughly cooked, and in this connection a small group of cases which occurred is interesting. One patient was a fishmonger, and three others were regular customers buying fresh fish; the fishmonger and two of his customers were probably infected about the same date, but in the fourth case symptoms did not appear till a month later, and the patient is inclined, for reasons mentioned above, to attribute his illness to oysters eaten off a barrow in the East End. The drainage of the fishmonger's house was bad. Another case is believed to have been contracted from eating fried fish while staying at Old Ford." Dr. Newman also states that in Finsbury there were eight cases of enteric fever, concerning which there was some evidence that they were caused by the consumption of fried fish. In Woolwich, in two instances infection had been preceded by the eating of fried fish, and in Greenwich in three instances. The consumption of ice-creams was probably responsible for the attack by enteric fever of twelve boys in June in the Borough of Finsbury. Dr. Newman states that they had all had icecream about the same time, and as far as could be gathered from the same source, namely, hawkers in the street. In six other cases in Finsbury, in which no other cause of infection, the patients attributed their illness to ice-creams. In Paddington, a case of enteric fever occurred, the person attacked having eaten ice-cream at a period before the illness which was consistent with it being the cause of the illness. In Woolwich the attack of three persons had been preceded by the eating of ice-creams. Watercress as a possible means of infection is mentioned in two reports. In Camberwell one or more of the persons attacked attributed their illness to the eating of watercress, and in Woolwich in two cases attack had been preceded by the eating of watercress. In several reports mention is made of the occurrence of cases due to infection from person to person, and Dr. Bryett records the occurrence in Shoreditch of series of cases probably caused in this way. In one of these series the first case was a girl aged 15 years who died, but the nature of whose illness had not been recognised ; her illness was followed by the attack of a young sister, a young brother and her mother, who became ill within a few days of each other. A few days later an adult relative living in another house, but who had helped in the nursing, and also the father of the family were attacked. Two younger children of the family were sent to Croydon, but were ailing at the time, and later an inmate of the house in which they were staying was attacked by enteric fever. In a second series the attack of a brother, sister and father followed that of the first case, a child aged five years. In Woolwich five cases were due to direct infection, three living in the same dirty house as the primary case, and the other two being employed in nursing the primary case. In Lambeth five cases were infected by preceding cases in the borough. In Wandsworth in eight cases out of 139 the disease was known to have been contracted in this way. In Battersea 10 such cases occurred. In Paddington two persons contracted the disease from nursing others. In Hackney there were four secondary cases and in Finsbury seven. The Widal test was more largely used in 1902 than before for the diagnosis of enteric fever. In Fulliam 54 such examinations were made, the result being positive in_20. In Westminster a positive result was obtained in 25 examinations, in St. Pancras 34 in 77 examinations, in Islington 45 in 114, in Finsbury 7 in 18, in Shoreditch 3 in 7, in Poplar 60 in 115, in Bermondsey 17 in 38, in Lambeth 34 in 91, in Wandsworth 2 in 6, in Camberwell 13 in 3G, and in Woolwich in 13 of 30 examinations. 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 1902 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-gioups adopted for the purposes of this table the greatest incidence of attack was upon males aged 10-15 and also upon females of the same age-period. The greatest incidence of death was upon males age 20-,5, and upon females aged 25-35. The fatality was greatest among both males and females aged 55 and upwards. 62 Enteric fever*, 1902. Age-period. Males. Females. Cases. Deaths. Case mortality per cent. Rates per 1,000 living Cases. Deaths. Case mortality per cent. Rates per 1,000 living. Cases. Deaths. Cases. Deaths. All ages. 1,955 342 17.5 90 16 1,452 240 165 60 10 0— 3 1 9.4 34 3 3 1 90 27 2 1— 6 1 7 1 2— 20 3 8 1 3— 32 1 18 1 4— 24 2 31 2 5— 200 9 4.5 90 4 198 14 7.1 88 6 10— 349 30 8.6 166 14 212 15 7.1 99 7 15— 341 53 15.5 162 25 195 29 14.9 83 12 20— 311 75 24.1 142 34 217 41 18.9 83 16 25— 378 82 21.7 101 22 342 76 22.2 77 17 35— 182 51 280 64 18 127 35 27.6 41 11 45— 7] 18 25-4 36 9 69 14 20.3 31 6 55 and upwards. 38 16 42-1 20 8 25 10 400 10 4 Diarehcea. The deaths in the administrative county of London attributed to epidemic diarrhoea and infective enteritis numbered 1,079 in 1902, while 1,425 deaths were attributed to diarrhoea and dysentery. The age distribution of these deaths was as follows— Disease. Under 1 year. 1-5 5-20 20-40 40-60 60-80 80 and upwards. All ages. Epidemic diarrhoea and infective enteritis 896 171 2 1 4 5 — 1,079 Diarrhoea and dysentery 1,038 187 9 23 40 93 35 1,425 Total 1,934 358 11 24 44 98 35 2,504 It will be seen from the following table that the London diarrhoea death-rate in the period 1892-1901 was lower than that of any of the undermentioned towns except Bristol, and in the year 1902 was lower than that of any except Manchester, Bristol, Bradford, Hull and Newcastle. Diarrhoea—Death rates per 1,000 living. Towns. 1892-1901. 1902. Towns. 1892-1901. 1902. London 0.811 0.541 Nottingham 1.26 0.72 Manchester 1.47 0.53 Bradford 0.94 0.18 Liverpool 1.49 0.94 Hull 1.64 0.41 Birmingham 1.34 0.71 Salford 1.71 0.64 Leeds 1.19 0.60 West Ham 1.25 0.85 Sheffield 1.54 0.56 Leicester 1.53 0.59 Bristol 0.67 0.38 Newcastle 0.84 0.26 The deaths and death-rate per 1,000 living in the year 1902 in each of the metropolitan boroughs are shown in the following table— * See footnote (*), page 51. 1 See footnote ('), page 13. 63 Metropolitan Borough. Deaths, 1902. Death-rate per 1,000 living, 1902. Metropolitan Borough. Deaths, 1902. Death-rate per 1,000 living, 1902. Paddington 75 0.51 Shoreditch 130 1.08 Kensington 81 0.45 Bethnal-green 61 0.46 Hammersmith 64 0.55 Stepney 237 0.78 Fulham 129 0.89 Poplar 110 0.64 Chelsea 40 0.53 Southwark 169 0.80 Westminster, City of 54 0.29 Bermondsey 89 0.67 St. Marylebone 67 0.50 Lambeth 180 0.58 Hampstead 12 0.14 Battersea 97 0.56 St. Pancras 83 0.35 Wandsworth 97 0.39 Islington 98 0.29 Camberwell 146 0.55 Stoke Newington 18 0.34 Deptford 76 0.67 Hackney 96 0.43 Greenwich 46 0.46 Holborn 19 0.32 Lewisham 64 0.48 Finsbury 69 0.68 Woolwich 61 0.50 London, City of 2 0.08 London 2,470 0.53 It will be seen from the foregoing table that the diarrhoea death-rate was highest in Shoreditch (1.08) and lowest in the City of London (0.08). The diarrhoea death-rates in London in each of the four quarters of the year 1902 were as follows—first quarter 0.12; second quarter 015; third quarter 1.42; and fourth quarter 0.44 per 1,000 living. Erysipelas. The deaths from erysipelas registered in the administrative county of London during 1902 (53 weeks) numbered 183 ; the corrected annual average of the preceding ten years was 236. 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.3 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 1902 5,536 1.19 183 .04 The number of cases of erysipelas notified and the case-rate of the year 1902, together with the case-rate of the decennium 1892-1901 for each of the metropolitan boroughs, are shown in the following table— Metropolitan borough. Cases, 1902. Case-rate per 1,000 living. Metropolitan borough. Cases, 1902. Case-rate per 1,000 living. 18921901. 1902. 18921901. 1902. Paddington 148 1.1 1.0 Bethnal-green 255 2.4 1.9 Kensington 189 1.3 1.0 Stepney 448 1.7 1.5 Hammersmith 118 1.1 1.0 Poplar 191 1.8 1.1 Fulham 124 1.1 0.9 Southwark 371 1.5 1.8 Chelsea 60 1.2 0.8 Bermondsey 190 1.6 1.4 Westminster, City of 144 0.8 0.8 Lambeth 337 1.2 1.1 St. Marylebone 219 1.7 1.6 Battersea 200 1.5 1.1 Hampstead 57 0.7 0.7 Wandsworth 243 1.3 1.0 St. Pancras 258 1.6 1.1 Camberwell 309 1.2 1.2 Islington 364 1.2 1.1 Deptford 151 1.4 1.3 Stoke Newington 52 0.8 1.0 Greenwich 122 1.4 1.2 Hackney 329 1.5 1.5 Lewisham 112 0.9 0.8 Holborn 85 2.1 1.4 Woolwich 96 0.9 0.8 Finsbury 157 1.9 1.5 Port of London — — — London, City of 32 1.0 1.2 London 5.536 1.4 1.2 Shoreditch 175 1.8 1.5 1 See footnote (1), page 12. See footnote (1), page 13. 64 The following table shows the age and sex distribution of the notified cases of erysipelas in 1902— Age period. All ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 2,348 197 94 96 129 121 295 488 445 283 142 58 Females 3,188 204 113 167 198 170 463 552 593 377 231 373 120 Persons 5,536 401 207 263 327 291 758 1,040 1,038 660 178 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 1902 attributed to puerperal fever* numbered 201, the corrected annual average of the preceding 10 years being 239. 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 1902 311 201 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 1902 .07 2.34 .04 1.51 Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1901 numbered 664, rose to 1,073 in 1902, being 358 below the corrected annual average of the preceding 10 years. The deaths from bronchitis in 1902 numbered 7,901, being 1,371 below the corrected annual average for the preceding 10 years. The deaths from pneumonia numbered 6,788 in 1902, and were 395 above the 10 years' average. * Including deaths from puerperal septicaemia an.i puerperal pyaemia. 1 See footnote (1), page 13. 65 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 1902 1,073 1,431.0 7,901 9,272.0 6,788 6,393.0 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, 1890-1902. Number of weeks. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 49—52* 6 81 28 546 58 49 56 71 52 342 46 56 99 Phthisis. The deaths from phthisis in the administrative county of London during 1902 (53 weeks) numbered 7,424. The death-rates from this disease per 1,000 living in successive periods have been as follows— Phthisis. 1851-60 2.86 1895 1v831 1861-70 2.84 1896 1.731 1871-80 2.511 1897 1.781 1881-90 2.091 1898 1.791 1891 2.021 1899 1.901 1892 1.891 1900 1.791 1893 1.911 1901 1.711 1894 1.741 1902 1.641 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 deaths occurring in the 53rd week of the years 1890, 1896 and 1902 are excluded from these figures. 1 See footnote (1), page 13. [9] 66 Metropolitan borough. Deaths, 1902. Death-rate per 1,000 living, 1902. Metropolitan borough. Deaths, 1902. Death-rate per 1,000 living, 1902. Paddington 155 1.05 Shoreditch 217 1.81 Kensington 232 1.29 Bethnal-green 260 1.97 Hammersmith 166 1.43 Stepney... 579 1.90 Fulham 200 1.38 Poplar ... 293 1.70 Chelsea 109 1.45 Southwark 550 2.62 Westminster, City of 328 1.78 Bermondsey 249 1.88 St. Marylebone 258 1.92 Lambeth 526 1.70 Hampstead 72 0.85 Battersea 229 1.31 St. Pancras 450 1.88 Wandsworth 221 0.90 Islington 513 1.50 Camberwell 402 1.51 Stoke Newington 66 1.26 Deptford 127 1.12 Hackney 323 1.43 Greenwich 119 1.19 Holborn 179 3.01 Lewisham 143 1.06 Finsbury 233 2.28 Woolwich 181 1.49 London, City of 44 1.69 London 7,424 1.601 The following table shows the crude phthisis death-rate and the phthisis death-rate corrected for differences in age and sex constitution of the various metropolitan boroughs. The " factors for correction," also shown in the table, have been calculated by applying the population of each of the metropolitan boroughs to the death-rates at each age and for each sex obtaining for London in the five years 1897-1901. Crude and corrected death-crates,1 per 1,000 persons living, in the County of London and the several metropolitan boroughs. Phthisis. Sanitary area. Standard death rate. Factor for correction for age and sex distribution. Crude death-rate, 1902. Corrected death-rate, 1902. Comparative mortality figure, 1902. (London 1,000.) London 1.74 1.00000 1.60 1.60 1,000 Paddington 1.80 .96659 1.05 1.01 631 Kensington 1.78 .97419 1.29 1.26 787 Hammersmith 1.74 .99600 1.43 1.42 887 Fulham 1.69 1.02786 1.38 1.42 887 Chelsea 1.83 .95018 1.45 1.38 862 Westminster, City of 1.95 .89205 1.78 1.59 994 St. Marylebone 1.85 .93836 1.92 1.80 1,125 Hampstead 1.75 .98862 0.85 0.84 525 St. Pancras 1.80 .96551 1.88 1.82 1,137 Islington 1.75 .99145 1.50 1.49 931 Stoke Newington 1.77 .97914 1.26 1.23 769 Hackney 1.68 1.02969 1.43 1.47 919 Holborn 1.97 .87894 3.01 2.65 1,656 Finsbury 1.72 1.01050 2.28 2.30 1,437 City of London 1.89 .91946 1.69 1.55 969 Shoreditch 1.66 1.04206 1.81 1.89 1,181 Bethnal-green 1.59 1.03984 1.97 2.15 1,344 Stepney 1.65 1.05281 1.90 2.00 1,250 Poplar 1.66 1.04772 1.70 1.78 1,112 Southwark 1.74 .99829 2.62 2.62 1,637 Bermondsey 1.65 1.05026 1.88 1.97 1,231 Lambeth 1.75 .99258 1.70 1.69 1,056 Battersea 1.69 1.02483 1.31 1.34 837 Wandsworth 1.72 1.01050 0.90 0.91 569 Camberwell 1.68 1.03522 1.51 1.56 975 Deptford 1.69 1.02969 1.12 1.15 719 Greenwich 1.67 1.04143 1.19 1.24 775 Lewisham 1.69 1.02543 1.06 1.09 681 Woolwich 1.70 1.01881 1.49 1.52 950 It will be seen from the foregoing table that in 1902 (comparing the corrected deathrates) the phthisis death-rate was highest in Holborn (2.65) and lowest in Hampstead (0.84). The phthisis death-rates in London in each of the four quarters of the year 1902 were as follows first quarter 1.84; second quarter 1.52 ; third quarter 1.38; and fourth 1.64 per 1,000 living. The necessity for "age and sex correction ' in the case of phthisis is well illustrated by the following figures showing the mean phthisis death-rates obtaining for London in the five years 1897-1901. 1 See footnote ('), pa^e 12. 67 London, 1897-1901. Age-period. Mean phthisis death-rate per 1,000 living. Age-period. Mean phthisis death-rate per 1,000 living. Males. Females. 0— 0.57 0— 0.48 5— 0.16 5— 0.21 10— 0.18 10— 0.32 15— 0.86 15— 0.83 20— 1.77 20— 0.92 25— 2.72 25— 1.63 35— 4.62 35— 2.60 45— 5.16 45— 2.30 55— 4.38 55— 1.73 65— 3.06 65— 1.18 75— 1.36 75— 0.72 85 and upwards 1.27 85 and upwards 0.44 All ages 2.24 All ages 1.28 When the large variations in the age and sex incidence of phthisis shown in this table are considered in relation to the variations in the age and sex constitution of the populations of the several metropolitan boroughs, it is obvious that the " all ages " death-rates calculated on the total deaths and population of each of these boroughs will show marked differences on this account alone. Thus, as will be seen, on referring to the first column of the table showing the "standard death-rate" in each borough, the population of Bethnal-green applied to the London death-rates at each age and sex gives an "all ages" death-rate of 159 per 1,000 living, while the population of Holborn applied to the same death-rates at each age and sex gives an " all ages " death-rate of 1.97 per 1,000 living, i.e., a death-rate nearly 24 per cent, in excess of that of Bethnal-green, solely due to differences in the age and sex constitution of the two populations. The "factors for correction " have been calculated upon the populations of the several boroughs as enumerated at the census of 1901, and the population of the principal workhouses and infirmaries (where these institutions are situated outside the area from which their inmates are drawn) have been included with the populations to which they properly belong (see page 14 ante). 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 12.) Phthisis (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddington 1 - 2 8 11 35 39 27 23 7 2 - 155 Kensington 9 4 3 5 15 41 53 54 24 8 1 - 217 Hammersmith 4 1 3 2 12 45 37 29 20 9 1 - 163 Fulham 9 2 3 17 22 38 45 41 17 6 - - 200 Chelsea 6 1 - 3 5 22 26 25 12 7 - - 107 Westminster, City of 8 4 6 12 24 57 98 67 35 10 1 - 322 St. Marylebone 13 2 3 4 18 46 61 48 30 19 3 - 247 Hampstead - 2 - 5 8 20 20 12 8 - - - 75 St. Pancras 18 3 6 17 31 88 118 110 44 15 1 - 451 Islington 22 6 13 30 57 119 132 74 38 10 1 - 502 Stoke Newington - - 1 5 11 15 11 11 6 3 1 - 64 Hackney 13 1 9 16 34 79 68 58 27 13 2 - 320 Holborn 4 1 1 4 9 40 44 37 25 8 2 1 176 Finsbury 10 2 4 11 11 48 68 46 22 7 - - 229 London, City of 1 - - 2 2 6 17 7 5 - - - 40 Shoreditch 11 2 1 9 15 41 66 47 16 4 2 - 214 Bethnal-green 14 5 1 13 17 56 53 46 33 16 5 - 259 Stepney 21 5 11 12 50 140 131 122 49 21 I 1 564 Poplar 11 5 4 10 25 64 73 64 27 10 2 - 295 Southwark 18 5 5 18 45 93 154 121 51 25 1 1 537 Bermondsey 12 5 8 17 13 49 55 53 20 4 - - 236 Lambeth 21 6 6 29 46 96 126 110 55 20 2 - 517 Battersea 3 5 2 19 24 54 44 43 23 5 - - 222 Wandsworth 6 6 2 14 24 57 63 35 16 5 - - 228 Camberwell 14 5 4 17 31 95 95 80 44 16 3 1 405 Deptford 7 1 1 6 12 30 28 21 11 2 - - 119 Greenwich 2 1 3 12 10 23 33 18 10 5 1 - 118 Lewisham 6 2 3 14 16 31 39 14 11 4 2 - 142 Woolwich 2 1 2 19 15 37 51 28 19 5 - - 179 London 266 83 107 350 613 1,565 1,843 1,448 721 264 34 4 7.303 68 The annual reports show some increase of administrative measures in London designed for the purpose of the control of tubercular disease. Thus a system of voluntary notification of such disease has been established in the Cities of London and Westminster and in Bermondsey, Finsbury, Greenwich, Hammersmith, Hampstead, Kensington, Lambeth, Southwark, Stoke Newington, Wandsworth and Woolwich. In several of these districts there was notification during part of the year only, and in a few arrangements for this purpose were not actually made until shortly after the end of this year, so that only 1,191 cases were actually notified in London in 1902. Several reports show that medical officers of health had recommended their authorities to institute a system of voluntary notification of phthisis, and only one report shows that the medical officer of health is opposed to this practice. Sanitary authorities are empowered, as shown by a letter of the Local Government Board, to pay a fee to medical practitioners notifying cases, and the amount paid for the notification of dangerous infectious diseases is that which has been adopted. The notification has been followed by the offer of disinfection free of charge in cases of change of residence or of death of the patient, the supply of leaflets giving advice as to care in dealing with the sputum and other matters, and often by inquiries as to whether there is reason for thinking that the disease has been contracted by exposure to another person suffering in a similar manner. In a few reports information as to antecedent phthisis in other members of the family is given. Thus in Finsbury Dr. Newman found that other members of the family had suffered from phthisis, and might have been the source of infection of the patients concerned in 59 cases notified, and 156 cases of death, and in Woolwich in nine notified cases. In Hampstead a phthisical family history was found in 17 of 41 cases, in Kensington in 104 of 247 cases. Dr. Newman moreover found by inquiry into the history of 16 children in Finsbury who died from tabes-mesenterica, that in seven instances the child was in contact with a relative suffering from phthisis, in six instances either a parent or brother or sister, and in three instances was in contact with a neighbour suffering from that disease. Again, Dr. Davies, as the result of inquiry into the death of three children in Woolwich from tubercular meningitis, found that " in two cases there was a person in the house recognised to be suffering from phthisis, and in the third case a man suffering from chronic winter cough and sputa, who refused to be examined as to whether or no he had phthisis." Disinfection after death from phthisis or after removal from a house of a person so suffering has been carried out in numerous cases. Bacteriological examinations of sputum from suspected cases of phthisis has given positive results in 48 of 118 examined in Fulham, in 22 of 98 examined in Hampstead, in 108 of 212 examined in Lambeth, and in none of 9 examined in Westminster. In respect of many districts the results were not stated. The parallelism between the incidence of phthisis and of overcrowding in the London districts has been shown in earlier reports to the County Council. Dr. Reginald Dudfield, in his annual report, shows that similar results are obtained when the overcrowding and phthisis incidence of the different wards of Paddington are examined. In 1900, at a conference of London poor law authorities, a resolution was adopted to the effect that provision should be made for the open air treatment of cases of consumption among the sick poor of the metropolis. In 1902, the Metropolitan Asylums Board received from their General Purposes Committee the following report— At the Board meeting on the 26th July last the Managers remitted to us for consideration and report (in connection with other letters previously received on the same subject) a letter from the Bermondsey Borough Council, in which they again urged the establishment by the Managers of sanatoria for the treatment of consumptive persons, and forwarded an epitome of the replies received from the other Metropolitan Borough Councils who had been asked to support their proposals. This epitome showed that of the twenty-six councils who had been asked to support the action taken by Bermondsey, ten approved of the proposal that the managers should provide sanatoria for the treatment of consumptive patients, five approved of the principle of the need for open air treatment for consumptives, but were not agreed as to the authority for carrying out the same, while the remaining eleven had either taken no action in the matter or were not in favour of the proposal. We have given due consideration to the whole question, but having regard to the important issues involved, and to the fact that there is not yet a general consensus of opinion amongst the Metropolitan authorities in favour of the Metropolitan Asylums Board undertaking the treatment of consumptive patients, we have deferred consideration of the matter for twelve months. The Board resolved that local authorities should be informed that in the absence of unanimity of opinion among the authorities of the metropolis the consideration of the question of the provision of accommodation for persons suffering from consumption should be adjourned for twelve months. For the limitation of the risk of infection from the sputum of persons suffering from pulmonary phthisis, and for the prevention of the objectionable practice of spitting in public places, the County Council has made a by-law under the Municipal Corporations Act of 1882, which is as follows— " No person shall spit on the floor, side, or wall of any public hall, public waiting-room, or place of publio entertainment, whether admission thereto be obtained upon payment or not." It may be noted that the words " any public carriage " would include a railway carriage, and that any person could take steps for obtaining the enforcement of the penalty in the event of breach of the by-law. Cancer. The deaths from cancer in the administrative county of London during 1902 (53 weeks) numbered 4,630, the corrected annual average for the preceding 10 years being 4,022. 69 The death-rates of this disease per 1,000 living in successive periods have been as follows— Cancer. 1851-60 .42l 1895 .831 1861-70 .48l 1896 .861 1871-80 .551 1897 .881 1881-90 .681 1898 .921 1891 .781 1899 .951 1892 .751 1900 .951 1893 .801 1901 .931 1894 .791 1902 .991 For the purpose of enabling the incidence of cancer on the several populations of the sanitary areas of London to be more precisely stated, factors have been calculated for correcting, as far as possible, for differences in the age and sex constitution of the several populations concerned. These factors are shown in the following table, together with the death-rates for each metropolitan borough, corrected by their application. Owing to the changes of area in the sanitary districts of London, caused by the London Government Act of 1899, the death-rates for the two years 1901 and 1902 are the only figures available for comparative purposes, but it can be seen from these figures that differences in the age and sex constitution of the population are largely responsible for the differences in the crude death-rates obtaining in the several districts. Thus, in 1901 the crude death-rates ranged between 0.67 per 1,000 living in Bermondsey and 1.28 in the City, whereas the corrected death-rates for the same year range between 0.73 and 105 in those districts respectively. Again, in 1902 the crude death-rates range between 0.67 in Stepney and 1.56 in the City, whereas the corrected death-rates range between 0.76 in Kensington and 1.28 in the City. For the purposes of this table deaths occurring in public institutions are as far as possible distributed to the areas from which they have been received, but there must be a residuum of cases, especially in the case of such a prolonged disease as cancer, in which the original residence of the patient is unknown or lost sight of, and the deaths of such persons tend to increase the rate of that district in which the institution is situated. The effect of a comparatively small number of such deaths in a district with a small residential population would be to materially increase the death-rate and the unfavourable position of the City, even after correction for age and sex, shown by the table, may possibly in some measure be due to this cause. Cancer. Crude and corrected death-rates2 per 1,000 persons living in the County of London and the several metropolitan boroughs. District. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate, 1902. Corrected death-rate. 1902. Comparative mortality figure, 1902 (London 1,000). Crude death-rate, 1901. Corrected death-rate, 1901. Comparative mortality figure 1901 (London, 1000). London 087 1.00000 0.93 0.93 1,000 0.88 0.88 1,000 Paddington 0.98 0.89478 0.96 0.86 925 1.03 0.92 1,045 Kensington 1.02 0.85622 0.89 0.76 817 1.12 0.96 1,091 Hammersmith 0.90 0.96811 0.85 0.82 882 0.84 0.81 920 Fulham 0.77 1.13828 0.75 0.85 914 0.88 1.00 1,136 Chelsea 1.03 0.84874 1.06 0.90 968 0.91 0.77 875 Westminster, City of 0.96 0.91348 1.07 0.98 1,054 0.83 0.76 864 Marylebone 0.99 0.88571 1.10 0.97 1,043 1.04 0.92 1,045 Hampstead 0.92 0.94816 1.11 1.05 1,129 0.96 0.91 1,034 St. Pancras. 0.92 0.95229 1.03 0.98 1,054 0.88 0.84 955 Islington 0.90 0.96704 0.98 0.95 1,022 0.91 0.88 1,000 Stoke Newington 0.98 0.89387 0.85 0.76 817 0.92 0.82 932 Hackney 0.88 0.99341 0.88 0.87 935 0.80 0.79 898 Holborn 0.95 0.91924 1.08 0.99 1,065 1.00 0.92 1,045 Finsbury 0.84 1.04071 0.81 0.84 903 0.78 0.81 920 London, City of 1.06 0.82316 1.56 1.28 1,376 1.28 1.05 1,193 Shoreditch 0.79 1.10518 1.04 1.15 1,237 0.81 0.90 1,023 Bethnal-green 0.78 1.12077 0.83 0.93 1,000 0.86 0.96 1,091 Stepney 0.74 1.17976 0-67 0.79 849 0.73 0.86 977 Poplar 0.81 1.08327 0-85 0.92 989 0.73 0.79 898 Southwark 0.82 1.06350 0-84 0.89 957 0.86 0.91 1,034 Bermondsey 0.81 1.08462 0-95 1.03 1,108 0.67 0.73 830 Lambeth 0.92 0.95333 101 0.96 1,032 0.99 0.94 1,068 Battersea 0.79 1.10798 0-86 0.95 1,022 0.81 0.90 1,023 Wandsworth 0.88 0.99116 0-93 0.92 989 0.89 0.88 1,000 Camberwell 0.87 1.00483 0-95 0.95 1,022 0.97 0.97 1,102 Deptford 0.81 1.07396 0-96 1.03 1,108 0.81 0.87 989 Greenwich 0.88 0.99795 0-86 0.86 925 0.70 0.70 795 Lewisham 0.92 0.95333 0-98 0.93 1,000 0.95 0.91 1,034 Woolwich 0.78 1.11933 0-86 0.96 1,032 0.71 0.79 898 1 See footnote (1), page 13. 1 See footnote (1), page 12. 70 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 12). Cancer (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddingrton — — 1 _ 3 3 17 27 42 26 17 3 139 Kensington 1 _ 2 7 20 31 40 40 16 1 158 Hammersmith 1 — 1 _ 1 2 7 23 23 29 8 2 97 Fulham — — 1 — — — 10 34 30 18 15 — 108 Chelsea — — 1 _ 3 5 16 26 23 4 — 78 Westminster, City of _ _ _ — 2 6 15 51 46 51 22 1 194 St. Marylebone I _ _ _ 1 4 13 35 39 36 15 2 146 Hampstead — _ _ _ _ 3 6 19 22 21 17 5 93 St. Pancras 1 _ 1 _ _ 6 25 51 70 60 28 1 243 Islington 3 1 _ 2 4 7 30 76 107 68 3] 3 332 Stoke Newington _ _ _ _ _ 1 2 7 14 16 2 2 44 Hackney 1 1 _ _ 1 6 18 40 48 57 23 — 195 Holborn _ _ — — — — 3 18 20 15 7 - 63 Finsbury _ — _ — — 1 9 19 19 19 13 1 81 London, City of — — _ — — — 2 9 11 13 5 — 40 Shoreditch _ _ 1 3 18 27 45 23 5 1 123 Bethnal-green 4 _ _ — — 2 6 26 31 27 9 2 107 Stepney 2 — 1 2 1 7 25 47 48 53 11 2 199 Poplar 1 — 2 — — 5 11 33 48 33 9 1 143 Southwark 2 — — — 1 8 22 38 54 36 11 1 173 Bermondsey 4 1 — 2 - 3 17 23 39 28 6 1 124 Lambeth 1 1 1 1 4 18 40 66 84 60 26 5 307 Battersea 1 — 1 - - 3 16 36 43 34 12 2 148 Wandsworth _ _ 2 _ 2 3 22 33 69 55 36 2 224 Camberwell 3 — — 1 17 20 49 72 65 20 2 249 Deptford 1 — — — — 2 11 29 23 31 9 1 107 Greenwich _ _ _ _ 2 — 11 21 25 18 7 — 84 Lewisham — 1 — — — 6 13 18 39 33 19 1 130 Woolwich 1 — _ — 2 4 8 28 24 26 10 - 103 London 27 5 12 8 28 130 422 930 1,201 1,014 413 42 4,232 Bubonic Plague. During the year 1902 in no instance was any person living in London suspected to be suffering from bubonic plague. Meteorology. The tables published in the Annual Summary of the Registrar-General, deduced from observations at Greenwich, under the superintendence of the Astronomer-Royal, show that the mean temperature of the air in 1902 was 49.2° Fahrenheit, or 05° Fahrenheit above the average of the 131 years, 1771-1901. The rainfall during the year amounted to 1934 inches, or 5.46 inches below the mean of 86 years. The temperature and rainfall in each month of 1902 are shown in the following table— Month. Temperature of the air. Departure from average of 131 years, 1771-1901. Rain. Highest by day. Lowest by night. Mean for month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. inches. January 52.7 24.7 41.8 + 5.0 9 0.64 February 54.1 14.3 35.2 — 3.6 13 0.79 March 60.5 26.6 44.4 + 3.3 15 1.36 Anril 68.2 30.9 46.9 + 0.7 7 0.42 May 71.0 29.8 48.4 — 4.2 22 3.33 June 80.7 41.1 57.6 — 0.8 15 3.10 July 86.1 42.4 61.7 — 0.1 12 1.09 August 79.0 42.8 60.6 — 0.4 19 2.93 September 75.1 36.8 56.6 0.0 8 1.65 October 67.1 32.6 49.8 + 0.3 14 l.24 November 57.9 27.2 44.7 + 2.1 12 1.29 December 56.7 24.5 41.2 + 2.1 13 1.50 71 PART II. Dairies, Cowsheds and Milkshops. The duty of registering milk vendors and of enforcing the regulations in respect of milk premises was transferred to the London sanitary authorities by the London Government Act of 1899. Reference to the work done by these authorities is made in the reports of all but three medical officers of health. In Paddington there were 173 milk premises on the register, of which there were 306 inspections, and various defects found were remedied. In Kensington there were 283 premises on the register. In Fulham 276 premises were on the register and were regularly inspected. In Chelsea 113 premises were on the register and periodically inspected. In Westminster 14 premises were registered during the year and there were 390 visits to milkshops. In St. Marylebone there were 243 inspections of milk premises. In St. Pancras there were 1,327 inspections of milk premises, 45 of which were found to be unregistered. In Islington there were 061 premises on the register and 20 added during the year; all these were visited from time to time. In Stoke Newington the milk premises were duly inspected throughout the year. In Hackney 340 milk premises were on the register ; an inspector was appointed especially for the inspection of cowsheds, dairies, milkshops and slaughterhouses ; he made 723 visits during the year ; cowsheds and dairies will be inspected once a month and milkshops once in six months; legal proceedings were instituted in one case. In Holborn there were 157 premises on the register, 19 having been added during the year ; all were inspected from time to time. In Finsbury 280 premises were on the register, and each was inspected periodically. In the City 528 premises were on the register ; this number includes premises where milk is consumed on the premises; they were regularly inspected. In Shoreditch there were 304 premises on the register and they were periodically inspected. In Bethnal Green 344 premises were on the register and were inspected by the inspector engaged in workshop inspection; there were 1,248 inspections, 8 unregistered vendors were found, and there were two prosecutions. In Stepney 1,466 premises were inspected and legal proceedings were instituted in two cases. In Poplar 437 premises were on theregister, the number added during the year being 27. Several unregistered vendors were found. In Southwark there were 427 premises on the register, and during the year 139 vendors applied for registration; 734 inspections were made. In Bermondsey there were 265 vendors on the register. In Lambeth 458 vendors were known and several were found during the year; all were under inspection. In Battersea there were 213 premises on the register, all of which were systematically inspected and any defects found were remedied. In Wandsworth there were 302 premises on the register, 42 being added during the year ; all were frequently inspected. In Camberwell there were 395 inspections of cowsheds and dairies and 650 of milkshops. In Deptford there were 183 premises on the register, 66 being registered during the year ; there were 503 inspections, and various defects remedied. In Greenwich there were 186 inspections and various defects were remedied. In Woolwich 164 vendors were on the register and their premises were inspected once during the year; defects found were remedied. Several of the medical officers of health make mention of the sale of milk in general shops, where paraffin, pickles, herrings, etc., are also sold. Small quantities of milk are frequently sold at such shops, often not more than a quart during the day. The prevention of this custom does not appear to have been regarded as practicable. In several reports it is stated that dirty conditions, especially dirty milk receptacles, were found. The County Council received during the year 294 applications for licences, of which 291 were granted. The number of licences granted in 1901 was 295 ; there was, therefore, a decrease of four licensed cowshed premises in London. The following table shows the number of applications received and the number of licences granted in each year since 1893— No. of applications received. No. of licences granted. 1894 456 446 1895 427 416 1896 405 393 1897 379 374 1898 357 354 1899 338 330 1900 323 321 1901 306 295 1902 294 291 During the year Mr. W. F. Shaw, F.R.C.V.S.. the Council's veterinary inspector, completed four inspections of all the cows in London cowsheds. The results of his inspections were as follows— 7th report. 8th report. 9th report. 10th report. Total number of cows examined 4,299 4,035 3,909 3,987 Affected with disease or defects of the udder 246 228 149 205 Affected with tubercular disease of the udder 2 4 5 3 Suspected cases of tubercular disease of the udder 2 3 1 2 Subjects of acute mastitis 28 28 30 34 Affected with chronic induration of the udder 15 7 4 8 Atrophy of one or more quarters 138 105 76 103 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 20 51 23 31 Hypertrophied udders without induration 3 — — 6 Giving milk of poor quality, dried-off cows 20 12 5 7 Recovered or removed from premises 18 18 5 11 72 These inspections were completed in February, May, August and October, and were the seventh, eighth, ninth and tenth inspections made by Mr. Shaw. In all cases in which Mr. Shaw certified that a cow was suffering from tubercular disease the owner was prohibited from using the milk for human consumption, and in the case of cows suspected to be so suffering the cow-keeper was cautioned against allowing the milk to be used. All such cows were kept under observation until removed for slaughter. Cows suffering from chronic disease of the udder were kept under periodical inspection. In several instances cows suffering from tubercular disease, and in which the udder was not apparently affected, were sent to the knackers. Mr. Shaw attributes the reduction in the number of cows found to be suffering from disease of the udder to the exercise of greater care by the keepers in the selection of cows for the London cowsheds, and to the fact that the milkers take greater care to keep the udders sound. He also says that owing to the higher price of beef during the year the keepers have been more willing to send the cows for slaughter, and hence few cows affected with chronic mastitis remained in the sheds, while many of the fat cows giving milk of a poor quality were sold for slaughter. The Council included in their General Powers Bill of 1902 provisions which would have enabled the Council to take samples of milk in London, to examine the cows on the farms from which milk found to contain tubercle bacilli was received, and to exclude from London the milk of cows suffering from tubercular disease of the udder. Opposition was offered to these provisions, and the clauses were struck out. It will be recollected that at the Congress on Tuberculosis held in London in 1901, Dr. Koch stated that he estimated that the extent of infection by the milk and flesh of tubercular cattle, and the butter made of their milk, was hardly greater than that of hereditary transmission, and, therefore, he did not deem it advisable to take any measures against it. In consequence, a Roval Commission was appointed to inquire and report whether tuberculosis in animals and man is one and the same disease; whether animals and man can be reciprocally infected with it; under what conditions, if at all, the transmission of the disease from animals to man takes place; and what are the circumstances favourable or unfavourable to such transmission. This Royal Commission has not yet reported, but results obtained since by several investigators have not supported Dr. Koch's thesis. Offensive Businesses. The reports of medical officers of health generally show that premises have been inspected on which offensive businesses are carried on. With respect to slaughterhouses in Paddington, of which there are 9, there were 743 inspections. The 12 slaughterhouses in Kensington were regularly inspected. In Hammersmith the slaughterhouses were inspected every fortnight. In Marylebone the number of inspections of slaughterhouses was 71. In Hampstead the 5 slaughterhouses were periodically inspected. The inspectors of food in St. Pancras made 462 inspections of the 21 slaughterhouses. The meat inspector made 2,565 visits to the 42 slaughterhouses in Islington. The slaughterhouses in Stoke Newington were duly inspected. In Hackney the inspector made 158 visits to the slaughterhouses, of which there are 29. The 6 slaughterhouses in Finsbury were regularly inspected. In the City are 9 slaughterhouses, which the medical officer of health states " cannot be regarded as desirable features in the centre of a great city." In Finsbury the 14 slaughterhouses were inspected. In Bethnal-green 24 visits were made to the 7 slaughterhouses. In Stepney there are 13 slaughterhouses, of which there were a number of inspections. In Poplar there are 20 slaughterhouses which were periodically inspected. In Southwark 71 inspections were made of 7 slaughterhouses. In Bermondsey there were 5 slaughterhouses; these required constant visiting to ensure compliance with the by-laws and prevent nuisance to the neighbours. In Lambeth the 33 slaughterhouses were kept under constant supervision; legal proceedings were instituted in one instance. In Battersea the 8 slaughterhouses were frequently inspected. In Wandsworth the 25 slaughterhouses were frequently inspected. In Camberwell there were 220 inspections of slaughterhouses. In Deptford there were 65 inspections of 6 slaughterhouses. In Greenwich there were 20 inspections of 7 slaughterhouses. In Lewisham there were 25 slaughterhouses visited. In Woolwich the 13 slaughterhouses were all inspected at least four times. In 1902 the County Council received 371 applications for licences for slaughterhouses, and granted 362. The following table shows the number of applications received and the number of slaughterhouses licensed in recent years— 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 543 537 1898 442 429 1893 538 529 1899 419 411 1894 518 506 1900 405 393 1895 497 485 1901 384 381 1896 478 470 1902 371 362 Inquiry made under the instructions of the Public Health Committee in the early part of the year, showed that of the 381 private slaughterhouses which were licensed in 1901, 220 were situated within 10 feet of a dwelling-house, 73 within 20 feet, 40 within 30 feet, 26 within 40 feet, 3 within 50 feet, 15 within 100 feet, and 4 within 200 feet of a dwelling, and further it was shown that 35 slaughterhouses had no entrance except through the shop. The Council has since adopted a resolution that no new slaughterhouse shall come into existence which is within 100 feet of a dwelling. 73 The following number of registered offensive trade premises were removed from the Council's register during the year— Tripe boilers 1 Manure manufacturers 1 Soap boilers 2 Fat melters 1 Total 5 The following are the numbers of authorised offensive business premises in existence at the present time— Fat melters 25 Tripe boilers 25 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 6 Manure manufacturers 4 Soap boilers 13 Tallow melters 11 Gut manufacturers 4 Gut scrapers 2 Animal charcoal manufacturers 1 Total 107 The following statements are made in annual reports with respect to premises in which offensive trades are carried on other than that of a slaughterer of cattle. Dr. Dudfield states that in. Kensington nuisance is caused by the business of a fat extractor carried on in Tobin-street, although complaints have been less frequent since certain works were carried out at these premises as the result of proceedings by the County Council in 1899. In Islington offensive smells from a knacker's premises were perceptible at some little distance from the premises; this matter is receiving the attention of the Public Health Committee of the County Council. In Hackney 13 visits were made to the three offensive trade premises in the borough. In the City it was found that the business of a fellmonger had been established without the consent of the Corporation; legal proceedings were instituted, and the business removed in consequence. In Southwark 8 premises received 67 inspections. In Bermondsey 13 premises were regularly inspected. In Wandsworth legal proceedings were instituted in two instances, and in the case of one, the business of a fat melter, concerning which an injunction had been obtained in 1901, prohibiting the business from being carried on, the premises were demolished. In Deptford there were 52 inspections of five premises, and legal proceedings instituted concerning one. In Hampstead, nuisance arising from a bedstead factory was complained of, due to escape of effluvia from the japanning chambers. As the result of proceedings, shafts and fans were provided to conduct the fumes through the furnace, and the chimney flue was increased considerably in height. Improvement was effected, but some nuisance still occurred, and the occupier eventually decided to remove the factory outside London. Two complaints were received as to nuisance from ballast burning and in each case the fire was extinguished on service of a notice. In Lewisham complaints were received of nuisance from the escape of sulphuretted hydrogen from gasworks. Summonses had been taken out in 1901 for similar nuisances, and the hearing of the case was reopened. The magistrate declined to convict, but held that the action of the Borough Council was justified, and that the gas company should pay a substantial amount to the Borough Council's costs. Removal of trade refuse. In very few districts is trade refuse systematically removed by the sanitary authority. The removal of trade refuse by the Borough Council of Woolwich was still continued during 1902. Dr. Davies states that a sum of £98 5s. 3d. was paid by tradesmen during the year for the removal of 7,861 receptacles of offensive refuse, of £64 11s. 6d. for the removal of 861 loads, and of £8 9s. 2d. of 1,015 bushels of inoffensive refuse. These amounts, Dr. Davies says, do not cover the cost of collection, but much nuisance is obviated, and an attempt to charge more might be unsuccessful. Dr. Caldwell Smith writes that the Wandsworth Borough Council had extended the system of removal of offensive trade refuse to the whole borough, and a large number of tradesmen have taken advantage of it. " A charge of fourpence per tin is made, the tins themselves being the property of the council. The removal is carried out daily or twice or three times weekly, as requested. In September last an arrangement was entered into with the contractor to remove to the destructor at Tooting during the night the fish and butchers' offal collected during the day, also to cleanse the tins before returning, free of cost, the poulterers' offal being destroyed in the furnaces. From a sanitary and financial point of view this arrangement has so far worked satisfactorily." In 1902, 10,338 tins of offensive matter were destroyed in the destructor. In a number of districts penalties were recovered for breach of the County Council's by-laws relating to the hours of removal of offensive matter, or to the construction of the carriage in which it was conveyed; thus such penalties were recovered in Westminster, Poplar, and Bermondsey in four instances, in Battersea in three instances, in Lambeth in two, and in Wandsworth in one instance. [10] 74 Complaints to the London County Council. During the year 591 complaints were made to the Council of alleged insanitary conditions, in connection with which the Council's officers inspected 2,153 premises. Nuisances. Smoke nuisances. The annual reports of medical officers of health show the following proceedings in connection with smoke nuisance— In Paddington, in consequence of complaints received, shafts and chimneys connected to five premises were specially kept under observation, and legal proceedings instituted with respect to a brewery, a penalty being recovered. In Kensington in several instances complaints were made by the London County Council, the Smoke Abatement Society, and private persons ; cautionary letters were found to suffice. In Hammersmith legal proceedings were instituted in respect to three laundries and a penalty recovered in each; nine summonses were also taken out against the Central London Railway, and a penalty recovered in each instance. In Fulham eighteen intimation notices and six statutory notices were served; a penalty was recovered from a firm of contractors for the Earl's Court Exhibition. In Chelsea eight smoke nuisances were abated. In Westminster 2,728 observations were made, and fifty-eight preliminary and eighteen statutory notices served; legal proceedings were instituted in six instances, four of which were successful; the proceedings in the two cases in which there was failure related to clubs which the magistrate held were private dwellings. In St. Marylebone the inspector made 162 visits to premises concerning which there were complaints ; the number of complaints was twenty-two. In St. Pancras there were 214 smoke shafts on the register; the number of complaints received was seventy-two, 145 separate observations were made, and sixteen intimation notices served. In Islington there were 229 observations. In Hackney 543 observations were made, and notices served in sixty-three cases. In Holborn chimney shafts were kept under observation, and twenty-seven notices served ; legal proceedings were instituted in four instances, penalties were recovered in three cases, and the summons was withdrawn in the fourth on payment of costs by the defendant. In Finsbury thirty-three smoke nuisances were abated ; legal proceedings were instituted successfully in two instances. In the City 3,536 observations were made relating to sixty-six premises ; in five cases legal proceedings were successfully instituted. In Shoreditch the shafts and chimneys were kept under observation, complaints were received from the County Council and Smoke Abatement Society, and in each instance steps were taken to prevent recurrence of the nuisance. In Bethnal Green there was one prosecution, a penalty being recovered. In Stepney notices were served in respect of 125 premises, most of which had no smoke consumers of any kind ; these consumers have since been constructed, and there was great improvement towards the end of the year ; there were legal proceedings and penalties recovered in eight cases. In Poplar legal proceedings were successfully instituted in six cases, and unsuccessfully in one ; notices were served when necessary and nuisance abated, smoke consuming apparatus being provided in some cases. In Southwark observations were made on 274 days, sixty-three complaints were received, twenty-six intimation and twelve statutory notices were served, and a penalty recovered in one case. In Bermondsey there were 460 observations, and 134 offences were reported, in eleven cases penalties were inflicted ; the medical officer of health states that the absence of jurisdiction of his authority over the Surrey Commercial Docks caused much difficulty ; the Port sanitaiy authority was communicated with, but before the presence of the Port inspector could be secured the nuisance had for the time ceased. In Lambeth the smoke inspector made 679 observations and inquiries, fifty-seven notices were served, and the nuisance was abated in each case ; complaints were received from the County Council ; a list of premises kept under observation is included in the report. In Battersea, the medical officer of health says, the action taken by the health committee in 1900 has had an excellent effect, and complaints are now much fewer ; during 1902, sixty-six observations were made, fifty-nine intimation and twelve statutory notices were served, legal proceedings being instituted in twenty-two cases. In Wandsworth there were forty-six cases of smoke nuisance, in three cases legal proceedings were instituted, two of which related to smoke nuisance from locomotives. In Camberwell in fifty-two cases smoke nuisance was abated. In Deptford observations were kept on various premises in the borough, and 159 cases of smoke nuisance were reported, and notices served in seven cases. In Greenwich 270 observations were made, statutory notices were served whenever necessary; information as to smoke nuisances was frequently received from the County Council. In Lewisham various premises were kept under observation in consequence of complaints, and the nuisance abated after notice ; in certain cases notices were served concerning railway locomotives. In Woolwich 105 observations were made, proceedings were taken against four offenders for eight separate offences, a penalty being recovered in each instance; the medical officer of health states that "although there is still a good deal of unnecessary smoke from the arsenal chimneys, I am glad to be able to record a distinct improvement at these factories." Nuisance from stable manure. The number of references in the annual reports to nuisance from stable manure are comparatively few, probably owing in part to the cool weather which prevailed during the summer months. The enforcement of the Council's by-law in abolishing receptacles for dung sunk below the level of the ground, has, however, no doubt largely reduced nuisance from this cause. Dr. Priestley states that in Lambeth, where there are numerous refuse and manure depots, with the exception of accumulations at Shot Tower Wharf, owing to foggy weather preventing barges 75 from getting down the river, no nuisances were discovered. In Wandsworth, however, Dr. Caldwell Smith states a number of complaints of accumulations were received, and Dr. Dudfield refers to nuisance in Kensington from peat moss litter at the time of removal, and of the need for the sanitary authority to undertake the systematic removal of stable manure. Steps generally were taken in the several districts to secure the removal of such manure when accumulations were found. Removal and disposal of house refuse. As the result of the County Council by-law requiring house refuse to be removed from all premises not less frequently than once a week, great improvement has been effected in the efficiency of this branch of work. The success attained by the Borough Council of Islington is referred to by the medical officer of health of that district, who states that the number of occasions in which the house occupier had to make application for the removal of his refuse was in 1902 only 198 ; this may be compared with the number of such applications in 1891, which amounted to 10,138. Less satisfactory results were attained in St. Pancras, where in 1902 the number of applications amounted to 2,172. In Hackney the number of applications in 1902 was 355, but this number would have been much less but for numerous applications in J uly, in which month an interval occurred between the expiration of former contracts and a new contract. During the year a new destructor, connected with the electric lighting station, came into use, and the old system of depositing the refuse on a shoot was abandoned; Dr. Warry includes in his report a table showing that the numbers of refusals to allow the scavenger to remove the refuse were never less than 4,106 in any week of the year, and were often twice that number. Refusal, however, is obstruction, for which the borough council can recover a penalty, and it is probable that resort to this measure would soon materially reduce the number of occasions on which difficulties are thus put in the way of the systematic scavenging of the district. A by-law of the County Council gives opportunity for the daily collection of house refuse by requiring the occupiers of houses after notice to deposit the dust receptacle on the kerbstone, or on the outer edge of the footway at such hour as the local authority may prescribe. The by-laws of the Council are not operative in the City, and the Corporation obtained parliamentary powers requiring house occupiers who do not deposit their house refuse in the ash-pit attached to the building, to deposit the refuse in a suitable receptacle on the kerbstone before eight o'clock in the morning, and enabling the Corporation to make by-laws for giving effect to this requirement. The medical officer of health of Woolwich states that the Plumstead dust destructor, which was being erected, would shortly be at work, and he suggests that the borough council's dust shoot might well be converted into a recreation ground. The Woolwich parish dust destructor has not given rise to complaints, "although it has been observed to produce a large amount of smoke of a light grey colour." The system of destruction of dust by fire is being increasingly adopted. The medical officer of health of the riverside district of Lambeth reports that " There is one matter that requires the immediate attention of the council, viz.: the provision of two (or more) destructors in different parts of the borough for the destruction of house (and other) refuse, in place of the present method of barging. By such a change, there would be a large financial saving as well as a great sanitary improvement." The medical officer of health of Greenwich refers to the use of Greenwich marshes for the tipping of rubbish. He states that "unfortunately the chief offenders in this respect appeared to be the borough council themselves, for the portion of waste land which is rented by them and used for the depositing of house refuse, was, at the time of my visit, in a most offensive, unsightly, and disgusting condition. The matter from cesspools appeared to have been deposited within a very few yards from the side of the public roadway, instead of, as it might have been, taken to the farthest extremity of the land. The portion used for depositing ash-pit refuse was also in a most unsightly condition, being covered with loose papers, blowing about in all directions; and I am certainly of opinion that the time has come when this council should seriously consider the question as to whether some better method of disposing of the refuse should not be adopted in the way of suitable refuse destructors." Again, the medical officer of health and the surveyor of Lewisham, after inspecting the three house refuse tips of the borough council, situated respectively on the east side of Hither Green-lane, the south side of Killearn-road, Catford, and on the west side of Bromlevroad and east side of Exburv-road, advised the council " to substitute as quickly as possible more efficient and sanitary methods for the disposal of this material." Nuisance from sewers. The medical officer of health of Kensington states that no complaints were received of emanations from the Counter's-creek sewer during the past year. The medical officer of health of Poplar refers to nuisance from the sewer in Old Ford-road, Cadogan-terrace, Wansbeck-road and Smeed-road. Alterations were effected in Smeed-road, and an opening closed and ventilating shaft erected in Old Ford-road, but other openings remain. Floodings in 1902 are reported in the Lewisham Village ward, in the Borougli of Lewisham, and in properties upon the lowlying land on the north side of Woolwich-road in the Borough of Greenwich. No flooding occurred in Hackney Wick in 1902. The Regent's Canal. The condition of the Regent's Canal was under consideration of the Council's Public Health Committee during 1902. Inspections were made during June and July and the canal water was found to be free from nuisance, but the dead bodies of animals were occasionally to be found 76 floating on the surface, and deposits of rubbish and silt were observed, in the north-west and southeast corners of Cumberland basin. At the dead end of Wenlock basin an accumulation of silt was found, and in the City-road basin deposits, which were offensive when stirred up, were found in some of the lay-byes, and at one wharf several carcases of animals were also noticed. In August, at the wharf of the Finsbury Borough Council in the City-road basin, the water was found, to be black, and an offensive smell was experienced which arose either from the water or the contents of barges. Analyses by the Council's chemist of samples taken from various parts of the canal between 23rd June and 25th September showed that these samples had an odour of a more or less decided character, and that the organic matter present was very largely animal matter, and the water generally inferior in quality to that of the Thames below the bridges. The Regent'sCanal Company were urged to have the lay-byes cleansed from deposit and to change the water in the canal by passing a large quantity down from the higher to the lower reaches. In his annual report the medical officer of health of Finsbury states that the water of the City-road basin showed signs of considerable pollution. He writes, " The bottom is covered with a thick sludge, which in one place measured more than 18 inches. It consists of putrifying animal and vegetable matter from which bubbles of gas are almost continually rising. When stirred up the condition is extremely bad. In some parts the water always appears to be black, and considerably charged with pollution, in other places it is comparatively clear." Dr. Newman did not, however, obtain evidence to show that the water at the time was in such a state as to be a nuisance or dangerous to the health of the surrounding community. The medical officer of health of Paddington states that the "cut" was emptied at Easter and about 500 tons of mud were taken from the bottom and quantities of water were drawn off periodically and replaced by a supply from the upper reaches of the canal. The River Lee. Dr. Warry, in his annual report to the Borough Council of Hackney, discusses the pollution of the River Lee, and in corroboration of earlier statements he quotes from a letter of thesecretary of the Lee Conservancy Board the statement that the pollution of the Channelsea River and backwaters about Stratford and West Ham, is caused by the sewage of Walthamstow and Leyton, and the discharges from the storm water outfalls of the London sewer at Old Ford. TheLee Conservancy Board in September sent to the Hackney Borough Council particulars of a scheme for the sewerage of the Lower Lee valley and a report of Sir Alexander Binnie upon the scheme. The scheme provided for the construction of an intercepting sewer " which, commencing near Waltham Holy Cross, would receive the sewage of the various districts in the Lee Valley and carry it either into the main drainage system of the London County Council at a point a little east of theAbbey Mills pumping station ; or, as an alternative, to an entirely new outfall to be constructed east of the River Roding and south of Ilford." It was proposed to acquire 120 acres of land, toconstruct open subsidence tanks, to deposit the sludge on the land, and to pass the sewage from the settling tanks to twelve artificial filters or contact beds, the effluent finally to be discharged into, the Thames. Sir Alexander Binnie expressed an opinion in favour of the independent outfall. Housing of the Working Classes. The following is a summary of the proceedings taken by the London County Council and the various metropolitan boroughs during the year 1902 in connection with the housing of theworking classes. Representations under Part I. of the Housing of the Working Classes Act. King-street area, Poplar.—This area, which had been represented by the medical officer of health of Poplar, consists of two small courts and the houses between them fronting on Kingstreet. It comprises nine dwelling-houses, a smithy, and the site of one house. On the 7th October the Council resolved that the borough council be informed that the Council was not prepared to deal with it by way of scheme, but was of opinion that it should be dealt with by closing orders under Part II. of the Act. Bridge-road and Emnett-street area, Poplar.—This area had been represented by the medical officer of health of Poplar. It consists of a block of buildings known as Arnold's-buildings,. having from 300 to 400 rooms in a state of dilapidation, and closed by magistrate's order, 8 small cottages in Providence-place, and 4 houses in Emmett-street. On the 28th January the Council resolved that the area was not of general importance to the county and should be dealt with under Part II. of the Act. Devonshire-place area, St. Marylebone.—This area had been represented by the medical officer of health of St. Marylebone. The area occupies about half an acre, and includes 26 houses in Devonshire-place, 4 houses fronting in Earl-street, and 9 houses fronting in Devonshire-street. Of the 39 houses, 13 are shops and business premises. The number of persons of the working class occupying the area was 355. In May, 1902, the Council, on the recommendation of the Housing of the Working Classes Committee, adopted a resolution that the area was not of metropolitan importance, and should be dealt with under Part II. of the Act. Burne-street area, St. Marylebone.—This area had been represented by the medical officer of health of St. Marylebone in April, 1901. The Housing of the Working Classes Committee reported on the area on the 14th October, and the Council resolved that the area was not of general importance to the County of London, and should be dealt with under Part II. of the Act. Schemes undertaken by the County Council tinder Part I. of the Act. Churchway area, St. Pancras.—On 24th June the Housing of the Working Classes Committee reported that Seymour and Somerset buildings were ready for occupation. These buildings 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. This completes the accommodation 77 to be provided on the Churchway area. In October the Committee reported that of 180 tenants in occupation, 134 came from the immediate locality of St. Pancras, 28 from St. Marylebone, and 18 from other districts. Clare-market area, Strand.—On 14th January the Council approved working drawings, bills of quantities, and specifications in respect of Siddons and Stirling buildings, Russell-court, Drury-lane, and authority was given for tenders to be invited. The buildings since constructed are of five storeys, and provide accommodation for 390 persons in 190 tenements of one room, 30 tenements of two rooms, 35 tenements of three rooms, and 5 tenements of four rooms. On 29th April the Housing of the Working Classes Committee reported that Fletcher-buildings, Duke's-court, were ready for occupation. These buildings provide accommodation for 230 persons in 35 tenements of two rooms, and 15 tenements of three rooms. These are the first buildings provided in the immediate locality for persons displaced by the Clare-market scheme. On 13th May the Committee reported that Sheridan-buildings and Beaumont-buildings, Duke's-court site, were nearlv ready for occupation. These buildings provide accommodation for 380 persons in 10 tenements of one room, 40 tenements of two rooms, 20 tenements of three rooms, and 10 tenements on four rooms, and with the completion of these buildings accommodation for 610 persons is provided in the immediate locality for persons displaced by the Clare-market scheme. Providence-place area, Poplar.—This area had been represented by the medical officer of health of Poplar. On 14th January the Council resolved to petition the Secretary of State to confirm the scheme. On the 22nd April the local inquiry was held, and on 15th May the Provisional Order was issued confirming the scheme with certain modifications. On 7th October the Housing of the Working Classes Committee reported that the Act confirming the Provisional Order received the Royal Assent on 22nd July. Webber-row area, Southwark.—On the 22nd December the Public Health and Housing of the Working Classes Committee reported to the Council a proposal to provide on this area a common lodging-house for 57 women, and also stated that the architect had submitted drawings showing how the remainder of the area could be utilised for five-storey block dwellings and shops. The accommodation proposed was for 404 persons in 101 tenements of two rooms, and 864 persons in 144 tenements of three rooms, thus providing for 1,268—an excess of 271 above the number displaced from the Webber-row area, the Wellington-place area, and the King's Bench-walk area which were included in one scheme. More accommodation will be provided on the two last areas. Oil the recommendation of the Housing of the Working Classes Committee the Council approved an estimate for £1,500 for preliminary expenses in connection with the preparation of working drawings, and instructed the Housing of the Working Classes Committee to prepare and submit working drawings, specifications and bills of quautities, and an estimate of the cost of erecting a women's lodging-house and block dwellings and shops is connection therewith on the Webberrow area. Nightingale-street area, St. Marylebone.—This scheme was being carried out by the Council at the expense of Lord Portman. On the 4th March the Council approved sketch plans prepared by Lord Portman's architect for the erection of two five-storey buildings for the accommodation of 630 persons in 40 tenements of one room, 100 tenements of two rooms, and 25 tenements of three rooms, subject to the size of the living and bed rooms being in no case less than the Council's minimum. Burford's-court, Tucker s-court and Favonia-street areas, Poplar.—These areas, included in one scheme, had been represented by the medical officer of Poplar, and after a local inquiry the scheme had been confirmed in 1900. The scheme provided for the erection, on a site in Preston's road, belonging to the Council, of buildings to accommodate 269 persons displaced from these areas. On the 25th March, 1902, the Council approved an estimate of £56,151 in respect of the erection of dwellings on the Preston's-road site and the neighbouring Norfolk-street site, and allocated part of the Preston's-road site for the accommodation of the 269 persons displaced by the Burford's-court, etc., scheme, and resolved that the rest of the Preston's-road site and the Norfolk-street site be appropriated for the purpose of Part III. of the Act. Upon this site it was proposed, by agreement with the School Board, to accommodate 1,030 persons displaced by the operations of that Board. On 22nd July the Council accepted a tender amounting to £14,959 for the erection of Ottawa and Baffin buildings, and a tender for the erection of the remaining four blocks at a reduction of 3½ per cent, on prices for the erection of Ottawa and Baffin buildings. Schemes undertaken by the Council under Part II. of the Act. Mill-lane area, Deptford.—On 14th January the Council resolved to invite tenders for the erection of 24 cottages on this area, and on 4th March a tender of £4,767 was accepted. Each cottage is self-contained, and consists of living-rooms, scullery, watercloset, and two bedrooms, with a small garden at the rear. Accommodation is thus provided for 144 persons. Ann-street area, Poplar.—On 4th November the Housing of the Working Classes Committee reported that Sydney and Melbourne buildings were almost ready for occupation. They provide accommodation for 440 persons in 65 tenements of two rooms and 30 tenements of three rooms. Adelaide-buildings was completed and occupied in September, 1901. In the three buildings accommodation has been provided for 630 persons against 261 displaced. Schemes undertaken by district authorities under Part II., the County Council contributing to the cost. Brantome-place and Prospect-terrace areas, St. Pancras.—On the 14th January the Housing of the Working Classes Committee reported that the Local Government Board had issued an order sanctioning this scheme, which is being carried out by the St. Pancras Borough Council, subject to certain conditions and modifications. Fulford-street and Braddon-street area, Rotherhithe.—This scheme is being carried out by the Bermondsey Borough Council. The County Council on 21st January approved a modification of the scheme, enabling the Bermondsey Borough Council itself to undertake the erection of the 78 necessary buildings on half the area cleared, subject to the dwellings being built in conformity with the plans approved in 1901. On 18th March the Housing of the Working Classes Committee reported that the borough council had resolved to offer prizes for the best design for laying out and building on this area. Queen Catherine-court area, Stepney.—A contract for the erection of buildings to accommodate 108 persons on this site was sealed on l6th April. Proceedings of the Council under Part III. of the Act. Millbank site, Westminster.—During the year the erection of buildings on this site was completed. On 6th May the Housing of the Working Classes Committee reported that Lawrencebuildings were ready for occupation. They provide accommodation for 296 persons in 50 tenements of two rooms and 16 tenements of three rooms. On 13th May the Committee reported that Morland-buildings were ready for occupation. They provide accommodation for 300 persons in 30 tenements of two rooms and 30 tenements of three rooms. On 29th July the Committee reported the completion of Wilkie-buildings, providing accommodation for a like number of persons in similar tenements, and on 7th October, of Gainsborough-buildings, accommodating 396 persons in 2 tenements of one room, 38 tenements of two rooms and 40 tenements of three rooms. Of the 895 tenements, 588 were occupied by persons who had removed from other parts of Westminster. Reid's Brewery site, Holborn.—On 21st October the Housing of the Working Classes Committee reported that Block D was ready for occupation, the building accommodating 250 persons in 15 tenements of three rooms and 40 tenements of two rooms; and on 2nd December the Committee approved an estimate of £51,896 for the erection of buildings on the Clerkenwell and Leather-lane frontages of the area. Caledonian Asylum site, Islington.—On 11th March the Housing of the Working Classes Committee reported the completion of the purchase of this site for £16,000. Old Oak-common-lane site, Hammersmith.—On 25th March the Council resolved to purchase about 50 acres of land in this locality at a cost of £30,000. Re-housing of persons displaced by street improvements. Holborn to Strand Improvement.—On 24th June the Council approved the estimate of £29,098, and the working drawings, specification and bills of quantities of Thackeray, Dickens and Coram buildings, Herbrand-street, for the accommodation of persons displaced by this improvement, and on 24th July accepted a tender amounting to £26,059 for the erection of the buildings, which will accommodate 680 persons in 20 tenements of one room, 100 tenements of two rooms and 45 tenements of three rooms. York-road, Garratt-lane and Merton-road Improvements.—On the 29th July the Council approved an estimate of £26,720, together with the working drawings, specification and bills of quantities in respect of the erection of two blocks of buildings on a site in York-road, Battersea, for the accommodation of persons to be displaced by these improvements, and on 7th October ordered the seal of the Council to be affixed to a contract for the erection of these (Durham) buildings at a cost of £23,000. Displacement of persons of the working class. On December 16th the Housing of the Working Classes Committee reported on applications under the Building Act which involved displacement of persons of the working class. These applications received since November 13th involved the displacement of 6,130 persons, of which it was proposed to rehouse 2,772 persons, leaving 3,358 persons unprovided for. In November the Committee reported on the report of the Joint Committee of Parliament, which sat during the year to consider the question of the revision of Standing Orders of Parliament, requiring the insertion in private bills of provisions for the rehousing of persons of the working class displaced in pursuance of the powers conferred by these bills upon their promoters. The proposed model clause, inter alia, requires the company, within one month after the acquisition of any land, to send to the Secretary of State, to the County Council and to any district authority concerned, particulars of the lands acquired, the number of houses occupied in whole or in part bv persons of the labouring class occupying the houses at the time of acquisition, and such information as can be obtained of the number who occupied them during the preceding five years, and who have been displaced in view of such acquisition. The Secretary of State shall, after such inquiry as he may think fit, determine the number of persons concerning whom an obligation of rehousing has arisen, and enter the same in a register, and shall give a certificate to the company specifying their obligations. This number, however, must not exceed the number entered in the register for which the company have not already provided dwellings, and in determining this number the Secretary of State may have regard to the following considerations—(a) To what extent, if at all, accommodation of a suitable kind for persons of the labouring class in the neighbourhood of the land acquired is or will be insufficient after the displacement; (b) whether the number of persons entered in the register as occupying any houses described therein is greater than the number permitted by law in the district in which the houses are situated; and (c) to what extnt, if at all, the company has given, or is prepared to give, financial assistance to any schemes or arrangements of the London County Council, or any local authority or other persons for the provision of labouring class dwellings, or for the transference of industries and the persons of the labouring class dependent thereon to more suitable localities. With respect to schemes under this section (a) the time within which a scheme is to be carried out shall be fixed therein; (b) the Secretary of State may direct provisions to be inserted in any scheme requiring the new dwellings to be completed fit for occupation before the persons in respect of whom the scheme is made are displaced, and prescribing the rents to be charged, and (c) 79 the Secretary of State may, if he think fit, attach to his approval of any scheme, any conditions not being conditions in excess of the conditions imposed by the London Building Act (1894), or any other Act or Acts, by-law, or by-laws, relating to buildings in the county of London, and also may require the company to give security for the carrying of the scheme into effect. Before giving any certificate or approving any scheme under this section, the Secretary of State shall cause a copy of the draft certificate or scheme to be sent to the London County Council, and to each local authority appearing to him to be concerned therein, and shall consider any representations which the County Council or any such local authority may, within a period to be prescribed by the Secretary of State, make to him with regard to the draft certificate or scheme. The Committee, in commenting on the proposed standing order, expressed, inter alia, the opinion that the obligation to provide new accommodation should include lands acquired by agreement as well as under the powers of any particular Act; that the register should be a register of all displacements, and not only of those displacements in respect of which the Secretary of State shall, after inquiry, have decided that an obligation to rehouse has arisen; that the obligation to rehouse should apply to the total number of persons displaced, and not be limited to the number which might legally occupy the houses; and that the discretion of the Home Secretary in attaching conditions to his approval of a rehousing scheme should not be limited by the requirements of the London Building Act of 1894. The Council referred the report to the Parliamentary Committee, with instructions to take all necessary steps to give effect as far as possible to the views expressed therein. The annual reports of medical officers of health supply the following information—In Fulham the medical officer of health represented 25 houses which were subsequently repaired by the owners. The Public Health Committee gave instructions for the preparation of plans of block dwellings to be erected on the vacant land in Townmead-road, in possession of the borough council. In Chelsea the borough council decided to purchase 1.6 acres of land on the east side of Beaufortstreet, and decided to erect upon it buildings containing 35 tenements of one room, 130 tenements of two rooms, and 96 tenements of three rooms, or 583 rooms in all. Eight bath-rooms and a hotwater room are to be provided in one of the blocks. The total outlay is £65,000, of which £12,700 represents the cost of the land. During the year 223 houses were demolished, the estimated population of which was 1,784. In Westminster 11 houses in Turner's-court were closed by magistrate's order. It is proposed to use the site of Turner's-court for a theatre. The Housing Committee of the City Council were taking steps to ascertain in what way the owners propose to provide new accommodation for 170 persons displaced. The Regency-street area, purchased for the erection of artizans' dwellings, had been cleared and the foundations laid. The buildings contain 45 tenements of one room, 161 tenements of two rooms, 126 tenements of three rooms, and 12 tenements of four rooms. The last are " self-contained," the others " associated." In one block nine bath-rooms are provided. In St. Pancras advance was made in dealing with several areas under Part II. of the Act. The amended Chapel-grove scheme was sealed in June, and the amended Eastnor-place scheme in March, and the Local Government Board duly petitioned for sanction. In respect of the Prospect-terrace and Brantome-place schemes, the consent of the County Council was obtained for the erection by the borough council of dwellings on the Prospect-terrace site, and for the formation of a new street through Brantome-place. Instructions were given for negotiation with the Skinners' Company, who had petitioned against the latter scheme. A tender was accepted to erect dwellings on the Great College-street site at a cost of £17,734. The borough council resolved to petition Parliament to relieve borough councils of the obligation to use insanitary areas for rehousing schemes or to repay to these councils out of imperial funds the difference between the market value and the housing value of such areas. In Holborn seven houses were represented by the medical officer of health; closing orders were obtained for two houses, and the others were repaired. The report contains a list of houses voluntarily closed, demolished, rebuilt, etc. The medical officer of health of Finsbury discusses the deterioration of five areas in the borough, which were being purchased by the County Council for the purpose of improvement. With respect to other areas, he reports that, as the result of representations he has made to the owners, the houses in a court off Sermon-lane were demolished. He describes Caroline-place, Baker's-row, which remains; Kemp-place, Baker's-row, the houses in which have been improved; Providence-place, Baker's-row, which the owners propose to demolish at an early date ; Easton-place, Easton-street, which the owners were improving; an area bounded by York-road, Ironmonger-row, Lever-street, and Hull-street, which will be rebuilt in two or three years. There remain some half-dozen other small areas which have received attention. In respect to two or three of them negotiations were still proceeding. The report contains a list of 64 dwelling-houses containing 429 persons, which were demolished in 1902 to make room for business premises. The medical officer of health of Bethnal-green discusses the condition of houses in Digby-street, Digby-walk, Lansdell-place, and Bonwell-street. The medical officer of health of Stepney reported to his council an area of 76 houses situated in Great Pearl-street, Wilk-court, Half Wilk-court, Wheeler-street, Union-place, Quaker-street, Pope's Head-court, Harrison's-court, New-square, and Pool's-square. The Borough Council decided to ask the County Council to prepare a scheme under Part I. of the Act. The Housing of the Working Classes Committee of the Council advised the Borough Council to procure closing orders ; steps were taken for this purpose, and 11 houses were closed and demolished, and other houses improved. The medical officer of health of Poplar gives account of the proceedings with respect to the areas in that district being dealt with by the County Council, and states that with regard to the Bridge-road area, which the County Council resolved was not of general importance to the county, the Borough Council informed the Home Secretary that they did not think any useful purpose would be served bv the appointment of an arbitrator to decide whether the area should be dealt with under Part I. or Part II. of the Act. The conversion of Arnold's-buildings into workmen's houses had been contemplated, but this having fallen through, it was decided to again 80 approach, the County Council. In Lambeth 14 houses were represented by the medical officer of health and subsequently repaired. Four blocks of labouring class dwellings have been erected by the London and South-Western Railway Company, and the scheme of the Ecclesiastical Commissioners for the erection of cottages in the Webber-street and Ufford-street area had made progress. The question was under consideration of opening up and improving the network of narrow courts between Lambeth-walk and St. Albans-street. Dr. Priestley says the houses are in fair sanitary condition, and Cannot be dealt with under the Housing of the Working Classes Act either singly or as forming an area. In Wandsworth, the Public Health Committee had under consideration a proposal to erect artizans' dwellings on two sites, the Rectory-grove site, Clapham, and the Hill's-yard site, Wandsworth Plain, but found the cost of land prohibitive. A sub-committee was re-appointed to further consider the question. In Greenwich no scheme for dealing with any special area has been adopted. In the Greenwich-market area many houses had been voluntarily closed by the Admiralty and by private individuals. In Woolwich 10 houses were represented by the medical officer of health, and closing orders obtained for three. Improvements were effected in the others on service of notices. He reported in October on two insanitary streets, New-street and Globe-lane having respectively a population of 132 and 65 inhabitants. The deathrate was 29'5 per 1,000 living per annum. The death-rate from phthisis was exceptionally high, and two of the cases occurred in rooms where the direct rays of the sun can never penetrate. Numerous improvements were effected, but in some of the houses the state of darkness continues. Under Part III. of the Act 25 new houses have been erected by the Borough Council in North Woolwich. The report of the Housing of the Working Classes Committee of the Camberwell Borough Council shows that the Council is erecting on land at Grove-vale 85 two-storied houses, 4 for single families and the remainder for two families, comprising 166 tenements, each of which is self-contained and includes a bath-room. The Council possesses also 135 houses in Hollington-street area. These houses have been put into a state of repair. The Committee state, " There is no displacement of population, even temporarily. In the majority of cases even the original tenants occupy the same rooms, and in all cases pay the same rent as formerly. There is no charge on the rates whatever, the working actually showing a profit, which commences to accrue immediately upon the acquisition of the property. The standard of living in the area has greatly improved, for which the Council is responsible, both directly and indirectly. Sub-letting, with its accompanying evils, is abolished. A class of persons, the poorest of the poor, is being housed in tenements at rents which, if they were not available, would force them to seek indoor parochial relief, and thus cause them and their families to become a burden on the poor rate. This may well be considered as a direct addition to the income of the estate in its relation to the general rate." 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 the 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, 1902 — Local Authority. Total number of houses concerning which the Council has received information that representations have been made from the 1/1/02 to the 31/12/02. 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 - - - - - - - - - - - Camberwell - - - - - - - - - - - Chelsea - - - - - - - - - - - Deptford - - - - - - - - - - - Finsbury - - - - - - - - - - - Fulham 25 - - 25 25 - - - - - - Greenwich - - - - - - - - - - - Hackney - - - - - - - - - - - Hammersmith - - - - - - - — - - - Hampstead - - - - - - - - - - - Holborn 7 5 - - 5 2 - - 2 - - Islington - - - - - - - - - - - Kensington - - - - - - - - - — - Lambeth 14 - - 14 14 - - - - - - Lewisham - - - - - - - - - - - Paddington - - - - - - - - - - - Poplar - - - - - - - - - - - St. Marylelone - - - - - - - - - - - St. Pancras 2 - - - - 2 — — 2 — — Shoreditch - - - - - - - - - - _ Southwark - - - - - - - - - - - Stepney - - - - - - - - - - - Stoke Newington - - - - - - — - - — - Wandsworth - - - - - - - - - - - Westminster - - - - - - - - - - - Woolwich 10 - - 4 4 3 - - 3 - 3 Total 58 5 - 43 48 7 - - 7 - 3 81 Houses let in Lodgings. A return appended to this report (see Appendix III.) shows in which districts the by-laws which are in force for houses let in lodgings contain an " exemption " provision such as exempts houses from regulation if the weekly rent of the tenement exceed a certain amount, or which gives the sanitary authority a power to decide whether the house shall be registered. This subject has for some time been under the consideration of the Public Health Committee, who, in February, 1902, thus reported to the Council— Section 94 of the Public Health (London) Act, 1891, provides that every sanitary authority shall make and enforce such by-laws as are requisite for the following matters (that is to say)— (а) for fixing the number of persons who may occupy a house or part of a house which is let in lodgings or occupied by members of more than one family, and for the separation of the sexes in a house so let or occupied ; (b) for the registration of houses so let or occupied ; (c) for the inspection of such houses ; (d) for enforcing drainage for such houses, and for promoting cleanliness and ventilation in such houses; (c) for the cleansing and lime-washing at stated times of the premises ; (f) for the taking of precautions in case of any infectious disease. The section does not apply to common lodging-houses. So long ago as 30th November, 1897, we reported to the Council that, although by-laws under this section or regulations under the Sanitary Act of 18G6 with respect to houses let in lodgings had been made in every London district, in only a limited number of districts was any considerable effort made to enforce them. We submitted a report by the medical officer showing the result of a detailed inquiry made by Dr. Hamer in the various districts, and pointing out the great advantages which were found to result when the work of regulating such houses was seriously undertaken, and when a sufficient staff was provided for the purpose. In view of the fact that the enforcement of the by-laws on this subject was so much neglected in many districts, the Council resolved to make a complaint to the Local Government Board as provided for in section 101 of the Public Health (London) Act, 1891. The sanitary authority with regard to which the Council decided to take this course in the first instance was the Vestry of Bethnal-green, which at that time had not registered or required the registration of any houses. The Local Government Board, however, replied that the Vestry did not appear to it to have been guilty of default in enforcing the by-laws, inasmuch as one of the by-laws (No. 2) allowed the Vestry discretion as to what houses should be required to be registered. The Vestry claimed to have exercised this discretion and not to have determined on any settled policy of not registering houses, although it did not see that much practical good would result from registration. The Vestry thus, by making and obtaining confirmation of a by-law giving it discretion, was enabled to render section 94 of the Act inoperative in its district, and the Council, after consulting counsel, determined to raise the question of the validity of this by-law, and wrote to the Local Government Board on the subject. The Board, however, replied that, while recognising that by-law No. 2 had not worked so well in this case, it did not regard the by-laws as invalid. Since the metropolitan borough councils came into office we have had further inquiries made as to the extent to which the by-laws are enforced in the various boroughs, and are informed that the number of houses on the register shows in several districts an increase compared with the figures obtained in 1897, although in one or two districts in which work was previously being done no houses have been newly registered, apparently owing to the fact that alterations in the by-laws have been under consideration. We are glad to observe that the Bethnal-green Borough Council has departed from the attitude of its predecessors, and has appointed a special inspector, with the result that 190 houses have already been found suitable for registration and will shortly be registered. A similar arrangement has recently been made in St.. Pancras and Stepney, while in Westminster, Southwark, Hampstead and Islington special inspectors have for some time past been employed on this duty. In Chelsea the position is the same as before, no action as to by-laws having been taken for some years. In Shoreditch the work is in the charge of the chief inspector. In Woolwich parish and in Lewisham there are a few registered houses, the inspection of which devolves upon a particular inspector. In Fulham a special inspector was formerly engaged on this duty, but during the past year, when the revision of the by-laws has been under consideration, he has been otherwise employed. In Hammersmith some of the houses put on the register have not since been inspected, and although the district inspectors have instructions to inspect such houses, they have not had time to do so. Many of the by-laws contain clauses exempting from their operation all houses above a certain rental. In other instances where no such limits of rental are specified there are clauses to the effect that a house shall not be subject to the by-laws until the sanitary authority resolves to require its registration or until it is reported by a committee as suitable for registration. In several cases it has been found that the limits of rental are so low as to exclude from the operation of the by-laws houses which it would be very desirable to deal with, and the discretionary power given by the form of the by-laws in other instances has led to neglect to carry out the requirements of the section. We have thought it desirable to take counsel's opinion as to the legality of exemption clauses in the by-laws, and under our instructions the following question was put to Mr. Cripps, K.C., viz.— " Whether there is power under section 94 of the Public Health (London) Act, 1891, to exempt " any houses from the operation of by-laws for the registration of houses let in lodgings or occupied " by members of more than one family, or whether every local authority is bound to make by-laws " for the registration of every such house in its district ?" Mr. Cripps' opinion was as follows— " In my opinion section 94 of the Act of 1891 is imperative, and there is no power to exempt " from the operation of by-laws for the registration of lodging-houses any houses so occupied as " to come within the lodging-house definition. A by-law in the Bethnal-green form, which enables " the local authority to exempt any or all lodging-houses within their district, is not a compliance " with the requirements of the Act, and I am unable to agree with the view put forward by the "Local Government Board." This opinion is of great importance, raising as it does the question of the validity of the exemption clauses in the by-laws of nearly all the London sanitary authorities. Having regard to the alterations of the areas of sanitary districts caused bv the London Government Act and to other circumstances, several of the metropolitan borough councils are proposing new by-laws in substitution for those now in force, and we think the Council should forward a copy of the question submitted to counsel, and of his opinion, to the Local Government Board and to all the borough councils. We also think that the Council should ask the Local Government Board not to confirm in the future any by-laws as to houses let in lodgings containing exemption clauses or clauses giving a discretionary power to the sanitary authority. We recommend— (a) That a copy of the question submitted to Mr. C. A. Cripps, K.C., and of his opinion with regard to exemption clauses in by-laws as to houses let in lodgings be sent to to the Local [11] 82 ment Board, and that the Board be asked not to confirm in the future any by-laws containing such clauses. (6) That a copy of the question and opinion be also sent to each of the metropolitan borough councils. The Local Government Board, however, did not concur in Mr. Cripps' view, and the Council, therefore, on the recommendation of the Committee, asked the Local Government Board to co-operate with the Council with a view to obtaining a decision of the Courts as to whether exemption clauses can legally be inserted in by-laws as to houses let in lodgings. The medical officer of health of Battersea states in his annual report that—"In Battersea it has been found that landlords will raise the rents of their dwellings in order to take them out of the scope of the by-laws," and that this authority has decided to submit to the Local Government Board, for confirmation, a revised set of by-laws containing no exemption clause, and these are now being considered by the Board. From the report of the medical officer of health of Holborn it appears that the Local Government Board desired to insert in new by-laws submitted by the Holborn Borough Council a by-law "which would in effect make it compulsory on the Council to register all houses, or parts of houses, let in lodgings, or occupied by the members of more than one family, the rental of the tenements of which were below a certain minimum," and that at an interview with the officers of the Board in January, 1903, " the Town Clerk pointed out that the proposal of the Local Government Board in framing the by-law in the manner proposed, would have the effect of depriving the Council of the power of exercising its discretion, as he claimed it had a right to do, and, moreover, would be contrary to the terms of an opinion which had been obtained by the London County Council from Mr. C. A. Cripps, K.C." The Borough Council decided to inform the Local Government Board that in the event of the Board still feeling themselves unable to confirm the by-laws in the form proposed, that the Board would not proceed further with its application for confirmation, but would continue to enforce the existing by-laws. The return referred to also shows the extent to which the by-laws were being enforced in the several districts. Information contained in the annual reports of medical officers of health supplies the following information as to the action of sanitary authorities in respect of this duty—In Paddington 586 houses were on the register, 194 of which were added during the year, all the rooms of which were measured ; there were 3,104 inspections of these houses and 27 summonses were taken out; in 61 instances the tenements were overcrowded ; two inspectors are employed in registration and general supervision, the defects found being remedied by the district inspectors. In Kensington 2,050 houses were on the register, 15 being added during the year ; 1,219 notices were served. In Hammersmith 1,359 houses were registered, 329 being added during the year ; one inspector is especially employed on these duties, but Dr. Collier states that as the number of houses dealt with increases this will not suffice. In Hampstead the number of registered houses was 908, 11 cases of overcrowding were abated, 227 houses were cleansed. In St. Pancras there were 1,270 houses on the register, 982 having been added ; the number measured was 386 ; there were 1,761 half-yearly inspections and 4,357 re-inspections after notices had been served ; between 4 a.m. and 11 a.m. 1,140 inspections were made by two inspectors; comparatively few cases of excessive overcrowding were found ; three inspectors were especially employed in the inspection of tenement houses. In Islington there were 533 houses on the register, being an increase of 13 upon the numbers in 1901, 6,626 visits were made, and 1,711 nuisances, including 76 cases of overcrowding were found and abated ; one inspector devotes his whole time to these duties, and another inspector divides his time between these duties and the purchase of samples under the Food and Drugs Act. In Stoke Newington there were 119 houses on the register. In Holborn there were 594 houses on the register ; these houses were inspected from time to time and the regulations enforced. In Finsbury there were 939 houses on the register, 612 having been added during the year; a number of houses remain which ought to be registered, and these will be proceeded with in due course ; legal proceedings were instituted in 26 instances and penalties recovered; of these proceedings, 14 were for overcrowding, and there were 89 other cases of overcrowding which were abated after notice; new by-laws were confirmed in November, 1901. In the City there were 391 houses on the register; they were re-surveyed during the year and frequently inspected; the number of notices served was 598. In Shoreditch there were 191 houses on the register ; 7 houses were added during the year. In Stepney there were 1,669 houses on the register, 6,831 visits and re-visits were made, 295 intimation and 188 statutory notices were served, and legal proceedings instituted in 3 cases ; in 107 cases overcrowding was abated ; new by-laws were confirmed in 1901. In Poplar there were 281 houses on the register, the number added during the year being 154; night inspections numbering 104 were made, and re-inspections numbering 1,084 were made; 142 notices were served and legal proceedings instituted in respect of 3 houses; the number of rooms measured was 698; among the conditions found were 130 cases of overcrowding, of which 125 were abated, the amount of overcrowding in the other 5 cases being very small; an inspector was appointed especially for the inspection of houses let in lodgings. In Southwark there were 970 houses on the register, 135 having been added during the year; there were 3,556 inspections and 11,834 re-visits were made; 1,342 intimation and 564 statutory notices were served; among the conditions found were 189 cases of overcrowding, which were abated; two female inspectors were appointed for the inspection of houses let in lodgings; their work is supervised by the chief female inspector, who also inspects under the Factory and Workshop Act and inspects blocks of tenement houses. In Bermondsey there were 206 houses on the register, and it was arranged these should be inspected once a quarter. In Lambeth there were 371 houses on the register, and these were regularly inspected. In Battersea there were 82 houses on the register, 33 having been added during the year; it is hoped this number will be increased during 1903. In Wandsworth there were 116 houses on the register, the number added during the year being 49; all were inspected 83 at least twice in the year and the necessary cleansing effected. In Camberwell the number of houses let in lodgings which were inspected was 409, and 488 notices were served. In Greenwich the confirmation of by-laws was awaited, and no houses were registered during the year. In Woolwich there were 129 houses on the register, 26 having been added during the year ; all were inspected twice, and a large number four times ; many notices were served, and legal proceedings were instituted in 2 instances for overcrowding; visits in the early morning were made; an inspector was appointed especially for these duties in Woolwich parish. The reports show, on the whole, progress in this method of dealing with houses requiring special measures for maintaining them in sanitary condition, the advance in some districts being much greater than in others. Medical officers of health in a number of instances express their opinion of the value of this procedure. Dr. Reginald Dudfield writes that in Paddington the annual cleansing required by the by-laws has been found to be of great value. Dr. T. Orme Dudfield states that the registration of houses let in lodgings has been found very useful in Kensington. In St. Pancras, Dr. Sykes reports, a vast improvement in such houses has been effected. In Islington Dr. Harris states this procedure leads to greater cleanliness, but he points out the necessity of inspection to ensure satisfactory results. In Finsbury Dr. Newman finds that the regulation of such houses leads to substantial improvement in their sanitation. Dr. McCleary reports that in Battersea regulation was of great assistance in raising the standard of these houses, and in Woolwich Dr. Davis found that improved sanitary condition was the result of thus dealing with houses let in lodgings. Common Lodging Houses. In November, 1894, the administration of the Common Lodging House Acts devolved upon the Council. In the following table will be seen the number of houses on the register, the authorised number of lodgers, and the number of convictions and penalties in each year since 1894— Year. No. of houses Oil register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties. No. of deaths. No. of 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 — 65 71 1897 581 28,718 26,121 — 31 30 92 11 — 59 48 1898 560 28,332 27,658 — 29 29 167 3 — S7 44 1899 544 28,448 28,229 1,162 25 22 183 9 — 96 54 1900 528 28,311 28,428 668 16 13 102 15 — 91 40 1901 514 28,0371 35,225 2,133 16 15 96 3 — 102 166 1902 491 28,970i 40,512 1,449 22 21 98 4 — 120 686 In the year 1902 proceedings before the magistrate were instituted in 22 instances, resulting in 21 convictions, the penalties inflicted amounting to £66 2s., with costs amounting to £12 2s. In addition to the number of inspections mentioned in the table, there were 1,899 day visits and 28 night visits to unregistered houses. The number of houses newly registered in 1902 was 15. The number of cases of infectious disease reported in common lodging-houses was as follows—Smallpox, 650; erysipelas, 14; diphtheria, 6; enteric fever, 7; scarlet fever, 2; measles, 3 ; chicken-pox, 2 ; total, 684. The following table shows the number of common lodging-houses, the authorised number of lodgers in such houses at the end of 1902, and the number of houses registered in each district during the year— Common lodging-houses. Sanitary district. Number of houses. Authorised number of lodgers. Number of houses registered in 1902. Battersea 8 273 1 Bermondsey 5 789 — Bethnal-green 18 781 2 Camberwell 9 609 — Chelsea 9 479 — Deptford 9 545 — Finsbury 7 471 — Fulham 2 68 1 Greenwich 7 228 1 Hackney 8 426 — Hammersmith 9 550 — Hampstead 1 35 — Holborn 43 2,414 2 Islington 40 1,292 — Kensington 33 1,019 — 84 Sanitary district. Number of houses. Authorised number of lodgers. Number of houses registered in 1902. Lambeth 9 688 Lewisham 1 30 Marylebone 20 964 1 Paddington 9 301 — Poplar 11 1,461 1 St. Pancras 15 990 Shoreditch 13 761 Southwark 56 4,086 4 Stepney 81 6,755 2 Stoke Newington 1 37 — Wandsworth 10 231 — Westminster 24 1,891 Woolwich 33 796* — Total 491 28,970½* 15 *½ = 1 child. With a view to learning the number of lodgers at a time when the London common lodginghouses might be expected to be most fully occupied, a census of the inmates of these houses was taken in June, 1897, on the occasion of the Jubilee of Her late Majesty, and on the dates in 1902 associated with the Coronation of the King. In June, 1897, when the authorised population of common lodging-houses was about 28,700, the result of a census taken on the nights of the 21st and 23rd gave an average of 20,762 persons actually occupying common lodging-houses. This census, however, did not include the number of persons occupying shelters, refuges, etc. In the following table, which gives the mean number of inmates of common lodging-houses in the week ending June 28th, 1902, and in the week ending 26th October, 1902, the figures for the principal shelters are included. The difference between the numbers of 23,503 and 24,801 in the two weeks respectively may not unlikely be due to the fact that in the earlier period persons of this class frequently find occupation in the country. In the week ending 28th June, 1902, the number of persons in the principal shelters was 1,901, comprising 1,632 men and 269 women, which would, if included in the census of June, 1897, have raised the population of that time to within about 800 of the population in June, 1902. Metropolitan borough. Average nightly number of lodgers for week ending 28th June, 1902. 26th October, 1902. Males. Females. Married couples. Totals. Males. Females. Married couples. Totals. Battersea 109 24 19 171 110 22 16 164 Bermondsey 483 — — 483 645 — — 645 Bethnal-green 560 — — 560 606 — — 606 Camberwell 372 — — 372 405 — — 405 Chelsea 346 43 — 389 370 35 — 405 Deptford 323 — — 323 514 — — 514 Finsbury 599 12 9 629 522 — — 522 Fulham 60 — — 60 48 — — 48 Greenwich 156 — — 156 115 — — 115 Hackney 282 — -— 282 298 — — 298 Hammersmith 316 11 8 343 377 6 8 399 Hampstead 23 — — 23 24 — — 24 Holborn 2,153 194 — 2,347 2,098 300 — 2,398 Islington 845 79 21 966 949 78 24 1,075 Kensington 394 176 81 732 434 227 81 823 Lambeth 456 — — 456 540 — — 540 Lewisham 24 — — 24 26 — — 26 Paddington 172 14 10 206 195 19 12 238 Poplar St. Marylebone 706 — — 706 746 — 746 1,451 — — 1,451 1,483 87 — 1,570 St. Pancras 768 114 — 882 791 98 — 889 Shoreditch 495 — — 495 641 — — 641 Southwark 2,856 262 11 3,140 2,964 255 17 3,253 Stepney 4,794 557 230 5,811 4,905 566 222 5,915 Stoke Newington 33 — — 33 33 — ■— 33 W ands worth 123 4 23 173 119 4 17 157 Westminster 1,625 115 13 1,766 1,658 122 16 1,812 Woolwich 398 30 48 524 415 25 50 540 20,922 1,635 473 23,503 22,031 1,844 463 24,801 85 Appended is a report on the accommodation for women in common lodging-houses which was presented to the Public Health Committee in July, 1902. The report shows that as compared with the numbers five years before, there has been increase in the number of women's beds by some 500, this increase being partially accounted for by the inclusion among the registered houses of a shelter containing from 200 to 300 beds. Particulars as to the accommodation provided for women will be found in the report (see Appendix IV.). In 1902, the Council obtained powers under the General Powers Act of that year for the annual licensing of common lodging-houses. Under Part IX. of this Act it was provided that the Council might, within six months from the passing of the Act, call upon the keepers of registered common lodging-houses in the administrative county to make application for a licence upon a form prescribed in the schedule. The Act received the Royal Assent on 31st July, 1902, and it was decided by the Public Health Committee that notices to apply for a licence should be served upon all the keepers of common lodging-houses on 1st January, 1903. The Act also provided for the County Council to make by-laws for subject matter beyond that for which the Council possessed powers under the Act of 1851. By-laws were accordingly made by the Council and confirmed by the Local Government Board. Seamen's Lodging-houses. Under the provisions of section 214 of the Merchant Shipping Act, 1894, the Council has made by-laws for the regulation of houses accommodating seamen. These by-laws came into force on the 1st October, 1901. The Act provides for the licensing of seamen's lodging-houses, but inasmuch as it is optional on the part of the keeper to make application for a licence, no such applications have been received. During the year 1902, 114 seamen's houses have been measured and apportioned. In carrying out this work much difficulty has been experienced, as many of the keepers are foreigners, having but a slight knowledge of English, and rarely reside in one place for more than a short period. In many cases a house has been measured, and shortly afterwards vacated, the keeper having taken premises elsewhere, either within or just outside the county. At the end of the year, however, there were 97 houses under regulation. These houses are divided among: the several sanitary areas as follows— District. Houses. Lodgers. Poplar 32 474 Stepney 64 1,165 Woolwich 1 26 Total 97 1,665 During the year 2,842 visits were made to these houses by the Council's inspectors, and in a few instances notices were served for the remedy of dirty or defective conditions. Customs and Inland Revenue Acts, 1890 and 1891. Several of the annual reports of medical officers of health show the number of applications received for certificates for exemption from inhabited house duty and the number of such certificates which were granted. In Westminster certificates were granted in respect of the London County Council's buildings in Millbank and Duke's-court, Drury-lane, and were refused for fifteen tenements of a block of buildings in Peter-street, Berwick-street, in other ownership. In Hackney 32 applications relating to 387 tenements were made and granted after certain alterations had been made in the buildings. In Shoreditch applications were received in respect of 33 tenements, and all granted after certain works had been carried out in 25 tenements. In Bethnal-green two applications were received in respect of 3 and 21 tenements respectively. In the case of the three tenements only one water-closet was provided, and the premises were dirty ; in the case of the 21 tenements the premises were so dirty that notices for the abatement of nuisances were served. The applications were refused. In Southwark certificates were granted for a large number of houses which are set out in the annual report. In Bermondsey certificates were granted for 12 premises. In Lambeth 2,723 applications were received, 1,688 were granted unconditionally, 785 on condition certain improvements were effected, and 250 were refused. In Battersea 56 houses were inspected under the Act and certificates were granted in 28 and refused in a like number of instances. In Wandsworth 93 certificates were granted relating to 480 houses. In the case of 4 of the houses the certificate was refused as the houses were not let to more than one family. In Greenwich a certificate for 51 dwellings was granted after requirements had been complied with. In Lewisham a number of applications were received. In Woolwich certificates were refused in the case of a block of flats for the reason that the soil pipes were within the house and there was no accommodation for a dust pail. Underground Rooms. The annual reports relating to the following districts show that the illegal occupation of underground rooms was discontinued in the following number of cases—Paddington, 2; Kensington, several; Chelsea, 10; Westminster, 13; Hampstead, 1; Islington, 48; Finsbury, 27; Bethnal-green, 6; Stepney, 118 (also 2 basements closed); Battersea, 4; Greenwich, 6; Woolwich, 2. A table in the report for Lambeth, under the heading "sanitary work," shows that 96 underground rooms were occupied, and a tabular statement in the report of the medical officer of health of St. Pancras shows that inquiry between November, 1901, and June, 1902, brought to knowledge the illegal occupation of 1,077 underground rooms. 86 Workshops and Work-places. The powers of sanitary authorities are not only extended by the Factory and Workshop Act, 1901, but certain duties necessary for efficient administration are imposed upon local authorities. Thus each local authority is now required to keep a register of workshops, and to distribute to other local authorities the addresses of out-workers whose home work is carried on in the districts of these other authorities. Medical officers of health, moreover, are required to report specifically in their annual report on the administration of the Factory and Workshop Acts in their districts. The reports of London medical officers of health for the year 1902 show that much work under the Act was done in London during that year, but the period which had elapsed since the passing of the Act of 1901 has been too short for a definite statement to be made as to the extent to which the provisions of the Acts have been administered in London as a whole. In the compilation of the register in the various sanitary districts, the information afforded by the lists of H.M. inspectors of factories has been available, and inquiry has been generally made for other premises than those already on these lists. It has been necessary for the rooms in workshops to be measured and their cubic contents calculated in order to enable a card to be exhibited specifying the number of workpeople who may be employed in each room. A large amount of work is involved in this initial proceeding, but when once it has been accomplished the duty of periodically inspecting workshops will be much simplified. It will be seen by reference to what follows that in many districts considerable progress is being made in this matter. Endeavour has been made in abstracting the reports of medical officers of health for the purposes of this report to state succinctly what has been done in each district. Owing, however, to want of uniformity in the method of statement as to the work done in each district under these Acts, it is not possible to make accurate comparison between the several districts in this respect, nor can opinion be formed in many cases of the efficiency of the administration, and the need for adoption of some uniform system of statement is obvious. As stated, however, in previous reports to the County Council, the efficiency and completeness of the administration undoubtedly depends largely upon the employment of special inspectors on this work, and certainly the employment of female inspectors—a practice now adopted in more than half of the London districts—has been productive of good results. In view of the approach of the time when underground bakehouses will be permitted only after certification as to their fitness by the sanitary authority much attention has been given in the several districts to these premises. In many districts the sanitary authorities have adopted " minimum requirements," with which underground bakehouses will have to comply before they will be regarded as fit for certification. In other districts a uniform standard has not been adopted, the fitness of each bakehouse being considered "on its merits." Some of the reports of medical officers of health show that structural alterations would have to be made in many underground bakehouses before they could comply with the requirements of the sanitary authority. A legal decision in 1901 was followed by a statement in the official memorandum of the 20th December, explaining the duties of local authorities under the Act, 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 " workplaces." In January, the County Council resolved " That considering the thousands of persons in London whose business compels them to have the greater part of their food in public restaurants and eating-houses, and in view of the great importance to the public health that such food should be prepared in wholesome and sanitary surroundings, it be referred to the Public Health Committee to consider and report as to the best means to exercise periodical inspections of the kitchens of restaurants and eating-houses on similar lines as bakehouses and factories are inspected." The Public Health Committee thereupon reported as follows— We may remind the Council that in 1898 an inquiry was made by Dr. Hamer as to the circumstances under which certain articles of food are prepared for sale in London. In his report, which was published in 1899, Dr. Hamer expressed the opinion that much larger use could be made by sanitary authorities of existing powers than was then the practice, but that it was desirable that they should have an additional power to require the removal of conditions exposing food to risk of contamination. We are considering the question of the legislation which is needed for this purpose in connection with proposed amendments of the Public Health (London) Act, 1891. The following are the paragraphs in Dr. Hamer's report which referred particularly to restaurants— "Restaurants, eating-houses, dining-rooms—I visited a number of these places in different parts " of London. Apart from defects which can be remedied under the Public Health Act, and which " are more or less frequently met with in different districts in accordance with the less or greater "efficiency of the supervision exercised by the sanitary authority, there are three or four points " to which consideration requires to be given. In the first place the situation of the water-closet " is in a large number of instances open to objection. It sometimes opens directly out of the dining" room or kitchen, and may have no means of ventilation other than through one of these rooms. "In the central parts of London, where space is very limited, there is a tendency for both closet " and kitchen to be relegated to the basement; one or both of them under these conditions may " be badly lighted and ventilated, and they not infrequently communicate directly with one " another. "The by-laws under Sec. 39 (i.) of the Public Health (London) Act, 1891, made by the Council, " provide that every person who shall hereafter construct a water-closet in connection with a build" ing shall not construct such water-closet 'so that it is approached directly from any room used ". . . . for the manufacture, preparation or storage of food for man.' The by-law is unfortunately not retrospective. There are special provisions, it may be noted, dealing with this " question as regards bakehouses and milkstores and milkshops. The proximity of the water-closet " to the kitchen leads in some cases to articles intended for food being exposed to risk of contami" nation, as for example, to quote instances observed in the course of recent inspection, when a " basket of radishes is placed on the water-closet floor or when milk churns stand close to the " water-closet. "A second consideration has relation to sleeping rooms. These are occasionally found com" municating with, or, as in a case I have noted, actually forming a portion of a kitchen. Here "again special provisions exist as regards bakehouses and milkshops, and the by-law quoted above "provides that no water-closet hereafter constructed shall communicate with ' a room used for the "' purpose of human habitation,' but as already stated the by-law is not retrospective. 87 "A third point to be borne in mind is the absence of any special powers in respect of cleansing "and lime-whiting. I have not met, however, with any instances in which a sanitary authority's "notice to remedy such conditions had been disregarded, or the power to enforce it contested, "by the occupier of a restaurant or eating-house. "The bakehouse, it may be observed, is further protected by provisions—that ' the cistern "supplying water to the bakehouse shall be distinct from the cistern supplying a water-closet,' "and that 'no drain or pipe carrying off fsecal or sewage matter shall have an opening within the "bakehouse.' The extension of powers of this kind to places in which food is prepared might "prove useful in particular instances. In some cases, however, it will be found that the under"ground cellar which serves as the kitchen of a central London eating-house is of necessity the "place in which the inspection chamber of the house drain is constructed, and sometimes the "ventilating pipe from such drain opens into the kitchen. Under such conditions it is manifest "that the cellar is not a lit place for use as a kitchen. As an instance, I may refer to an eating"house which I visited with Dr. Allan, the medical officer of health of the Strand district, in "which the cellar beneath the shop, which is used as a kitchen, is some six feet only in height, and "ventilates into a small space (in front of and directly communicating with it) situated under a "grating in the pavement in front of the shop. In the kitchen are a copper and a stove, and close "to these is a manhole cover. The 'air inlet' of the drain is situated beneath the grating in the "pavement, or as it may be otherwise described, at the extreme front end of the kitchen. There "is a trapped gully communicating with the drain and situated at the back of the kitchen. For "many years we were informed a pony was brought down every night from the shop through a "trap door, now disused, into this cellar, the pony's stable being thus within the kitchen. The "use of a place of this kind for the purposes of storing and preparing food points to the need of "the existence of power on the part of the sanitary authority to proceed for the remedy of so "objectionable a condition of things." We have taken the advice of the solicitor on the question of the inspection of the premises referred to, and he is inclined to think that any medical officer of health or sanitary inspector would be entitled, under section 47 of the Public Health (London) Act, 1891, to enter kitchens of hotels and restaurants, and to inspect and examine any article, whether solid or liquid, intended for the food of man, and deposited in any place for the purpose of sale or of preparation for sale. In case of legal proceedings the proof that the food was not "deposited for any such purpose," or was not "intended for the food of man," rests with the person charged. If any such article of food appears to such medical officer or inspector to be diseased, unsound or unwholesome, or unfit for the food of man, he may seize and carry it away in order to have the same dealt with by a justice. Moreover, section 2 (1) (g) of the Act provides that any factory, workshop or workplace which is not a factory subject to the provisions of the Factory and Workshop Act, 1878 (now the Factory and Workshop Act, 1901), relating to cleanliness, ventilation and overcrowding, and (i.) Is not kept in a cleanly state and free from effluvia arising from any drain, privy, earth closet, water closet, urinal or other nuisance, or (ii.) Is not ventilated in such a manner as to render harmless as far as practicable any gases, vapours, dust or other impurities generated in the course of the work carried on therein that are a nuisance or injurious or dangerous to health, or (iii.) Is so overcrowded while work is carried on as to be injurious or dangerous to the health of those employed therein. shall be nuisances liable to be dealt with summarily under the Public Health (London) Act, 1891. In a memorandum, dated 20th December, 1901, issued by the Secretary of State on the provisions of the Factory and Workshop Act, 1901, it is stated that in a case arising under section 38 of the Public Health (London) Act, 1891, it has been held that the expression " workplace" includes any " place where work is done permanently, and where people assemble together to do work permanently of some kind or another," and 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." It would therefore appear that the sanitary authorities have power to enter and inspect such kitchens under section 10 of the Act of 1891, and to take the necessary action with a view to the removal of insanitary conditions and the provision of sanitary conveniences for the persons employed therein. We observe from a recent report of the medical officer of health of Kensington that a systematic inspection has been made of all the restaurants in the borough to the number of 111, with the interesting result that the kitchens of workmen's dining rooms and coffee-houses were, as a rule, found to be cleaner and better kept generally than those of the higher class restaurants. * * * * * We have no information as to the proceedings of the other sanitary authorities in this matter, and we think it would be advisable for the Council to address a circular letter to them calling attention to their powers above referred to, and expressing the hope that they will cause similar inspections to be made in their 'districts, if they have not already done so. We recommend— That a copy of this report be sent to each of the Metropolitan Borough Councils (except Kensington), with an expression of the Council's hope that unless they have already done so they will cause the kitchens of hotels and restaurants in their districts to be inspected, and will exercise their powers under the Public Health (London) Act, 1891, for the removal of any insanitary conditions that may be found as a result of the inspections. The recommendation of the Committee was adopted by the Council, and a circular letter was accordingly addressed to the borough councils on the 26th March, and the replies received showed that on the 22nd July, 1902, when the Committee again reported to the Council that eighteen borough councils had already decided to inspect the kitchens of hotels and restaurants, viz.— Bermondsey. Kensington. Camberwell. Paddington. Chelsea. Poplar. City of London. St. Marylebone. Deptford. Southwark. Finsbury. Stepney. Greenwich. Stoke Newington. Hampstead. Wandsworth. Islington. Westminster, City of and that eight borough councils agreed to make inspections of the nature referred to, viz.— Battersea. Holborn. Fulham. Lambeth. Hackney. Lewisham. Hammersmith. Shoreditch. 88 The Bethnal-green, St. Pancras and Woolwich Borough Councils had not replied to the Council's circular letter at the date of the Committee's report to the Council. Hence an important beginning has been made of the inspection of places where food is prepared for sale. The inspection of the kitchens of restaurant's under the powers which at present exist relates to the welfare of the persons employed therein, and not specifically to the prevention of contamination of food, but such inspection will contribute to provide wholesome surroundings for food supplies. Dirty conditions were found and remedied in many places, and water-closets opening directly into kitchens were in a number of cases abolished. In what proportion of kitchens the state of dirt was extreme is not generally stated, but Dr. Newman reports that he found some of the kitchens and cellars in Finsbury in a disgraceful condition. The proceedings of the London sanitary authorities under the Factory and Workshop Acts, as shown in the annual reports of medical officers of health, were as follows— Paddington.—At the end of 1902 there were 1,217 workshops on the register, 800 having been added during the year. The number of rooms measured during the year was 577. The number of laundries included in the 1,217 workshops was 316. The number of inspections of the above premises was 3,628. Among the conditions found and dealt with were, overcrowding in 44 instances, dirty conditions in 194, deficient ventilation in 14, nuisance from gas fumes in 41, want of separate water-closet accommodation in 33, insufficient water-closet accommodation in 9, and wet floors in 10 instances. The number of bakehouses was 80, of which 67 were underground. The conditions required in underground bakehouses for the purpose of certification was under consideration during the year, and the borough council adopted a schedule of requirements. The number of refreshment houses and fried-fish shops which were inspected was 156 and 24 respectively. Various defects were found and remedied. The number of out-workers living in Paddington was 184; all of these were visited, and nineteen cases of infectious disease occuring in their houses were notified. The list of notified cases of infectious disease is compared daily with the register of out-workers. Two female inspectors and one male inspector were especially employed on duties under this Act. The work was not fully organised until the middle of June, and hence the above record relates only to a part of the year. Kensington.—In 1902 there were 1,713 premises on the register, including laundries and restaurants; in 729 of these workshops, men were employed and in 984, women. During the year 177 workshops in which women were employed were registered, and 208 workrooms measured. There were 4,417 workroom inspections where women were employed, and men's workrooms were inspected from time to time. The number of workshop laundries was 298 and of factory laundries 44. The number of bakehouses was 111, of which 95 were underground. A schedule of requirements for underground bakehouses was adopted by the borough council. The number of restaurants and dining-rooms in the borough was 82; a water-closet opening directly out of a kitchen was abolished and another ventilated directly from a dining-room was reconstructed. Among the conditions found in workshops and dealt with were overcrowding in 26 instances, defective ventilation in 26, dirty conditions in 145, and additional water-closets required in 22 instances. The residences of out-workers in the borough, 222 in number, were visited. Lists of out-workers were communicated to other authorities. Notifiable infectious diseases occurred in 30 workshops or houses connected therewith, and in 8 houses in which out-workers resided, in 3 of which the cases occurred in the rooms occupied by the out-workers; the necessary precautions were taken, in some instances work being stopped until after disinfection. Penalties were recovered in two instances. Two women inspectors were employed for premises on which women were employed; with respect to premises on which men were employed, Dr. Dudfield states: "Considerable improvement with regard to workshop inspection generally took place in 1902, consequent on the employment of additional male inspectors, which permitted of men's workshops being brought under supervision. Hammer smith.—The number of workshops on the register was 955, this number including 321 laundries. In addition there were 64 restaurants, hotels, etc. There were 64 bakehouses, of which 42 were underground. Requirements as to underground bakehouses were adopted by the Public Health Committee of the Borough Council in June, 1903. Notices were served as to insanitary conditions in 77 bakehouses and as to 247 workshops. There were 176 out-workers resident in Hammersmith. An inspector was specially employed in the inspection of workshops. Dr. Collier did not feel justified in recommending the appointment of a female inspector for this purpose. Fulham.—There were 171 workshops on the register, this number including 37 laundries. Notices were served in respect of defective ventilation in 12 instances, dirty conditions in 43, and insufficient provision of water-closets in 18 instances. There were 73 bakehouses in this district, of which 53 were underground. The Public Health Committee adopted certain requirements with which underground bakehouses must comply before the Council will be recommended to grant certificates. The number of restaurants inspected was 26, and notices were served in nine instances. One female inspector has been appointed since 1902 for the inspection of workshops and laundries where women are employed. Chelsea.—The number of workshops registered during the year was 415, and 619 inspections were made. Notices were served in respect of overcrowding in 2 instances, defective ventilation in 2, dirty conditions in 66, separate water-closets for the two sexes in 10, and drainage of floors in 5 instances. There were 47 bakehouses in the district, of which 40 were underground. The Public Health Committee adopted a schedule of requirements with which underground bakehouses will have to comply before a certificate will be granted. There were 42 restaurant kitchens inspected; among the conditions dealt with were dirty conditions in 14 and defective drains in 14 instances. There were 122 outworkers resident in Chelsea; concerning 89 these the homes of 96 were inspected, and 15 notices for cleansing were served ; in one instance work was stopped on account of a case of infectious disease occurring in the house. Lists of outworkers were sent to other authorities. One female inspector is employed for the purpose of inspection of workshops and houses of out-workers, and for special investigations. Westminster.—There were 2,037 workshops on the register, the number added during the year being 86. The rooms of 298 workshops were measured. The number of workshops visited was 1,091, and 692 were inspected. The conditions remedied included—dirty conditions in 233 instances, defective ventilation and light in 98, fumes from gas stoves in 66, and overcrowding in 32 instances. Thirty-two separate water-closets were provided. Difficulty was experienced in connection with the light and ventilation of underground workrooms, and a higher standard of minimum cubic space for persons working in them is suggested by Dr. Allan. There were 107 bakehouses in Westminster, of which 97 were underground. A schedule of requirements for underground bakehouses was adopted by the Public Health Committee, and 20 such bakehouses were visited by the Committee, who eventually recommended certificates in four instances; the works required in others had not been completed by the end of the year. Dr. Allan anticipates a considerable reduction in the number of underground bakehouses. The number of visits to bakehouses was 228, and 85 bakehouses were cleansed. There were 1,532 outworkers on the register; special inspections of out-workers homes were not made, except in so far as the district inspectors were able to include them in their ordinary work. Lists of out-workers were sent to other authorities. It was necessary to stop work in several instances owing to the occurrence of a case of smallpox on the premises. Inspection of kitchens of restaurants was carried out in the ordinary way. Legal proceedings were instituted in respect of two workshops. St. Marylebone.—There were on the register 1,562 workshops in which women were employed, and 115 in which men were employed. Workrooms were measured. The number of inspections of workshops was 2,109, of bakehouses 482, of restaurants, etc., 430, of domestic workshops 245, and of home workers' premises 839. Cleansing was effected in 32 instances, gas stoves ventilated in 17, overcrowding abated in 6, and additional water-closets provided in 6 instances. Legal proceedings were instituted in one instance. There were 94 bakehouses, of which 82 were underground. No schedule of requirements for underground bakehouses was adopted, each of such bakehouses being considered on its merits. The number of restaurants, etc., inspected was 149, of which 80 required cleansing. The number of out-workers on the register was 267. The number of visits to their homes was 489. One male and one female inspector were employed specially on duties under the Act. Hampstead.—There were 530 workshops, including laundries, on the register. The number added during the year was 325. There were 947 inspections and 352 re-inspections of workshops, and 101 workrooms were measured. In 87 instances workrooms were found dirty and cleansed, in 12 ventilation was improved, in 18 instances overcrowding was found. In 8 shops there were no water-closets, and in 25 separate accommodation for the two sexes was required. There were 40 bakehouses in the borough, of which 27 were underground. No general schedule of requirements for underground bakehouses has been adopted, each of such bakehouses being dealt with on its merits. There were 52 laundries, of which 22 were ordinaryworkshops, 25 domestic workshops, and 5 were factory laundries. There were 74 outworkers. Lists of out-workers were sent to other authorities. A female inspector was employed in the inspection of workshops and in special investigations; a male inspector has similar duties and in addition the inspection of slaughterhouses, dairies, etc., and collection of samples under the Food and Drugs Acts. St. Pancras.—There were 1,079 workshops on the register. The number of inspections was 487, and of re-inspections after service of notice 23. The number of domestic workshops and home work places on the register was 171, and of these 226 inspections were made. A notice was served in respect of one home work place. The number of laundries was 89; of these there were 118 inspections and 16 re-inspections, 7 notices being served. There were 182 bakehouses, of which 150 were underground. The number of inspections of bakehouses was 800, and of re-inspections 43. Plans of underground bakehouses were prepared for the consideration of the Public Health Committee in connection with the issuing of certificates. No schedule of requirements for underground bakehouses was adopted. There were 170 kitchens of restaurants on the register, of which there were 245 inspections and 90 re-inspections, in connection with which 34 notices were served. Circular letters were sent to employers reminding them of their duty to communicate lists of out-workers to the sanitary authority; other authorities have been notified of outworkers living in their districts. A register of out-workers is kept. A male and female inspector are especially employed on these duties; the latter also inspects day schools. Islinaton.—There were on the register 1,667 workshops, work places, laundries and bakehouses, in 583 of which men only, and in 1,084 of which women only, were employed. The number registered during the year was 56. The number of workrooms measured was 293. The laundries numbered 199 and the bakehouses 263, of which 119 were underground. There were 8,060 inspections and re-inspections of workshops, including 1,093 visits to bakehouses. Among the conditions dealt with were overcrowding in 4 instances, defective ventilation in 5 instances, dirty rooms in 231 instances, and 16 new water-closets were provided. With respect to underground bakehouses, the Public Health Committee adopted a schedule of requirements with which such bakehouses must comply for the purpose of certification. The number of kitchens of restaurants, etc., inspected was 399; many improvements were effected, water-closets in close proximity to kitchens were abolished, and external ventilation provided in others. " In many of these places fragments of food were scattered about the kitchens because they were not provided with either bins, boxes or other means for collecting or storing refuse food, and consequently it became necessary to request the owners in 90 instances to supply them." The number of out-workers was [12] 90 542, the homes of all of whom were duly visited. As the result of information supplied by the notification of infectious diseases, 328 cases of such disease were found to have occurred on business premises. In visiting the homes of outworkers it was found that underclothing was being made in one home where children were recovering from measles, and in another where a woman suffering from erysipelas was busy making shirts. Lists of out-workers resident in other districts were communicated to the authorities concerned. One male and one female inspector are especially employed on these duties. Stoke Neuington.—There were 137 workshops on the register. "In respect of cleanliness, air-space, light, ventilation, and provision of suitable and sufficient sanitary conveniences, the workshops and work places in the borough are maintained in a satisfactory state." There were 21 underground bakehouses, and a schedule of minimum requirements of such bakehouses with which there must be compliance before certification, was adopted by the Borough Council. A list of outworkers was kept, aud lists of those resident in other districts communicated to the sanitary authorities concerned. In a few instances it was necessary to stop home work on account of the occurrence of a case of infectious disease on the premises. Hackney.—There were 1,658 workshops on the register; in 985 women only were employed, in 11 men only, and in 640 both sexes were employed; this number includes 157 laundries. There were 137 inspections and 1,151 re-inspections of workshops by the female inspector, and 51 workshops were inspected by the male inspectors. Among the conditions found by the female inspector were dirty rooms in 80, defective ventilation in 41, overcrowding in 20, and absence of separate water-closet accommodation for the two sexes in six instances; she found nuisances on 246 premises, dealt with 177, of which 154 were abated and the remaining 69 were dealt with by the district sanitary inspectors. There were 119 bakehouses, of which 66 were underground; these were systematically cleansed. Dr. Warry states: " The Public Health Committee are still considering the principles which should guide them in certifying underground bakehouses as suitable for the trade carried on therein." The number of kitchens of restaurants, etc., inspected was 121, of which 31 were found to be dirty. There were 1,583 out-workers on the register, but the houses of only 219 were visited. Dr. Warry calls attention to the insufficiency of the stall', and to the need for the appointment of an additional female inspector. Lists of outworkers resident in other districts were sent to the several sanitary authorities. One female inspector is usually employed in the inspection of workshops where women were employed and of the homes of out-workers, the inspection of other premises devolving on the male district inspectors. Holborn.—The number of workshops placed on the register was 350, and 750 were inspected; 162 notices were served, and among the conditions dealt with were 65 dirty workshops, 27 overcrowded and 20 insufficiently ventilated workshops, as well as 19 instances of insufficient watercloset accommodation. Notices were sent to H.M. Factory Inspector of 94 workshops in which an abstract of the Act was not exhibited. There were 41 bakehouses in the borough, of which 37 were underground. Dr. Bond states that minimum requirements might be applied to the majority of underground bakehouses, with which they should comply before certification, but that it was " undesirable for the Council to lay down any hard-and-fast rules that could be applied equally to all." Each of such bakehouses was being considered on its merits. The number of kitchens of restaurants, etc., which were inspected was 122, and in respect of these 40 notices were served ; there were found six water-closets in improper positions, and in two instances additional water-closets were required; in 16 instances the kitchens were dirty, and in six instances the ventilation was insufficient. The number of out-workers placed on the register was 148. Special inspectors are not employed on duties under the Act. Finshury.—There were 1,374 workshops on the register, this number including bakehouses and laundries. Systematic inspection of workshops throughout the borough has not been so extensive as it would have been had not the prevalence of smallpox made claims upon the time of the workshops inspector. Nevertheless, 1,958 visits of inspection were made to factories and workshops by the inspector, and much work done. In 10 streets which were thoroughly inspected there were found to be 237 workshops, of which 61 were so dirty as to require notices for cleansing. It is proposed to go through every street in the borough in due course so as to obtain a complete record of all factories and workshops. The work done included 120 workshops cleansed, overcrowding abated in 8 instances, drainage of floors of laundries carried out in 2 instances, and additional water-closets provided in 43 instances. Notice was sent to H.M. Factory Inspector of 32 workshops in which an abstract of the Act was not exhibited. As the result of personal inspection, Dr. Newman says that there were 220 restaurants, etc., in which 964 people were employed in the actual preparation of food ; 150 notices were served for considerable defects, some of the kitchens and cellars being in a disgraceful condition. There were 69 bakehouses in Finsbury, of which 46 are underground. Dr. Newman states it is inevitable that certain underground bakehouses will be closed. He presented his authority with a report on bakehouses showing that among the conditions found in underground bakehouses was excess of carbonic acid in the atmosphere in much higher degree than in bakehouses above ground. A copy of requirements in respect of bakehouses was sent to each occupier in Finsbury, but each underground bakehouse would be considered on its merits. Notice of 1,535 outworkers was received from Finsbury employers and of 218 from other authorities, and the addresses of 941 of these were communicated to other authorities. It had only been possible to make 81 visits to 62 home workers. Dr. Newman estimates that there are not less than 750 home workers in Finsbury. In three instances there was occurrence of a case of infectious disease in the homes of outworkers. A summons was taken out in respect of a dilapidated and damp workshop, but the summons was dismissed, the magistrate stating that the matter was one between landlord and tenant. One inspector was especially employed in workshop inspection. 91 City.—The workshops and workplaces, exclusive of kitchens, measured and inspected were 341 in number, and there were 1,591 workshops re-inspected. Among the improvements effected were 193 water-closets provided or improved, overcrowding abated in 5 instances, and 170 rooms cleansed, 472 notices being served. Dr. Collingridge states that 1,452 workshops were on the books of H.M. Factory Inspector, and that he estimated, with the additional premises being discovered, that the number of workrooms to be inspected would be 2,500, of work places (kitchens, etc.), 214, and of bakehouses, 44, of which 36 were underground. With respect to underground bakehouses, the Committee decided upon a general course of action, but at the same time determined to deal with each case upon its merits. The number of outworkers resident in the City was 90. Legal proceedings were instituted in respect of two workshops. One female inspector was especially employed on these duties, and two additional male inspectors were appointed in November. Shoreditch.—A register was being compiled, and 333 sanitary notices were served in respect of 391 factories, workshops and work places. Among the conditions dealt with, overcrowding was abated in 4 instances, cleansing was carried out in 506 rooms, 80 water-closets were constructed and 50 re-constructed. There were 84 bakehouses in Shoreditch, of which 51 were underground. A schedule of the conditions with which underground bakehouses must comply before certification was adopted by the Borough Council. The workshops and eating-houses inspected numbered 138, 69 of which required attention ; 38 fried-fish shops were inspected. In all cases the necessary notices were served and complied with. There were 967 out-workers resident in Shoreditch; the addresses of those living elsewhere were forwarded to the authorities concerned. Bethnal Green.—The number of workshops measured and placed on the register was 178. In 161 instances notices were served to cleanse and repair premises; 31 new water-closets were provided, and other conditions dealt with. Very little overcrowding was found. There were 99 bakehouses in Bethnal Green, of which 37 were underground. A schedule of requirements for underground bakehouses before certification was adopted by the Public Health Committee. Notices were served in respect of dirty bakehouses, and in one instance a penalty recovered. The homes of 603 out-workers were visited; 36 were found to have insanitary conditions within them. Of 973 out-workers of which notice was received, the addresses of those not resident in the borough were sent to the authorities concerned. In 42 instances H.M. Factory Inspector was informed of premises in which an abstract of the Act was not exhibited. One male inspector is employed on these duties, and on the inspection of houses let in lodgings, cowsheds and milkshops. Stepney.—The number of workshops on the register was 2,344. The number of workshops inspected was 2,607; 522 were lime-washed and cleansed, in 107 ventilation was improved and effluvium nuisances abated, in 29 hoods to gas stoves were provided; in 165 instances additional water-closet accommodation was provided, in 79 instances overcrowding was abated. There were 201 bakehouses in Stepney, of which 93 were underground. A schedule of requirements for underground bakehouses was adopted by the Public Health Committee, and the condition of each will be considered on this basis before a certificate is granted. The number of laundries on the register was 19. The number of firms employing out-workers was 690; the number of out-workers employed was 3,756, of which 2,366 were tailors and 873 clothiers. Penalties were recovered in respect of two overcrowded workshops, and in one for failing to cleanse and lime-white. Poplar.—Reports of the inspectors included in the medical officer's report shows that there were 412 workshops, work places, laundries, etc., on the register, of which there were 619 inspections and 363 re-inspections. The number of workshops newly discovered and registered was 67, and 50 workrooms were measured. The number of notices served was 149, and among the conditions improved were 132 rooms cleansed, 4 water-closets provided, ventilation improved in 1 instance, and overcrowding abated in 6 instances. Additional water-closets were also provided in 9 factories. There were 117 bakehouses in Poplar, of which 40 were underground. A schedule of requirements for underground bakehouses was adopted by the Borough Council, and each bakehouse will be considered on its merits. The homes of 1,098 out-workers were visited, and the addresses of others not living in Poplar were communicated to the proper local authorities. Cases of infectious disease numbering 56 were associated with out-workers in Poplar. One female inspector is especially employed on these duties. Southwark.—There were 1,007 workshops on the register, in 595 of which men and in 412 of which women were employed, and of these there were 1,302 inspections and 2,525 re-inspections. Workrooms numbering 633 were measured, and 606 notices served. Among the work done was abatement of overcrowding in 17 instances, improvement of ventilation in 142 instances, cleansing of rooms in 792 instances, and construction of sanitary conveniences in 33 instances. There were 126 bakehouses in the borough, of which 50 were underground. The Council adopted a schedule of minimum requirements, with which there must be compliance before underground bakehouses were certified. The number of eating-houses, etc., inspected was 210. The homes of 92 outworkers were inspected. One female inspector was especially employed on these duties. Bermondsey.—There were 966 workshops and work places on the register, and Dr. Brown thinks this is probably not two-thirds of the actual number in the borough. There were 271 primary inspections of premises, and 134 notices served ; in 4 instances legal proceedings were instituted. Cleansing was required in 33 instances, ventilation was improved in 10, and in 44 instances additional water-closets were provided. There were 108 bakehouses in the borough, of which 36 were underground. The subject of certification of underground bakehouses was under the consideration of the sanitary authority during the year. Information was received of 252 places where out-work is done in the borough. Information concerning out-workers in other districts was sent to the authorities concerned. Lambeth.—During the year 105 workshops, including 29 laundries, were added to the register. The number of workrooms measured was 318. The number of workshops inspected was 280, and 333 were re-inspected. Among the defects found, among others, were overcrowding in 4 instances, dirty rooms 208, ill-ventilated rooms 7. In the 105 newly registered workshops separate water-closets for the two sexes were wanting in 14 instances, and in 3 instances waterclosets were found communicating directly with the rooms. There were 204 bakehouses in Lambeth, of which 89 were underground. A schedule of requirements for underground bakehouses was adopted by the Borough Council in November. All the underground bakehouses required improvement. The number of kitchens of restaurants, etc., inspected was 225, dirty conditions and accumulations of refuse were found in many instances. The inspection of outworkers' premises will be chiefly carried out by the female inspector. H.M. Factory Inspector was informed of places in which protected persons were employed. One female inspector is especially employed on duties under the Act in addition to some other duties. Battersea.—The number of workshops on the register was 454; probably the total number in the borough is between 600 and 700. There were 1,919 inspections and re-inspections. Among the conditions found were 127 dirty rooms, 13 overcrowded rooms, 15 instances of laundry floors requiring drainage, and 37 defective water-closets. The number of laundries in the district was 73. There were 83 bakehouses, 49 of which were underground. A list of requirements for underground bakehouses was sent to a majority of the occupiers of such bakehouses ; in 3 instances it was found that the bakehouse could not be made suitable, and all others required extensive alterations. There were 83 restaurant kitchens inspected. Dr. McCleary thinks further powers are needed for dealing with these places. Information as to 320 out-workers was received, and particulars concerning 72 were communicated to other authorities. The outworkers' premises were registered and regularly inspected. Dirty conditions were found and remedied in some of these premises, and iu 2 instances a case of infectious disease led to suspension of work. Information concerning 82 workshops in which an abstract of the Act was not exhibited, and in which protected persons were employed, was forwarded to H.M. Factory Inspector. A male and female inspector were especially employed on these duties. Wandsworth.—There were 1,257 workshops on the register ; in 328 men, and in 929 women were employed, and there were 1,842 inspections and re-inspections of these premises. The number of workrooms measured was 791. Notices to the number of 217 were served, and among the work done was overcrowding abated in 12 instances, ventilation improved in 11 instances, and 214 rooms cleansed. There were 395 laundries in Wandsworth, 226 of which were workshops or work places, and the remainder factories. There were 85 restaurant kitchens, all of which were inspected, and notices served where necessary. The number of bakehouses in the borough was 153, of which 60 were underground. A list of requirements for such bakehouses was adopted and sent to the occupiers. There were 208 out-workers on the register, and their homes were all visited ; eleven cases of infectious disease occurred in these houses. Information as to the addresses of out-workers was sent to other authorities. One female inspector was especially employed on duties under this Act. Camberwell.—There were 953 inspections and re-inspections of workshops and 420 inspections and re-inspections of laundries. The number of notices served was 106. Overcrowding was abated in 18 instances, an additional water-closet was provided in one instance, ventilation was improved in 3 instances, and cleansing effected in 28 instances. There were 455 inspections of bakehouses ; the Borough Council adopted a schedule of requirements for underground bakehouses with which there must be compliance before certification. The kitchens of 50 eating-houses were inspected; 12 of them were found to be dirty, and in one instance a water-closet opened directly out of the kitchen. The number of out-workers visited was 647, and in 43 instances the work was being done on dirty premises ; 15 cases of infectious disease was found among outworkers. Information as to the addresses of outworkers was sent to other authorities. A female inspector was especially employed on the above duties. Deptford.—There were 246 workshops on the register, including bakehouses and laundries. The number inspected and measured during the year was 186. Among the improvements effected were overcrowding abated in 10 instances, 2 water-closets were provided, and 3 water-closets directly connected with workrooms abolished. There were 79 bakehouses in Deptford, of which 34 were underground, and there were 361 inspections of bakehouses. A schedule of requirements with which underground bakehouses must comply before certification was adopted by the Borough Council. The number of outworkers on the register was 165, and there were 208 inspections of their premises. The number of " references from other boroughs " was 253, and lists of outworkers resident in other boroughs were communicated to the authorities concerned. One male inspector, who also inspects milk premises, offensive premises, canal boats, and purchases samples under the Food and Drugs Act, is especially employed on the above duties. Greenwich.—There were 175 workshops on the register, 24 being added, during the year, and the rooms of 97 were measured. There were 186 visits of inspection to these premises. The conditions dealt with are not shown in the annual report separately from those in other premises in the borough. There were 18 laundries measured and 160 inspections of bakehouses. A schedule of requirements applicable to all underground bakehouses was not adopted, but each was considered on its merits. The outworkers' premises on the register numbered 79; these were inspected from, time to time. Yery few employers send lists of outworkers to the Borough Council until such have been asked for at least once or twice. Dr. Annis states that the 186 visits to workshop premises are certainly not, in his opinion, as many as the importance of the matter requires, " but, unfortunately, it is all that the staff have been able to accomplish, with a due regard to the carrying out of their other work." 93 Lewisham.—There were 225 inspections of workshops; the conditions found are not shown in the annual report separately from those found on other premises in the borough. Ninety bakehouses were visited. There were 27 underground bakehouses in Lewisham. Requirements with which underground bakehouses must comply were adopted by the Borough Council. A male inspector was especially employed on these duties during a portion of the year only. Woolwich..—There were 166 workshops under inspection, and 496 visits were paid by the inspectors. Sanitary defects in workshops were remedied. These included 19 cases of overcrowding, 14 of want of ventilation, 7 of insufficient water-closet accommodation, and 28 of dirty conditions. There were 71 bakehouses in the borough, of which 34 were underground. With respect to the latter, a schedule of minimum requirements was adopted by the Borough Council. The kitchens of several restaurants were inspected and insanitary conditions remedied. The names and addresses of 147 out-workers resident in the borough were received and their premises inspected. Nuisances were found and remedied on 40 premises. Information as to out-workers resident in other districts was communicated to the authorities concerned, and in two instances information of the omission to exhibit an abstract of the Act was sent to H.M. Factory Inspector. The above duties devolve especially on two inspectors who have other general duties. Inspection of Food, etc. Ice creams. In referring to the subject of enteric fever on page 61 account is given of cases of this disease which were associated with the consumption of ice cream. In 1892 Dr. George Turner inquired, on behalf of the London County Council, into an outbreak of enteric fever in Southeast London, which he found to be due to the consumption of ice cream purchased from Italian vendors in the streets, who manufactured this article in Mill-lane, Deptford, where the Council has since carried out an improvement scheme on account of the insanitary condition of this area. Attention having been thus directed to this subject, other outbreaks of this disease in other parts of the country have been found to be due to a similar cause. Dr. Hamer, at a later date, inquired into the conditions under which ice cream was manufactured in London, and in 1902 the Council included in their General Powers Bill of that year the following provisions empowering London sanitary authorities to control the conditions under which this commodity is manufactured. These provisions are— Any person being a manufacturer of or merchant or dealer in ice creams or other similar commodity who within the County—• (а) Causes or permits ice creams or any similar commodity to bo manufactured, sold, or stored in any cellar, shed, or room in which there is any inlet or opening to a drain, or which is used as a living room or sleeping room ; (b) In the manufacture, sale, or storage of any such commodity does any act or thing likely to expose such commodity to infection or contamination, or omits to take any proper precaution for the due protection of such commodity from infection or contamination ; or (c) Omits on the outbreak of any infectious disease amongst the persons employed in his business, or living or working in, on, or about the premises, in or on any part of which any such commodity as aforesaid is manufactured, sold, or stored, to give notice thereof forthwith to the medical officer of the sanitary district in which such business is carried on or such premises are situate ; shall be liable for every such offence on conviction in a court of summary jurisdiction to a penalty not exceeding forty shillings. Every itinerant vendor of any such commodity as aforesaid shall, if not himself the manufacturer thereof, exhibit in a legible manner on a conspicuous part of his barrow a notice, stating the name and address of the person from whom he obtains such commodity, and if such vendor is himself the manufacturer of such commodity he shall in the same manner exhibit his own name and address. Every such itinerant vendor who shall fail to comply with the provisions of this section, shall be liable for each offence on conviction as aforesaid to a penalty not exceeding forty shillings. These provisions came into force in November, 1902. The County Council prepared a translation of these provisions into Italian for the use cf sanitary authorities and the persons concerned. This translation was largely used. The annual report of the medical officer of health of the City contains an account of the illness, in July, of two telegraph boys, which was brought to his knowledge by the medical officer of the General Post Office, and which was believed to be due to the eating of ice creams bought at an Italian shop in Aldersgate-street. The symptoms complained of were severe pains in the epigastrium, nausea, headache, and depression. Samples of ice cream purchased in the neighbourhood were submitted bv Dr. Collingridge to Dr. Klein for bacteriological examination, and found to be poisonous, and when injected under the skin of guinea pigs caused the death of the animals. Other cases of illness among telegraph boys followed, also attributed to the eating of ice creams, and other samples of ice cream were, at the instance of Dr. Collingridge, examined by Dr. Klein. Of 23 samples thus examined 12 were found to contain virulent bacteria, and in some cases, to produce the death of guinea pigs when injected beneath the skin of those animals. In respect of one sample, Dr. Klein stated that the microbes were non-sporing, and that, therefore, they appear to have obtained an entrance to the material after it had been boiled. The ice cream which was poisonous had generally been manufactured on insanitary premises, and the length of the period of exposure of the ice cream to these conditions appeared to be important in this connection. The Corporation issued a notice to ice cream makers pointing out the precautions which should be taken to prevent contamination, one of which was that when, in the process of manufacture, the materials are boiled, freezing must take place immediately afterwards, and another, that ice cream should not be kept for a longer period than 48 hours after manufacture, and that if remaining then unsold must be destroyed. Other reference to the subject of the sale of ice cream is found in the report of the medical officer of health of Finsbury, in whose district was manufactured some of the ice cream 94 cerned in the cases of illness in the City mentioned above. Dr. Newman states that the premises concerned were insanitary. He gives particulars of the Italian quarter in Finsbury, and states that efforts have been made for a number of years to supervise the ice cream industry, and that already 94 premises on which this business is carried on were known to the sanitary authority. In Paddington a list of 25 makers and vendors has been compiled, 12 being Italians selling from street barrows. Of these, 3 were found to make ice creams in stables where animals were kept, one 111 a disused stable, one in a living and sleeping room, and seven in sculleries and open yards. In Kensington the medical officer of health visited the premises on which ice cream was manufactured. In Hammersmith there are 20 such premises, the inspection of which was allotted to the inspector employed in connection with smoke nuisance, and 6 notices were served. In Fulham the various vendors were informed of the requirements of the Act; arrangements have been made for the regular inspection of the premises, and six samples of ice cream were examined bacteriologically. In Westminster the requirements of the Act were made known to the various vendors. In Hampstead a list of vendors was prepared, all of whom were notified of the requirements of the Act and their premises regularly inspected. In Islington there are 183 places known in which the manufacture of ice cream is carried on. The provisions of the Act were brought to the knowledge of the vendors, and Dr. Harris says that already there has been great improvement in the manner in which ice creams are made. The medical officer of health of Hackney points out the need for interchange of information between the various sanitary authorities as to ice cream vendors who manufacture in one district and sell in another. In Holborn notices were exhibited throughout the borough showing the provisions of the Act. All the premises were inspected and the Act enforced ; many of them will no longer be used for this purpose. In the City 32 premises on which ice cream is manufactured were inspected and 15 were found to be insanitary. The medical officers of health of other districts were communicated with concerning 141 vendors in the City who manufactured their ice cream in 48 places in other parts of London ; of these places 9 were stated to be in an unsatisfactory condition. Notices were served when necessary concerning the places in the City where this ice cream was sold. In Shoreditch 63 ice cream shops were inspected and insanitary conditions of major or minor importance found in 25. In 3 instances water-closets were in dangerous proximity to the place where the ice cream was made, in one case it was discovered that the copper used in its preparation was utilised for the boiling of dirty underclothing, and in another the ice cream was manufactured in a room used for living and sleeping. Samples of ice cream were bacteriologically examined. In Bethnal-green there were 53 places where ice cream was manufactured, of which 22 were found to be insanitary. Each proprietor was served with a notice of the requirements of the Act. In Southwark there were 50 inspections and 123 re-inspections of premises used for the manufacture of ice cream, 27 intimation and 6 statutory notices being served for the remedy of defects ; these were complied with, or the use of the premises abandoned. In Bermondsey there were 68 premises, the occupiers of which were notified of the requirements of the Act. All were inspected and improvements effected where necessary. In Lambeth samples of ice cream were examined bacteriologically. In Battersea there were 80 premises used for the manufacture of ice cream, 12 of which were occupied by Italians. Various insanitary conditions were found, including the manufacture of the ice cream in living-rooms in 29 instances, and in rooms communicating with a water-closet in 7 instances. In 6 instances structural alteration of the premises was required. In Camberwell there were 242 inspections of ice cream shops. In Deptford copies of the provisions of the Act were posted and bills distributed. In Greenwich a circular was sent to the occupiers of some 100 premises. In Lewisham no action was taken during the year. Unsound food. The annual report of Dr. Collingridge shows that the supply of meat to the Corporation Markets, Smithfield, was 405,019 tons in 1902, and that 865 tons were seized during the year, the latter amount including 257 tons of imported frozen and chilled meat. In 23 instances there were prosecutions and in 22 instances penalties were recovered. In the remaining case it was shown that some other person, and not the person summoned, was responsible. Dr. Collingridge states that for the first time Servian sheep were sent into the market. He writes, " They were to a great extent badly selected, weak and poor, to which defects emphasis had been given by most indifferent dressing, in course of which a small piece of liver had, in most cases, been left in the carcase between the diaphragm and kidney. Many of these livers were full of flukes, which in some cases were found singly or in bunches on the surface of the chest wall, clearly showing the reason for their condition. As a consequence, a large proportion of the carcases were seized. In spite of this, they continued to come in varying numbers and at irregular intervals for several weeks. A rumour then reached us that owing to the large number seized in the City, it was intended to avoid the London market and send them to provincial towns for sale. The Port sanitary authority were at once communicated with, with a view to their inspection at the point of debarkation, and some considerable number were seized by their officers. Notwithstanding these preventive measures, diseased sheep from this source continued to arrive on the London market up to 16th January. It is understood that larger consignments will be sent next year." Dr. Collingridge suggested that in such event it would be well to bring these facts to the notice of the Servian Government. In Finsbury a large meat trade is carried on in the neighbourhood of the City markets, and a special meat inspector is employed. During the year more than 75 tons of meat were surrendered or seized. There were 18 prosecutions in connection with the seizure of meat. In three cases the defendants were sentenced to imprisonment without the option of a fine, and in other cases fines varying from £50 to £2 were inflicted. 95 The inspection of slaughterhouses by the sanitary authorities has given some opportunity for the inspection of the carcases of animals killed in them, but from the number of inspections which have been made in some districts it does not appear that much use has been made of this opportunity. On the other hand, in Paddington, the carcases of 4,570 sheep, 136 bullocks, and of 26 calves were inspected. In St. Pancras, one inspector who saw 500 animals killed states that the carcase of a pig and a number of lungs and livers were surrendered and destroyed. In Islington the inspector examined 44,785 animals killed in the slaughterhouses, and the entire carcases of 11 animals (0 cows and 5 sheep) were seized and destroyed; among the animals killed 307 were found to be more or less diseased, 95 being affected with tuberculosis. In Hackney slaughterhouses were visited, usually at the time of slaughter; there were 2,110 oxen and heifers and 26,387 sheep and lambs killed in these slaughterhouses in 1902; the carcases of 74 oxen and heifers, of 267 sheep and of 3 calves were inspected, and the viscera of 6 oxen and 8 sheep found to be diseased. In Wandsworth slaughterhouses were frequently inspected, not only for the purpose of seeing that the by-laws were carried out, but also for the purpose of inspecting the animals after slaughter. There can, of course, be no complete inspection of all the animals killed in private slaughterhouses, but it would be well for efforts to be made in this direction pending the time when public slaughterhouses will be substituted for private slaughterhouses. Dr. Annis, the medical officer of health of Greenwich, states in his annual report that, " when inspecting these premises, especially in connection with the renewal or otherwise of their annual licence, I found and reported to the Public Health Committee that these inspections had revealed the fact that no less than three of these premises were not in actual use, and had not been used for some considerable time; the butchers occupying the premises, preferring, for various reasons, to make use of the public slaughterhouse, or buying the meat killed therein, thus showing that, even with the much-vaunted facilities of the private slaughterhouse adjacent to the shop to hand, such facilities appear to be overbalanced by other considerations in favour of the public abattoir. This practice of the butchers themselves would seem to show that the argument so frequently raised when the question of the provision of a public abattoir is brought to the front, 1.e., that the inconvenience attaching to the use of a public slaughterhouse, as opposed to a private one, is too great, is raised from ulterior motives." Seizures of meat are also recorded in the annual reports relating to Westminster, Hampstead, Shoreditch, Bethnal-green, Stepney, Poplar, Deptford, and Woolwich. Seizures of other articles of food are recorded in the annual reports relating to a number of districts. In the City 362 cartloads of vegetables, fruit, condensed milk, etc., were surrendered and 1,148 tons of fish were condemned in or near Billingsgate Market. The reports as to many of the other districts show that seizures of other articles of food were made in Paddington, Fulham, Chelsea, Westminster, Hampstead, St. Pancras, St. Marylebone, Islington, Hackney, Holborn, Finsbury, Shoreditch, Bethnal-green, Stepney, Poplar, Southwark, Bermondsey, Lambeth, Battersea, Wandsworth, Deptford, Greenwich and Woolwich. Among the articles thus seized were fish, rabbits, fruit, vegetables, butter, eggs, tinned milk, and other tinned foods. The largest amount of tinned food destroyed was in Stepney, in which district are wharves on the river. Dr. Thomas states that notices were served on the various wharfingers, importers, brokers, etc., calling their attention to the fact that unsound food, whether exposed for sale or not, was liable to be seized, and this no doubt caused the surrender of a large quantity of canned goods. Among the list of articles destroyed, which are stated in his report, are nearly 103,000 tins of various articles of food. In Bermondsey there are also wharves on the river, and 820,146 tins of food were landed in this district and a quantity of unsound food destroyed with the consent of the owner, including 368 tons of grain of which notice was received from the medical officer of the Port. Dr. Brown states that the appointment of a special inspector for the examination of food landed on the wharves will have to be considered. The reports also show that in addition to those already mentioned there were prosecutions in which penalties were inflicted in Paddington in 4 instances, in Fulham in 2, in Westminster in 2, in Hampstead in 1, in St. Pancras in 2, in Bethnal-green 18, in Stepney 3, in Southwark 2, and in Woolwich in 2 instances. Cases of poisoning from food are recorded by the medical officers of health of Westminster and St. Pancras. Dr. Allan received complaints from persons in Westminster who became ill after dining at a certain restaurant. An examination of the copper saucepans in use was made, and it was found that they required to be re-tinned. Some tomato soup which was cooked in one of them was, on analysis, found to contain 0.227 grains per pint of metallic copper, equal to 0.897 grains of copper sulphate. In St. Pancras eight members of a family suffered from marked gastric symptoms after eating some sausages, a polony, and a pork pie bought in Derby. Dr. Sykes states that these were bought at the same shop as pork pies which caused at the same time in Derbv a serious outbreak apparently due to ptomaine poisoning. Dr. Sykes says, "It was traced to the eating of pork pies, the meat of which had become contaminated in the chopping house by excremental matter and the large intestines of the animals slaughtered in an adjoining building. The meat was chopped up in a place where the large intestines were being prepared for sale." Among the articles seized in Westminster was a tin of tomatoes, the appearance of which led Dr. Allan to send it for analysis. It was found to contain tin in soluble form to the amount of two grains of metal in the pound. "The amount present in the whole sample was five grains of metal, equivalent to eight grains of tin chloride." 96 Disinfection. The principal changes made during the year in the arrangements for disinfection in the several sanitary areas as shown in the annual reports of medical officers of health may he summarised as follows— The medical officer of health of Paddington reports that the work of disinfection in that district is still done by a contractor, that the Borough Council is satisfied with the system, and that, although the Local Government Board urged them to consider the advisability of doing the work with their own staff, as smallpox had occurred among the contractor's men, no further steps have been taken. The Borough Council has now received a communication from the County Council on the subject, and the matter stands referred for report. The medical officer of health of Chelsea reports that during the past year a new disinfecting station has been built and equipped on the Borough Council's new wharf in Lots-road. It contains an incinerator furnace for destroying infected bedding. The medical officer of health of Westminster regrets that no further steps have been taken to provide a site for a central disinfecting station for the borough. During the year a new disinfecting chamber has been provided in St. Pancras, which had been working continuously since 1899. The medical officer of health of Hackney reports that early in the year the new disinfecting station was completed and made available for use. The Borough Council of Shoreditch decided to provide an additional apparatus owing to the large amount of work required to be done. The new apparatus came into use in December, and the medical officer of health reports that so far it has answered well. The Borough Council of Bethnal-green has sanctioned the provision of a new disinfecting station with a second set of apparatus at a cost of £2,800. In Poplar a new boiler has been fixed in the disinfecting house, and alterations have been made in the station in view of the possibility of an additional disinfector being required. The Borough Council of Lambeth is now in possession of two machines working on the high pressure saturated steam principle, and situated in the old building at Wanless-road, which has been enlarged and altered. Stabling, van-sheds, etc., are to be provided during the coming year. The new disinfection station at Battersea was opened in March. Until that date the work had been undertaken by a contractor, but by carrying out the work themselves the Council has been able to do the work much more economically, even during the short time the machine has been at work. In Wandsworth the medical officer of health reports that all the work has been done most satisfactorily, but that the station is now insufficient for the needs of the borough, and a proposal is under consideration to remove the present station to Tooting, and to erect there a much larger building containing two disinfectors, with proper accommodation for handling and storing articles. Shelters. During the smallpox prevalence of 1902 the shelters which had been provided by the several sanitary authorities proved of great value in providing accommodaton for persons who were accommodated during the disinfection of their homes. They also served for the temporary accommodation of particular persons who had been exposed to infection, and whom it was desirable to keep under supervision. The medical officer of health of Kensington reports that the question of providing a shelter still awaits settlement, and he supplies strong reasons for such provision. In connection with the subject of smallpox the medical officer of health of Fulham states that five families were accommodated at the Council's shelter. In Chelsea a shelter has been erected in connection with the new disinfecting station; it consists of two bedrooms, a kitchen, and a living-room, together with bath-room, water-closet, and sink-room. In Westminster 20 persons were admitted to the shelters at Horseferry-road and Dufour's-place, in connection with the occurrence of cases of smallpox. The Marylebone shelter was used 47 times by persons while their rooms were being disinfected. In a few instances it was found advisable to detain "contact" cases in the shelter for some little time. The medical officer of health of Hampstead states that the shelter was only used in one instance, but that instance proved the value of the provision of such accommodation; the family occupied but one room, the disinfection of which could not be carried out during their occupancy. The St. Pancra3 shelter was used in connection with the cleansing and disinfection of (584 smallpox "contacts." The persons using the Islington shelter were admitted principally owing to the smallpox outbreak, and during the year 57 families availed themselves of this accommodation. In Hackney the shelter was opened and ready for use in March, and during the year 97 persons were admitted, of whom 3 refused to remain after admission; the persons housed received board during their stay. In Holborn 129 persons made use of the shelter. In Finsbury there are two reception houses or shelters, which accommodated during the year 72 families. The City shelter provided accommodation for 23 families during the year. In Shoreditch the shelter was made use of by 105 families, and the medical officer of health says it was of inestimable value. In Bethnal-green, after much difficulty premises were found and furnished, and the chief disinfector placed in charge. During the year 1,341 persons passed through the Poplar shelter. In Southwark 415 persons were admitted to the shelter. The medical officer of health of Bermondsey reports that the new shelter will probably be open by July, 1903; it consists of four tenements of three rooms, with a tenement for a caretaker. In Battersea the Borough Council has decided to erect a shelter, and plans have been approved for a two-storied building on land adjoining the public mortuary; it will provide accommodation for three families; the need of such accommodation was much felt during the smallpox outbreak. The medical officer of health of Wandsworth reports that the two shelters were found in a few cases to be invaluable ; the Putney shelter was used on four and the Larchroad shelter on six occasions. In Deptford, temporary lodgings were obtained for three families 97 until such time as the shelter was made habitable and furnished, since when it has been occupied three times by six persons. In Woolwich, the shelter was used by 32 persons, in most instances owing to the occurrence of cases of smallpox in their homes. In Lambeth the shelter was not used, and the medical officers of health of that district and of Paddington are of opinion that disinfection can be effected in such a way as to render the removal of the inmates from a tenement unnecessary. The Cleansing of Persons. The arrangements made under the Cleansing of Persons Act are referred to in only a few of the reports of the medical officers of health. In Chelsea, at the disinfecting station a bath-room has been provided for the use of persons who wish to have a hot bath while their wearing apparel is being disinfected. In Marylebone, special provision has existed since 1898, and since that date 19,888 baths have been supplied. There has been a considerable increase in the number of women using the baths; in 1902 there were 278 women cleansed, whereas in 1900 there were only 28. In St. Pancras the medical officer of health states that he ascertained that applicants at the workhouse gate were referred to the relieving officers, and that since 1898 there had been four or five such applicants; he therefore recommended baths should be placed in the building adjoining the disinfecting station so that persons inadmissible to the public baths could use them while their clothes were being disinfected; he also recommended that a notice concerning these arrangements should be placarded in all public places in the borough. In Holborn 32 persons were cleansed. In Finsbury the only arrangements for cleansing have been those made by the Holborn Board of Guardians, who instructed the officers at the City-road Workhouse to give facilities to any persons applying to be cleansed and their clothes disinfected. Mortuaries. The following information relating to mortuaries is supplied by the reports of the medical officers of health. In Paddington the new mortuary was to be opened early in 1903; it is situated at Paddington-green. The erection of a mortuary chapel for North Kensington has been begun on a site at the north-east corner of Avondale-park, the inhabitants being unwilling to use the mortuary in the parish churchyard, either owing to its distance from their homes or for other reasons. In Lambeth there are still only two mortuaries, no site for Norwood Ward, having, as yet, been found ; the High-street mortuary is not separately provided with any special accommodation for bodies of persons who have died from infectious disease, so that such bodies from all parts of Lambeth have to be taken to the Wanless-road mortuary. The new Battersea mortuary was opened in April ; the medical officer of health states that this has long been needed, the old building having proved quite inadequate for the purpose for which it was intended. In the Borough of Wandsworth the Putney mortuary has been closed, and since the end of April the mortuary in Wandsworth Parish has been used ; nothing further has been done with reference to the erection of the new mortuary in Wandswortn, as the land on which it had been decided to build is not yet available. The Public Health Committee of the Deptford Borough Council have had under consideration the site for a mortuary and a coroner's court, which they have reason to believe will be acquired during 1903, and plans have been submitted by the surveyor which will be presented to the Council in due course. In Greenwich the question of the provision of suitable mortuary accommodation is being considered by the Public Health Committee ; the ground has been purchased, plans were adopted by the Committee, and await the sanction of the Council to the proposed scheme. Water Supply. The following particulars showing the position of the filtration works of the several water companies is extracted from the annual report of the Water Examiner appointed under the Metropolis Water Act, 1871— Name of Company. Subsidence reservoirs. Filters. Monthly rate of filtration per squars foot per hour, 1902. No. of days' supply. Area. Area per million gallons of average daily supply. Mean monthly averages. Maximum monthly averages. Gallons. Gallons. Chelsea 16.2 8 .68 1.61 1.89 East London 30.2 31 .77 1.07 1.42 Grand Junction 3.2 24½ 1.33 .90 1.00 Lambeth 4.1 121/3 .43 2.36 2.73 New River 4.2 165/6 .42 2.31 2.65 Southwark and Vauxhall 13.4 37½ 1.15 1.26 1.39 West Middlesex 18.0 221/3 1.01 1.27 1.40 [13] 98 The Water Examiner directs attention to the recommendations of the Royal Commission, over which Lord Llandaff presided, 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: "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." He further points out the need for water issuing from each filter bed to be delivered into a distinct well, so that distinctive samples may be obtained for examination, and failure in the efficiency of filtration may be traced to the particular filter which is at fault. In the report of Dr. Thorpe the variations during the year in the amount of organic carbon," oxygen consumed," and organic nitrogen in each company's water are shown diagrammatically. The effect on the water supplied of the flood in the rivers in June, already referred to (see page 58), are thus made obvious. At a time when cholera was threatening London, inquiry was made on behalf of the Council concerning wells providing private supplies, and a number of such wells which were found to be supplying water unfit for drinking purposes were closed. Communications with regard to such supplies were, a few years later, addressed to medical officers of health and various well waters were examined; under the instructions of the Public Health Committee this was again repeated in 1902. The report of the medical officer of Wandsworth contains a list of premises having private supplies and the changes effected since the inquiry was instituted. Dr. Thorpe states in his report that his examination of water drawn from the stand-pipe in Riding-housestreet showed that the water was of different quality from that usually found in water derived from the Thames. Inquiry led to the discovery that there was a 1 in. connection between the communication pipe supplying the Langham Hotel and the system of deep-well water supply within the hotel, and that a cock had accidentally been left open leading to admixture of the two waters. He adds : " In the case of the Langham Hotel water no harm was done, as the deep-well supply was of excellent quality; but when it is remembered that in London there must be numerous private supplies, used for trade purposes, derived from more or less polluted sources, it is obvious that the accidental introduction of such water into the service mains might lead to very grave consequences." 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 that the grant apportioned to the district, the difference shall be paid out of the fund to the sanitaiy authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish; and if it exceeds the grant 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 have been guilty of such default as in such section mentioned, and have made an order limiting a time for the performance of the duty of the authoritv, 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 in each year will be made by the Registrar-General upon returns which the Local Government Board will receive from the authority making the poor rate in each parish showing the total number of houses entered in the rate book of the parish. The following table shows the estimated population on the 6t.h April, 1902, 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, 1903— 99 District. Estimated population, 6th April, 1902. Equalisation charge, being excess of contribution over grant. Net grant, being excess of grant over contribution. £ s. d. £ s. d. Paddington 143,695 4,708 4 11 - - - Kensington 173,450 17,713 11 11 - - - Hammersmith 113,551 — - - 7,804 9 2 Fulham 140,892 - - - 11,796 6 8 Chelsea 72,399 4,242 18 8 - - - Westminster, City of 178,489 96,426 12 10 - - - St. Marylebone 129,953 13,633 5 4 - - - Hampstead 83,306 5,646 12 - - - - St. Pancras 234,184 - - - 6,441 3 1 Islington 335,632 - - - 25,980 17 8 Stoke Newington 51,653 - - - 2,811 8 5 Hackney 217,014 - - - 18,627 13 9 Holborn 58,463 10,225 3 8 — — - Finsbury 100,906 1,726 13 10 - - - London, City of 26,361 115,402 8 9 - - - Shoreditch 118,114 - - - 6,682 9 5 Bethnal-green 128,755 - - - 15,358 1 1 Stepney 295,951 - - - 30,388 11 10 Poplar 16S,762 - - - 17,400 4 - Southwark 203,728 - - - 14,214 3 1 Bermondsey 128,698 - - - 5,706 15 4 Lambeth 303,872 - - - 20,041 3 11 Battersea 170,127 - — - 12,171 15 4 Wandsworth 239,788 - - - 13,524 3 2 Camberwell 261,100 - - - 25,678 9 8 Deptford 109,937 - - - 9,790 1 7 Greenwich 97,737 - - - 7,587 1 9 Lewisham 134,489 - - - 7,508 18 9 Woolwich 123,830 - - - 11,171 4 3 Inner Temple 127 600 15 - - - - Middle Temple 107 358 15 - - - - Sanitary Administration of Hammersmith. The question of the sufficiency of the staff of sanitary inspectors in Hammersmith was under the consideration of the Public Health Committee of the Council at the date when the changes consequent upon the passing of the London Government Act, 1899, were taking place. As the result of communication with the Vestry of Hammersmith, it was felt that further consideration would be better postponed until after these changes had been made. In 1901 the newly-constituted Borough Council appointed an additional inspector, but later the medical officer of the borough recommended the appointment of another inspector. This was not agreed to by the Borough Council. In January, 1902, the County Council decided to have an inquiry made by Dr. Young into the sanitary administration of the district, and as to the sufficiency of the sanitary staff, having regard more especially to the regulation of houses let in lodgings. When Dr. Young began his inquiry he found that the Borough Council had, in the meantime, decided to appoint an additional inspector, and this officer shortly afterwards took up his duties. As the result of the inquiry Dr. Young came to the conclusion that there would be advantage in giving effect to a recommendation of the Public Health Committee of the Borough Council as to the division of Hammersmith into six sub-districts, and the allotment of an inspector to each. He also thought that the time of one of the sanitary inspectors, who was chiefly engaged in superintending the removal of house refuse, should be wholly devoted to the duties which more usually devolve on these officers. He further recommended, in view of the large number of laundries in the district, and of the women employed in them, that the authority should consider the desirability of appointing a woman inspector. Dr. Young's report is appended. (See Appendix Y.) Legislation. In addition to the Council's General Powers Act, the sanitary provisions of which have already been mentioned, two Acts were passed during 1902 to which reference may be made— (a) The Midwives Act, which provides for the constitution of a Central Midwives Board, with power to frame rules for the registration of midwives and for regulating, supervising, and restricting within due limits the practice of midwives. After April 1st, 1905, no person may use the title of midwife without being certified under the Act, and after April 1st, 1910, no woman may habitually and for gain attend women in childbirth otherwise than under the direction of a qualified medical practitioner unless she be certified under the Act. The London County Council is constituted a local supervising authority, and the following duties, inter alia, devolve upon the Council— To exercise general supervision over all midwives practising within their area in accordance with the rules to be laid down under the Act. 100 To investigate charges of malpractice, negligence, or misconduct on the part of any midwife practising within their area, and should a prima facie case be established, to report the same to the Central Midwives Board. To suspend any midwife from practice, in accordance with the rules under the Act, if such suspension appears necessary in order to prevent the spread of infection. To report at once to the Central Midwives Board the name of any midwife practising in their area convicted of an otfence. During the month of January of each year to supply to the secretary of the Central Midwives Board the names and addresses of all midwives who, during the preceding year, have notified their intention to practise within their area, and to keep a current copy of the roll of midwives, accessible at all reasonable times for public inspection. To report at once to the Central Midwives Board the death of any midwife, or any change in the name or address of any midwife in their area, so that the necessary alteration may be made in the roll. The County Council may delegate their powers to the Metropolitan Borough Councils. The number of persons who described themselves as midwives at the Census of 1901 was 364. (I) The Cremation Act. This Act empowers burial authorities to provide and maintain crematoria, and empowers the Secretary of State to make regulations prescribing in what cases and under what conditions cremation may take place. Sanitary Inspectors. In a return appended to this report will be found particulars of the number of sanitary inspectors appointed in the several sanitary areas of London, and of the manner of their employment. (See Appendix VI.) Since the previous return in 1901 there was an increase of 26 inspectors, nine of whom were females. Thus in the return which relates to the beginning of 1903, there were 281 male inspectors and 21 female inspectors in London. The following table shows the months in which the annual reports of medical officers of health were received. The reports relate to the City of London, and 28 metropolitan boroughs— March 3 July 13 April 1 August 2 May 4 September 0 June 3 October 3 Shirley F. Murphy, Medical Officer of Health. December, 1903. To the London County Council. 101 Medical Officers of Health of Metropolitan Boroughs in 1902. 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 T. 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. London County Council. SMALLPOX IN LONDON COMMON LODGING-HOUSES, 1901-1902. Presented to the Public Health Committee, 17th December, 1903. Shirley F. Murphy, Medical Officer of Health. Dr. Hamer's Report. History of the outbreak. The smallpox epidemic of 1901-1902 was not in its first developments associated with spread of disease among common lodging-house inmates. Six cases of smallpox had been recognised in London during the first half of 1901, but none of these affected occupants of common lodging-houses; in two instances infection was traced to persons coming from Paris. Early in June the first indications of increasing prevalence were manifested; two groups (comprising six cases in all) were notified from Hackney, in which a laundry played a part in disseminating infection; furthermore, an unrecognised case of the disease contracted in Paris caused some mis,chief in Wandsworth and elsewhere, a laundry again being concerned in the diffusion of the malady. In the week ending August 10th smallpox began to show ability to spread in St. Pancras, end for some weeks the epidemic smouldered mainly among foreigners living in that portion of the borough lying to the west of Tottenham court-road, and in a neighbouring area in St. Marylebone; dissemination of the disease was no doubt facilitated in several instances by concealment of cases or by failure to recognise the fact that smallpox was in question. In the last few days of September cases were detected in Finsbury, and were traced to returned hop-pickers (see annual report for 1901 of the medical officer of health of Finsbury), and special anxiety was now felt as to common lodging-house inmates, having regard to the fact that numbers of hop-pickers were returning to London, and in many instances were resorting to common lodging-houses. On August 23rd a case had been removed from a Salvation Army shelter in Bethnal-green, and on September 8th a second patient was removed from this shelter ; daily inspection was made of these premises by the Council's officers, but no further case occurred there. On August 24th a case was removed from the Burne-street shelter. On September 19th a man was attacked, who stated he had slept in casual wards and various common lodging-houses; on September 22nd a man was removed from Shoe-lane casual ward, and on October 3rd a man who had slept in various shelters, etc., was removed to the ships. In the middle of October there was unmistakable evidence of serious risk of involvement of the common lodging-house population. Reference may first be made to the case of a man who had frequently slept at the Burne-street shelter, and who was removed on 19th October from the Marylebone casual ward. Mr. Wynter Blyth reported that this man had walked the streets in the neighbourhood of Covent Garden on the night of the 18th till the early morning, when he was probably delirious, and had then made his way to Regent's Park, where he passed the day on one of the seats. This was the second case associated with Burne-street; accordingly, close watch was kept on these premises, and on the night of November 1st the 369 men who occupied bunks at the shelter were inspected by the Council's medical officers, but no case of commencing smallpox was detected. Again, it is interesting to note, in view of subsequent behaviour of smallpox in Stepney, that on the 22nd October a woman was removed suffering from smallpox from a shelter in that district. She had walked to London from Perry-wood, in Kent, where she had been "hopping"; her husband, who had accompanied her to London, had not stopped in Stepney, but had proceeded to Barnet. The first considerable outbreak affecting occupants of common lodging-houses, however, occurred in Holborn. E. W., a woman who developed the eruption of smallpox on October 13th, was engaged selling walnuts in Covent-garden until the 15th, when she was taken to the Endellstreet Infirmary and there notified, but while the arrival of the ambulance was being awaited she escaped. Immediately on its being known that she was at large the Council's inspectors were instructed to search for her. One of her friends, a blind woman, suggested that she should be looked for, after "closing time," in a particular basement at Upper Rathbone-place. This information was communicated to Mr. Wynter Blyth, who caused a watch to be kept on these premises. Careful observation was maintained on occupants of the Holborn common lodginghouses by the Council's inspectors, and some of the premises in question were visited in the early [14] o hours of the morning by the Council's medical officer of health and Mr. Wynter Blyth. The woman E. W. was actually encountered by a common lodging-house keeper on the 17th and handed over to a police-constable, but she again escaped. At length, on the 18th, the deputy at 8 and 10, Parker-street (a common lodging-house for women), acting upon instructions given by the Council's inspector, caused E. W., who applied for a bed at that house, to be again handed over to a police-constable, and this time the patient was removed to hospital. During the five days when she was at large E. W. appears to have infected a number of persons. After the lapse of a time which would correspond with the incubation period of the disease, four women at 8 and 10, Parker-street, two women at 2-8, Kennedy-court, two women at 25, Stanhope-street, and two women at 14 and 15, Whitehorse-yard, all houses at which E. W. was well known, developed smallpox. Simultaneously two men at 29, Yere-street, a man at 4, Greville-street, two men at 104, Harmood-street, and a woman at Hanbury-street sickened with this disease. Nos. 29, Vere-street and 4, Greville-street are in the near neighbourhood of the group of women's houses involved ; Harmood-street and Hanbury-street are far removed in point of distance, but there are grounds for associating the Harmood-street cases, at any rate, with the Holborn cases. In further succession to this batch of secondary infections, a series of cases occurred at 104, Harmood-street, at Fullwood's-rents, and at 4, Greville-street, and a first case (probably infected by one or other of the cases belonging to this batch) occurred at 20-25, Queenstreet, a house accommodating men, and was succeeded by a somewhat prolonged succession of cases in that house. 1 he Hanbury-street case, too, was followed by a series of further cases, other women's houses in Whitechapel were involved, and from these still other houses were later infected. In connection with the Holborn outbreak, as it may perhaps be termed, the Council's medical officer at once instituted the system of endeavouring as far as possible to keep together the inmates of infected houses; in particular, persons occupying the same bedroom as the sufferers were kept under daily observation, and where necessary (to prevent migration to other lodginghouses) their beds, and in some instances their food, were provided at the cost of the Council. At one of the houses early implicated the Council's inspector was able to secure the vaccination of practically all the inmates, but in most, cases no considerable measure of success in the matter of vaccination could be obtained. At 8 and 10, Parker-street there seemed to be special reasons for concluding that E. W.s influence had been operative. Several women concerning whom suspicion had arisen had been isolated at these premises, and four actual cases of smallpox were notified. There appeared to be ground for assuming that there would be great difficulty in keping the remaining women (some of whom might be developing the disease) under observation in the house. It was decided on the 2nd November to quarantine all the occupants, and the subsequent history of smallpox at these premises will later be further referred to in connection with the consideration of the practicability of the enforcement of the quarantine system in dealing with smallpox " contacts." The outbreak had hitherto, so far as common lodging-houses were concerned, been in the main a Holborn outbreak, though already in October a prevalence, which later assumed considerable dimensions, had commenced at Rowton House, Hammersmith; and, as previously mentioned, a case had occurred at a shelter (Hanbury-street) in Wliitechapel, a locality which was subsequently severely attacked. During November and December the Rowton House outbreak ran its course: several cases were contributed, too, at this time by houses which had been already infected in Holborn ; a house in Queen-street, Seven Dials, in particular may be specially referred to in this connection : furthermore, important new developments in the concluding months of 1901 were the involvement of certain women's houses in Southwark and the extension of the disease in Stepney. Hitherto the cases had mainly affected the districts of two of the inspectors of common lodginghouses, those of Messrs. Garner and Kershaw, and these two inspectors made daily visits to all houses specially under suspicion, and were thus able to detect many of the cases of illness on the first manifestation of symptoms, and to secure their isolation until one of the Council's medical officers, or the poor-law medical officer, could reach the house. In case of necessity steps were then taken by the inspectors for securing the removal of the patient. In instances in which it was necessary to ensure the continued residence in the house of a lodger who was unable to pay for his bed, the inspector had been instructed to make the necessary arrangements, and in those cases in which the lodger was under suspicion of suffering from smallpox in its initial stages, or in which it was desirable that particular inmates of the house should be kept under special observation (generally not leaving the premises) the inspector paid for such lodger's food and bed during the period of his detention. For example, at 104, Harmood-street four lodgers were thus isolated, at an early stage of their illness, by the inspector ; at 22-25, Queen-street six lodgers were isolated, and their speedy removal was secured ; the keeper's wife at a common lodging-house at Rathbone-place, five lodgers at Fullwood's-rents, two lodgers at 4, Greville-street, and two lodgers at 14, Whitehorseyard, were similarly isolated and dealt with by the Council's officers; at 29 and 30, Vere-street the inspector of the district, Mr. Garner, had already at this date isolated 11 cases (later other cases were isolated by him at this house), and early in January the same inspector picked out eleven men, at 33, Great Peter-street, whom he regarded as possible subjects of the disease. These men were at once isolated, and eight of them duly developed smallpox. When the Southwark group of houses became involved, the Council's inspectors, Messrs. Wheaton and Gibb, proceeded on similar lines, and in a report to the Committee of January 16th the medical officer referred to six particular occasions on which the removal of patients had been expedited by them in Southwark, including instances in which the patients were isolated at the very commencement of symptoms by the inspector, and were thus prevented from spreading infection during the period before the case could be certified. In Southwark this work was greatly 3 facilitated by the co-operation of the medical officer of health, Dr. Millsom, who devoted much personal attention to securing the isolation of suspects and to furthering the carrying out of vaccination. To Stepney, which had at first been comparatively free from attack, the main seat of incidence of the disease had shifted during the last four weeks of 1901 and the early weeks of 1902. The uufortunate escape of a man who was notified from No. 1, Heneage-street, and who was for three or four days at large, may have contributed in some degree to spread of the disease in this locality ; the influence exerted by the Hanbury-street shelter and other women's houses has already been referred to. The Heneage-street house became markedly implicated in December, when the Hanbury-street outbreak was at its height; in the early part of January cases occurred at 39, Commercial-street, 177, Whitechapel-road, 106, St. George's-street, 27 and 29, Brick-lane, 56 and 58, Flower and Dean-street, and other common lodging-houses in Stepney. The night inspector had from the first intimation of the growth of the outbreak in Stepney been told off to assist the inspector of that district; additional assistance was, moreover, rendered by other officers, but the involvement of two large houses in Westminster and the continuance of cases in Southwark made large demands at this time upon the Council's officers. Accordingly early in January the medical officer was authorised to arrange with Dr. Taylor, of Mile End-road, to make night inspections with a view to the early detection of cases of smallpox. The experience hitherto gained showed that no fewer than 44 of the cases which had occurred in common lodging-houses (amounting at this time to about 200 in all) had been detected and dealt with in the first instance by the Council's officers. Of the 44 cases, 27 were among the number for whom payments had been made, and the ability to make arrangements for food and lodging led to a number of persons who were sickening from disease being prevented from mixing with other lodgers in the kitchens and from migrating to other common lodginghouses, while in some instances individuals were confined to the house who would otherwise have gone to work. Three inspectors, Messrs. Garner, Kershaw, and Wheaton, had been hitherto more particularly engaged in dealing with cases of suspicion. Mr. Kershaw at this juncture unfortunately resigned, but the medical officer obtained authority to secure the services of additional inspectors in order that from this time forward Messrs. Garner, Wheaton, and Shapley might devote the whole of their time to the inspection of the houses invaded by smallpox. It had been arranged that the services of the medical men on the list of the Council's district officers should be made available in case of necessity for the purposes of diagnosis. The special circumstances of Stepney had, as already stated, made it necessary to employ Dr. Taylor to make medical inspections there ; on the 10th January he had commenced to carry out this duty on alternate nights, later (February 2nd) authority was given for daily inspection to be undertaken for a time, and it was then found convenient to make the visits in the early morning rather than at night as originally arranged. At first great difficult}' was experienced in persuading lodgers to be vaccinated. On January 30th, 1902, the Public Health Committee authorised the exhibition in all common lodginghouses of a notice recommending lodgers, who were not protected against smallpox by recent vaccination, to submit to the operation. During January and February the difficulties previously encountered, owing to growing apprehensions excited by the spread of the outbreak, were lessened, and at a few houses a large proportion of the lodgers were now protected. Thus, at the Burnestreet Shelter, Dr. Greenwood succeeded on February 1st, with the co-operation of the medical officer of the Council and the officers of the Salvation Army, in vaccinating 130 men, and later all the lodgers at this shelter were (vaccinated; the completeness of the results obtained in this particular instance was in large degree attributable to the attitude adopted by the medical officer of the district, Mr. Wynter Blyth. The outbreak at Burne-street just referred to had commenced on January 15th ; the two Westminster houses involved at the close of 1901 continued during the early weeks of 1902 to furnish cases, the Vere-street prevalence terminating on March 14th, while that at 33, Great Peterstreet continued some weeks longer. Stepney meanwhile was the chief source of anxiety. In addition to houses already mentioned, 35, Dorset-street, 19 and 19½, Brick-lane, and 5, Flower and Dean-street were now specially attacked. There was, moreover, a sharp outbreak at 217, Bow-road, Poplar, during February, and about the middle of that month a case occurred at St. Olave's-chambers, Southwark, and was followed by a group of secondary cases. During March it became manifest that the epidemic among the general population, having reached its height, was now on the wane, and this statement also holds good for the common lodging-house population, though in the latter half of the month cases were still occurring at 33, Great Peter-street, and a fresh prevalence became established at St. Olave's-chambers. The Stepney cases, however, markedly diminished in number, although 20-22, Whitechapel-road, a shelter which had suffered earlier, again became involved. In April the decline in the number of cases in London as a whole became pronounced ; those occurring in common lodging-houses were not much less numerous than in March, but April, like March, compared favourably with February. Towards the end of April and in the early days of May a considerable outbreak of the disease occurred at St. Olave's-chambers, and on May 2nd the Chairman of the Public Health Committee authorised the employment of a medical man, Dr. F. W. Smith, to pay visits in the early morning to this Southwark lodging-house, in the same way as was being already done in the Stepney lodging-houses. The Council's inspector, Mr. Gibb, accompanied Dr. Smith early each morning to this house, and later to other lodginghouses which were attacked ; several cases of smallpox were thus detected at an early stage, and their removal to hospital was expedited. In Stepney, Dr. Taylor was now inspecting only three times weekly, there having been a falling off in the number of cases in this district. 4 About the middle of May this second prevalence in Southwark was practically at an end, but there was then a considerable outbreak (14 cases being notified within four or five days) at Bow-chambers, Poplar. Here again the system of early morning inspections was put in force, and Dr. Taylor, accompanied by the Council's inspector, Mr. Shapley, kept the inmates of the house under daily observation; only three cases were later notified from these premises. Between May 28th and June 4th eleven cases developed at 177, Whitechapel-road, and to this house Dr. Taylor and the Council's inspector now devoted special attention. The epidemic during May and June became notably less widespread, and with cessation of the 177, Whitechapel-road prevalence, on June 22nd, may be said to have come to an end. A few cases had been notified from Rowton-house, King's-cross, and there was a further group of cases at these premises in July. No case, however, was reported from a registered common lodging-house between June 25th and August 16th. On that last-named date a man at 177, Whitechapel-road developed smallpox, and a further case occurred at the same house on August 22nd. On May 26th Dr. Smith was asked to visit the common lodging-houses in Southwark at less frequent intervals; his visits were soon after further reduced in number, and finally discontinued ; Dr. Taylor's last visit was made rather more than a fortnight after the termination of the outbreak at 177, Whitechapel-road. The distribution of cases of the disease among large and small houses. There were at the time of the outbreak upwards of 500 registered common lodging-houses in London, capable of accommodating some 28,000 lodgers. Many of the houses were " associated houses," day rooms and yards being used in common by the occupants of premises which adjoin one another, but appeared at that time in the Council's records under distinct registered numbers. Again, there were some 20 or 30 institutions receiving from 3,000 to 4,000 inmates of the common lodging-house class which were not at the time of the epidemic on the Council's register. For the purpose of examination of the behaviour of smallpox the associated houses may be regarded, in each instance, as constituting a single house, and the 20 or 30 institutions above referred to may be treated as if they had actually been registered. It then transpires that there were— (a) 18 houses each accommodating some 250 lodgers and upwards, representing a total population of rather more than 6,000 persons. (b) 23 houses each accommodating approximately 200 lodgers, representing a total population of about 4,600 persons. (c) 90 houses each accommodating approximately 100 lodgers, representing a total population of about 9,000 persons. (d) 196 houses each accommodating a small number of lodgers, representing a total population of about 9,000 persons. To group (a) belong 325 of the cases of smallpox, i.e., there were in this group 54 „ (b) ,, 41 ,, „ ,, „ 30 „ (c) ,, 147 ,, ,, ,, ,, 16 „ (d) „ about 75 ,, ,, ,, ,, 8 attacks per 1,000 of the population. Some 700 cases occurred in the total population of 28,000, i.e., about 25 per thousand. Only one house in group (a) entirely escaped, and an attack rate of 1 in 50 was exceeded in 80 per cent, of the houses in this group. Only two houses in group (6) entirely escaped, and an attack rate of 1 in 50 was exceeded in 40 per cent, of the houses. Fifty houses in group (c) entirely escaped, and an attack rate of 1 in 50 was exceeded in 20 per cent, of the houses. More than half the houses in group (d) entirely escaped, and an attack rate of 1 in 50 was exceeded in only 10 per cent, of the houses. It will be seen, therefore, that the incidence upon large houses has been quite disproportionate, and clearly the aggregation of numbers of lodgers in large common lodging-houses constitutes a source of special danger when an outbreak of smallpox is in question. It might be thought that the size of dormitories was of importance in this connection, but in the recent outbreak, as will be seen later, the tendency of the disease to spread in sleeping rooms has been less marked than might perhaps have been anticipated. The distribution of cases occurring among common lodging-houses in different parts of London. If the common lodging-houses be grouped according to the metropolitan boroughs in which they are situate, it transpires that— Stepney, with some 6,000 persons belonging to the common lodging-house class, furnished 309 cases. Southwark, with some 4,000 persons belonging to the common lodging-house class, furnished 122 cases. Westminster, with some 1,800 persons belonging to the common lodging-house class, furnished 98 cases. Holborn, with some 2,000 persons belonging to the common lodging-house class, furnished 79 cases. Poplar, with some 1,500 persons belonging to the common lodging-home class, furnished 37 cases. 5 Marylebone, with some 1,250 persons belonging to the common lodging-house class, furnished 32 cases. The remaining boroughs, with some 12,000 persons belonging to the common lodging-house class, furnished 107 cases. Greenwich, Hampstead, Lewisham, and Paddington escaped altogether; these boroughs, however, contain only a small common lodging-house population. More noteworthy is the fact that— Islington, with some 1,200 persons of this class, contributed 5 cases only. Kensington, with some 1,000 persons of this class, contributed 8 cases only. Woolwich, with some 800 persons of this class, contributed 4 cases only. In these three boroughs there are groups of common lodging-houses with a considerable aggregate population, but no one house of large size. It may be of interest to note in connection with the relative immunity of Kensington and Woolwich that there is a good deal of intercommunication between common lodging-houses in those two districts and on the other hand but little interchange of lodgers between houses situated in them and the Stepney and Southwark houses. Moreover, the Council's inspector, Mr. Shapley, finds that the age distribution of the men in Woolwich differed markedly from that of men in the Stepney houses. The Woolwich houses, too, contain a considerable tramp population, and both Woolwich and Kensington suffered to a notable extent during the prevalence of smallpox among tramps in 1893. It will be seen that the six boroughs which stand first, in respect of number of persons accommodated in common lodging-houses, also stand first in respect of number of cases of smallpox affecting such persons. Stepney presents numerous instances of large houses, nearly all of which were attacked ; in Southwark one large house and in Westminster two large houses contributed largely to the number of cases ; in Holborn the number of large houses is less in proportion and cases were more generally distributed ; two large houses, one in Poplar and one in Marylebone, notably contributed to the cases in those boroughs. Incidence of the disease upon sex. About 120 cases occurred among the women, who numbered approximately 2,500 (4.8 per cent.), as compared with 660 cases among the 25,000 men (2.6 per cent.). The incidence upon women was thus nearly twice as great as upon men. It may be noted that whereas 89 women (inmates of common lodging-houses) had been attacked up to the 8th March, 1902, only 16 attacks among women of this class occurred after that date. Thus, in its inception, the outbreak, so far as the common lodging-house population was concerned, was in considerable measure entitled to be described as a women's outbreak. Again, no fewer than 85 of the attacks occurring among women must be allocated to Stepney, and it may be noted that in this borough there are some 800 female inmates of common lodging-houses. It may be mentioned that of the 800 Stepney women about 250 were at the time of their attack using accommodation supplied for " doubles " in lodginghouses. Among users of such accommodation in Stepney 18 cases were notified, 13 in women and 5 in men ; in only one instance was it noted that subsequent to the attack of one of the two persons constituting a " double," the other individual developed smallpox. This fact, at first sight, perhaps, somewhat surprising, is in agreement with other facts, which show that only a small proportion of the occupants of common lodging-houses in London are susceptible, at any rate under the ordinary conditions of exposure, to infection by smallpox. The extent to which infection has been transmitted in common lodging-house dormitories. This question has been made the subject of careful inquiry. Messrs. Garner, Kershaw, Shapley, and Lightfoot, four of the Council's inspectors, have collected all the particulars on the matter it was possible to ascertain in respect of common lodging-houses visited by them ; the ground covered includes the large majority of the common lodging-houses, in which several persons were attacked, and in which evidence of infection having been transmitted in dormitories might therefore be expected to have been forthcoming. Broadly speaking, spread of the disease in this manner has only been observed in a few instances. In numerous cases smallpox has developed in several different parts of the house, but a tendency to be limited to occupants of particular sleeping rooms has been little marked. In all, full particulars have been ascertained with regard to 300 cases of the disease, and out of this number in only 28 instances was there any reasonable ground for suspecting that infection had been communicated in the dormitory. Seven of these cases must be regarded as very doubtful, having regard to the existence of other possible sources of infection, owing to prevalence of smallpox in the neighbourhood, among the patients' friends, or in the common lodging-house itself, or again to such considerations as the position of the bed occupied by the person first attacked in relation to that occupied by the supposed secondary case. To this last consideration importance may be attached, because in the majority of instances in which the evidence under other heads was of a fairly conclusive character it was the rule to find that the bed of the supposed secondary case was in close proximity to that of the original sufferer. The annexed table shows, for each of the 28 instances referred to, the length of time elapsing between the development of the eruption in the primary case and the removal of the patient to hospital, and also indicates the time of development in relation to these dates of the eruption in the supposed secondary case. 6 It appears that in none of the cases of suspected dormitory infection was the removal of the primary case effected before the second day dating from the appearance of the eruption ; in several of them removal was delayed until the third, fourth, and fifth days after the rash developed, or even longer. Again, judging by the date of appearance of the rash in the secondary case, it may be assumed that the mischief caused by the primary case did not, as a rule, become operative until some short time after the appearance of the eruption, for between the date of the second eruption and that of the first there was, as a rule, an interval of rather more than 14 times 24 hours. In three instances in which this was not the case (the tenth, fourteenth, and twenty-sixth in the table) the fact of dormitory infection having occurred at all is doubtful, and in the remaining instance (the seventh in the table) there is some uncertainty about the dates, and the time of occurrence of the earlier of the secondary cases is almost certainly antedated. It seems clear, therefore, that prompt removal of a case of smallpox (within a few hours of the first appearance of the rash) obviates almost all risk of spread of the disease to persons who have occupied the same sleeping room as the patient. It had been noted early in the epidemic, for example, that at 8 and 10, Parker-street such prompt removal of a batch of three cases was not followed by further cases in those houses, and numbers of similar instances were later forthcoming. It appears, therefore, that the importance of facilitating removal at the earliest possible moment can scarcely be over-estimated, and that were it possible in a fairly well vaccinated population (such as the common lodging-house population) to effect such early removal in all instances there would be little likelihood of spread of the disease. Thus, while aggregation of persons in large houses has been seen to have favoured diffusion of smallpox, the infection has apparently only been disseminated in a very small proportion of instances in the dormitory. Inquiries made by the inspectors raise the presumption that intercommunication of lodgers in the common kitchen may occasionally have served to promote spread of infection, but one of the most common places for acquirement of the disease seems to have been the bar of the public-house. It has frequently transpired that the secondary cases occurred in men who were in the habit of drinking with the original sufferer, and potmen and other persons associated with public-houses have in several instances been attacked at about the time when cases were occurring in a common lodging-house hard by. Peculiarities observable as regards incidence upon particular common lodging-houses. This question may be dealt with under the following heads— (a) As to the extent of the mischief in those houses which suffered in a specially notable degree. The heaviest incidence observed was at a house, 104, Harmood-street, with only some 40 lodgers, in which 10 cases occurred. At 35, Dorset-street (80 lodgers), at 8 and 10, Particulars as to cases of smallpox in which infection was apparently transmitted from one to another occupant of the same common lodging-house dormitory. Letter denoting common lodging-house. Day of removal of primary case of smallpox, the day of development of rash being taken as the first day. Day on which eruption in the supposed secondary case developed, the day of the development of the rash in the primary case being taken as the first day. Days 2 3 4 5 6 7 8 9 13 14 15 16 17 18 19 20 •21 Remarks. Common lodginghouse A ... ... ... ... ... x ... ... ... ... ... ... ... ... ... x x ,, ,, ... x ... ... ... ... ... ... ... ... ... ... x ... ... ... ... ,, B ... x ... ... ... ... ... ... ... ... ... x ... ... ... ... ... 1<< << x ... ... ... ... ... ... ... ... ... ... ... x ... ... ... ... ,, c ... ... x ... ... ... ... ... ... ... x x x ... ... ... ... ... ,, ,, x ... ... ... ... ... ... ... ... ... x ... ... ... ... ... ... ,, D x ... ... ... ... ... ... ... x x ... x x ... ... ... ... ,, E ... x ... ... ... ... ... ... ... ... x x x x ... ... ... ... ,, F ... x ... ... ... ... ... ... ... ... ... x ... ... ... ... ... ,, ,, ... ... x ... ... ... ... ... x ... x ... ... ... ... ... ... Doubtful. ,, ,, ... ... x ... ... ... ... ... ... ... ... ... x ... ... ... ... Doubtful. ,, ,, ... x ... ... ... ... ... ... ... ... ... x ... ... ... ... ... ,, G x ... ... ... ... ... ... ... ... ... ... x ... ... ... ... ... ,, H ... x ... ... ... ... ... ... ... x ... ... ... ... ... ... ... Doubtful. ,, ,, ... x ... ... ... ... ... ... ... ... ... ... x ... ... ... ... ,, ,, ... x ... ... ... ... ... ... ... ... ... x ... ... ... ... ... Doubtful. ,, I ... x ... ... ... ... ... ... ... ... x ... ... ... ... ... ... ,, J ... ... ... x ... ... ... ... ... ... ... ... x ... ... ... ... Doubtful. ,, ,, ... ... x ... ... ... ... ... ... ... x ... ... ... ... ... ... 11 11 ... ... x ... ... ... ... ... ... ... x ... ... ... ... ... ... 11 ,, ... ... ... x ... ... ... ... ... ... ... ... ... x ... ... ... ,, K ... ... ... x ... ... ... ... ... ... ... x ... ... ... ... ... ,, L ... ... x ... ... ... ... ... ... ... ... x ... ... ... ... ... ,, M x ... ... ... ... ... ... ... ... ... ... ... ... x ... ... ... ,, N ... ... ... x ... ... ... ... ... ... ... ... x ... ... ... ... 11 11 ... x ... ... ... ... ... ... ... x ... ... ... ... ... ... ... Doubtful. ,, O ... ... ... ... ... ... ... x ... ... ... ... ... x ... ... ... Doubtful. ,, ,, x ... ... ... ... ... ... ... ... ... ... x ... ... ... ... ... D I AGR AM indicating date of occurrence of the rash in cases of Smallpox in. large common -lodging houses (those having some ZOO or more inmates ) in which 6 or more cases of Smallpox occur red bet ween Oct .20th., 1901 and June 23rd., 1902. 7 Parker-street (60 lodgers), and at 4, Greville-street (60 lodgers), one-fifth of the total number were attacked; in 8 other houses (5 of which were houses with 100 beds and upwards) more than one-tenth of the lodgers suffered. It has been already seen that an attack rate of one in fifty was exceeded in 80 per cent. of a group comprising the largest houses, but was only exceeded in 10 per cent. of a group which includes the houses of least considerable size. It is noteworthy that even in houses which were situated in specially affected areas, and in which the disease was again and again introduced, the large majority of the occupants escaped attack. It appears to be clear, therefore, that in London in 1901-1902 only a small percentage (probably not exceeding 20 per cent.) of the common lodginghouse population was susceptible to the disease, or at any rate susceptible to infection under the circumstances of their exposure to it. The behaviour of smallpox in the larger common lodging-houses will be seen on reference to the accompanying diagram, which indicates the date of occurrence of cases in all the houses having some 200 or more inmates in which six or more cases of smallpox occurred between October 26th, 1901, and June 23rd, 1902.* The cases belonging to the several common lodging-houses are arranged in this diagram in a horizontal series, each case occupying a position which corresponds to the date upon which the rash occurred. Each vertical column represents two days (see dates given at the head of the columns). The houses are arranged in order of size, the first three containing some 600 beds each; then follow five with some 400 beds each, seven with 300 beds, and nine with 200 beds. Each case is represented by a rectangle, whose breadth is half that of one of the ruled squares, and whose height is inversely proportionate to the size of the house to which the case belongs. Thus— In houses with 200 beds the height is that of 1 of the ruled squares. ,, ,, 300 ,, ,, 2/3 ,, ,, ,, ,, 400 ,, ,, ½ ,, ,, ,, ,, 600 ,, ,, 1/3 ,, ,, The hatched squares represent the extent to which inmates of houses were persuaded to undergo vaccination, and indicate the time of carrying out such vaccination. If practically all inmates were vaccinated 20 squares are hatched, if only half the inmates 10 squares, and so on. (b) As to the cause of the occurrence of a considerable group of cases in a common lodging-house. In a few instances groups of 4 or 5, in some instances 9-12, cases (this last-named number was never exceeded) occurred at particular houses (see the diagram referred to). In the larger groups in each instance there was unmistakable evidence to the effect that the persons attacked had been in close association with a man or woman who had remained at large for several days subsequent to having developed symptoms of smallpox. The group of 12 cases (common lodging-house L, see diagram) occurred in friends of a man who sickened on December 24th and developed hæmorrhagic smallpox, but who was not isolated until December 26th. Another considerable group (common lodginghouse P) was associated with a hæmorrhagic case, in which symptoms of illness existed for four or five days before the disease was diagnosed. Another group (common lodginghouse T) was associated with a case of confluent smallpox in a man who remained unisolated for four days after his eruption first appeared. (c) As to the effect of panic vaccination upon the course of outbreaks in common lodging-houses. Such vaccination was performed with completeness in the case of four houses (A, C, F and W), less completely (more than 50 per cent. of the inmates protected) at two others (N and P), while in the remainder vaccination of 25 per cent. of the inmates was in no instance accomplished, though in all of them an appreciable proportion of the lodgers was vaccinated. Upon the diagram referred to, the relation of the vaccination in point of time to the occurrence of the cases of smallpox is, as already mentioned, indicated. At the houses C, P and N, the disease had caused considerable mischief before the wholesale vaccination of inmates was resorted to. The outbreak came to an end after the vaccination was carried out, but probably most of the susceptible persons had then already been infected. At the house W vaccination was resorted to rather earlier, and no case occurred after its adoption, save one, that of a man who had escaped the vigilance of those carrying out the vaccination. At the houses A and F the results obtained were particularly striking. (See Diagram.) It appears from the reports of the medical officer of health of Hammersmith, Dr. Collier, that vaccination was performed with completeness at Rowton-house, and its effect in checking spread of disease there appears to have been marked. Dr. Collier records, however, that smallpox occurred in a man, Fred. Geo. Kirby, removed on December 20th, 1901, with a modified pustular rash, who had been vaccinated about 17 days before. Such cases were carefully looked for in the case of inmates of common lodginghouses, of whom, as will be seen, some thousands living in infected houses were vaccinated, but no such instance was discovered. * The particulars with regard to smaller houses were in each instance ascertained, but considerations of space prohibit their inclusion in this diagram. In a few of these smaller houses there were 6 or more cases of smallpox. 8 (d) As to difficulties in securing the prompt isolation of lodgers with a view to preventing spread of disease. This matter has already been more than once commented upon. Thus, the fact that where groups of cases have occurred they have been traced to unisolated sufferers from smallpox has been noted, while, on the other hand, over and over again in the course of the outbreak instances have been forthcoming in which, isolation having been promptly secured, the disease has not spread. Again, the evidence adduced, in this connection, with regard to the liability of occasional occurrence of second cases in the dormitory occupied by the original sufferer, if that sufferer were not promptly removed to hospital, sufficiently indicates the importance of early isolation. Under the system that has been put in practice, in the case of common-lodging houses, persons who have complained of being ill, or who have been singled out by deputies, etc., or by the Council's officers, because they presented evidence of illness, have been carefully watched and removed as soon as a diagnosis could be made, but it has not been practicable to cope successfully with the difficulties presented by cases in which the sufferer has abstained from making complaint and has succeeded in evading observation. The mischief caused by such persons has been considerable. At 33, Great Peter-street a concealed case gave rise to a group of secondary cases; these were all promptly isolated by the Council's inspector, but infection was re-introduced into the house, on more than one occasion, by men who, though suffering from the disease, managed to keep out of the way until they had infected others. At 20-25, Queen-street the same experience was forthcoming; cases were isolated with promptitude, but from time to time infection was re-introduced by individuals who succeeded in evading notice during the early days of their illness. In some instances these concealed cases presented very mild forms of the disease, in others the attack was more severe, but the patient nevertheless continued to attempt to do his daily work up to the latest possible moment. The discovery of the existence of these concealed cases involved much work of a quasi-detective character; the Council's inspectors found, for example, in several cases that lodgers who considered they had "only a beer rash," on being interviewed, proved to be the subjects of unmistakable smallpox. In some instances medical attendance was repeatedly declined, and it was only the insistence of the inspector which brought about the notification of the case. A system of compulsory daily medical inspection of all common lodging-house inmates would no doubt have given better results than were actually attained in the recent outbreak, but such a system would, of course, have involved considerable expense. The plan actually adopted was not a costly one; it threw, however, a considerable tax upon the Council's staff, and for a time necessitated the employment of two medical men, one in Southwark and one in Stepney. The large majority of the inmates of infected houses were kept under observation, and during January, February, and March, some 30 or 40 houses, several of which were large houses, were daily inspected, approximately 5,000 actual "contacts" being dealt with. The expense incurred (excluding that involved in quarantining the inmates of 8 and 10, Parker-street, fees paid to Drs. Taylor and Smith, and the salaries of the Council's own officers) was only £14 14s. 1d., or, say, l¾d. per contact. The extent to which re-infection of houses occurred after successful early isolation of the original sufferers was in a few instances very disappointing. Indeed, in groups of houses situated in localities in which the disease was especially rife, it almost seemed as if smallpox was not to be prevented from affecting a certain percentage of the inmates, as if, in fact, it must exhaust, despite all efforts, the susceptible material in the common lodging-house population. This may be more or less true in particular instances, but on the whole it may be reasonably claimed that prompt isolation did much to limit spread of the disease among the common lodging-house population. Still more remarkable was the extent to which smallpox was confined to inmates of common lodginghouses and the poorer class of tenement houses, thus failing to obtain any foothold among the rest of the population of London. The condition of inmates of common lodging-houses as regards having suffered from previous attach by smallpox. It is not possible to state with complete accuracy the extent to which persons occupying common lodging-houses in London have suffered from smallpox of late years. It was found, however, on making inquiry into this question—among 1,000 common lodging-house inmates in Stepney—that of 224 who had so suffered, 79 gave the date of their attack as being prior to 1870, 76 suffered during the years 1870-79, 31 between 1880-89, and 13 from 1890-1901. It may be roughly assumed that something like 1 in 20 (probably a somewhat larger proportion) of the common lodging-house population were attacked in the great outbreak of 1870-1, and that in the smaller outbreaks of 1877, 1881 and 1885 considerable, though smaller, proportions of common lodging-house inmates (1 in 40, or thereabouts) were affected. From 1886 onwards for several years there was marked freedom from smallpox in London. At length, in October, 1891, the disease was introduced among the foreign population living in the neighbourhood of Tottenhamcourt-road, and later in 1891 and the following year it appears to have been on several occasions imported by men tramping into London from the provinces. The prevalence of 1893 was notably favoured by spread of the disease among the vagrant class; indeed, out of a total of 2,400 cases, 325 occurred among vagrants, 31 being reported from the Blackfriars Shelter, 32 from Burnestreet Shelter, 14 from Horseferry-road Shelter, 16 from Medland-hall, and 179 from other common lodging-houses. (See Dr. Long's report to the Metropolitan Asylums Board, 1893.) 9 Among the common lodging-houses, 33, Great Peter-street, and the two Victoria Homes at Whitechapel particularly suffered. The outbreaks in these common lodging-houses and shelters seldom extended beyond one or two generations." In 1894 the common lodging-house class suffered to a less notable extent; indeed, two localised prevalences in Marylebone (not affecting common lodging-houses) accounted for a considerable proportion of the cases in that year. In 1895 the incidence upon vagrants was again marked; out of 35 cases in June, 29 occurred in persons of this class, and in the course of the year 17 cases were removed from the Blackfriars Shelter and 27 from the shelter in Whitechapel-road. The extent to which, at the commencement of the outbreak, the inmates of common lodging-houses had been vaccinated and re-vaccinated. It needs to be borne in mind that a considerable amount of vaccination was carried out during the course of the 1901-2 outbreak; this fact will, of course, have entailed alteration, as the epidemic pursued its course, in the extent to which common lodging-house occupants were found to have been subjected to the operation. Moreover, a considerable proportion of these persons were attacked by smallpox during the outbreak. It is necessary, therefore, to have due regard in each instance to the precise period at which particulars were ascertained. In the first place, the result of four detailed surveys made at different dates may be given; it will then be well to refer to other evidence collected which bears upon the extent of alterations brought about during the progress of the epidemic. The four surveys alluded to were the following— (a) Survey made at 8 and 10, Parker-street early in November, 1901. This survey relates to women, and represents!, save as regards one particular to be mentioned presently, the state of affairs prior to the 1891-2 outbreak. Dr. Farrar made examination of the women who were being kept under observation in these two houses, and I subsequently made inquiries with regard to them, in order to fill up gaps in the information and clear up doubtful points. The results ultimately obtained were as follows— Seventeen women stated that they had been vaccinated in infancy, and subsequently re-vaccinated, and presented more or less complete evidence that such was, in fact, the case. With regard to five others, moreover, this was said to be true, and, thousrh the evidence was of a less satisfactory character, it may reasonably be supposed that the statement was correct. Thirteen women said that they had been vaccinated in infancy only, and presented evidence suggestive of the fact that this was the case. Three women believed they had been vaccinated in infancy (two of them said they had been vaccinated twice), but no vaccination scars of any sort could be detected. Seven of the thirty-eight women stated that they had suffered from smallpox (these included the three cases presenting no evidence of having ever been vaccinated, but none of the cases presenting evidence of having been re-vaccinated). These thirty-eight women were in no way selected, save in so far as they did not include four cases which had been removed, during the few weeks prior to the survey, suffering from smallpox. The state as to vaccination was not precisely ascertained prior to removal in these four cases; so far as it was known the women had been vaccinated in infancy but not re-vaccinated. From these facts it may be inferred that approximately 59 per cent. of the women were vaccinated and re-vaccinated; 33 per cent. of the women had been vaccinated in infancy only (ten out of the thirty-three per cent. having had smallpox); 8 per cent. were unvaccinated (all those included in this 8 per cent. had had smallpox). (b) A survey made by Mr. Garner, the Council's inspector, early in April, 1902, of seventy-eight male lodgers in Campbell's lodging-house, Vere-street. None of these lodgers had been re-vaccinated, attempts to persuade men at this house to be re-vaccinated having proved unsuccessful. They were in no sense selected, save in so far as they do not include the cases which had been removed from the house suffering from smallpox. Of such cases, six or seven may be regarded as the number which would have to be allotted to the 78 cases in order to make the sample a complete one; of these six or seven it may be assumed that the majority had been vaccinated in infancy. (None, so far as is known, had been re-vaccinated.) The inclusion or exclusion of these seven cases will be found to have no large effect on the percentages obtained. Of the 78 lodgers, 42 had been vaccinated and re-vaccinated, 33 had been vaccinated in infancy only, or only vaccinated on one occasion, 3 had never been vaccinated. Eighteen of the 78 stated that they had had smallpox prior to 1901; these 18 included 6 of those vaccinated in infancy only, and the 3 who had never been vaccinated. It will thus be seen that 9 of the 78 claimed they had been vaccinated and re-vaccinated, and that they had also had smallpox. It is noteworthy, however, that 4 of the 9 put the date of their attack of smallpox before that of their re-vaccination; one of them said he had suffered from smallpox at 11 years of age, when unvaccinated, and had subsequently been vaccinated and re-vaccinated at 18 and 30 years of age respectively. The remaining 4 claimed to have had smallpox at intervals of 8, 10, 13 and 42 years respectively after re-vaccination. Thus approximately it may be stated that— 54 per cent. of the men were vaccinated and re-vaccinated (about one-tenth of these belonged to the group of 9 men referred to already as having stated they had suffered from smallpox subsequent to re-vaccination). [15 ] 10 42 per cent. had been only once vaccinated (about one-fourth of these said they had had smallpox. 4 per cent. were unvaccinated (all had had smallpox). In the two above-mentioned surveys the facts noted were observed as carefully as was practicable ; in the first of these the arms of all the women were examined by Dr. Farrar or by myself; the particulars as to antecedent smallpox were, however, necessarily based upon the recollection of the individuals in question, though in several instances the statements were corroborated by the fact of the existence of the characteristic scars. The two surveys only relate, unfortunately, to a comparatively limited number of cases. In the investigation now to be referred to a much more extended inquiry was made, but the statements rest absolutely upon the authority of the common lodging-house inmates, no examination of the arms of these persons having been undertaken. (c) Mr. Shapley, between 18th April and 8th May, 1902, questioned 1,000 inmates (750 men and 250 women) of common lodging-houses in Stepney as to vaccination, revaccination, and previous attack by smallpox. The cases were in no sense selected, save in so far as they did not include a few cases which had been removed to hospital during the preceding three or four months suffering from smallpox. Twenty-seven persons who had been so removed, and had recovered and returned to Stepney, were included in the 1,000 cases, but some ten or twenty cases over and above this number would have to be allotted to the 1,000 cases in order to make the sample a complete one. As in the previous surveys, however, the inclusion or exclusion of these cases would have had no great influence upon the percentages obtained. Among the 1,000 cases, 240 had been vaccinated since the commencement of the epidemic. In order to make comparison between the results obtained in (c), and those obtained in (a) and (b), the fact of such recent vaccination must be ignored. Of the 1,000 persons, 224 said they had had smallpox (27 of them having suffered during the present epidemic). Two of the 224 said they had had smallpox twice. Of the 250 women— 101 stated that they had been vaccinated in infancy and subsequently re-vaccinated. 136 stated that they had been vaccinated in infancy only, or only vaccinated on one occasion. Thirteen stated that they had never been vaccinated (seven of these said they had had smallpox, two having been attacked during the 1901-02 outbreak). Fifty-six of the 250 said that they had suffered from a previous attack of smallpox, some 50 of these having so suffered prior to 1901. Thus, approximately, 40 per cent. were vaccinated and re-vaccinated; 54 per cent. were only once vaccinated; 6 per cent. were unvaccinated. Of the 750 men— 305 stated that they had been vaccinated in infancy aud subsequently re-vaccinated. 366 stated that they had been vaccinated in infancy only, or only on one occasion. Seventy-nine stated that they had never been vaccinated (30 of these said they had had smallpox, one of them having suffered in the present outbreak). 168 of the 750 said that they had suffered from a previous attack of smallpox, some 148 of these having so suffered prior to 1901. Thus, approximately, 4l per cent. were vaccinated and re-vaccinated; 48 per cent. were only once vaccinated; 11 per cent. were unvaccinated. (d) Mr. Shapley in September, 1902, questioned 100 men in Woolwich in a similar way to that described as having been adopted by him in Stepney; 14 of them had been vaccinated since the commencement of the 1901-2 epidemic, but the fact of such recent vaccination will, as in the case of Stepney, be here ignored, in order to make the figures given comparable with previous figures. It then transpires that— 40 stated that they had been vaccinated in infancy and subsequently revaccinated. 51 had been vaccinated in infancy only, or only once (of these five said they had had smallpox). 9 stated that they had never been vaccinated (of these six said they had had smallpox). It will be seen that inquiries (a) and (b) give a larger percentage of vaccinated and re-vaccinated that of "once vaccinated," while in the case of (c) the "once vaccinated" exceed the vaccinated and re-vaccinated, in both sexes, and the same holds true in (d). Again, the percentage of unvaccinated is rather higher in (c) (men) and (d) than in (a) and (b). The differences may be in part due to differences associated with the fact that inquiries (a) and (b) related to houses in Central London, inquiry (c) to houses in East London, and inquiry (d) to houses in Woolwich. I am disposed, however, to think that the method of inquiry has been the more important influence in determining these differences, and that the results in those cases, in which actual examination of arms for scars was made, are nearer to the truth than those based merely upon the statement of the lodgers themselves. The mean of the results obtained in inquiry (a) and inquiry (c) (females) gives 50 per cent. vaccinated and re-vaccinated, 43 per cent. once vaccinated, and 7 per cent. unvaccinated. The mean of the reeults obtained in inquiry (b), inquiry (c) (males), and inquiry (d) gives 45 per cent. vaccinated and re-vaccinated, 47 per cent. once vaccinated, and 8 per cent. unvaccinated. 11 The differences in the case of the two sexes are thus inconsiderable. Inquiries (a) and (b) point to the conclusion that the percentages of common lodging-house inmates remaining, after separation of the groups "vaccinated and re-vaccinated" and "attacked by smallpox, were 23 per cent. females and 32 per cent males. All the persons making up these percentages, it would appear, had been "once vaccinated." It is probably not far from the truth to say that at the beginning of the 1901-2 outbreak nearly three-quarters of the common lodginghouse population had either been "vaccinated and re-vaccinated," or had suffered previously from smallpox; again, about one-fourth of the common lodging-house population had merely been vaccinated in infancy; finally, a very small percentage indeed were totally unprotected either by vaccination or previous attack of smallpox. With a view to obtaining as correct an idea as was possible of the extent to which common lodging-house inmates were vaccinated during the outbreak, inquiry was made at all the common lodging-houses in February, 1902, by the Council's inspectors, and further inquiries of a less complete character were made in April, and at a later date. The number of persons whom the Council's inspectors had actually seen operated upon* in February, amounted to about 2,000; later reports show that while this number was largely added to it was probably not doubled. In addition, a number of common lodging-house inmates were vaccinated in workhouses, by public vaccinators, or again at the instance of philanthropic bodies, etc. Mr. Shapley ascertained in Stepney, in April, that of 1,000 lodgers, selected at random, 224 had been vaccinated since the commencement of the epidemic. In September, among 100 men in Woolwich questioned by Mr. Shapley, only 14 said they had been vaccinated since the commencement of the epidemic. Woolwich, however, had suffered comparatively little from smallpox, only four cases having occurred there among the common lodging-house population, and there appears to be no doubt that a smaller proportion of persons of this class was vaccinated during 1901-2 in Woolwich than was the case in many other parts of London. It may safely be assumed that, taking the common lodginghouse population as a whole, nearly one-fourth were vaccinated during 1901-2. It should be borne in mind, however, that the vaccination of common lodging-house inmates was much more completely secured in some districts than in others; in Marylebone and Southwark particularly good results were obtained. If 75 per cent. and 25 per cent. be taken as representing the proportions of those "revaccinated, or having previously undergone attack by smallpox," and "once vaccinated," respectively at the outset, and if the persons vaccinated during the outbreak be supposed to have been equally distributed between these two classes, it will follow that at the end of the outbreak about 81 per cent. had been re-vaccinated prior to the end of the outbreak or attacked by smallpox prior to the beginning of the outbreak, and that the remaining 19 per cent. had been once vaccinated. During the outbreak about 2½ per cent. of the common lodginghouse population contracted smallpox, this 2½ per cent. being drawn in the main from the once vaccinated group, but including also a considerable proportion of those comprising the very small number of unvaccinated. Thus finally it may be stated that about 83 per cent. of the common lodging-house class had been re-vaccinated or attacked by smallpox at the end of the outbreak, and about 17 per cent. remained in the class of once vaccinated only. This last class, it will be observed, had diminished during the course of the outbreak from about 25 per cent. to the percentage (17 per cent.) just named. The cases of smallpox among common lodging-house inmates in 1901-2 were, as has been seen, almost entirely limited to the class of persons who had been vaccinated in infancy only— there being scarcely any unvaccinated persons living In common lodging-houses. In claiming its victims from the class in question, smallpox, as is its wont, affected more particularly those upon whom the protection afforded by vaccination in infancy had been more remotely conferred. The average man or woman in the 17 per cent. referred to above as remaining in the class of once vaccinated only at the end of the outbreak was, it may be assumed, less likely to take smallpox, under equal conditions of exposure, than the average individual in the original 25 per cent. It cannot, however, be doubted that the 17 per cent., though they have escaped smallpox in 1901-2, nevertheless consist in large part of more or less susceptible material. The extent of limitation of smallpox to particular areas and particular houses in 1901-2 sufficiently indicates that, more especially in the smaller houses and in outlying districts, many lodgers must have altogether escaped being exposed to infection. Methods adopted with a view to limiting the spread of infection. (a) Quarantining inmates of infected houses. This method was tried by the Council in only one instance, that of 8 and 10, Parker-street, and the experience gained in this case was instructive. In the absence of power to enforce quarantine, the maintenance of such a system is of necessity dependent upon offering free lodging and free food to "contacts." It was repeatedly urged, on the occurrence of a case of smallpox in a common lodging-house, either that the house should be closed or that all the inmates should be placed in quarantine for a period corresponding to the incubation period of the disease. Closing the house was obviously most undesirable, the object held in view being not to disperse the lodgers and so create fresh centres of infection, but rather to keep them as far as possible together and under observation. To impose strict quarantine upon all the inmates of the house would, had it been practicable, undoubtedly have been the most efficient means of securing the desired end. An obvious initial objection to the proceeding was its cost, the outlay necessary to induce lodgers to remain in the house quite prohibiting its adoption on any considerable scale. In the instances in which this system was * The inspector having in most instances made arrangements to be present at the time of attendance of the public vaccinator. 12 tried by borough councils in London, the results, as regards the early isolation of contacts who developed symptoms of smallpox, do not appear to have been encouraging; this was also the case at 8 and 10, Parker-street. The inducement to apply the quarantining system at this house was, however, particularly strong. The woman E. W. has been already referred to as having developed smallpox on 13th October and remained at large until 18th October, and as having been finally apprehended on that day at 8 and 10, Parker-street. She was well known to the women at this house, but the deputy insisted that she had not slept there for some weeks previously. Between the 24th and 29th three women at 8 and 10, Parker-street sickened with smallpox, and as has been seen, cases were reported from other houses which E. W. had been in the habit of frequenting. It was probable that E. W.'s relations with the women at 8 and 10, Parker-street had been more or less intimate, and there was further ground for apprehending that cases might develop among the "contacts" of the three women whose infection was traceable to E. W. The occupants of the house were almost without exception of the "unfortunate class," and for this reason it was thought there would be special difficulty in keeping them under daily observation. The women already attacked, and others, who at the time presented symptoms which excited suspicion, had occupied several of the dormitories at the house, and had mixed freely with other inmates in the common kitchen. The prospect of maintaining any sort of control over the movements of the sixty or more women lodgers was not unnaturally regarded as being almost hopeless. The shelter of the Holborn District Council was full, an attempt which had been made by the medical officer of health of Holborn to retain some of the contacts within the house had been unsuccessful, and it was ultimately decided on 2nd November to take over the entire management of 8 and 10, Parker-street for a limited period. The keeper of the houses signed an agreement on that date whereby the Council, in consideration of the payment of 26s. per day, obtained control over the houses for a fortnight certain, and for such further period as might be deemed necessary, subject to one week's notice on either side. The keeper agreed to provide for the board of the women, those who consented to remain continuously in the house receiving 10d. a day. A nurse was engaged to attend daily at tile premises to take the temperatures of the lodgers and to observe that the conditions of the agreement with the keeper were fulfilled. The inmates were kept under close medical inspection. Contrary to expectation, little difficulty was experienced in persuading the women to remain in the house. There were some sixty inmates on 2nd November, and with few exceptions these remained throughout the three weeks during which the Council retained control of the premises. One or two additional women were from time to time removed to the house from other lodging-houses, in cases in which it was deemed specially desirable that such persons should be kept under medical observation. Each morning the provisions for the day were fetched by two or three women, but save for this liberty no one was allowed outside on pain of forfeiture of the allowance of lOd. One woman only was a source of difficulty; she soon insisted upon going out, and when she returned was penitent but intoxicated; with a view to not losing sight of her this offence was condoned on the understanding it must not be repeated, but after a time the restraint became unendurable to her ; she again left the house, and, as was subsequently ascertained, was apprehended the same night by the police for being drunk and disorderly. Save in this case, and in one or two other exceptional instances,* the letter of the agreement of the inmates to remain in the house was strictly carried out. This very satisfactory result was in the main attributable to the influence exerted by the "deputy," who proved a most capable manageress. No attempt, it may, however, be noted, was made to impose a fixed diet upon the women; they spent their lOd. as they pleased. The Council's expenditure amounted to nearly £67 in three weeks, this sum including—rent and payment for food, £61 3s. 6d., a sum of £2 17s. 6d. paid to the nurse, £2 2s. paid to the deputy, and 13s. 6d. for travelling expenses incurred by Dr. Farrar. On 3rd November a woman who had not slept in the house on the preceding night, but who had often previously lodged there, applied for admission. The deputy allowed her to occupy a bed, and when the medical inspection was made in the morning the woman was found to have a very mild attack of smallpox, her eruption dating apparently from 1st November. This was the only case of smallpox isolated as the result of the supervision exercised over the women, for none of the other lodgers developed the disease during the three weeks of their detention. Later some further cases occurred in the house; in two instances, women who had been in occupation during the three weeks' quarantine were attacked, and there was some suggestion that infection might have been retained in a bundle of clothes which had been concealed by one of the women and so escaped being disinfected; whether this was so or no, the later cases at these houses occurred at dates separated by considerable intervals both from one another and from the time when the inmates were in quarantine. The non-appearance of cases of smallpox among the sixty women during their detention at 8 and 10, Parker-street is only on a par with what happened in very many otheT common lodging-houses in London during 1901-2. It was the exception rather than the rule for the disease to manifest ability to spread in a common lodging-house subsequent to the occurrence of a single case. It was quite clear that to attempt to deal with other common lodging-houses on the lines adopted at Parker-street was out of the question. The Council was urged to do so in several instances, and in a few cases similar attempts were made by borough councils, but as soon as the epidemic had attained considerable proportions such a system was manifestly impracticable. * Cases in which a woman was allowed a day out. this concession being granted because it was clear that if such a course were not adopted, the woman would have left the house altogether. 13 (b) Daily inspection of inmates of infected houses, with money payments in particular instances in which it was deemed necessary to secure persons being kept under observation. This system was found, provided considerable judgment was exercised in connection with the offer of food and lodging, capable of being carried out in such a way as to secure the large majority of the occupants of infected houses being kept under daily observation at quite a small cost; in a considerable proportion of instances, moreover, such observation led to the early isolation of cases developing the disease. At first it was thought that medical inspections of inmates of infected houses in the early hours of the morning would be necessary, but as soon as a considerable number of houses became involved it was seen that this plan, if adopted, would involve retaining the services of medical men on a large scale. In Southwark and in Stepney two medical men were specially engaged, with satisfactory results, but for purposes of effectual and economical administration it was found that the better plan was to rely in the first instance upon the services of the common lodging-house inspectors. Three inspectors were told off to visit infected houses; the chief inspector also devoted practically all his time to the work, and one of the Council's medical officers was summoned by telephone or messenger in case of need. By reason of the intimate knowledge possessed by the inspectors of the ways of occupants of common lodging-houses, and owing to the extent to which they were able to learn from the lodgers themselves or by aid of deputies, night men, etc., when there was any reason to suspect that a lodger was ill, they were able to effect far more than would have been accomplished by medical inspection. Payment for beds was only exceptionally made, being limited to those instances in which exposure to infection had been particularly intimate, while if the lodger was destitute and unable to obtain work a small sum was given him for food. Men in work were encouraged to pursue their daily employment, but were seen so far as was practicable by the inspector each day. It was found that early morning visits, just when the men had risen and were breakfasting and preparing for work, were best adapted for the purpose of seeing lodgers. Deputies, etc., rendered assistance by detaining suspected cases until the arrival of the inspector, in the event of there being at some other house a prior claim upon his attendance. Some of the deputies threw themselves into this detective work with much zeal. As soon as there was reasonable cause for suspicion lodgers were dispatched to one or other of the points at which the Council's officer was likely to be found, and as a rule the deputy was able to induce the sick lodger to go to bed and await the Council's officer's visit. One particularly capable deputy was able to secure the notification and removal of a patient by keeping him for a short time under lock and key, and the same deputy, in conjunction with one of the Council's inspectors, had to forcibly hold down another lodger, covered with the smallpox eruption, until the arrival of the ambulance. Concealed cases proved the main source of difficulty, concealment being in some instances wilful, in others being associated with unwillingness to admit disability caused by illness. The object steadily kept in view by the inspectors was that of bringing back to one place of rendezvous day by day, for a period of at least a fortnight, all persons who had been specially exposed to infection, so far as was reasonably practicable; it was by obtaining the confidence of lodgers and deputies that the best results were achieved. In the event of there being doubt as to whether or no a lodger was sickening with smallpox, he was isolated, i.e., kept in a separate room in the lodging-house, and seen from time to time by one of the Council's medical officers, the poor law medical officer, or some other medical man. Keepers of common lodging-houses readily afforded all necessary facilities for carrying out such isolation. In houses in which a group of cases had occurred a special room was by permission of the keeper set apart for suspects, and thus in not a few instances lodgers were removed as soon as it was possible to make a diagnosis of the nature of their disease. The measure of success obtained by employment of the methods above detailed may be gauged in the following manner. Returns prepared by the Metropolitan Asylums Board give, in the majority of instances, the date of eruption and the date of removal. If to the cases in which removal was effected on the day of appearance of the eruption the number one be affixed, to those in which removal was effected on the second day the number two, and so on, and the average of these numbers be taken, a figure is obtained which may be looked upon as a sort of index of efficiency. This index in London cases (exclusive of common lodging-house cases) is approximately 3. An average of 752 cases taken comparatively early, about the middle and again towards the close of the epidemic, works out at 2.96. The corresponding average of 752 common lodging-house cases works out at 2.72, showing that despite the special difficulties encountered in dealing with this section of the population, removal to hospital was secured on an average some six hours earlier than was the case in the population as a whole. The average for two large areas in which the system of supervision by the Council's inspectors had specially full play works out at 2.40, representing a further improvement; removal of cases in the houses In these areas being effected some eight hours earlier than in common lodging-houses generally, and some fourteen hours earlier than in the population as a whole. Even in these areas it will be seen that the period at which removal was effected was, on the average, only some 32-56 hours after the appearance of the rash. The cases here in question of course include those constituting the original source of infection in a house in which, it may be, the nature of the illness was for several days unrecognised, as well as subsequent cases, some promptly isolated, some for a time concealed or unrecognised. To materially reduce the index of efficiency below that obtained in the two groups of lodging-houses nothing short of daily inspection of all the inmates of common lodginghouses would have sufficed; all that it was practicable for the Council's officers to attempt in the way of inspection day by day was that of the occupants of particular houses, to which attention had been specially directed by the occurrence and removal of a case of smallpox. W. H. Hamer, Assistant Medical Officer of Health. Appendix II. London County Council. OCCUPATION OF PERSONS ATTACKED BY SMALLPOX. Presented to the Public Health Committee, 17th December, 1903. Shikley F. Murphy, Medical Officer of Health. Dr. Hamer's Report. Analysis of the returns made by medical officers of health furnishes information which throws light upon some of the ways in which smallpox was spread during the outbreak 1901-2. The returns in the majority of instances indicate the occupation and the place of employment of the person attacked. A study of the particulars given clearly indicates that the sufferers were largely drawn from certain sections of the population, and it is difficult, therefore, to formulate precise ideas as to the way in which the occupations of the sufferers might be expected to group themselves. Clearly the census returns of occupations and the data furnished by Mr. Charles Booth in his "Life and Labour of the People in London" cannot be appealed to for comparative purposes, as the figures in both these instances relate to the population as a whole. The sufferers from smallpox, concerning whom particulars are given in the returns now in question, contain many labourers, housewives, schoolchildren, carpenters, painters, tailors, dressmakers, plumbers, plasterers, and so on. To attempt to estimate whether headings such as these appear, among the 4,000 entries,* with greater or less frequency than might have been anticipated, is not likely to be profitable; the terms are, of course, not used with any common understanding as to definition, and it is difficult, to take a concrete instance, to know how to deal with expressions such as "milliner," "machinist," "mantle maker," "blouse maker," and to decide whether they should or should not be held to fall appropriately under the generic term "dressmaker"; again, "labourer" is a very indefinite expression; "charwoman," "cleaner," "laundress," and "domestic duties" may be more or less interchangeable, and so on. All that can be done in these circumstances is to make some comment upon the particular occupations, which stand out so strikingly among the headings returned, as to make it appear that special circumstances have determined the incidence in question. In doing this, the order of the 24 headings adopted in the census return may be conveniently followed. Under the professional class the Registrar-General includes three headings. (1) General or local government, represented, among smallpox sufferers, by three police constables, a rate collector, an assistant relieving officer, a clerk to a public vaccinator, two sanitary inspectors, and no fewer than 38 disinfectors (i.e., persons engaged in work in connection with the disinfection of articles or rooms). (2) The defence of the country is very poorly represented by a soldier or two. (3) Professional occupations. Here, clergymen, priests, ministers, are conspicuous by their absence, though among those attacked were, it may be noted, a City missionary, a pew opener, and a lady visitor. The legal profession supplies a solicitor and two law writers; the medical, a doctor; while it may be noted that two doctors' servants, the son of a caretaker of a surgery, a chemist's assistant, a chemist's errand boy, a nurse, a housemaid at a general hospital, a cleaner at a fever hospital, and an attendant at an ambulance station are also returned among the 4,000 sufferers. To this professional class there remain to be added two schoolmasters, one or two actresses, a newspaper reporter, ten newsboys, the "daughter of a dramatic author," and an " artist's model." The domestic class (4) contains a few domestic servants, eight waiters, five waitresses, together with no fewer than 29 women and 58 men engaged in service in connection with publichouses, most of the 29 women being barmaids, and the majority of the 58 men barmen and potmen. That 87 persons working in public-houses should be attacked is at first sight very surprising, and, taken in conjunction with the fact that in 18 instances (over and above the 87 referred to) infection is stated to have been contracted in a public-house, it might be held that question should be raised as to some special reason for the association in so marked a manner of the public-house with smallpox infection. In certain parts of London, however, there is one public-house to every 25 dwelling-houses, and the number of persons occupied in or in connection with public-houses must form a considerable percentage of the population in such localities. To determine what the percentage of the total population belonging to the particular class likely, cœteris paribus, to be attacked actually is, it is necessary to ascertain how many persons should be allocated to a public - house. Mr. Shapley, one of the Council's inspectors, has consulted a lodging-house deputy who is now a teetotaller, but who has intimate knowledge concerning the personnel of nineteen public-houses and beer-houses in his neighbourhood, and it transpires that the average number of persons to be allotted to a public-house is 5.2. Taking the number to be assigned to each ordinary dwelling-house at ten, this would make it probable a priori, other things being equal, that about one in every fifty persons attacked would be associated with public-houses. This result is in close correspondence with the actual facts. Having regard, however, to the fact that the persons associated with public-houses belong in many instances (publicans, publicans' wives, etc.) to a class socially superior to that which has generally been attacked in London as a whole, and to the further fact that exposure to infection in the publichouse is limited as to time and so on, it must be admitted that it is not a little remarkable the number of sufferers associated with public-houses should be so large. Under the Registrar-General's heading (5) "Commercial occupations" there are but few entries to be made; a commercial traveller should certainly be included, and presumablv also four insurance agents, and four bookmakers' clerks. The insurance agent and the bookmaker's clerk, it will be seen, suffer with the rate collector already referred to, and in this connection it * There are upwards of 5,000 returns, but only in about 80 per cent. of these are there entries under the headings here in question. [16] 2 may perhaps be mentioned that a "collector" and a "piano tuner" are included among the 4,000 sufferers. "Conveyance of Men, Goods, and Messages" (6). Here there are carmen, 'bus and tram drivers and conductors, cabmen and guards, but such entries do not occur in large numbers, and probably to no greater extent than might a priori have been anticipated. Special interest attaches, however, to eight "watermen," as it is noteworthy in these cases that the individual in question had in almost all, if not all, cases been engaged, about the time he must have been infected, in navigating the Thames in the neighbourhood of the smallpox ships, and in one or two cases there is strong presumptive evidence that infection must have been air-borne. It remains to refer here to three sorters in the General Post Office, two ticket sorters, a ticket collector, a few messengers, porters, errand boys, etc., and three lift operators. "Agriculture" (7) and Fishing (8) are barely, if at all, represented; there is one gardener, it is true, but he is a " cemetery gardener." Members of the industrial class are included by the Registrar-General under the numbers 9 to 23. In (9) Books, prints, maps, are a few book-folders, printers and bookbinders. In these cases, as in those of brush-makers and cigarette-makers, to be later referred to, there seems to have been some spread of disease in connection with workshops, and there is no reason for assuming the nature of the industry had any special influence in determining smallpox incidence. In (10) Makers of machines and implements, there are very few entries to be made. In (11) Houses, furniture and decorators, the case is far otherwise, there are carpenters, builders, bricklayers, paperhangers, plasterers, plumbers, and painters. The fact that at least 86 persons engaged in work in connection with the construction of smallpox hospitals were infected accounts to a large extent for the heavy incidence upon this class. A sister, a mother, two brothers, six wives, one friend of a wife, four sons, and one patient of a mother, of men who had worked at smallpox hospitals were also attacked. There also fall to be included here under the heading "funeral furniture maker— undertaker," 16 men who removed coffins or did other duty undertaken in connection with funerals. Again, there are numerous cleaners, charwomen, and french polishers, a window cleaner, and two carriage cleaners. The last-named should perhaps be referred to (12) Carriages and harness. In (13) Ships and boats, and in (14) Chemicals and compounds, there are a few or no entries. Tobacco and pipes (15) includes a few cigarette-makers already referred to. Under the head (16) Food and lodging reference should be made to many of the 4,000 entries. Innkeeper, publican has already been discussed in speaking of the hotel servant. There are one or two coffee-house keepers, and in connection with lodging-house keepers (at least two keepers and the wife of a keeper were attacked) it may be noted that seven deputies and other members of common lodging-house staffs, three persons employed at Rowton Houses, and five workers at Salvation Army shelters, are included in the returns. Beer sellers, cellarmen, etc., have been included in dealing with potmen, etc., under the heading of inn servants. It remains to mention one or two dairymen, butchers, fishmongers and bakers, or men employed by these tradesmen, and two or three workers in mineral water factories. Heading (18) Dress includes numerous tailors, milliners, dressmakers, and more curiously as many as nine hairdressers, not to mention three persons referred to as barbers. There are two dealers in ready-made clothing, and it is no matter for surprise to find an " old clothes dealer." Animal substances (19). There are but few cases to be allotted here, most noteworthy are the two or three brush-makers already referred to. Vegetable substances (20) and mineral substances (21) may be dismissed without further comment. General or unspecified commodities (22) includes pawnbrokers (represented by three cases, including pawnbrokers' assistants), costermongers, hawkers, street-sellers (of watercress and flowers; newspaper boys have been already alluded to). The number under these headings is not surprising, having regard to the extent to which common lodging-houses were involved. Several of the women are entered as "unfortunates." Under the heading (22) should presumably also be included "labourers," "machinists," etc. Refuse matters (23) is a heading of importance, as there are among the small-pox cases entries to be relegated to town drainage service, scavengers, and rag-gatherers. There are two rag-and-bone dealers, two paper sorters, five dust sifters, four dustmen, and five rag-sorters; there are further two lavatory attendants. The unoccupied class (24) is represented by numerous entries such as "unemployed," " tramp," and " gipsy." The replies of the medical officers of health furnish a good deal of interesting information under the heading "further remarks." Thus it has already been noted that in 18 instances publichouses are credited with having been the source of infection; in other instances a club, theatre, school, or omnibus is thought to have been incriminated, one patient believed she was infected at a dance, another on Boat Race day, at least three sufferers had stood in the crowd round an Asylums Board ambulance, and one had looked out of an open window and watched the removal of a case; in one instance it is noted that the patient was removed from a house in the near neighbourhood of the South Wharf. In 19 cases persons had visited the ships on the day when they may have been infected, and eight others thought they had been infected while waiting in out-patient rooms of hospitals. In six instances the question of "return cases" is raised, and five other persons are presumed to have been infected by reason of the existence of means of communication (other than such as has already been specified) between them and the Asylums Board Wharf or hospitals. In more than a hundred instances it is recorded that infection was traceable to a previous case erroneously supposed for a time to be one of chickenpox. Apart from varicella, supposed influenza seems to have been the chief source of trouble. Finally, it may be stated that at least three instances are mentioned of escape of the patient after the diagnosis had been made, and while the ambulance was being fetched. W. H. Hamer, Assistant Medical Officer of Health. Appendix III. 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 efiect 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 Eltham 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; printed 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, Yictobia-stkeet, Westminster, S.W., Agents for the tale of the Publications of the London County Council. No. 610. Price, 2d., post free 2½d. [6489 2 as already stated, the by-law3 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. Tabular Statement of Replies from the Medical Officers of Health to the Council's letter of 28th November, 1902, together with other particulars. Metropolitan borough. 1 Population (1901). 2 Number of inhabited houses (1901). 3 Tenements (1901). Number of houses now on register. 6 Number newly entered on register during present year. 7 Frequency with which registered houses are inspected. 8 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 ? 9 Number of proceedings instituted under the by-laws before the magistrate during the present year— (а) Concerning cleansing. (b) „ overcrowding. (c) „ other matters. 10 Date when by-laws were confirmed. 11 Whether by-laws contain rent-limits or other exemptions. 12 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. 13 Remarks. 14 Total number. 4 Less than 5 rooms. 5 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 11.)‡ Yes. Owners decline to supply requisite particulars for registration since decision in Weatheritt v. Cartley. - 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 1s. 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 11.)|| 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 long as, the vestry deem it unnecessary to register. § Whenever the vestry may deem it expedient to put regulations in force. || IUntil 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. 1 Population (1901). 2 Number of inhabited houses (1901). 3 Tenements (1901). Number of houses now on register. 6 Number newly entered on register during present year. 7 Frequency with which registered houses are inspected. 8 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 ? 9 Number of proceedings instituted under the by-laws before the magistrate during the present year— (a) Concerning cleansing. (b) „ overcrowding (c) „ other matters. 10 Date when by-laws were confirmed. 11 Whether by-laws contain rent-limits or other exemption. 12 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. 13 Remarks. 14 Total number. 4 Less than five rooms. 5 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, (b) 0, (e) 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 (a) 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 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 11.)† "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. course was adopted in conformity with the wishes of the Board. 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 (b) 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 bv-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. 1 Population (1901). 2 Number of inhabited houses (1901). 3 Tenements (1901). Number of house now on register. 6 Number newly entered on register during present year. 7 Frequency with which registered houses are inspected. 8 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 ? 9 Number of proceedings instituted under the by-laws before the magistrate during the present year— (а) Concerning cleansing. (b) „ overcrowding. (c) „ other matters. 10 Date when by-laws were confirmed. 11 Whether by-laws contain rent-limits or other exemption. 12 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. 13 Remarks. 14 Total number. 4 Less than 5 rooms. 5 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 II.)† 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 (c)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 previously 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† None. 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. Martin-inthe-F ields) 30-11-93 Yes† (St. Margaret, Westminster) 16-1-95 (See bylaw II.)‡ (St. James, West minster) 10-12-94 (See bylaw II.)‡ (St. George, Han over- square) 12-7-94 (See bylaw II.)‡ (Strand) 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 (а) One (b) One 16-11-95* (See bylawIII.)§ (Woolwich) 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 families. Revised by-laws under the consideration of the Local Government Board. London 4,536,541 571,768 1,019,546 672,030 16,433 3,944 * Woolwich also includes the district of Eltham, which prior to 1899 was in the Lee district. By-laws containing rent-limits of exemption were made by the Lee District Board in 1895. † Rent limits of exemption. ‡ Until the landlord has been required to furnish a statement as to certain particulars. § Houses with respect to which it shall have been reported by the Public Health Committee that such house ought to be registered. Appendix IV. London County Council. REPORT BY THE MEDICAL OFFICER ON ACCOMMODATION FOR WOMEN IN COMMON LODGING-HOUSES. (Ordered to be printed by the Public Health Committee, 3rd July, 1902.) Public Health Department, 8, St. Martin's-place, W.C. 21 st July, 1902. In 1897 I presented to the Committee a report on the accommodation which the common lodging-houses of London provide for women and children. In discussing the subject I described as one house two or more contiguous houses in the same occupation which had been adapted in such a, way that some part of them was used in common by the inmates. Thus dealt with, the report showed that there were at that time altogether 73 common lodging-houses receiving women, and that these houses provided accommodation for 1,505 single women or women occupying beds for one person and 732 occupying "doubles" or beds provided for married couples, the houses thus accommodating 2,237 women. Examination of the common lodging-houses at the present time shows, when the houses are thus considered, that there are on the register 69 houses, receiving 2,151 single women and 574 beds for married couples, or an increase of nearly 500 beds for women. In 1897, 801 women were accommodated in houses occupied by this sex only; at the present time such accommodation exists for 1,491 women, the result being, in part, due to the inclusion in the latter figure of a shelter for between 200 and 300 women, which was not included in the earlier figures. In 1897, in houses providing for single men and single women, there was accommodation for 90 men and 97 women; in 1902 these numbers are respectively 132 and 86. Again, in 1897, the accommodation in houses used for single women, single men and "doubles," provided for 277, 581 and 253 respectively; in 1902 the numbers respectively are 142, 313 and 93. The total number of "doubles" was in 1897, 732; it is now 575; and whereas in 1897 in houses containing 129 married couples there were 399 single men, in 1902 there are now only 95 married couples in houses also accommodating 274 single men. The reduction in the total number of "doubles" bas taken place chiefly in houses occupied jointly by single men, single women and married couples. The changes here shown are due to more than one circumstance. They are caused in part by former common lodging-houses being abandoned, and by new common lodging-houses coming into existence, and are further due to the fact that the Council has discouraged, as far as it has been possible to do so, the use of houses by single persons of both sexes. Hence houses which contained beds for both sexes are now more largely devoted entirely to one or the other sex. The chief inspector, moreover, informs me that in a very short time the keepers of two of the largest houses providing for single women and single men under the same roof will voluntarily abandon this arrangement. Trifling alterations in the numbers of persons accommodated in these houses are continually being made, but the figures given in this report may be regarded as a very close approximation to the actual facts. Since the Council has had the supervision of common lodging-houses much has been done to provide water-closets and washing accommodation properly separated for the two sexes, in houses used jointly, but, as will be seen from the accompanying statement, this is still far from complete. In my report of 1897 I pointed out that the accommodation provided for women was generally interior to that provided for men, although the charge made for lodging was often higher. As the result of inspection I have recently made, I find this statement is still true so far as relates to the kitchens and lavatories, although, as in other respects, improvement has in recent years been made in the provision for washing. The following statement as to each house is derived from the reports of the several inspectors. Shirley F. Murphy, Medical Officer of Health. Westminster, 1.—This house is registered for 86 persons (single women and married couples). The front portion of the building consists of basement and four upper floors, the rooms on these four floors contain 42 beds for single women, the basement being used as kitchen and lavatory by these women only; the rear portion consists of ground floor and one upper floor, the ground floor has a kitchen for married couples only, with a lavatory out of which opens a dormitory containing 10 beds for single women; the upper floor contains 14 cubicles for married couples and two cubicles for married couples with two children under 10 years. The lavatory on ground floor is used by the whole of the lodgers for washing purposes, and has six fixed wash-basins with two washing troughs for clothes, but the lavatory in basement has five wash-basins and two troughs used by single women only. There are four water-closets situate in open area on ground level, one of these is set apart for men only. The charges at this house are—1s. per night for couples, and 6d. per night for single women. [3843 2 Westminster, 2.—These premises, consisting of two houses, are registered for 81 women. They are shortly to be demolished. The buildings consist of basements with three upper floors, each house having separate stairs, kitchen and lavatories, but there is one entrance only. The basements are used as kitchens, the whole of the upper floors are used as dormitories. The lavatories are in vaults under the yards, and contain three wash-basins each, with tubs for washing clothes. Thero are four waterclosets, two situated in each yard. The charge is 6d. per night. Chelsea.—This house is registered for 42 single women. The building consists of basement, kitchen and lavatory, with three upper floors; a small front room on ground floor is used as an office, all the other rooms are used as dormitories. There are two water-closets situate in the open yard at rear. The lavatory in rear basement contains three wash-basins for use of women, but their clothes are all sent to the laundry. The charge is 6d. per night. Holborn, 1.—This house is registered for 34 women, who do not pay for their lodgings, and consist largely of discharged prisoners. Several of them are employed in a laundry here. The building consists of basement and four upper floors. The basement contains the kitchen in its front portion, the lavatory is in the rear, and has two baths and five wash-basins. There are two waterclosets, which were recently constructed on the ground floor. The ground floor is used as an office and matron's rooms, the first and second floors are used as dormitories and contain hammock beds, the top floor is used as a laundry. Holborn, 2.—These premises consist of three houses (numbered 18,19 and 20), and are registered for 100 persons and contain beds for 92 single women. The buildings of Nos. 18 and 19 consist of a basement (No. 18) and four upper floors with one staircase for both houses, also situate in No. 18. The basement and back room on the ground floor are used as kitchens, the two front rooms on the ground floor and all upper rooms are used as dormitories ; No. 1 room in No. 20 contains 18 beds; it is approached through the third floor of No. 19 and does not communicate with the men's portion of the same house; indeed there is no communication with the men's part of the same premises, except through the yard, the door of which is kept fastened. The lavatory is in a partly-covered yard and contains five wash basins and three tubs for washing clothes, with four water closets, all used solely by the women, who pay 5d. each per night. Holborn, 3.—These houses (numbered 8 and 10) are occupied together but do not communicate, except through basement room in back yard. At the rear is a very large dormitory on ground floor, the basement of which is used as a common kitchen. The front basement of No. 8 is also used as a common kitchen. The houses consist of basement, ground and three upper floors. In the back room (basement) of No. 8 are situated eight fixed basins for washing purposes. There are also six large and two small washing and foot baths. There is one w.c. in the yard of No. 8, and three in the yard of No. 10. The houses are old but well maintained. 78 women, bed 6d. per night. Holborn, 4.—This is a group of eight old houses approached by an archway out of Newton-street, all of which are occupied by women. The ground floor rooms of all the houses on one side are used as kitchens, a portion of the ground floor of the houses on the opposite side being used used as lavatory. There are altogether six w.c.'s and six fixed wash-basins, and in addition 13 washing and foot baths. These houses are well maintained. 107 women, bed 5d. per night. Holborn, 5.—This consists of basement, ground and three upper floors, and was formerly occupied by men, but only women are now admitted. The basement room is occupied as a common kitchen. In a very small yard at the rear is one w.c. and a slate slab with three fixed basins ; another w.c. is situated on the first floor, built out but approached from the stair landing. The kitchen accommodation is not good, and the maintenance only fair. 23 women, bed 6d. per night. Hammersmith.—This is a group of five very old two-storey cottages (numbered 13, 15, 17, 19 and 21) with a common yard at the rear, in which are situated two w.c.'s for men and one for women. These are placed some distance apart, so that separation is effected. There are separate lavatories for each sex each containing three basins. The common kitchen is situated on the ground floor of No. 17, and is dark and insufficient. The small ground floor back additions of Nos. 15 and 19 are also available as day-rooms, but are not so often used. Generally speaking, the front rooms contain single beds, and the back rooms are occupied as " doubles." The houses are extremely old and the ground floor rooms damp. The charge for a single bed is 4d., and for a double bed 8d. per night. Two w.c.'s for men, one w.c. for women, three basins for men, three basins for women. 33 single men, 7 single women, 8 doubles. Paddington, 1.—This house consists of a basement, ground and three upper floors. It is occupied as a servants' registry office and home, accommodating 31 women. A portion of the top floor projects over the adjoining house. The ground floor is occupied privately, a portion being used as a registry office. There are two w.c.'s on the stairs; one of these is used by the women working in an adjoining laundry. Wash basins are provided in the dormitories. The premises are not well maintained. Many of the lodgers use the dormitories as workrooms, and some eat their food there. 31 women, beds, 3s. 6d. per week. Paddinqton, 2.—This house consists of a ground floor and three upper floors, and is occupied by married couples and women. There is a common kitchen (detached) in yard, also three w.c.'s, one for men and two for women. The lavatory in the yard contains four wash-basins. The general maintenance of the house is indifferent, and the premises are old and worn out. One w.c. for men, two for women. 15 doubles, 15 women; beds, single, 4d. and 6d., double, 8d. Kensington 1.—These three old houses (numbered 4, 6 and 8) are occupied together, with a common entrance at No. 8. They consist of ground and first floor only, and are each occupied by married couples and women. There are two kitchens (detached) at rear of Nos. 6 and 8 for common use. There is one w.c. ia each yard, the one in No. 6 being reserved for the use of women only. In 3 this house is a lavatory with one basin for the use of the women. The lavatory for men is in the back addition of No. 8 and contains three loose tubs only. The accommodation here is of the poorest description, and the houses are quite worn out. 31 men, 10 doubles. Beds, 8d. double; 4d. single. Kensington 2.—These two houses (numbered 34 and 36) consist of basement, ground and two upper floors, and are occupied together by married couples and women. The common kitchen is in the basement of No. 34. There are three w.c.'s in common yard, two for women, and one for men. There is also a lavatory in No. 36 with two basins for men and three for women. The separation here is good. 9 men, 10 doubles, 32 women. Beds, double Is.; single 5d. and 6d. Kensington 3.—This house consists of basement, ground and two upper floors, and is occupied by married couples only, the ground floor front room being occupied by the manager. There is a common kitchen in the basement, and two w.c.'s in the yard, one for men and one for women, also a double lavatory with three basins in each, with proper separation. 11 doubles, bed Is. Kensington 4.—This house is occupied by women only. There are two w.c.'s in yard, and a lavatory with three fixed basins. The accommodation at all these houses is fair, and the premises are well maintained. 26 women, beds 4d. and 6d. Kensington 5.—These two premises are occupied together, and provide for men, women and married couples. There are two w.c.'s in common yard for men, and a lavatory with three fixed basins. In one of the basements are two w.c.'s for women, and a lavatory with three fixed basins for their use. The common kitchen is the ground floor of a building in yard, and the single men occupy the dormitory over. 17 men, 24 women, 12 doubles; beds, doubles Is., singles 5d. Kensington 6.—These two houses (numbered 31 and 33) are occupied together, with a common entrance at No. 33. Married couples and women are provided for. The common kitchen is situated in half-basement of No. 33. The two w.c.'s and lavatory are situated in common yard at rear of No. 31. There are two w.c.'s for men and two for women, and three wash-basins for men and three for women, each properly separated. The premises generally are well maintained. 20 men, 27 women, 11 doubles. Beds, double, Is.; single, 5d. Kensington 7.—This house is occupied by married couples and women, and consists of basement, ground and two upper floors. There are two w.c.'s in yard used in common. In the back basement room is a lavatory fitting containing four basins, one being partitioned ofl for the use of men. The main basement room is occupied as a common kitchen. The accommodation is poor. 11 women, 8 doubles. Beds, double, lOd.; single, 4d. Kensington 8.—This house consists of basement, ground and two upper floors, and is occupied by married couples and women. The common kitchen is in the basement, and in the yard are two w.c.'s, one for men and one for women. These are not separated. There are also three basins for women and one for men in common lavatory, no separation being provided. 14 women, 4 doubles. Beds, double, lOd.; single, 4d. Kensington 9.—This house consists of basement, ground and two upper floors, and provides for married couples, women and men. The basement is occupied for kitchen purposes, one room being provided for married couples and women, and another for men only. A w.c. on the ground floor is reserved for the exclusive use of women, and three others in yard for men. Separate lavatories are provided for each sex. The men's lavatory contains four basins, and is situated in the yard. A two-basin fitting in basement is for the use of women only. The accommodation generally is fair. 43 men, 7 women, 11 doubles. Beds, double Is., single 5d. Kensington 10.—This house accommodates married couples and women, and consists of basement, ground and two upper floors. There are two w.c.'s in yard, one for men and one for women. In the washhouse in basement is a fitting with three basins. One is separated for the use of men only. The separation, however, is not effectual. The kitchen is in front basement room, and is used in common. A small room on this floor is occupied by the deputy. The kitchen is not a good one, but the upper part of the house is well maintained. 21 women, 5 doubles. Beds, double 10d., ingle 5d. Kensington 11.—These two houses consist of basement, ground and two upper floors, and are occupied by married couples and women— In the first house there is one w.c. in yard for common use, but the yard being common with that of the house adjoining where there are more fittings, some sort of separation is thus secured. Three wash-basins are provided, one being partly separated and kept for exclusive use of men. The front basement room forms the common kitchen, and the back room is occupied by the deputy. The lavatory is in washhouse on this floor. The kitchen is not a good one nor is the washing accommodation satisfactory, but the upper part of the house is well maintained. The second house is occupied by married couples and women, and its arrangements are similar to those in the preceding house, except that in the yard two w.c.,s are provided. There are three wash-basins, The kitchen is not good, 36 women, 10 doubles. Beds, double, lOd. ; single 5d. Kensington 12.—This house consists of basement, ground, and two upper floors, and is now occupied exclusively by women. There are two kitchens in basement, also three w.c.'s and a lavatory fitted with seven basins. The kitchens have been recently improved, and the houses are well maintained. 80 women. Beds, 5d. and 6d. St. Pancras 1.—This house consists of basement, ground and 3 upper floors. The two rooms in basement are occupied as kitchens and lavatories. Three w.c.'s are situated in yard at the rear. Only women are admitted, and the premises are well maintained. 36 women. Beds, 9d. and Is. St. Pancras 2.—This house consists of basement, ground and three upper floors. The entire basement is occupied as kitchens and lavatories. The two w.c.'s for the use of lodgers are situated at 4 the end of basement passage. Another w.c. on floor above is used by deputy only. The premises are well maintained and only women are accommodated. 31 women. Beds, 8d and Is. St. Pancras 3.—This house consists of basement, ground and three upper floors. The house is modern. The w.c.'s are now situated in the front area (they were situated in the house before registration) except one for private use which is on the first floor, and ventilates into an internal court. The rooms are well lighted and ventilated. The kitchens are situated in the basement, and are free from objection. There are eight wash-basins and four washing troughs, all situated jn a well-lighted area. Women only. 77 women. Beds, 8d. and Is. St. Marylebone 1.— This is a servants' registry office, and contains only one registered room. This is situated at rear of ground floor, and is lighted by a skylight. There is a small common kitchen in basement. There is a w.c. in the front area for the use of lodgers. Wash-basins are provided in the dormitory. The remaining part of the house is private. Women only. 6 women, Beds, 3s. 6d. per week. St. Marylebone 2.—This is a servant's registry office, and is registered for 10 beds only. A portion of the house is used for lodgers; this portion consists of the front rooms on the 1st and 2nd floors. The front room in the basement is occupied as a kitchen. The w.c. for common use is situated in the back yard. Washing accommodation is provided in each room. Women only. 10 women. Beds, 6d. per night, or 3s. per week. Finsbury—These two old houses are occupied together, with a common and central entrance. Married couples and single women are accommodated. The building consists of ground and two upper floors. There are two w.c.'s in yard, with a wooden partition separating them ; also a lavatory with four fixed basins for common use. The common kitchen and deputy's quarters are situated on ground floor. The houses are included in one of the Council's " Improvement schemes " and will soon be closed. 6 doubles, 15 singles (women); Is. double, 6d. single. Islington 1.—This consists of basement, ground and two upper floors, and is occupied by women only. The lavatory is situated in the basement, and consists of a zinc trough with four loose basins. There are two w.c.'s, one on the ground and one on the first floor, both internal, but well lighted and ventilated. The common kitchen is on the ground floor. 38 women ; beds, 6d. and 8d. Islington 2.—These houses are occupied together and have a common entrance. They consist of ground, first and second floors. The common kitchen and deputy's quarters are on the ground floor. There are two w.c.'s, one in each yard. No proper provision is made for washing except that in some of the rooms, wash-basins are provided. Other lodgers who pay less have to wash at a sink in the washhouse, two loose basins being provided for this purpose. These houses are well maintained, though externally they have a neglected appearance, inasmuch as it has been deemed necessary to put up wire guards to protect the glass in windows. 30 women; beds, 6d., 8d. and 9d. Islington 3.—These houses, which may be described as Nos. 8 and 10, are occupied together and have a common entrance at No. 8. No. 10 is occupied by married couples and single women. There are two w.c.'s at the rear of this house for the use of women only. No. 8 contains " doubles " only. The ground floor of this is occupied as a common kitchen for married couples and single women. A lavatory, with four fixed basins for the women is situated in No. 8. The houses consist of ground, first and second floors. No. 8, 10 doubles. No. 10, 5 doubles, 14 women. Beds, double, Is.; single, 6d. Islington 4.—These houses (numbered 23 and 25) are let out as furnished rooms, except the first and second floor front rooms of each house, which are occupied in the case of No. 23 by married couples and women, and_ in No. 25 by women only. The ground floor front of No. 25 is the common kitchen, and the washhouse contains a good slate fitting with four fixed basins. The w.c.'s (one in each yard) are common to all the occupants of the houses. The houses consist of ground, first and second floors. Two doubles, 12 women. Beds, doubles Is., singles 6d. Islington 5.—This house contains furnished rooms, only one room being registered, this is occupied by women only. There is a common kitchen at rear of ground floor. There are two w.c.'s, both available for all the occupants of the house. Two loose basins form the only washing accommodation provided. Six women. Beds, 6d. Islington 6.—These three houses (numbered 35, 37 and 39) are occupied together and have a common entrance at No. 35. There is accommodation for married couples and women at No. 35, and for men only at No. 37 and No. 39. There is a kitchen in the common yard for use of the married couples and women, with a well-arranged lavatory containing three basins and washing trough for women only. There is also a kitchen for men with a similar fitting containing five basins for the use of the men only. In the women's yard are two w.c.'s for their use, and in the men's yard four. The houses contain ground, first and second floors, with an extended back addition. These houses are well maintained. 13 doubles, 6 single women, two w.c.'s, three basins for women. Beds, double, 9d., single, 6d. Stepney 1.—This consists of an old swimming-bath, and contains two large dormitories, one of which has galleries all round, and the other has been sub-divided 60 as to form a separate room for mothers with children. The washing accommodation consists of about 20 loose basins. There is a trough closet with nine seats, which has been condemned. Two small houses adjoining, known as the "Metropole" were formerly open for the reception of lodgers, but are now occupied by members of the stafl only. 276 beds for women and children. The watercloset and washing accommodation is being improved, and the premises, although not actually registered, are treated as registered for the purposes of this report. The charge per head is 2d. Stepney 2.—This consists of basement, ground, first, second and third floors, and is occupied by single women and married couples; the latter being accommodated on second and third floors. The lavatory is situated in the common yard at rear, and is open for use by men and women. There are 5 five wash-basins and two washing-troughs. In this yard are situated two w.c.'s for men and two for women ; these are separated by wooden screens. There are two kitchens ; one in basement and one on ground floor; they are occupied in common. The house is old and the w.c., lavatory and kitchen accommodation indifferent. 41 women, 29 couples. Beds, double Is., single, 6d. Stepney 3.—These houses are occupied together, having a common entrance and common w.c. and lavatory accommodation. The houses together contain 39 double beds and 69 beds for single women. The common kitchens are situated on ground floor. The lavatory is situated in the basement and consists of six wash-basins and four washing-troughs. The w.c.'s are situated in a common yard, and consist of four w.c.'s for men and four for women. The latter are enclosed with wooden partition. The building has three storeys above ground floor, and the double beds are situated on the first floor. The houses are very old, and the accommodation indifferent. 39 doubles, 69 single women, eight w.c.'s, six wash-basins, four wash-troughs Beds, double Is., single, 6d. Stepney 4.—These extremely old houses are occupied together having a common entranco. There is a basement under one, which, together with a portion of ground floor, is occupied as a kitchen common to lodgers of both sexes. The houses contain 26 double beds and 52 single beds for women. The lavatory is in the common yard, and consists of a waoden slab with five basins and one washing trough. In this yard are situated two w.c.'s for men and three for women, the latter being screened by a wooden partition. The keeper is about to reconstruct the lavatory fitting. There are two storeys above the groundfloor. 26 doubles, 52 single women; two w.c.'s for men, three w.c.'s for women ; five basins, one washing-trough. Beds, double Is., single, 5d. Stepney 5.—These premises consist of a front house with an extensive back addition. There is a common yard in rear in which are situated three w.c.'s for women and two for men. In this yard also is the lavatory fitting, consisting of six fixed basins for common use. The w.c.'s are properly separated and are newly constructed. The common kitchen is on the ground floor. There is accommodation for 37 married couples and five single women. The house is clean and well maintained and the accommodation generally above the average. 37 doubles, five single women; two w.c.'s for men, three w:c.'s for women ; six wash-basins. Bed, double 9d., single 5d. Stepney 6.—This house consists of basement, ground, first, second and third floors, and provides accommodation for 35 doubles and 45 single men. The cubicles for married couples are situated on two upper floors. The lavatories are situated in basement, and consist of a fitting with three basins in two separate rooms, so that proper separation in this respect is provided. The common kitchen is on the ground floor. The w.c.'s, three for men and three for women, are situated in the common yard at rear, and are not well arranged, nor is effectual separation secured. The house is very old. 35 doubles, 45 single men; six w.c.'s, six basins. Beds, double 9d., single 6d. Stepney 7.—These houses (numbered 28 and 29) consist of a ground, first, second and third floors, with a smaller building at rear of each house. The kitchen (common) is situated on the ground floor of the building at rear of No. 28. Access to these premises is by an archway out of the street and beneath the houses. The whole block contains 23 double beds. The lavatory is situated at rear of No. 29, and consists of three basins only. There are also three w.c.'s for common use, there being little separation. 23 doubles, three w.c.'s, three basins. Beds, double 9d. Stepney 8.—This is a substantial brick building with stone staircase leading to upper floors, there are three above the ground. The basement is occupied entirely for kitchen and lavatory purposes. This house, until quite recently, contained 55 double and four single beds for women. After a fatal assault committed on the premises the keeper abolished " doubles " and the house now contains 114 beds for women. There are seven wash-basins and two washing-troughs, and six w.c.'s for common use. The lavatory fitting is not good, otherwise the house is well maintained. 114 women, seven wash-basins, six w.c.'s. Beds, single 5d. Stepney 9.—These are three very old houses, consisting of ground and two upper floors. Two rooms on the ground floor are occupied as a common kitchen. There are three w.c.'s in small yard at rear, also five wash-basins and four washing-troughs. The remaining room on the ground floor is occupied as a dormitory. The accommodation is poor, but the premises are clean. The houses are quite worn out. Accommodation for single women only. 66 women, three w.c.'s, five wash-basins, four washing troughs. Beds, single 6d. Stepney 10.— This consists of ground floor with three floors above and accommodates married couples only. Two rooms at rear of ground floor are occupied as common kitchen. The w.c. and lavatory accommodation is situated in a small yard at the side of kitchen. These fittings and w.c.'s are separated by wooden partitions. 51 doubles, three w.c.'s for men, three w.c.'s for women ; three wash-basins for men, two wash-basins for women ; two troughs. Beds, double Is. Stepney 11.—This is a rescue home, and no payment is made by the lodgers. The room registered is situated on ground floor. The following accommodation is provided—1 w.c. and three washbasins in lavatory. 12 women. Southward 1.—This is one of a group of very old and worn-out houses occupied together. The single women and married couples occupy a small two-storey building in the yard. The single women occupy the ground floor, the couples that which is above. A very small, dark room on the ground floor of one of the houses is occupied as kitchen for these lodgers. For washing accommodation there are five loose basins in a cement fitting in the space leading out from this kitchen. There is a w.c. for women in the common yard, protected by a screen. The accommodation generally is of a low standard. One w.c. for men, one w.c. for women. Five basins for women, two basins for men. Double beds 8d., single beds 4d. Southward 2.-—This consists of basement, ground and three upper floors, and a small cottage in yard. Single men and single women are lodged here. The women occupy a large dormitory on fiist 6 floor, and the cottage at rear. The two upper floors and ground floor are occupied by men. The kitchen in basement is used in common by both sexes. The yard contains four w.c.'s, two for men and two for women ; those for women are provided with a screen (a recent erection). The washing accommodation for women is provided in ground floor of cottage at rear, and consists of a slate slab with four fixed basins. There are six basins in two cement fittings in front area for the use of male lodgers. This house is well maintained, but the mixture of sexes in the main building is objectionable. 38 single women, two w.c.'s for women, two for men, four basins for women, six for men (separate) beds, 6d. Southward 3.—This is a group of four cottages (numbered 95, 97, 99 and 101) with a large building at No. 99, occupied by women only. There are four w.c.'s in open yard, seven wash-basins in lavatory and four washing troughs. The common entrance is at No. 99. Here also is a large kitchen for use of all lodgers. These houses are well maintained and the accommodation is good. An objectionable feature is that the back addition has been connected with Nos. 101 and 103, so that the back rooms of front house ventilate through the dormitories of rear building. Beds 6d. 85 women. Southward, 4.—These two small cottages, numbered 13 and 14, were formerly occupied by eight doubles and six single women, but have been out of use for some time. The keeper, however, contemplates re-building the houses and using them for single women only. The plan for this has already been approved, and two additional beds allowed. There are two w.c.'s in yard and four wash-basins in a small lavatory. No. 13, eight doubles; No. 14, six singles (women); charge, 6d. Southwarh 5.—This house (numbered 12,) consists of ground floor and three floors above. The ground floor contains two kitchens, a small one for women and a larger one for men. A staircase in centre of room leads to upper floors, the first of which is occupied parti} by single women and partly by single men. The staircase is for common use, and rooms for both sexes lead off" the same landing. The keeper contemplates a change, which will restrict the use of this house to men only. The women use the w.c.'s and lavatories in yard of Nos. 13 and 14, referred to above. The accommodation for men is in yard of No. 12, and consists of four w.c.'s and six wash-basins in a cement fitting. The w.c. accommodation is good, but the lavatory needs improvement. The upper part of this house is well maintained, but the kitchens are not always kept in satisfactory condition. 36 women, four w.c.'s,. six basins ; bed, 6d. Southward 6.—This is a corner house with no open yard. It consists of basement, ground and three upper floors and is occupied by women only. The basement is used partly as kitchen, partly as lavatory; in the latter are also situated four w.c.'s, these are ventilated into the open air by means of a shaft. Their position is open to objection, but the house is well managed, and the nuisance is reduced to a minimum. The lighting of the kitchen has been greatly improved by the use of prism lights, and the ventilation has also been improved. A disconnecting lobby was recently provided between kitchen and w.c. apartment. In the lavatory there are six wash-basins and three washing-troughs. The upper part of the house is maintained in a very clean and wholesome condition. Bed 6d.^ 82 women. Southwark 7.—This old house was formerly occupied by men. It is now registered for 28: women. It consists of ground floor and two upper floors. The kitchen and private rooms are on ground floor. In the yard there are three w.c.'s, three fixed wash-basins and a bath. The house iswell maintained. 28 women, three w.c.'s, three basins, 1 bath. Bed 6d. Southwarh 8.—These two very old houses (numbered 7 and 8) are occupied together, and consist of ground and three upper floors. The common entrance is at No. 7. No. 8 contains 13 doubles. In a small yard there is a w.c. for the use of men only, and also a lavatory fitting with two fixed basins. This house communicates with No. 7 on the ground floor. No. 7—This house is occupied by single women only. The ground floor is a small room occupied as a common kitchen for lodgers in both houses. This room is about 2 ft. 6 in. below the street level. The upper roomscontain 21 beds. There are two w.c.'s in small yard for use of women, also four fixed basins (new provision). The houses are extremely old, staircases steep and narrow, but the general maintenance is good. No. 8—13 doubles, one w.c. for men, two basins for men. No. 7—21 beds (women), 2 w.c.'s (women), four basins (women). Doubles Is. 6d., singles 6d. Wandsworth 1.—This consists of a small cottage having ground and one floor above; it is occupied by married couples and contains one family room. There is one wash-basin in washhouse for common use, and one w.c. in yard. The accommodation provided is of a poor description. 8| doubles ; beds, lOd. double, 5d. single. Wandsworth 2.—These two cottages consist of ground and one floor above, and are occupied together. There is a common entrance. In one cottage there are men and married couples, and in the other women and married couples. The yard is common and contains two w.c.'s, one for men and one for women. No washing accommodation is provided beyond a couple of loose basins. The back rooms of each house are occupied as kitchens. The accommodation generally is of a poor description. 10 men, 8 women, 5 doubles ; beds, doubles, Is.; singles, 6d. Wandsworth 3—This house is a double one with central entrance, and consists of ground and two upper floors, with an extensive back addition, the upper rooms of which are approached from the back room of the main building. The premises are occupied by single men and married couples. The latter are housed in top floor of main building only. There is a common kitchen for married couples on ground floor of main building, and a kitchen for single men on the same floor of back addition. There is a lavatory in common use, but the keeper is about to provide proper separate accommodation. There are at present two w.c.'s for the common use of lodgers,, without separation, but the keeper is providing three additional w.c.'s, so that separate accommodation will soon be available. 63 men, 10 doubles. Beds, lOd. double. 7 Wandsworth 4.—These three cottages are occupied together. They consist of ground floor and one floor above. There is one common entrance. The first cottage is partly occupied by the keeper, and contains accommodation for " doubles," with one family room. At the rear is a lavatory with one basin for the use of women only. The second cottage is occupied by married couples and contains one family room, and has the common kitchen on ground floor (for vise of all the houses). At the rear is a w.c, for women only. The third cottage is occupied by men only. In the rear is a w.c. for men, and a lavatory with three fixed basins in good order. The houses are old, but fairly well maintained. 7 doubles (two children). Doubles, 8d. and Is. One basin (women), one w.c. (women); three basins (men), one w.c. (men). Battersea.—These three houses (numbered 53, 55 and 57) are occupied together, and consist of basement, ground and two upper floors. There is a common entrance. All the houses are occupied by married couples and single women. The kitchens consist of the dark basement rooms, and are not free from objection. The wash-basins, four in number, are situated at the rear of No. 57; these are for •common use. There is also a washhouse which contains four washing-tubs and one portable bath. In the yard of No. 55, there are two w.c.'s for the use of women only, and in a small yard at rear of No. 57 there are two w.c.'s reserved for men. These are effectually separated. The common arrangements generally are not good, but the dormitories are clean and well maintained. 37 women, 30 doubles. Beds, doubles, Is.; singles, 6d. 4 basins (common), 2 w.c.'s (women), 2 w.c.'s (men). Woolwich 1.—This house is one of two very old two- storied buildings (with attic). Report says they are about 200 years old. They are built of old ships' timbers and plaster. The ground floor ■contains a deputy's room and a kitchen which opens direct into the street. The kitchen is also used by the lodgers of an adjoining house used by men, so that it serves for 18 men, two married couples, one single woman. The first floor contains a front room registered for five, partitioned up into three cubicles, two of them with double beds, and one with a single bed usually occupied by a woman, and a two-bedded room for men at back. The attic is registered for three and occupied by men. 'There is no separate washing accommodation. In the scullery is a wooden stand with two loose basins and there is another loose basin in a stone sink. This is shared in common with the lodgers next door. There are two w.c.'s one for men and one for women. There is a good supply of tubs for clothes washing. The ceilings of the dormitories are very low, but the houses are kept clean; beds Is. for double and 6d. for single. Woolwich 2.—This house was originally a public-house, but losing its licence it was converted into a common lodging-house. The kitchen is on the ground floor and is used in common by all the lodgers. There is a large washhouse containing a slate slab with six fixed basins ; it is a very good fitting, but is used by both men and women. It is entered from a small yard containing a urinal and three w.c.s', one for women and two for men. There is a good supply of tubs, etc., for clothes washing. 44 single men, 8| doubles. Price of doubles. Is. Woolivich 3.—This is a five-storied building with a two-storied cottage in rear, with a paved yard containing w.c.'s, etc., between. There is an open area between the house and the street, providing access to the basement kitchen. This kitchen is used by all the lodgers (40 men, 10 married couples). The ground floor, consisting of two rooms, is occupied by the manager. The first floor, registered for 11, contains six cubicles, five with double beds and one with a single bed. The second floor, registered for 10, contains five doubles. There are two rooms on the attic floor, the front with four beds and the back with three; they are occupied by men. Each floor of the back house is registered for 16. and is occupied by men. The upper floor is reached by an external wooden staircase from yard. There is separate washing accommodation. The women use the washhouse, which contains a zinc-lined wooden slab, with three fixed basins. The men wash in a corner of the yard which has been roofed over, and contains a slate slab with four fixed basins. There are three w.c.'s, one with a lobby in front being reserved for women. Good supply of tubs, etc., for clothes washing. The price of a ■double bed is Is. Woolwich 4.—This consists of a five-storied front building and a two-storied cottage at rear of yard. An open area divides the house from the street and provides access to the basement kitchen. This is used by all the lodgers. The ground floor contains two rooms, the front used privately by the ■deputy, the back, registered for three, is occupied by single women. The first floor also contains two rooms. The front, registered for 7, is partitioned off into four cubicles, three with double beds, and one with a single bed. The back room is occupied by men and registered for four. Nine men sleep on the next floor, six in the front room, and three in the back. The attic floor is also occupied by men, five in the front and three in the rear. There are four rooms in the back house, two on each floor. The front room on the ground floor contains three cubicles, each with a double bed, the back is registered for nine and occupied by men. 17 men sleep on the upper floor, access to which is by a wooden staircase in the centre of the building. A portion of the yard has been roofed over and contains a brick and cement fitting with five basins. It is a very poor fitting and is used in common. There is no privacy, and very little protection from the weather. Of the three w.c.'s one is reserved for women. Baths, etc., are supplied for clothes washing. 46 single men, six married couples, four single women. Beds, Is.; 6d. is charged for single women's beds. Woolwich 5.—These two houses (numbered 21 and 21a) form an isolated brick building, originally the old casual ward. It consists of three storeys. There is a basement once used as a kitchen, but now containing sand and coke. The kitchens on the ground floor, one in each house, are used in common by all the lodgers of both houses. Access is obtained through No. 21a, and then through the common yard into No. 21. There is an entrance direct into No. 21 from forecourt, but this door is rarely opened, except in the very hot weather, and then principally for the purpose of ventilation. There is no communication except through the yard. The ground floor of No. 21a contains the kitchen, the room in the rear, although registered for three, is occupied privately by the 8 deputy. The first floor contains five cubicles, each with a double bed. The top floor is registered for 12, and is occupied by single women. The ground floor of No. 21 contains the kitchen and a room in the rear occupied by women and registered for three. The first floor is registered for nine, and contains four cubicles, each with a double bed. The upper floor, registered for eight, is occupied by men. The washing accommodation is separate; that for the women is enclosed, and contains a slate slab with three fixed basins. That for the men is merely roofed over and comprises a slate slab with three fixed basins. There is a good supply of baths, etc., with copper for clothes washing. There are three w.c.'s, one is reserved for women. Eight single men, 15 single women, nine married couples. Beds, doubles Is.; singles 6d. Woolwich 6.—These are two three-storied houses (numbered 50 and 51) with basements. The houses come flush up to the pavement, and two or three steps lead up to the entrance on ground floor. No. 50 was the second house registered under the Common Lodging-houses Acts, and is the oldest registered house in London. The front basements are used as store and washing rooms. The back basements are on the yard level and are used as kitchens. There is no communication between these houses except through the common yard. The ground floor of No. 50 contains two rooms, the front is occupied by a double bed and the back is partitioned off into two cubicles, each with a double bed. The next floor contains four cubicles (a double bed in each), two in the front room and two in the back. There is a double bed in each of the two attics. In No. 51 there are four cubicles on the ground floor, two in the front room and two in the back. The next floor is similarly occupied, and there is a double bed in each of the two attics. The washing accommodation is separate and enclosed, three basins for men and two for women, there is also a loose basin in a stone sink for the use of women. There are separate w.c.'s for men and women. A fair supply of baths, etc., with a copper for clothes washing. 19 married couples. Beds Is. Woolwich 7.—A three-storied building (numbered 56 and 56a). Access through adjoining house, No. 56a, into a common yard, and then through a washhouse into the kitchen. No. 56a is registered for men. The ground floor of 56 contains the kitchen and a front room, divided into two cubicles, each with a double bed. On the first floor are two rooms, a double bed in the back room, and two cubicles, each with a double bed in the front. The front room on the top floor contains two cubicles, one with a double bed and one with a single. There is a double bed in the back room. There is separate washing accommodation, the women wash in the scullery, which contains a slate slab with two fixed basins. The married men have to pass through, however, on their way to and from the yard and kitchen. The single men in No. 56a, and the married men of this house have a washhouse in the yard to themselves. There is a separate w.c. for use by the women. The men have a w.c. and a urinal in a small yard adjoining the single men's kitchen. Copper, baths, etc., for clothes washing. 18 single men in 56a, and 7 married couples in 56. Double btds Is. Woolwich 8.—This is a very old house (numbered 63 and 64). Access can only be obtained through the kitchen of No. 64 (which accommodates men only). Both kitchens open out to a common yard. The basement is used for storing sand. On the ground floor is the kitchen, it has been built out from the house and is lighted by a skylight. On the same floor are two small rooms, the back with a double bed, the front divided into two cubicles, each with a double bed. On the first floor there is accommodation in the front for two doubles, and in the back for a family. The attic is registered for three, but only contains a double bed. A portion of the yard has been roofed over and enclosed. It contains a slate slab with three fixed basins, it is used in common with the men of adjoining house (20 men). There is separate w.c. accommodation. Baths, etc., are provided for clothes washing. 20 men in No. 64, and 7 married couples in No. 63. Double beds, Is. Woolwich 9.—Two very old three-storied cottages (numbered 76 and 77). The entrance is through No. 77. Both houses open into a common yard; there is no communication except through this yard. The basement once used as a kitchen, now only contains sand and coke. The present kitchen, a one-storied building, is built in the yard. It is used by the occupants of both houses. There are two rooms on the ground floor of No. 76. The front is registered for 2 adults and a child and contains a double bed. There is a double bed in the back room. On the next floor the front room has been partitioned off into three cubicles, two with double beds and one for a single woman. The room in the rear contains two cubicles each with a double bed. The room on the top floor contains three cubicles, two with double beds and one with a single bed usually occupied by a woman. The ground floor of No. 77 consists of a front room for four single women, and a back room occupied by the deputy. On the next floor the room in the front registered for five, contains three cubicles, two with double beds and one with a single bed. There are three women in the back room. The room on second floor contains three cubicles, two with double beds and one with a single bed for a woman. The women wash in loose basins in a sink in the scullery attached to the kitchen. The men use a washhouse in the yard containing three loose basins. Two w.c.'s one for men and one for women. 11 single women and 12 double beds, 6d. for single; married couples Is. Woolwich 10.—Two very old three-storied houses (numbered 81 and 82); the first floor of No. 81 is situated over the bar of public-house adjoining. They form one house, with one entrance, one kitchen, and one yard. There is a basement in which coke and sand is stored. The ground floor contains the kitchen, used by 12 women and 12 men. There is a room in front occupied by five women, and a small room ofl the entrance passage occupied by the deputy. On the first floor there is a room occupied by seven women, and three rooms, registered for 12 but containing 11 beds, with men. The two attics are not now in U6e, once they each had a double bed. A portion of the yard has been roofed over, but not enclosed, and is used as a washhouse, the basins for the two sexes being separated by a partition. There are two w.c.'s, one for men and one for women, and a good supply of baths, etc., for clothes washing. 12 single men and 12 single women. Beds 6d. 9 Particulars of Unregistered Lodging-houses for Women. Newport Market Refuge, Coburg-row, Westminster. This is a free refuge and has accommodation for about 23 women. The lavatory is situate in building in the yard and is solely for the use of the women ; it contains two bath-rooms, five fixed wash-basins, five wash-troughs and four w.c.'s, also a disinfector for verminous clothes. The lavatory is approached from doimitory which contains 23 hammocks. There is no day-room. The women are not admitted until 5 p.m. " Emily Harris Home," 60, Frith-street, Soho, Westminster. This is a home for 24 working girls who pay 8s. per week for food and lodgings. The building consists of basement with ground floor and three upper floors. The day room and two bath rooms are situate in basement. The ground floor is used privately, the rooms on upper floors are used as dormitories and contain two to five beds each. A wash-stand is provided for each bed, and there are two wash troughs for clothes on third floor landing. There are two water-closets, one on first floor landing and another on ground floor which also contains wash-stand. The room in ground floor back addition is used as a dining-room. Fields-lane Refuge, Vine-street, Holborn. This refuge has accommodation for 30 women, beds and food are free. The beds are in two common dormitories containing 13 and 17 respectively. There is no day-room, but women are allowed to take their food and sit, before going to bed, at tables placed in the dormitories, the beds being rolled up during the day. The lavatory is situate in basement and contains two baths, three fixed wash-basins, three loose basins and washing troughs. There are four w.c.'s in yard, all of which are for the use of the women. Dr. Barnardo's free shelter for women and children, No. 12, St. John's-place, Kensington. This is a free shelter for destitute women and children. The house consists of basement, ground and two upper floors. Fixed bunks are provided which accommodate a mother and child. There are five w.c.'s on the first floor and three on the ground floor. The basement contains a kitchen which is well lighted and ventilated, a lavatory with five fixed basins, two fixed baths and a laundry. The premises generally are well maintained Shaftesbury Institute (Union and Harrow streets'), St. Marylebone. This consists of three old houses communicating on ground and some of the upper floors, and having basement, ground and two upper floors. It is occupied partly as a night shelter for women, and has also a number of 6d. beds for women. Some of the upper rooms are used as a creche. There are three w.c.'s in basement for use of lodgers, and two others in upper part of the house for private use. For washing purposes there are 11 loose basins and a bath in basement. The lodgers paying 6d. have washing accommodation in their dormitories. No common kitchen is provided for lodgers, but food can be purchased in bar on ground floor. The houses are very old and badly arranged. 65 women, beds 6d., shelter 2d. (Sara Pylce House), No. 45, Great Prescott-street, Stepney. This is a new building consisting of basement, ground and three upper floors. The basement is occupied as a kitchen, and the ground floor is used privately. The upper floors contain dormitories with about 30 beds. There are five w.c.'s, two baths, and five fixed basins, and the smaller rooms have wash-stands. The house is open for the reception of females only, and is chiefly used by Jewesses, although others are admitted. Most of the lodgers are immigrants who are met at the ships by an agent of the home. They stay here for periods varying from one night to a month or more. The charge made is Is. per day for food and bed. The house is exceedingly well arranged and well kept. 30 women, three w.c.'s, two baths, five wash-basins. No, 27, Fournier-street (Spitalfields Church), Stepney. This rescue home only accommodates four persons at one time. No charge made. No. 12, Bock-street (Br. Barnardo's Home for Women), Stepney. This house is not now open for the reception of women, but will probably be re-opened next winter. No. 63, Brushfield-street (The Nest), Stepney. A girls' home, only working girls received here. Only sleeping accommodation provided, no meals taken on the premises. There are three dormitories with six beds in each. The girls pay Is. 3d. per week. There is a small room comfortably furnished in which the girls can sit and do a little sewing. No washing done on the premises. Each bedroom has a wash-stand with fittings. No. 81, Commercial-street (Br. Barnardo's free shelter), Stepney. The building is of the warehouse class, and consists of basement, ground and three upper floors. The basement is occupied as a kitchen, and the lavatories are situated here. The trough w.c. is situated in front area. The washing accommodation consists of four fixed basins in slate slab, and provided with hot and cold water. The ground floor is occupied privately by the manager. The three upper floors are used as dormitories. The lodgers sleep on iron bedsteads, but [ 2 ] 10 the accommodation is poor. Only women and children are admitted, and boys must be less than five years old. There are 82 single beds, average number of women would be about 40, whilst the usual number of occupants, including children, is about 50. No charge is made. The premises are well maintained. No. 91a, Whitechapel High-street, Stepney. A home for respectable working girls, fitted to accommodate 63 lodgers. At the present time 53 are staying here. The charge is 3s. 6d. per week, and strict inquiry is made into the respectability of every lodger. Some occupy cubicles, others small rooms containing three or four beds. There are eight w.c.'s, two on each landing, two bath-rooms, a washhand basin is provided for use of each person. Providence-row night shelter, Stepney. These premises are open for lodgers of both sexes and for children during the winter months only. No charge is made. The accommodation provided consists of fixed raised bunks, with leather aprons for covering. Separate washing and w.c. accommodation is provided in the basement, and the premises generally are well maintained. About 112 women and children are admitted. No. 1, Church-row, Limehouse, Stepney. This is a Roman Catholic home for women, in connection with a convent opposite. There are 85 women at present stopping here, no casual lodgers, and it is quite free. 85 women free. Sanitary districts. Number of registered premises. Number of groups of houses. Number of single women. Number of married couples. Number of groups of houses accommodating. Prices. "Women only. Married couples only. Women and married couples. Men and married couples. Men, women and married couples Men and women. Double bed. Single bed. Westminster 3 2 133 16 l ... l ... ... ... 1/- 5d. and Chelsea 1 1 42 l ... ... ... ... ... ... 6d. 6d. Holborn 14 5 334 5 ... ... ... ... ... ... 5d. and 6a. Hammersmith 5 1 7 8 ... ... ... ... l ... 8d. 4d. Paddington 2 2 46 15 1 1 ... ... ... 8d. 4d. and 6d. Kensington 19 12 278 92 2 1 4 l 4 ... 8d., lOd. and 1/- 4d., 5d. and 6d. St. Pancras 3 3 144 ... 3 ... ... ... ... ... ... 8d., 9d., and 1/- St. Marylebone 2 2 16 ... 2 ... ... ... ... ... ... 3/6 per week. Finsbury 1 1 15 6 ... ... 1 ... ... ... 1/- 6d. Islington 8 6 106 30 3 ... 2 ... 1 ... 9d. and 1/- 6d., 8d. and 9d. Stepney 20 11 635 240 4 2 4 l ... ... 9d. and 2d., 4d., V- 5d. and 6d. Southwark 13 8 307 27 3 ... 2 ... l 2 8d., 1/and 1/6 4d. and 6d. Wandsworth 6 4 8 30 ... 1 ... 2 l ... 8d., lOd. and 1/- 4d. and 6d. Battersea 3 1 37 30 ... 1 ... • •• ... 1/- 6d. Woolwich 15 10 43 80 ... "i 1 4 3 1 1/- 6d. Total 115 69 2,151 574 25 5 17 8 11 3 There are a few beds reserved for ch ildren Figures relating to unregistered premises are not included in this table, except Salvation Army shelter for women. 11 Women in Common Lodging-houses. Situation. Lodgers. Entrance. Kitchens. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single. Westminster 1 ... 52 16 common. basement, ground floor. women, married couples. basement for women. ground floor for married couples. no proper separation. 1/- 6d. Westminster 2 ... 81 ... women only. basement. women only. in vaults under yard. women only. ... 5d. Chelsea ... 42 ... do. do. do. in basement. do. ... 6d. Holborn 1 ... 34 ... do. do. do. do. (good fitting) in yard. do. fr ee. Holborn 2 ... 92 ... do. basement and ground floor. do. do. ... 5d. Holborn 3 ... 78 ... do. basement. do. women only. do. ... 6d. Holborn 4 ... 107 ... do. ground. do. do. do. ... 5d. Holborn 5 ... 23 ... women only. basement. women only. women only, fair. women only. ... 6d. Hammersmith 33 7 8 common, used by men, women, married couples. ground floor. common to men, women, married couples. separate. separate, but in common yard. 8d. 4d. Paddington 1 ... 31 ... women only. basement, very dark. women only. washstands in dormitory. internal on landings. 3s. 6d. per week. Paddington 2 ... 15 15 common to women and married couples. basement. single women and married couples. no proper separation. no proper separation. 8d. 4d. or 6d. Kensington 1 31 ... 10 common to single men and married couples. ground floor. single men and married couples. do. do. 8d. 4d. 12 Situation. Lodgers. Entrance. Kitchens. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single. Kensington 2 9 32 10 common to single men, single women and married couples basement. men, women, married couples. fair, separate. no proper separation. 1/- 5d. or 6d. Kensington 3 ... ... 11 married couples only. do. married couples. do. do. 1/- 5d. or 6d. Kensington 4 ... 26 ... women only. do. women only. fair, women only. do. 1/- 5d. or 6d. Kensington 5 17 24 12 common to men, women, married couples. basement. men, women and married couples. good fitting, no proper separation. do. 1/- 5d. Kensington 6 20 27 11 do. half basement. women and married couples. proper separation. separation. 1/- 5d. Kensington 7 ... 11 8 common to women and married couples. basement. do. fair; no proper separation. no proper separation. lOd. 4d. Kensington 8 ... 14 4 do. ground floor. do. do. do. lOd. 4d. Kensington 9 43 7 11 common to men, women, married couples. basement. men, women and married couples. fair separation. separation. 1/- 5d. Kensington 10 ... 21 5 common to women and married couples. do. women and married couples. no proper separation. no proper separation. lOd. 5d. Kensington 11 ... 36 10 do. do. do. do. do. 10d. 5d. Kensington 12 ... 80 ... women only. do. women only. women only. women only. ... 5d. and 6d. St. Pancras 1 ... 36 ... do. do. do. do. do. ... 9d.&l/- St. Pancras 2 31 ... do. do. do. do. do. ... 8d. & 1 /- 13 Situation. Lodgers. Entrance. Kitchens. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single. St. Pancras 3 ... 77 ... women only. basement. women only. women only. women only. ... 8d. & y. St. Marylebone 1 ... 6 ... do. do. do. do. do. 3/6 per week. St. Marylebone 2 ... 10 ... do. do. do. do. do. 3/- per 6d. week. 6d. Finsbury ... 15 6 common, women and married couples. ground floor. women and married couples. no separation. no separation. / JT 1/- Islington 1 ... 38 ... women only. do. women. women only. women only. ... 6d. & 8d. Islington 2 ... 30 ... do. do. do. do. do. ... 6d., 8d. & 9d. 6d. Islington 3 ... 14 15 separate (women and married couples). ground floor. women and married couples. separate. separate. 1/- Islington 4 ... 12 2 common, women and married couples. ground floor. women and married couples. no separation. no separation. 1/- 6d. Islington 5 ... 6 ... common with tenants ot furnished rooms. ground floor. women only. no separation, scullery at rear. no separation. ... 6d. Jsl'ngton 6 68 6 13 common, men, women and married couples. do. women and married couples. separate. separate. 9d. 6d. Stepney 1 ... 276 ... women and children. none. women and children. poor fitting, women and children. poor fittings, women and children. ... 2d. Stepney 2 ... 41 29 common, women and married couples. ground floor and basement. women and married couples. common in yard. separate. 1/- 6d. Stepney 3 ... 69 39 do. ground floor. do. common in basement. separate. 1/- 6d. Stepney 4 ... 52 26 do. ground floor and basement. do. no separation. separate. 1/- 5d. 14 Situation. Lodgers. Entrance. Kitchen. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single Stepney 5 ... 5 37 common, women and married couples. ground floor. women and married couples. no separation. separate. 9d. 5d. Stepnev 6 45 ... 35 common to men and married couples. do. men and married couples. separate (poor) no proper separation (partitioned off). 9d. 4d. Stepney 7 Stepney 8 ... 114 23 used by married couples only, women only. do. basement. married couples, women. no separation (poor), women only (poor). no separation, separate. 9d. 5d. Stepney 9 ... 66 ... women only. ground floor. women. women only (good). separate. ... 6d. Stepney 10 ... ... 51 married couples only. ground floor. married couples. separate (fair). separate. 1/- Stepney 11 ... 12 ... Rescue Home, women only. ... ... ... fr ee. Southwark 1 41 11 6 common to men, women, married couples. ground floor (dark). women and married couples. no proper separation, very poor indeed. no proper separation. 8d. 4d. Southwark 2 80 38 ... common to men and women. basement. men and women. separate. no proper separation. ... 6d. Southwark 3 ... 85 ... women only. ground floor. women. women only (fair). women only. ... 6d. Southwark 4 ... 6 8 out of use at the present time; proposal to rebuild as women's house. ... 1/- 6d. Southwark 5 40 36 ... common, men and women. ground floor, do. men only, women only. separate (fair). separate. ... 6d. Southwark 6 ... 82 ... women only. basement. women. women only. women only. ... 6d. Southwark 7 ... 28 ... do. ground floor. women only. do. do. ... 6d. Southwark 8 ... 21 13 common, women and married couples. do. women and married couples. separate. separate. 1/6 6d. 15 Situation. Lodgers. Entrance. Kitchen. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single. Wandsworth 1 ... ... 8½ married con pies only. ground floor. married couples. no proper separation. no separation. lOd. ... Wandsworth 2 10 8 5 common, men, women and married couples. do. men, women and married couples. no separation. no separation. 1/- 6d. Wandsworth 3 63 ... 10 common, men and married couples. do. men and married couples. do. do. lOd. ... Wandsworth 4 14 ... 7 men and married couples. do. married couples. separate. separate. 8d., 1 /- 4d. Battersea ... 37 30 common to women and married couples. basement (dark). women and married couples. no separation. do. 1/- 6d. Woolwich 1 18 1 2 common, men, women and married couples. ground. men, women and married couples. do. no proper separation. 1/- 6d. Woolwich 2 44 ... 8½ common, men and married couples. do. men and married couples. do. do. 1/- 6d. Woolwich 3 39 ... 10½ do. basement. do. separate. separate. 1/- 6d. Woolwich 4 46 4 6 common, men, women and married couples. do. men, women and married couples. no separation. no proper separation. 1/- 6d. Woolwich 5 8 15 9 common, men, women and married couples. ground floor. men, women and married couples. separate. no proper separation. 1/- 6d. Woolwich 6 ... ... 19 married couples only. Basement (yard level). married couples only do. separate. 1/- Woolwich 7 18 ... 7 through men's house at No. 56a. ground floor. do. do. do. 1/- 16 Situation. Lodgers. Entrance. Kitchen. Lavatory accommodation. W.c.'s. Price. M. W. M.C. Position. Used by Double. Single. Woolwich 8 20 ... 7 through men's kitchen at No. 64. ground floor. married couples only. no separation. no proper separation. 1/- Woolwich 9 ... 11 12 common, women and married couples. do. women and married couples. separate (poor). do. 1/- 6d. Woolwich 10 12 12 ... common, men and women. do. men and women. partial separation, no privacy, poor. do. ... 6d. Unregistered Houses. Westminster— Newport Market Refage, Coburg-row ... 23 ... Women only none. women. good (temporarily closed owing to smallpox) ... 60, Frith-street, Soho ... 24 ... do. basement and ground floor. do washstands in bedrooms (wor king girls only). 8/- for food and loder inc. Holborn— Field-lane. ... 30 ... do. none. do. good (bed and (food eaten in food free), dormitories) free. Kensington— 12, St. John's-place, Dr. Barnado ... 46 ... do. basement. do. good. ... free. Marylebone— Shaftesbury Institute, Union-street, Edgwareroad ... 65 ... do. ground floor. do. 6d. lodgers wash in washliand stands in dormitories. 2d. lodgers wash in loose basins in the basement. beds, 6d. shelter, 2d. 17 Situation. Lodgers. Entrance. Kitchens. Lavatory W.c.'s. Price. M. W. M.C. Position. Used by accommodation. Double. Single. Stepney— 45, Great Prescott-street ... 30 ... women only. basement. women only. good. ... Is. per day, food and bed. 27, Fournier-street ... 4 ... Rescue Home for Girls. ... ... ... free. 12, Dock-street ... 58 ... at present closed, open next wi nter. ... ... free. (Dr. Barnardo) 63, Brushfield-street ... 18 ... Girls' Home, no food on premises. ... ... ... Is. 3d. per week. 81, Commercial-street ... 82 ... women and • • • • • • good. ... free. (Dr. Barnardo) 91a, Whitechapel High- ... 63 ... children. Home for Working Girls (references required). ... ... 3s. 6d. per week. Providence - row night shelter Men 112 (women childr and en) separate. none. ... ... ... free. 1, Church-row, Limehouse ... 85 ... no casual lodgers (Roman Catholic Home). ... ... free. London Country Council. THE SANITARY ADMINISTRATION OF HAMMERSMITH. Report by the Medical Officer presenting report by Dr. Young on the sanitary administration of Hammersmith. (Ordered, by the Public Health Committee to be printed, 24th April, 1902.) Public Health Department, 8, St. Martin's-place, W.C. 27th June, 1902. I present Dr. Young's report on the sanitary administration of Hammersmith. It will be recollected that the sufficiency of the staff of sanitary inspectors in that district was, as the result of a report by the Medical Officer of Health of Hammersmith, under the consideration of the Public Health Committee of the London County Council towards the close of the period when the administration of Hammersmith was vested in the former vestry. In May, 1900, in reply to a communication addressed to the vestry, the County Council was informed by that body that the matter had been considered by a committee of the vestry, and that it had been decided to take no action at the time in view of the impending change in the Authority, consequent upon the passing of the London Government Act of 1899. In 1901 the Borough Council increased the staff by the appointment of an additional inspector; later, the medical officer of health recommended the appointment of another inspector. This was not agreed to, and the report of the Committee dealing with the subject, making recommendations as to the division of the district into six sub-districts, was referred back for further consideration. In January of the present year the County Council, as the result of information obtained concerning the extent of regulation of houses let in lodgings in the several metropolitan boroughs, wrote to the Borough Council asking that facilities might be given to Dr. Young to inquire on their behalf into the sufficiency of the staff. When Dr. Young began his inquiry he found that the appointment of an additional inspector had been decided on, and this officer took up his duties while Dr. Young was thus engaged. Hence, since the attention of the County Council was directed to the subject two additional inspectors have been appointed. There had, however, in the meantime been transferred to the Borough Council the administration of regulations as to milk premises and offensive trades previously vested in the County Council. Dr. Young„ as the result of his inquiry, thinks there would be advantage in giving effect to the recommendation of the Public Health Committee of the Borough Council as to the division of Hammersmith into six sub-districts, and allotting an inspector to each. He also thinks that the work in connection with the regulation of houses let in lodgings should, at any rate for some time, be undertaken by two other inspectors acting for the whole borough. There is already a special inspector for workshops and outworkers, and Dr. Young thinks this service should be supplemented by the appointment of a female inspector. If these proposals be carried out, the only additional appointment would be the female inspector, but Dr. Young recommends that the service of an officer now employed largely in superintending the removal of house refuse should be wholly devoted to the work which more usually devolves on a sanitary inspector, and this would still further increase the staff available for this purpose. These recommendations appear to me to be deserving of adoption. Shieley F. Muephy, Medical Officer of Health. printed 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. 614. Price 3d., or post free, 3£d. [2883 2 Report by Dr. Young. Situation and description of district.—Hammersmith is the extreme western district of the county of London on the north side of the river Thames. In shape it is a long narrow district, extending from the county boundary near Willesden-junction on the north to the river opposite Barnes on the south. Its length from north to south is three miles, whilst its greatest width from east to west is nearly one mile and three-quarters. The boundaries of the district are—on the north and west the county of Middlesex, on the south the river Thames (on the opposite shore of which is Barnes) and the district of Fulham, and on the east the district of Kensington. Under the provisions of the London Government Act, 1899, changes in the boundaries of sanitary districts occurred. In the case of Hammersmith, these changes are so slight, that, so far as the alteration in the area or the population of the district is concerned, they may be disregarded. The changes which took place were slight rectifications of the boundary line between Hammersmith and Fulham and Hammersmith and Kensington, so that where the dividing line previously passed through houses or premises, it now is carried along the centre of the roadway. The effect of the alteration has been as follows— Transferred from Hammersmith. Population, 1901. Transferred to Hammersmith. Population, 1901. To Fulham 519 To Kensington1,040 From Fulham 472 From Kensington 1,356 The surface of the district has a gradual fall from the northern part to the river, the highest point, namely, 129 feet above ordnance level, being at the north end of Scrubs-lane, near Willesden-junction, and the lowest, namely, 14 feet above the same level, being on the Lower Mall. The superficial soil consists of sand and gravel at the southern or river portion, of brick earth in the centre, and of clay at the extreme northern part of the district. These overlie the London Clay. The area of the district under the jurisdiction of the borough council corresponds with the area of the civil parish of Hammersmith. An imaginary line drawn from east to west a little north of and practically parallel to the line of the main Uxbridge-road which traverses the district, divides it into two distinct parts. The area to the north of this line is practically all open land, except for a narrow strip along the eastern boundary, adjoining Kensington, and for a small area at the extreme north which are occupied by houses. This land consists of 215 acres of open space known as Wormwood-scrubs and Little Wormwood-scrubs, and of fields belonging to private owners and not yet built on. Brickmaking is carried on in one part of this land. The area to the south of this imaginary line is almost entirely occupied by houses, except as regards a small area as yet not built on, on the extreme western boundary. In this southern portion, however, the following are maintained as open spaces for the use of the public, and cannot, therefore, be built on, viz.—Ravenscourt-park, containing 31| acres; Shepherd's Bush-green, 8 acres; Brook-green, 4f acres ; and Wendell-park, 4 acres. The erection of new buildings at the present time is practically limited to the unoccupied land in the west part of the district, and to the erection of flats in place of old houses which have been pulled down. In the last annual report of the borough council, it is stated that under Part iii. of the Housing of the Working Classes Act, which had been adopted in March, 1901, the Council had given instructions for the erection on land belonging to them and adjoining their electric lighting station in Fulham Palace-road, of three double buildings containing twenty-four tenements, some of three and some of four rooms, for the accommodation of persons of the working class. The London County Council has also resolved, recently, to acquire from the Ecclesiastical Commissioners under Part iii. of the Act, about 50 acres of land near Old Oak-common-lane, and adjoining the south-west part of Wormwood-scrubs, for the erection of cottages for the working classes. This scheme will provide for the accommodation of some 9,000 persons. The recent construction and opening of the Central London Railway, which forms a cheap and rapid means of transit between the northern part of. Hammersmith and other parts of London, will tend to cause the erection of other houses on the land at present vacant and available for building near Wormwood-scrubs. It may also have the effect of changing the class of population resident in this part of the district, and many houses now occupied by single families may become occupied by more than one family. These changes would tend to cause increase in the population. The rateable value of Hammersmith for the year 1901 was £684,059. Under the Equalisation of Rates Act, 1894, the sanitary authority received a grant from the equalisation fund of £6,822 18s. 8d. for the twelve months, March, 1900-1901. Population and vital statistics.—The sanitary district of Hammersmith is, for statistical purposes, part of the registration district of Fulham which also includes the sanitary district of Fulham. The district of Hammersmith corresponds with the registration sub-districts of north and south Hammersmith. The total area of the district is 2,286-3 acres, 30-1 acres of which are tidal water and foreshore, while the remainder is land and inland water. The population at the census of 1901 was 112,239, or an average of 49 persons per acre. In London, as a whole, the average was 55. 3 The following table sets out the population and number of inhabited houses at each census since 1851— Year. Inhabited houses. Decennial increase per cent. Population. Decennial increase per oent. Average number of persons to each inhabited house. Males. Females. Persons. 1851 3,115 7,819 9,941 17,760 5.7 1861 4,164 34 10,770 13,749 24,519 38 5'.9 1871 6,719 61 19,304 23,387 42,691 74 6.4 1881 10,543 57 32,743 39,173 71,916 68 6.8 1891 14,049 33 44,195 53,044 97,239 35 6.9 1896 14,538 104,199 1901 15,198 8 52,714 59,525 112,239 15 7.4 According to the above figures the number of inhabited houses and the population have markedly increased since 1851; the largest rate of increase taking place chiefly between 1861 and 1881. During the period 1S81.91, the rate of increase, both as regards houses and persons, diminished considerably, and during the last decennium, the rate of increase diminished still further. During the period from 1851, the average number of persons to each inhabited house has been slowly increasing. The figures of the last census give an average of 7'4 persons to each house. In London in 1901, the corresponding number was 7'9. In the census reports for 1891 and 1901, details are given of the population living in each class of tenement containing less than five rooms per tenement, and tenements are described as being' overcrowded when the number of occupants is greater than two persons per room. The following table gives for 1891 and 19U1, the percentage ot the population living in tenements of one to four rooms, and in which the number of occupants exceeds two persons per room— Tenements with Hammersmith. London. Kensington. Fulham. Paddington. 1891. 1901. 1891. 1901. 1891. 1901. 1891. 1901. 1891. 1901. 1 room 2.53 1.78 5.10 3.26 4.31 2.91 2.48 1.26 3.93 2.57 2 rooms 4.97 4.60 7'84 6.54 8.14 7.43 4.58 2.97 8.14 6.53 3 „ 4.12 3.38 4.57 4.14 3.47 3.39 5.37 4.16 3.56 3.26 4 1.82 2.00 219 2.07 1.30 1.11 2.08 2.46 1.18 1.21 It will be seen that there has been in Hammersmith a diminution in the percentage of the population living under a condition of overcrowding in one, two and three room tenements and a slight increase in the case of four.room tenements. In London, where the proportion of the population overcrowded is greater at both periods than in Hammersmith, a similar change has also taken place, except as regards the four.room tenements in which the overcrowding was slightly less at the last census. The figures for the adjoining districts are also given. The population of Hammersmith is made up of persons engaged in commercial occupations, many of whom, no doubt, reside in the district owing to its accessibility to the central parts of London, of persons engaged in professional occupations and their subordinate services, of shopkeepers, and of persons of the working class. In the census report of 1901, tables are given as to the occupations of the population in each sanitary district of London. From the table relating to Hammersmith, so far as it is possible to make out, it appears that rather more than half the total number of males of 10 years of age and upwards, and who are occupied, may be included as artisans or persons of the working class. This table also gives particulars as to the number of females, of the same age as above, who are engaged in occupations. About one.third of the total number of 10 years of age and upwards is so engaged, namely, 16,328 out of a total of 47,958 females. About one.fourth of these is classified under the heading domestic indoor servants, while about another fourth is stated to be engaged in work connected with the making of articles of dress and in laundry work. The remainder is engaged in various occupations. Indication as to the character of the population of a district may be obtained from the number of domestic servants employed. A table in the census report gives the proportion per cent, of domestic indoor servants to the number of families or separate occupiers in London as a whole and in each of the different sanitary districts. In Hammersmith the proportion is 19.3, whilst for London generally it is 24.5, the range being from 5.7 in Shoreditch to 81.4 in Hamp. stead. In ^he districts of Fulham and Kensington, which adjoin Hammersmith, the proportions are 18.6 and 80.0 per cent, respectively. The proportions in Kensington and Hampstead are considerably in excess of those in other districts of London, the next highest being 65.8 per cent, in the case of Westminster and 55'2 per cent, in Chelsea. 4 At the last census the population of Hammersmith consisted of male persons in the proportion of 46'95 per cent., and female persons 53.03 per cent. The age and sex distribution of the population in Hammersmith and in the county of London is as follows— 0— 5— 10— 15— 20— 25— 35— 45— 55— 65— [75 &, up. Hammersmith M F London M F 5.41 5.3S 5.46 5.46 4.88 493 4.86 4.90 4.42 4.82 4.58 4.67 4.28 5.10 4.61 5.13 4.93 5.38 4.79 5.74 8.32 9.43 8.19 9.65 6.25 6.94 6.19 6.84 4.30 4.98 4.30 4.81 2.68 3.37 2.62 3.11 1.13 1.80 1.21 1.72 0.37 0.90 0.41 0.75 In Hammersmith the proportion of males in the working period of life is greater than in London and the proportion of females greater at 35 years of age and upwards. The birth.rate in Hammersmith during recent years and in London generally has been as follows— Tear. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. Hammersmith, per 1,000 living persons 29.5 29.6 28.6 28.3 28.3 29.7 28.2 28.1 27.1 London, per 1,000 living persons 30.9 31.0 30.1 30.6 30.2 30.1 29.7 29.7 29.1 The birth rate in Hammersmith has therefore been lower than in London. In the following table are the rates per 1,000 persons living of deaths from all causes, and from the principal zymotic diseases (namely, smallpox, measles, scarlet fever, diphtheria, typhus, enteric and ill.defined fevers, diarrhoea), and the infantile death.rate per 1,000 births. For comparative purposes the corresponding rates for London as a whole, and for the two adjoining districts of Kensington and Fulham, are also given— General death rate per 1,000 living.* Zymotic death rate per 1,000 living. Deaths under 1 year of age per 1,000 births. 1890.9 1900 1890.9 1900 1890.9 1900 Hammersmith 19.5 18.1 2.66 2.23 1.69 162 London 20.7 19.8 2.72 2.23 1.59 158 Kensington18.7 17.4 1.99 1.66 1.72 180 Fulham 19.9 18.6 3.39 2.91 1.72 147 * These rates are corrected for age and sex distribution. The death rate from all causes and the zymotic death rate has been lower in Hammersmith than in London, but the infantile mortality greater. Condition of houses.—The houses in Hammersmith are for the most part two storeys high. Some of them have half.basement floors, but a large number contain only 'ground and first floor rooms. In the main thoroughfares and here and there in other streets three storey premises exist. In some parts are to be seen houses of greater age than the majority of houses in the district. These are of the cottage type, and were evidently in existence at the time when the district was semi.rural in character. They are chiefly to be found in the southern or river portion of Hammersmith. Within recent years some big block buildings have been erected for flats, and on the east side of Fulham Palace.road an extensive group of artisans' dwellings has lately been constructed by the Guinness Trust. A large building known as Rowton House, for the use of men, and capable of accommodating some eight hundred persons, has also been erected in Hammersmith.road, near to its junction with the Broadway. The houses generally are situated in streets of a width ample for affording sufficient space for purposes of light and ventilation, and are provided at the rear with adequate yard space. The existence of back.to.back houses or of houses without rear yard space is exceptional. Of the former there are four separate groups containing in all eight cottages in St. Ann's.road, and a group of four cottages in Rose and Crown.lane, a narrow footway on the south side of Hammersmith.road. Of the latter, there are a few instances, namely, Vine.cottages, Simpson's.cot. tages, Albert.place, and some houses in Aspen.place. These premises, however, have ample open space in front. There are not, in my opinion, in the district at the present time any well.marked groups of houses, courts, and alleys, in which, owing to the narrowness, closeness and bad arrangement or bad condition of the streets and houses or groups of houses, or the want of light, air, ventilation and proper conveniences, the conditions are such as call for action under the Housing of the Working Classes Act. During the course of my inspection of the district I visited 526 inhabited houses, and regarding these, I made note of the existence of the following defective conditions :—Rooms, passages or staircases in need of cleansing in 86 instances, dilapidations of plastering, floors, 5 or brickwork in 17 instances, foul or defective watercloset pans 21 instances, inadequate or defective paving of yards 24 instances, dampness of walls 47 instances, unpaved and undrained forecourts or front gardens 35 instances, defective stack pipes or guttering 12 instances, yards in a dirty condition, or animals so kept as to be a nuisance 21 instances, defective or inadequately-covered ash bins 45 instances, inadequately-covered water cisterns 12 instances, defective flushing apparatus 14 instances, and overcrowding in 25 instances. It is noticeable that the list of defects, with the exception of the dampnebs of walls, consists mainly of conditions of a kind which are likely to recur in property of the poorer class. The presence of dampness is, I think, chiefly attributable to the fact that the houses in which it is found are old, and are probably not provided with a damp course ; but it is often most noticeable in the wall of the ground floor front room of houses, and there is little doubt that the condition is in part due to the want of paving and draining of the narrow strip of forecourt so often found between the front wall of the house and the railings separating it from the pavement. These small pieces of ground, originally, no doubt, intended to serve for plants, are generally neglected, and the paving of them with a fall towards the roadway, together with the provision of an air brick in the house wall below the floor level, would doubtless tend to ameliorate the condition of dampness. Waste pipes from sinks, and drain inlets within houses generally discharge above ground outside the house so as to afford aerial disconnection, and drain inlets outside the house are usually provided with properly trapped gullies. As regards soil pipes, means of ventilation exist, but in several instances it was observed that this was effected by means of a rain-water pipe, or by a galvanised iron pipe of smaller diameter than the soil pipe. These instances, however, occurred in houses where the drains had been constructed some years ago and previous to the date when the by-laws regulating their method of construction came into force. On three occasions, however, I observed that alterations or repairs had been made recently in connection with drains, which were not in compliance with the by-laws, the work in each case had been carried out without the knowledge of the sanitary authority. In premises where the drains are of old construction there is generally wanting either an air inlet or an intercepting chamber. Houses let in lodgings or occupied by members of more than one family.—The number of premises of this class which had been placed on the register by the sanitary authority up to March, 1902, was 1,088. This total has been obtained since October, 1896, when the register was first commenced, and is the result chiefly of information obtained by the sanitary inspector engaged in the work of systematic house to house inspection of all inhabited houses in the district. This systematic house to house inspection, which has now been once completed for the whole district, had already, in October, 1896, been in force for some time, and part of the district had already been visited, but previous to this date no special action was taken by the sanitary authority as to registering houses let in lodgings, and note was not made of them with a view to their registration. Consequently, the number given above is not regarded as representing the total number of houses which are registrable under the by-laws in force in Hammersmith. These by-laws,which were approved by the Local Government Board in 1896 in place of regulations previously in force, contain a clause exempting from their operation houses occupied by members of more than one family, but in which the rent paid by the lodgers is above certain limits. Thus houses are exempt when the rent paid by the lodgers is 5s. a week or more in the case of unfurnished rooms, and 8s. a week or more for furnished rooms. Among the 526 houses which I visited during this inquiry, I made notes as regards 254 as being occupied by more than one family. Of these, in 192 houses the rents paid by the lodgers are within the limit, but in 62 the rents paid are such as to exempt the premises from registration. In practice, this rent limit does not appear to bring under regulation all premises for which the by-laws are more especially useful, whilst, on the other hand, certain houses which come within the operation of the by-laws and some of which are registered are not specially in need of the supervision intended. Thus, as regards houses which I visited and which come within the limit, I noted 22 instances in which the conditions were not such as needed supervision so far as the special requirements of the by-laws, namely, the maintenance of cleanliness and the prevention of overcrowding are concerned, whilst as regards houses let in lodgings, but exempt from registration, 20 premises were noted which appear to be of the type for which the by-laws are intended. Many of the latter are let in floors, and in several, I made note of conditions for dealing with which the by-laws would be of considerable advantage. Thus, if the list of defects set out earlier in the report be considered, so far as they relate to the two classes of houses let in lodgings, the following tabular statement may be made— Dirty rooms, passages or staircases in Overcrowding in Dirty condition of yards in Yard paving defective or inadequate in Foul or deftctive w.c.'s or defective flush apparatus in Defects of flooring, plaster, brickwork in Defective or inadequately covered ashbins in Houses occupied by more than one family and registrable under the by-laws (192 houses) 50 houses 15 houses 11 houses 23 houses 12 houses 10 houses 14 houses Houses occupied by more that one family but exempt from registration (62 houses) 14 houses 2 houses 4 houses 10 houses 8 houses 7 houses 8 houses 6 The above remarks refer chiefly to the case of unfurnished lodgings. The furnished tenement of the poorer class, with but a few exceptions, does not exist in the district. A result of the application of the by-laws in some cases has been that the rents which were slightly below the limit of exemption before, have been raised so as to avoid registration under the by-laws. Common lodging-houses.—There are nine houses registered as common lodging-houses, with accommodation for a total of 550 persons. Five of these houses are virtually one set of premises, consisting of five two-storey cottages, the yards of which have been converted into one single yard. These premises are registered for single men, single women and married couples. The remaining are all for single men. One of them has accommodation for 334 lodgers. At the time of my inspection in two instances the condition of the bedding was not satisfactory.* House refuse collection and disposal.—The collection of house refuse is carried out by men employed for this purpose by the sanitary authority. The work is done under the supervision of one of the sanitary inspectors, who also devotes part of his time to obtaining samples under the Food and Drugs Act, but the staff engaged in the collection forms part of the Surveyor's department. Ash-bins are cleared once a week, except in the case of institutions such as Wormwoodscrubs Prison and Nazareth House, at which collection is made more frequently. The carts when loaded convey the refuse to the wharf in Chancellors-road, whence it is removed by barges down the river Thames. TI ater supply.—Hammersmith is supplied by the West Middlesex Water Company and the Grand Junction Water Company, and a constant supply is provided throughout the district. Nearly all houses are supplied with storage cisterns—it is quite exceptional to find cases where they do not exist, and where the water is drawn direct from the main. The cisterns are mostly situated outside the premises, placed on the roof of back additions or of the external water closet. In some cases they are situated inside the house, and in some of these they are placed under the floor of rooms used either for living or more often for sleeping purposes. In such cases the cistern is immediately under the joists supporting the floor, and attempt has been made to comply with the requirement of the by-laws as to providing an adequate cover by placing pieces of boarding in the intervals between the joists. This position is an extremely objectionable one for a cistern containing drinking water, and is one which renders the risk of fouling of the water almost a matter of certainty when the floor is washed. The storage cisterns are in nearly all cases separated from water closets by means of separate flushing cisterns, but in a few instances I found that the supply for flushing the water closet was obtained direct from the drinking water cistern. Factories and workshops, including bakehouses.—The total number of industrial premises which have been visited and entered on the register is 1,188, including 63 bakehouse premises. In addition to this number, the addresses of 78 outworkers, which have been forwarded by other sanitary authorities or by the inspectors of the Home Office, have been placed in a register kept for this purpose, and the premises have been visited and kept under observation. A considerable proportion of the workplaces in this district are laundries, ranging from large factory laundries to small businesses carried on at private houses, where only three or four persons are employed. I visited throughout the district many of these workshop premises and found them generally in satisfactory condition. The bakehouses were also cleanly and well kept. Of these premises 40 are underground bakehouses. The above number of workshops is thought to comprise the bulk of such premises existing at the present time in the district, but the list of outworkers' addresses is being continually increased. During recent years a great number of workshops and factories have been erected rat land in the neighbourhood of Willesden-junction, and it is possible that others may be built in the future. If this should occur, the amount of work involved in looking after these premises by the sanitary authority will be much augmented. Slaughterhouses, cowsheds and offensive trades.—There are thirteen slaughterhouses and one cowshed in the district. These premises, at the time of visit, were found to be in compliance with the by-laws. The cowshed is not made use of to any extent, and when inspected only two cows were found there. There are two hundred and thirty-one registered milkshops and dairies. The only offensive trade carried on in the district is that of fat extraction. This is done at four premises on a small scale. They are situated in an open position in Old Oak-lane, adjoining Wormwood-scrubs on one side and fields in Acton on the other. At each set of premises there are also piggeries, and in at least one the piggery is within the prescribed distance of forty yards of a public way or open space, in contravention of the Act. All the premises are old, and are, I believe, held by weekly tenants. Disinfection—(a) For articles of clothing and bedding.—For this purpose a steam disinfecting apparatus (Goddard, Massey and Warner) has been provided in a building specially erected for the purpose at the wharf in Chancellors-road. This building contains two rooms, into each of which one door of the apparatus opens, this affording the only means of communication between them. The infected articles are placed in the apparatus in one room, and after the process is complete are removed from it into the other. Communicating with each room is a shed for the vans, one of which is reserved for bringing the infected articles, the other for returning them after disinfection. * In one of these cases the keeper has since been prosecuted and fined £5 10s. and costs, in the other a notice had at the time been served and the b ds hare since been disinfected and cleansed. 7 (b) For rooms.—Rooms are disinfected by sulphur fumigation for four to six hours. "When this period is over the room and windows are opened, the walls are washed down, and the floors sprinkled with a mixture of carbolic acid and water. A mixture of about a quarter of a pint of commercial carbolic acid to seven pints of water is used for this purpose. In connection with disinfection, two assistants are employed by the borough council. In the case of rooms the disinfection is done under the supervision of the district sanitary inspectors, who direct the men as to the amount of sulphur which should be used in each case. After a room disinfected, if it is in need of cleansing, the inspector serves a notice upon the landlord for this to be done. The process of disinfecting articles by steam is done by the two disinfecting assistants and one of the men employed at the wharf, who acts as engineer for the disinfecting apparatus. The assistants are provided with macintoshes, which they put on when handling infected articles, but which they take off when going to the non-infected room to remove from the apparatus articles after the process of disinfection is complete. A laundry in connection with the disinfecting station has not been provided. The sanitary authority have not provided' a shelter for the use of persons during the disinfection of their rooms. Mortuary accommodation.—A satisfactory mortuary has been provided in connection with, and at the rear of, a coroner's court in Fulham Palace-road. It contains two mortuary chambers, one for persons dying of infectious complaints and one for those dying from other diseases or as the result of accidents, on either side of a viewing lobby, from which they are separated by windows. There is also a post-mortem room with a small laboratory attached. There is a caretaker of the court and mortuary who resides on the premises. By-laws made by the sanitary authority.—The following by-laws have been made by the sanitary authority, namely— For the keeping of water-closeta supplied with sufficient water for their effective action under Section 39 (2) of the Public Health (London) Act, 1891. For the prevention of nuisances arising from any snow, ice, salt, dust, ashes, rubbish, offal, carrion, fish, or filth, or matter, or thing in any street. For preventing nuisances arising from any offensive matter running out of any manufactory, brewery, slaughter house, knacker's yard, butcher's or fishmonger's shop, or dunghill, into any uncovered place, whether or not surrounded by a wall or fence. For the prevention of the keeping of animals on any premises in such place or manner as to be a nuisance, or injurious or dangerous to health. As to the paving of yards and open spaces in connection with dwelling houses under Section 16 (1) of the Public Health (London) Act, 1891. For securing the cleanliness and freedom from pollution of tanks, cisterns and other receptacles used for storing of water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drinks for the use of man under Section 50 of the Public Health (London) Act, 1891. With respect to houses let in lodgings, or occupied by members of more than one family under Section 94 Public Health (London) Act, 1891. These by-laws do not call for comment except those relating to houses let in lodgings. Reference has already been made to the fact that these by-laws contain a clause which exempts certain houses, the exemption being based on rental, and to the fact that, as aj result, some houses are exempt, in regard to which advantage would be derived from the application of the by-laws. If, however, all houses occupied by more than one family were brought under the by-laws the number of houses in Hammersmith which will be subject to registration and periodic inspection will be considerable, and may comprise the bulk of the premises in the district.* Food and Drugs Act.—Samples for analysis are collected by one of the sanitary inspectors who is also engaged in supervising the collection of house refuse. During the twelve months to March 31st, 1901, 316 samples were analysed. Recently an inspector from the Board of Agriculture conferred with the Town Clerk on the subject, and as a result it was decided that the number of samples obtained during each year should be increased. * The actual number of houses occupied by members of more ihan one family cannot be given but mav be roughly estimated. The total number of inhabited houses in 1901 wa» 15,198, whilit the total number of "separate occupiers" was 25,810, that is 10,612 in eiceps of lhe number of houses. If no house contained more than two separate occupiers this would be the number of houses let in lodgings. As a matter of fact some houses contain more, but on the other hand it is possible that all lodgers may not have been returned as separate occupiers. In all probability the number of houses let in lodgings or occupied by memberB of more than one family may be put at between 8,000—9,000. 8 Staff of the Public Health Department.—The staff, at the time of this inquiry, appointed for carrying out the duties of the sanitary authority under the Public Health and other allied Acts was as follows— A medical officer of health; Nine sanitary inspectors; Two clerks and one temporary clerk; Two disinfecting assistants, and an engineer at the wharf whose time is partly engaged in the work of steam disinfection; A caretaker and his wife at the coroner's court and mortuary. In addition there is a drainage inspector and assistant drainage inspector in the Surveyor's department. The following is an account of the apportionment of work among these officers— One inspector is entirely concerned in making a house to house inspection of the whole district, except that he is occasionally made use of for some special duty which may arise, or in acting for one of the other inspectors who may be away. A complete house to house inspection has been made, and is now being carried out for the second time. This inspection has taken about six years to complete. The inspector, when he discovers any defects which require dealing with, serves an intimation notice, but has no further concern with the matter, due compliance with the requirements being then attended to by the inspector of the sub-district in which the premises are situated. This officer also reports houses occupied by members of more than one family, and which, being within the limit, are registrable under the by-laws as to houses let in lodgings. Four of the inspectors have each been allotted a sub-district, and in these they are concerned in duties arising out of the work of the house to house inspector, with complaints and the making out of the necessary notices, with re-inspection to see that requirements are carried out, and with attendance at court if proceedings are instituted. They also make house to house inspection, not systematically, but when not otherwise busy. Further, they visit all premises at which cases of notifiable disease has occurred, test the drains, and supervise the disinfection of rooms by the disinfecting assistants. A sixth inspector is occupied in the systematic inspection of houses let in lodgings, obtaining particulars as to occupation, and taking measurements of rooms. To the seventh inspector is allotted the duty of systematic inspection of factories, workshops, bakehouses, and houses where outworkers live. The eighth inspector visits periodically the cowshed, dairies, milkshops, and slaughterhouses, and is concerned with keeping observation on chimney shafts with a view to the prevention of smoke nuisance. The ninth inspector daily supervises the collection of house refuse by the men employed by the borough council for this purpose. These men form part of the surveyor's department. He also obtains samples for analysis under the Food and Drugs Act, but his time is chiefly occupied in connection with dust collection. This officer is partly under the supervision of the surveyor; the others are under the control and supervision of the medical officer of health. The sanitary inspectors make out the preliminary notices, and each keeps a diary in which is set out the conditions found in premises visited. The notices are either sent by post or personally delivered by the inspectors. A report book for each inspector, which is a copy of the preliminary notices, is kept by the clerical staff. Both these books are presented to committee, and if any further action is needed as regards any case, instructions are given for the serving of a statutory notice. These notices are filled out by the inspectors and delivered by them or sent by post. The disinfecting assistants carry out the work of disinfecting rooms and articles of clothing, having the assistance, as regards the latter, of an engineer to get up steam for the disinfecting apparatus. The two drainage inspectors in the surveyor's department, referred to above, supervise the carrying out of drainage works in all premises, both new and old, though as regards the latter the sanitary inspectors, in the course of their re-inspections, also have concern in noting how the work is progressing, and finally in satisfying themselves that the requirements of their notices have been carried out. Conclusions.—It will be well before setting out the conclusions, which the facts given in the foregoing part of the report indicate, to refer briefly to the sanitary administration and the changes which have taken place in the staff of the public health department in recent years. Until March, 1886, Hammersmith formed part of the district under the Fulham District Board of Works. By the passing of the Metropolis Local Management Amendment Act, 1885, this Boar3 was dissolved, the area under their jurisdiction was divided into the two districts of Fulham and Hammersmith, and the vestry of Hammersmith was incorporated and was vested with the powers of a local authority. For the purpose of the sanitary administration of the district, the newly constituted vestry appointed a medical officer of health, four sanitary inspectors and one inspector to supervise the work of house refuse collection and to obtain samples for analysis under the Food and Drugs Act. The medical officer of health, in his first annual report to the sanitary authority, namely, for the year 1886-87, stated that the vestry decided to register two houses under the regulations then in force as to houses let in lodgings, but owing to the fact that alteration in the regulations was under consideration of a committee, no house was registered. He expressed the opinion that the regulations should be properly enforced, that the majority of the houses of the poor occupied by more than one family should be registered and that special inspectors should be appointed for the purpose, as it was impossible for the existing staff, with the numerous duties which had to be performed, to properly enforce the regulations. No increase in the staff was made. In the annual reports for each of the two following years, namely, 1887-8 and 1888-9, it is stated that no house was registered under the regulations, and in that for 1890-91 that it 9 had not been found necessary to register any house. In this report the medical officer of health also recommended alteration in the division of duties among the existing staff of inspectors, and further referred to the subject of the staff as follows—"It is necessary that the small class dwellings in the parish should be under regular and systematic inspection. . . . At present the several sanitary inspectors have so many duties to perform that they have practically no time for regular house to house inspection," and added that—"To keep the parish under sufficient inspection, it is absolutely necessary that two sanitary inspectors should be employed with no other duty than to regularly and systematically inspect the dwellings of the poor and lodge in the office the result of their inspection. The defects discovered should be referred to the other inspectors " for any necessary action. This opinion he re-affirmed in his report for the year 1891-2, and in January, 1893, an additional inspector (making six in all) was appointed for the purpose of house to house inspection. In 1896, consequent on the passing of the Factory and Workshop Act, 1895, the vestry appointed an additional sanitary inspector for the special purpose of dealing with workshops and factories in the district. In his annual report for 1897 the medical officer of health states as regards houses let in lodgings, that 216 had been registered by the sanitary authority. He adds that he had advised the Public Health Committee to instruct the four district inspectors to visit and to report on the registered premises once in each quarter, but this advice was not acted upon, and he expresses the opinion that it would be found necessary to employ another inspector to carry out this work. In the report for 1898 it is stated that 218 houses had been registered during the year, and that as the result of a communication on the subject from the London County Council in July, 1898, the Public Health Committee had again considered the matter, and had instructed "the district inspectors to visit and report as far as they were able, on the condition of the registered premises at each meeting of the committee. Since that order was given, with only one exception, 3rour inspectors have reported that pressure of other duties has prevented them from visiting and reporting upon any of the registered premises." The medical officer of health adds the opinion that if this work is to be carried out it will be necessary to appoint another inspector for the purpose. He also draws attention in this report, as regards the inspector engaged in visiting factories and workshops, that a very large proportion of his time "is occupied in making observations on chimney shafts, and he has consequently not been able to carry out his duties as a factory inspector at all to the extent that is necessary or was intended" at the time of his appointment. In his report for 1899 he again states that houses let in lodgings, of which 72 had been registered during the year, making a total of 506, had not been inspected after registration owing to inadequacy of staff, and he repeats his remarks as to the inspector for factories and workshops. As regards house to house inspection, it is stated that this had now been completed once for the whole district, and that it had been six years in progress. In the last published report, namely, that relating to the year 1900, the medical officer of health again reports that inspection of registered houses let in lodgings had not, owing to pressure of other duties, been inspected, although the committee had instructed each district inspector to visit twenty-four houses in each fortnight, and re-affirms his opinion as to need of an additional inspector for the purpose. He again repeats his remarks as to the inspector for factories and workshops. In a special report at the first meeting of the Public Health Committee of the newly constituted borough council, in November, 1900, he draws attention to the above facts, as well as to the fact that certain statutory duties had been transferred under the London Government Act, 1899, to the borough council. Previous to the year 1900, namely, in October, 1899, a copy of a special report to the vestry by the Medical Officer of Health of Hammersmith, as to the sufficiency of the existing staff, had been forwarded to the London County Council. As the result of correspondence following this, between the vestry and the Council, it was deemed advisable, in view of the changes which were then pending under the provisions of the London Government Act, to await these changes before making alteration in the staff. From a copy of the report- of the meeting of the borough council on 20th November, 1901, given to me by the Chairman of the Public Health Committee, it appears that shortly after the coming into force of the London Government Act this committee of the newly-created borough council recommended the appointment of an inspector in place of one who had resigned, and of an additional inspector, and reported that they would further consider the question of staff later. The recommendation was adopted, and in March, 1901, the borough council directed, on the recommendation of the Public Health Committee, to place this additional officer in charge of inspecting houses let in lodgings. On 1st April, 1901, as the result of a communication from the medical officer of the London County Council on breaches of by-laws in certain slaughterhouses, the medical officer of health of Hammersmith presented a special report to the committee as to the necessity of systematic inspection, once a fortnight, of slaughterhouse, cow-house and noxious trade premises, and once a month of milkshop premises. He further expressed the opinion that this could not be done by the existing district inspectors without neglecting other work, and again pointed out that the inspection of factories and workshops had been interfered with owing to the inspector for this purpose having to act as smoke inspector. He recommended that as the recently-appointed additional inspector was to be engaged in the duty of inspecting houses let in lodgings, the other inspector, who was appointed at the same time in order to fill a vacancy caused by the resignation of one of the four district inspectors, should be utilised for the duties transferred from the London County Council, and that another inspector should be appointed to take up the duties (viz., of a district inspector) of the officer who had resigned. The Public Health Committee, 10 in their report to tlie borough council on 20th November, 1901, having set out this report of the medical officer of health, state as follows— Upon the receipt of the foregoing report, we, as a temporary measure, assigned to the new inspector the duty of inspecting factories and workshops, which had previously been carried out by Inspector S. H. Brown, and assigned to the latter inspector the duties transferred from the London County Council and those relating to smoke inspection. We were not, however, able to arrange for the whole time of any one of the inspectors to be devoted to the inspection of houses let in lodgings. We have carefully considered the proposal of the medical officer of health that a further additional sanitary inspector should be appointed, and also a report, presented by our chairman, suggesting the re-arrangement of the sanitary districts and of the duties of the sanitary inspectors, in order to avoid the necessity of appointing another inspector. Particulars have been obtained as to the system in operation in other metropolitan boroughs with regard to the allocation of the duties of sanitary inspectors, from which it appears that it is the general practice to divide the borough into sanitary districts, with a sanitary inspector to each who practically carries out all the duties of a sanitary inspector in the particular district assigned to him, with the exception that certain special duties, which vary in the different boroughs, are as a rule carried out by one or more inspectors specially appointed for the whole borough. So far as Hammersmith is concerned we have at present four district inspectors and four inspectors whose duties are concerned with the whole borough, the latter being— 1. Inspector Oatley—Dust inspector and inspector under the Sale of Food and Drugs Acts ; 2. Inspector Gee—House to house inspector ; 3. Inspector S. H. Brown—who attends to smoke cases, and duties transferred from the London County Council; 4. Inspector Neighbour—Factories and workshops inspector; so that under the system at present in force it is quite possible for four inspectors to be inspecting in the same road on the same day. We are of opinion that this system must of necessity entail considerable overlapping, besides an immense expenditure of labour, with but few, if any, corresponding advantages. We therefore recommend— (a) That the borough be divided into six sanitary districts, instead of four as at present, (ft) That one inspector be appointed to each of the six districts, with instructions to carry out the whole of the sanitary duties, including the inspection of factories, workshops, laundries, bakehouses, and every month to inspect 50 houses let in lodgings, and make 50 house to hous« inspections in his district, and report the result thereof at the first meeting of the committee in each month. (c) That the time of the seventh inspector be devoted to cases of smoke nuisance, and to carrying nut the whole of the duties transferred from the London County Council. (d) That no alteration be made in the duties of Inspector Oatley. (e) That the six districts to be assigned to the sanitary inspectors be as follows: — No. 1 District to consist of the whole of the No. 1 Ward (approximate number of dwellings, 2,707 ; estimated population, 16,931). No. 2 District to consist of the whole of the No. 2 Ward (approximate number of dwellings, 4,132 ; estimated population, 25,838). No. 3 District to consist of the whole of the No. 3 Ward (approximate number of dwellings, 3,809 ; estimated population, 23,819). No. 4 District to consist of the whole of the No. 4 Ward, with the addition of so much of the No. 6 Ward as is bounded on the east by the West London Railway, as far as an imaginary line drawn in an easterly direction from the centre of Ducane-road; on the west by the centre of Ormiston-road, and by an imaginary line drawn in a northerly direction from Ormiston-road to Ducane-road; on the north by the centre of Ducane-road; on the south by the northern boundary of No. 4 Ward (approximate number of dwellings, 2,755; estimated population, 17,232). No. 5 District to consist of the whole of the No. 5 Ward, with the addition of so much of the No. 6 Ward as is bounded on the north by the south side of Ducane-road ; on the east by the proposed No. 4 sanitary district; on the west by the western boundary of the borough ; and on the south by the northern boundary of the No. 5 Ward (approximate number of dwellings, 2,849 ; estimated population, 17,819). No. 6 District to consist of the whole of the present No. 7 Ward, with the whole of that portion of the No. 6 Ward which is not included in either of the proposed No. 4 or No. 5 sanitary districts (approximate number of dwellings, 1,693 ; estimated population, 10,594). The borough council did not adopt this report of the committee, and referred the question back to the committee for further consideration. On the 18th December following the committee again reported, stating they had adjourned the discussion on the proposals contained in the last report, but recommended the appointment of an additional inspector. The committee also reported at this meeting of the borough council that they had received a letter from the Local Government Board, adverting to the remarks of the medical officer of health of Hammersmith, in his annual report for 1900, with reference to the urgent necessity for an increase of the sanitary staff, and asking what action the borough council had taken or propose to take in the matter, and recommended that the Board be informed that an additional inspector had been appointed in March, 1901, and another was about to be appointed. In November, 1901, the Public Health Committee of the London County Council had under consideration the result of an inquiry as to the action taken by London sanitary authorities under the by-laws as to houses let in lodgings. The information obtained as regards Hammersmith was to the effect that there were about 800 houses on the register, that the district inspectors (four in number) were instructed to keep them under inspection, but had no time to do so, and that many of the houses had not been visited since registration. Thereupon it was decided that inquiry into the sanitary administration of the district, having regard more especially to the enforcement of the by-la.ws as to houses let in lodgings, should be made. The facts as to the condition of the district obtained during this inquiry are set out in the foregoing part of the report. It is necessary to add that at the time when I commenced inspection of the district the additional inspector had just taken up office, and one of the staff of inspectors had been allotted entirely to the work of visiting houses let in lodgings, and is now engaged in obtaining particulars as to the premises which are already on the register. 11 The statement in the above-quoted report of the Public Health Committee of the Hammersmith Borough Council as to the system in vogue in other London districts for apportioning -duties among the sanitary staff requires to be amplified. All sanitary authorities have proceeded on the plan of dividing up their district, and allotting an inspector to each division, but practically all have also allotted special duties to special inspectors. I have made out the following table from a. report to the London County Council, dated June, 1901. It shows the -districts in which, in addition to district inspectors, officers are also engaged in special duties, and the nature of the duties- Districts with a chief inspector. Districts with special inspectors for houses let in lodgings. Districts with special inspectors for Factory and Workshops Act. Districts with inspectors for other special purposes.* Districts with female inspectors for special duties. Kensington (1). Westminster (1). Hampstead (1). Islington (1). Shoreditch (1). Bethncil-green (1) Southwark (1). Bermondsey (1). Batter sea (1). Woolwich (1). Fulham (1). St. Pancras (2) Islington (2). Hackney (1). Bethnal-green (2). Stepney (2). Hammersmith (1). St. Pancras (1). Marylebone (1). Islington (1). Hammersmith (3). Chelsea (1). Westminster (2). St. Pancras (2). Islington (1). Hackney (1 and 1 temporary). Holborn (1). Shoreditch (1). Bethnal-green (2). Southwark (1). Lambeth (1). Camberwell (1). Greenwich (1). Kensington (2). St. Pancras (1). Marylebone (1). Islington (1). Hackney (1). Poplar (l). Southwark (5). In PaJdington all are district inspectors, but there is an assistant inspector for Food and Drugs Act. In Stoke Newinglon all are district inspectors (on trial). In Finsbury all are district inspectors except a special meat inspector in the Metropolitan Heat Market. In Dep'ford all are district inspectors. In Wanndsworth duties mot finally arranged. * Other special duties includes smoke nuisances, duties transferred from London County Council, Food and Drugs Act, inspection offood and food places, house to house inspection, emergencies, infectious disease, and in the case of Hammersmith, supervision of house refuse collection. It would appear, therefore, from this table that the experience of districts in London tends to show that there is advantage in some of the staff being concerned with special duties. The conclusions to which I am led as the result of this inquiry, and after conversing with the chairman of the Public Health Committee, the town clerk, and the medical officer of health of the Borough of Hammersmith, are as follow— (1.) There would be advantage in a reapportionment of duties among the sanitary inspectors, and in an increase in the number of the sub-districts. The medical officer of health is fearful, as regards duties which require regular and systematic attention, that if they are placed upon district inspectors they are liable to interruption in being carried out regularly and systematically, owing to the fact that district inspectors are engaged in duties arising out of complaints, and infectious disease which occur irregularly, but which must take precedence of other work. I agree with this if the number of district inspectors is small and the areas with which they are concerned are large, but with the existing staff of nine inspectors it is possible to increase the number of subdistricts, and if this is done, some duties now engaging the attention of special officers can be carried out by the district inspectors. (2.) The number of sub-districts into which the whole district should be divided may be as proposed by the Public Health Committee of the borough council in their report, 21st November, 1901, namely, six ; and the additional duties which should be transferred to the district inspectors are— (a) house to house inspection, (h) the duties transferred from the London County Council, (c) the noting of smolce nuisances, (d) the taking of samples under the Food and Dmgs Acts. (a) .4s regards house to house inspection, this duty may be transferred to the district inspectors, inasmuch as the borough council have appointed an additional officer with a view to dealing with nouses let in lodgings, and having those placed on the register periodically inspected. I shall refer later to this inspection, but for the present it is sufficient to say that the carrying out of this periodic inspection will materially reduce the number of houses which will require visiting as a matter of house to house inspection, and the need which there was in the past of having an inspector specially engaged on this duty has no longer the force which it had. (b) Duties transferred from London County Council. These duties include the systematic inspection of slaughterhouse, cowshed and milkshop premises, and offensive trades. They are not so numerous in the district that, when divided amongst several officers, any difficulty in inspecting them systematically should arise. 12 (c) Smoke nuisances. At the present time the duty of keeping chimney shafts under observation is carried out by an inspector, who is also concerned with the duties enumerated in (b). There would be advantage if all the inspectors were instructed to take note of offences of this character during the discharge of their daily duties, since by this means observations could be kept daily in different parts of the district. The need for special observation, involving the watching of one or other chimney shaft will arise at times. Provision for this is referred to later (see 5 below). (d) Collection of samples under Food and Druqs Act. The addition of this duty to the work of the district inspectors would not be onerous. An average of two samples , week for each of the six inspectors will result in a yearly total of over six hundred. (3.) The existing arrangement of a special officer for inspection of premises under die Factory and Workshop Act should be continued, and in view of the number of laundries and of women employed in them the sanitary authority should consider as to the desirability of appointing a woman inspector. (4.) The work in connection with houses let in lodgings will, at the present time,, need special attention, inasmuch as already the sanitary authority has placed on the register a number of these premises, but in many cases no further action has been taken. Further, information as to the total number in the district which are registrable and as to the frequency with which they should be inspected, namely, whether they need inspection, once a month, once in six months, or once in each year, is incomplete. Registration under the by-laws entails a minimum inspection of this class of house once a year in order to see if the annual cleansing required by the by-laws has been carried out. In the case of many houses inspection at this interval of time is sufficient in the district of Hammersmith, but as regards others more frequent inspection is desirable, and in order to obtain this information, as well as to ascertain the actual number of houses let in lodgings as quickly as possible, two inspectors should be engaged on the work. In order to obtain the services of two officers for this work with the existing staff of nine inspectors, it will be necessary to make alteration as regards the duty of the inspector at present specially engaged in supervising the collection of house refuse and in obtaining samples under the Food and Drugs Act. The latter part of his work is already arranged for above. As regards the former, it is, I think, quite unnecessary that a sanitary inspector should be engaged for the greater part of his time in supervising the carrying out of work by men employed by the borough council for the purpose of dust collection and under the supervision of the surveyor. Now that the system of collection has been planned out and is found to act well, an intelligible and reliable foreman, under the direction of the surveyor is sufficient for directing the men. The district sanitary inspectors in the course of their daily house inspections will act as a further check in case of neglect to remove the house refuse. If this alteration is made, the sanitary inspector at present occupied in this work will be free for other duties and it will allow two officers to be engaged in connection with houses let in lodgings. (5.) In cases in which it is found necessary to make prolonged observation, as regards smoke nuisance from a chimney, one of the two officers engaged in connection with houses let in lodgings might be employed. (6.) In connection with houses let in lodgings, it is desirable that alteration should be made in the exemption limit at present in force; either the present rent limit should be raised, or there should be no rent limit at all. In the latter case, it will be necessary to consider in each case whether the circumstances of the house are such as need the supervision intended in the by-laws. (7.) The sanitary authority should deal with the piggeries which are within the prescribed distance (namely 40 yards) of Wormwood-scrubs, under Section 17, Public Health (London) Act, 1891. C. W. F. Young, Assistant Medical Officer of Health. Appendix VI. 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, March, 1903. I present a return based upon information supplied by the medical officers of health of the City and the metropolitan boroughs. During the last ten years returns have been presented to the Fublic Health Committee giving particulars as to the sanitary inspectors employed in the several districts of London. Each return has shown an increase upon the numbers stated in the preceding return, and the facts which have been ascertained for the purposes of the present return indicate still further increase. The following table shows the number of inspectors employed in London in several years to which the returns relate— Year Number of sanitary inspectors in the whole of London. 1893 188a 1894 219a 1895 228a 1898 256a 1901 275 1903 301 Thus it will be seen that since 1893, the number of inspectors has increased by some 60 per cent. In 1901, the number of sanitary inspectors employed in each of the metropolitan boroughs was ascertained and comparison between these numbers and those obtaining in 1903 may thus be made. Metropolitan boroughs. Number of sanitary inspectors. Increase (+) or decrease (—) in 1903 compared with 1901. Metropolitan boroughs. Number of sanitary inspectors. Increase (+) or decrease (—) in 1903 compared with 1901. 1901. 1903. 1901. 1903. Battersea 9 11 + 2 Lewisham 6 8 + 2 Bermondsey 7 9 + 2 Paddington † 6 12 + 6 Bethnal-green §n 9 — 2 Poplar 8 8 — Camberwell 12 14 + 2 St. 'Marylebone 7 † 8 + 1 Chelsea 4 4 — St. Pancras 14 16 + 2 Deptford 5 7 + 2 Shoreditch 6 6 — Finsbury 7 9 + 2 Southwark ‡18 17 — 1 Fulham 6 6 — Stepney 17 18 + 1 Greenwich 5 ††7 + 2 Stoke Newington 2 3 + 1 Hackney †l5 14 — 1 Wandsworth 13 §§11 — 2 H ammersmith 8 9 + 1 Westminster, City of 11 11 — Hampstead 5 7 + 2 Woolwich 8 9 + 1 Holborn *5 5 — City of London || 14 ||17 + 3 Islington ‡20 20 — Kensington 13 13. — London 275 301 + 26 Lambeth 13 13 — a Excluding inspectors employed in districts mentioned in Schedule C of the Metropolis Management Act. * Including one vacancy and cne temporary inspector. † Including one temporary inspector. ‡ Including one vacancy. § Including three vacancies. || Including seven meat inspector*. †† Including two temporary inspectors. §§ There arc also five inspectors concerned with drains and sanitary fittings in old and new houses; these officers are under the direction and control cf the Surveyors. Of the 301 inspectors employed in London 20 are women. At the date of the last return 11 of the sanitary inspectors were women. The increase in the total number of inspectors in London since the date of the last return is therefore largely due to the appointment of women inspectors who are now employed in 15 districts in the inspection of workshops. Shirley F. Murphy, Medical Officer of Health. printed foe 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., Agenti for the tale of the Publication* of the London County Council. "No. 630. Price 3d., or post free 3£d. [6469 2 3 SANITARY OFFICERS. Metropolitan borough Number of sanitary inspectors. Census, 1901. Duties of sanitary inspectors. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowde tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitar) inspector. Males Fe- male Inhabite houses. d Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Battersea 10 l 23,462 38,987 24,089 3,032 168,907 88,999 18,381 2,133 3,544 2,190 276 l5,355 8,091 1,671 One supervises generally, inspects in all cases of importance and where statutory proceedings are about to be taken, and is specially concerned with combined drainage. (a) 9 disinfecting assistants. 5 (b) 5 drain-testing assistants. Eight have each an assigned district, in which they are'concerned with duties under the Public Health Act. They supervise drainage of new buildings, for which they receive £10 more yearly. Two of these perform duties under the Pood and Drugs Act, being assisted by a deputy. (c) 1 mortuary keeper and 1 temporary assistant. One is concerned with factories, workshops and workplaces. One (female) inspects places employing female labour, and investigates fatal cases of diarrhoea, etc. Bermondsey 9 - 15,817 29,073 22,064 4,307 130,760 86,156 25,726 1,757 3,230 2,452 479 14,529 9,573 2,858 One supervises generally, performs duties arising under Food and Drugs Act in whole parish, takes part in house-to-house inspection, and inspects bakehouses, slaughterhouses, cowhouses and common lodginghouses. (a) 4 disinfecting assistants. 3 and 2 office youths (b) 2 mortuary keepers. Eight have each an assigned district, in which they are concerned with duties arising under the Public Health, Factory and Workshop, and Food and Drugs Acts. They also supervise drainage work, either construction or reconstruction. (c) 1 shelter caretaker (female). Bethnal-green 9 - 14,005 28,209 23,732 6,384 129,680 98,853 38,410 1,556 3,134 2,637 709 14,409 10,984 4,268 One superintends, attends all committee meetings, and is responsible for the operations of the entire sanitary staff. (a) 1 general assistant. 5 Five have each an allotted district, in which they are concerned with duties arising under Public Health Act. (b) 3 disinfecting assistants. One is concerned with duties under the Factory and Workshop Act, outworkers and the like, the inspection of registered tenement houses, cowsheds and milkshops. (c) Mortuary keeper. (d) 1 urinal flusher. One is concerned with the inspection of food, slaughterhouse and offensive trade premises. (e) 9 dust-pail foremen. One supervises construction of new buildings. Camberwell 13 l 36,671 56,985 31,926 4,073 259,339 117,648 25,012 2,619 4,070 2,280 291 18,524 8,403 1,787 One is concerned with smoke nuisances and Food and Drugs Act, and is emergency inspector under all Actsof Parliament relating to public health. (a) 7 disinfecting assistants. 3 Eleven have each an allotted district in which they carry out duties arising under the Public Health and Factory and Workshop Acts and exceptionally under the Food and Drugs Act. (6) 1 mortuary keeper. One is mainly occupied in clerical duties and inspects in emergency cases. One (female) is chiefly concerned with laundries, factories and workshops employing female labour. Chelsea 3 l 8,641 17,467 12,082 1,914 73,842 37,723 10,659 2,160 4,367 3,020 478 18,460 9,431 2,665 Two have an allotted district, in which each is concerned with house-to-house inspection, and inspection under the Factory and Workshop Act, and (with assistants) disinfects clothing and bedding. (a) Mortuary keeper. None (b) 2 disinfecting One carries out duties connected wth infectious disease and complaints, and obtains samples under the Food and Drugs Act. and drain-testing assistants. One (female) is concerned with inspection of workshops and outworkers' homes where female labour is employed. Also special investigations. Deptford 7 - 15,823 24,615 13,956 1,667 110,398 51,861 9,999 2,260 3,516 1,994 238 15,771 7,409 1,428 Five have each an assigned district in which they perform generally the duties of a sanitary inspector. (a) 2 disinfecting assistants. None One is charged with the duties under the Dairies and Milkshops Order, Factory and Workshop Act, Canal Boats Acts, and the regulations as to slaughterhouses, knackers' yards, offensive businesses, throughout the borough. One is concerned with infectious disease. All inspectors are qualified to act under the Food and Drugs Act. Finsbury 9 - 9,280 24,097 20,515 6,373 101,463 78,346 35,723 1,031 2,677 2,279 708 11,274 8,705 3,969 Six have each an allotted district in which they carry out duties imposed by the Metropolis Management, Public Health and Food and Drugs Acts, and supervise sanitary and drainage works in old buildings. They also supervise houses let in lodgings and are concerned with smoke nuisances. One also has oversight of Regent's Canal (within borough) and boats thereon. (a) 1 assistant disinfector. 2 and 1 office youth (b) 2 mortuary keepers (one of whom disinfects). One is concerned with Factory and Workshop inspection. (c) 1 shelter keeper (also disinfects rooms). One is a meat and market inspector. One supervises generally. • For the purposes of this report the term " overcrowded tenement* " is applied to those tenements of less than 5 rooms which at the date of the 1901 censuB were occupied to the extent of more than two perions per room. 4 5 Metropolitan borough Number of sanitary inspectors. Census, 1901. Duties of sanitary inspectors. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenement under 5 rooms. Overcrowdt tenements Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Male males Inhabite houses. d Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Fulham 6 - 18,534 32,137 21,681 2,341 137,289 81,364 14,892 3,089 5,356 3,613 390 22,881 13,561 2,482 Five have each an assigned district, in which they perform all duties arising under the Public Health Act, Factory and Workshop Act, and the Food and Drugs Act. (a) 3 drainage inspectors. 2 (b) "4 disinfectors and 4 assistants. One, until recently, employed in the inspection of houses let in lodgings, is at present employed in the inspection of dairies, cowsheds, bakehouses, etc. (c) 1 jnortuary keeper. Greenwich 7* 14,240 19,702 10,877 1,199 95,770 41,260 7,947 2,034 2,815 1,554 171 13,681 5,894 1,135 One is concerned with infectious disease. (a) 3 disinfecting assistants. 2 Four have each an allotted district in which they are concerned with duties under the Public Health and Factory and Workshop Acts. Two (temporary) are engaged upon house-to-house inspection. Hackney 13 l 30,634 48,794 29,089 3,684 219,272 104,876 22,332 2,188 3,485 2,078 263 15,662 7,491 1,595 Twelve have each an assigned district, in which they are concerned with duties arising under the Public Health, Factory and Workshop and Food Adulteration Acts. One of these inspectors performs duties under the Canal Boats Acts (for which he gets £26 a year, no part of which is repayable by the London Coanty Council).* (a) 1 Dust inspector. 4 and 1 messenger. (b) 9 assistants for disinfecting. (c) 1 mortuary keeper, 1 temporary shelter caretaker (and wife). One is concerned with dairies, cowsheds, milkshops, slaughterhouses and knackers' yards and is also food inspector. One (female) inspects workshops, laundries, etc., where female labour is employed, and the houses of outworkers. The inspectors supervise reconstruction and alteration of drains but not in new premises. (d) 1 drain-testing assistant, 1 smoke nuisance assistant. (e) Varying number of dustmen. Hammersmith 9 - 15,198 25,810 15,505 2,185 112,239 55,259 13,192 1,689 2,868 1,723 243 12,471 6,140 1,466 Four have each an assigned district, in which they are concerned with all duties arising under Public Health (London) Act. (a) 2 assistants for disinfection. 3 One makes a systematic house-to-house inspection of the district. (b) 1 mortuary One is employed on houses let in lodgings. keeper. One is employed on duties arising under the Food and Drugs Act and supei'vision of dustbins. (c) 2 drainage inspectors. One is concerned with duties transferred from the L.C.C., and also smoke nuisances. (d) 1 or 2 labourers for cleansing and disinfection. One is concerned with factories and workshops. Hampstead 6 l 11,294 16,998 7,178 864 81,942 24,211 5,215 1,613 2,428 1,025 123 11,706 3,459 745 One supervises work of other inspectors, visits premises with medical officer of health, investigates cases of infectious diseases and is (a) 2 disinfecting assistants. 3 sible for work of disinfecting assistants. (b) 2 drain-testing assistants, one of whom acts as mortuary keeper. Four have each an allotted district, in which they are concerned with duties arising under the Public Health Act. One carries out the inspection of slaughterhouses, dairies, factories and workshops, and takes all samples under the Food and Drugs Act. One (female) is engaged in the inspection of premises where females are employed, and makes special investigations. Holborn 5 - 4,703 13,790 10,772 2,783 59,405 35,724 14,875 941 2,758 2,154 557 11,881 7,145 2,975 Four have each an allotted district, in which they are concerned with duties arising under the Public Health, Factory and Workshop and Food and Drugs Acts. (a) 2 disinfecting assistants. 3 (6) 1 mortuary keeper. One is engaged on special inspections under the direction of the medical officer, such as factories and workshops, houses let in lodgings, restaurants, etc. Islington 19 1 38,645 79,129 55,801 10,071 334,991 196,423 56,948 1,932 3,956 2,790 504 16,750 9,821 2,847 One supervises and visits premises when it is necessary to serve a statutory notice. (a) 6 disinfecting assistants. 7 and 1 messenger, who assists in clerical work. Fourteen have each an allotted district, in which they are concerned with duties arising under the Public Health Act (except as regards houses let in lodgings and workshops), and also inspect milkshops and dairies and on Sundays in rotation take samples of milk under the Food and Drugs Act (b) Mortuary keeper. (c) Caretaker of shelter. One inspects workshops and bakehouses. One inspects houses let in lodgings. One assists previous inspector and takes samples of food and drugs. On# inspects meat, food, and cowsheds. One (female) inspects workshops and outworkers' homes where females are employed. Kensington 11 2 22,131 38,349 21,115 4,599 176,628 73,425 26,207 1,702 2,950 1,624 354 13,587 5,64£ 2,016 One acts as chief inspector and exercises supervision. (a) Assistant for disinfection. 5 Ten have each an allotted district, in which they are concerned with al duties arising under the Public Health (London) Act. They also obtain samples under the Food and Drugs Act, and obtain water samples for analysis. (b) Mortuary keeper. Two (female) are engaged mainly in the inspection of workshops workplaces, laundries, etc., where females are employed. * Includes two temporary impectors. G 7 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Duties of sanitary inspectors. Assistants. Clerical itaff. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitan inspector. Males. Fe- males Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Lambeth 12 l 41,511 70,887 44,495 6,548 301,895 153,184 36,904 3,193 5,453 3,423 504 23,223 11,783 2,839 Twelve have each an allotted district, in which they are concerned with all duties arising under the Public Health and Factory and Workshop Acts. One of these whose district is small "also deals with smoke nuisances, and carries out duties under the Food and Drugs Act assisted by deputy. They supervise the execution of drainage works in both new and old houses. (a) 10 disinfecting assistants. 3 (b) 2 mortuary keepers and a deputy. (c) 1 temporary caretaker of shelter (female). One (female) carries out duties under the Factory and Workshop Act, inspects underground conveniences, and performs duties of a general character. Lewisham 8 - 22,750 27,701 8,561 535 127,495 28,928 3,416 2,844 3,463 1,070 67 15,937 3,616 427 Five have each an assigned district in which they carry out general sanitary duties. (a) 8 disinfecting assistants. 2 One is engaged on duties arising under the Factory and Workshop Act. (b) 2 drain-testing assistants. Two are engaged in house-to-house inspection. Paddington 10 2 17,684 33,661 21,815 3,404 143,976 73,232 19,531 1,474 2,805 1,818 284 11,998 6,103 1,628 Six each supervise a district, performing all duties under the Public Health (London) Act; they take charge of drainage works in existing buildings, and attend to notified cases of infectious disease. (N. 13.—Drainage works in new buildings under direction of surveyor.) (a) Inspector under the Food and Drugs Act. 4 (b) Mortuary keeper. One has supervision of workshops and work-places, and has generally the enforcement of the Factory and Workshop Act. (c) Caretakerand wife at shelter. Two attend to houses let in lodgings, and the enforcement of by-laws under section 94, Public Health (London) Act, 1891. (d) 6 navvies (employed for opening defective drains, etc.). One has to watch food supplies, and inspect slaughterhouses, cowsheds, dairies, refreshment-houses, etc. Ice-cream inspection also falls to him. Two (female) inspect all workplaces where women are employed, and make inquiries into infectious disease not scheduled for notification. (e) One disinfecting assistant. Poplar 7 1 22,613 35,787 26,216 4,414 168,822 105,497 27,700 2,827 4,473 3,277 552 21,103 13,187 3,462 Seven have each an assigned district in which they carry out duties under the Public Health, Metropolis Management, Factory and Workshop, Food and Drugs, and Canal Boats Acts. There is- also an assistant inspector (temporary officer since Octobei, 1901) for measuring up rooms of houses let in lodgings, making night visits, etc. (a) 4 disinfecting assistants. 4 and 1 temporary. (b) 5 labourers (who assist inspectors). One (female) inspects all places where female labour is employed. St. Marylebone *7 1 13,536 31,623 22,947 5,180 133,301 74,153 28,147 1,692 3,953 2,868 647 16,663 9,269 3,518 Five have each an allotted district in which they are concerned with all duties arising under the Public Health and Food and Drugs Acts, etc. They supervise all drainage work, both as regards new premises and reconstructipn. (a) 3 disinfecting assistants. 2 and 1 messenger. (b) Mortuary keeper. One is concerned with duties, arising under the Factory and Workshop Act and deals with smoke nuisances. (c) Caretaker of shelter (female). One (female) is concerned with duties arising under the Factory and Workshop Act. One (temporary) acts as dust inspector. St. Pancras 15 1 23,715 57,045 45,023 10,158 235,317 155,790 56,423 1,482 3,565 2,814 635 14,707 9,737 3,526 Eight inspectors have each an assigned district in which they deal with infectious diseases, complaints, drainage and nuisances generally. (a) 3 disinfecting assistants and 1 general assistant 7 and 1 temporary clerk and 1 messenger. Two are inspectors of food and food-places, carry out the Food and Drugs Act and the by-laws regulating slaughterhouses and dairies. (b) Caretaker of mortuaries and coroner's court and 1 temporary shelter attendant (wife of caretaker) Two perform duties under the Factory and Workshop Act. Of these two, one (male) also deals with bakehouses and one (female) deals with outworkers' lists, domestic workshops, laundries and day-schools. Three deal with tenement houses, making inquiry as to occupation, measuring them for registration purposes', inspecting them when registered and also deal with the inspection and re-inspection oi underground dwellings. One is engaged in inspecting food, slaughterhouses, cowhouses and bakehouses. Shoreditch 6 12,743 27,031 22,940 6,269 118,637 89,580 35,529 2,124 4,505 3,823 1,045 19,773 14,930 5,921 One is concerned with duties under the Public Health and Factory and Workshop Acts, and generally superintends and assists other inspectors. Also attends to the registration of houses let in lodgings. (a) 1 general assistant. 3 (b) 1 disinfector and 2 assistants. l ive have each an allotted district in which they perform duties arising under the Public Health and Factory and Workshop Acts, etc., and one of these inspectors is also concerned with carrying out duties arising (c) 1 mortuary keeper. under the Food and Drugs Act and smoke nuisances. The inspectors have supervision of drainage work both in new premises and existing houses and they also test drains. All inspectors, except the chiei inspector, take food and drug samples in rotation on Saturday nights and Sundays. (d) Caretaker (female) of shelter. * Includes a temporary inspector. 8 9 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Duties of sanitary inspectors. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Inhabited houses. Average per sanitary inspector. Males. Females Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. 13 4 Southwark 20,878 47,808 39,612 8,133 206,180 - 147,923 46,073 1,228 2,812 2,330 478 12,128 8,701 2,710 One supervises generally the work of the other inspectors. (a) 9 disinfecting assistants. 6 One carries out the Adulteration Acts, inspection of bakehouses, houses, dairies, milkshops and noxious trade premises. (b) 2 mortuary keepers, and a superintendent and his wife at reception house. Eleven have earh an assigned district, in which they are concerned with duties under the Public Health Act, and the inspection of factories and workshops. They supervise all drainage work in old houses and in new premises drainage work above the ground level. Three (female) visit houses let in lodgings and factories and workshops employing females. (c) 1 assistant drain tester. One (female) is concerned with infectious disease. There is also a male assistant to this inspector. Stepney 18 - 31,462 61,113 49,182 16,541 298,600 209,200 99,179 1,748 3,395 2,732 919 16,589 11,622 5,510 Fifteen have each an allotted district, and are concerned with duties arising under the Public Health, Factory and Workshop and Food and Drugs Acts. These inspectors supervise the construction of drainage work in old as well as new houses as far as the front wall of the house. (a) 10 disinfecting and general assistants. 7 Two are concerned with houses let in lodgings. One inspects wharves and food landed at such premises. Stoke Newington 3 - 7,717 11,824 5,813 497 51,247 18,611 . 2,835 2,572 3,941 1,938 166 17,082 6,204 945 The three inspectors have each an assigned district in which they carry out general sanitary duties. (a) 1 disinfecting assistant. 1 Wandsworth 10* 1 37,764 49,756 21,052 1,525 232,034 76,329 10,337 3,433 4,523 1,914 139 21,094 6,939 940 Nine have each an assigned district in which they carry out duties under the Public Health Act, including all by-laws and repair of drains and sanitary fittings. They also take samples under the Food and Drugs Act as required. (a) 10 disinfecting assistants. 4 (b) 3 mortuary keepers. One carries out duties under the Food and Drugs Act over the whole borough, inspects meat, and performs special duties under the Public Health Act as required. One (female) is chiefly occupied in laundries and workshops which employ female labour. Westminster (City of) 11 - 18,366 41,244 26,668 4,346 183,011 83,624 23,856 1,670 3,749 2,424 395 16,637 7,602 2,169 One inspector exercises supervision. (a) 9 disinfecting assistants. 6 (and 1 messenger and 1 clerical assistant to inspectors) 3 Eight inspectors perform all the duties of sanitary inspectors. Two perform duties under the Food and Drugs Act, abatement of smoke nuisances, inspection of street markets, slaughterhouses, offensive trades, cowhouses, and inspection of food generally. (b) 2 mortuary keepers. Woolwich 9 - 18,086 24,585 14,017 1,243 117,178 50,985 7,727 2,010 2,732 1,557 138 13,020 5,665 859 One acts as chief inspector, supervises generally, inspects premises concerning which complaints have been received, and is concerned with special drainage matters and combined drains, and the inspection of new buildings, etc. (a) 3 disinfecting assistants. (6) 3 drain-testing assistants. Eight have each an assigned district in which they perform duties arising under the Public Health Act. (c) 1 mortuary keeper. Additional duties are undertaken by certain of these inspectors. They include duties under the Food and Drugs Act, the inspection of factories and workshops, and the inspection of food in Woolwichmarket and principal shops, registered houses let in lodgings, cowhouses, slaughterhouses, etc. City of London 16† 1 3,865 5,339 3,307 504 26,923 10,625 2,921 227 314 195 30 1,584 625 172 One is concerned with notified infectious diseases. (a) 3 disinfecting assistants. 3 One is specially engaged in carrying out the provisions of the Food and Drugs Act. (b) 1 mortuary keeper. Eight are concerned with duties arising under the Public Health Act One of these (female) also visits places where females are employed. County of London Seven inspectors are engaged in meat inspection. 281 20 571,768 1,019,546 672,030 124,773 4,536,541 2,449,789 726,096 1,900 3,387 2,233 415 15,072 8,139 2,412 * There are also five inspector concerned with drains and sanitary fittings in old and new houses under control of the Surveyors. t Includes 7 meat inspectors. Hontion Counts Council. EXAMINATION OF THE ATMOSPHERE OF THE CENTRAL LONDON RAILWAY. PART I.—REPORT BY THE CHEMIST. In accordance with the instructions of the Parliamentary Committee of the 23rd January, 1902, the atmosphere of the Central London Railway has been examined chemically, physically, and bacteriologically. The chemical examination was commenced on March 10th, and the last samples were collected on October 24th. During the period between these dates 88 samples were collected and examined. The first sample for the bacteriological examination was taken by Dr. Andrewes on March 14th and the last on June 19th. The results of the bacteriological examination are fully dealt with in the report presented by the medical officer. Dr. Andrewes collected samples for the bacteriological examination at the same time and place as the chemist collected samples for the chemical examination. The days on which this joint collection was made are marked in Table I. with an asterisk. It will be seen that in most cases the conclusions as to the quality of the air which were arrived at from the chemical examination are in accord with those indicated by the bacteriological examination. The chemical examination consisted in the determination of the amount of carbon dioxide (carbonic acid) in the air, and of the amount of oxygen absorbed from permanganate by the organic matter present in the air. I have set out in Table I. the results of the examination of the 88 samples of air, together with the date, time and place of their collection. The results of the examination of the outside air of the street in the immediate neighbourhood where the samples were taken in the railway are also included in this table. For the purpose of showing the relative amount of contamination of the air at different points on the railway, I have also set out the results of the examination in further tables, Nos. II. to VII. The carbon dioxide was estimated by Pettenkofer's method, glass bottles of about 5 5 litres capacity being filled with the air of the locality by blowing air through them by means of handbellows. The organic matter was estimated by collecting samples of the air in a similar manner and then introducing into the bottles solution of potassium permanganate acidified with sulphuric acid. The amount of permanganate which underwent change was estimated by the usual process of titration. Table I. shows that the quantity of carbon dioxide in the air of the Central London Railway varied considerably, whilst the quantity present in the outside air varied only to a slight extent. The amount of organic matter present in the air of the tube and in the external air underwent considerable fluctuation. Table II. shows the number of volumes of carbon dioxide in 10,000 volumes of air collected in the stations, together with the number of volumes of carbon dioxide in 10,000 volumes of the air collected outside the station a few minutes after the samples were taken in the station. Table III. shows the number of volumes of carbon dioxide in 1.0,000 volumes of air collected in the passages, as compared with the quantity present in the outside air. Table IV. gives the determinations of carbon dioxide in the air in the lifts and tunnels, as compared with those made in the fresh air. Table V. shows the quantity of carbon dioxide in the air of the carriages, as compared with the quantity in the fresh air outside the station. Table VI. contains the maximum and minimum amounts of carbon dioxide per 10,000 volumes of the air collected at the different places on the railway. Table VII. For the purpose of comparison I have included a seventh table, which show3 the volume of carbon dioxide in 10,000 volumes of air collected on railways other than the Central London Railway. A consideration of the results obtained from the examination of the samples of air collected on the Central London Railway shows that, generally, the quantity of carbon dioxide was highest in the air of the carriages; but that, contrary to what might reasonably have been .expected, the largest quantity was not found in the carriages where smoking was allowed. The highest proportion of carbon dioxide (14*7 volumes in 10,000 of air) was present in the air of an ordinary passenger carriage on October 10th. The smallest quantity found was that present in an empty carriage on October 16th, viz., 9*6 volumes in 10,000 volumes of air. The air in the passages leading to and from the stations was generally better than that in the lifts. On one occasion (June 6th) the air in the lift at the Oxford-circus station contained 15-2 volumes 2 of carbon dioxide in 10,000 volumes of the air, or about four times the quantity found in the fresh air outside the station. On May 16th and 30th, and again on October 24th, two samples of air were collected, one just before the traffic was stopped at midnight and the other early in the morning, after the tube had been ventilated by the passage of air and before the morning traffic had commenced. The following results were obtained on the examination of these samples— Carbon dioxide in Date. Place of collection. Time. volumes per 10,000 volumes of air. May 16th Tottenham-court-road station 12.10 midnight 8'6 May 16th do. 5.0 a.m. 6.8 May 30th Chancery-lane station 12.5 midnight 7'4 May 30th do. 4.30 a.m. 4-5 Oct. 24th Oxford-circus station 12.10 midnight 10-3 Oct. 24fA do. 4.35 a.m. 4-4 The results obtained from the samples collected in the early morning show that the ventilation on May 16th was not satisfactory, but that on May 30th and on October 24th a very fair condition of the air in the tube was produced by the ventilation, although the condition of the air was still somewhat inferior to that of the outer air. The results of both the chemical and the bacteriological examination, which extended over a considerable period of time, has supplied information not hitherto obtained. It is undoubtedly desirable that an investigation of this character should be extended to other underground railways and that a further examination of the air of the Central London Railway should be carried out when the promised improvement in the system of ventilation has been made. Conclusions. It will be noticed that about 22 per cent, of the samples collected contained less than twice as much carbon dioxide as that found in outside air, and that 34 per cent, contained less than two and a half times as much. These results were obtained under the present system of ventilation. But it is certainly desirable to adopt a system which gives more uniformly satisfactory results. I am of opinion that samples of air taken at any point on the railway should not contain more than 8 volumes of carbon dioxide in 10,000 volumes of the air, that is, not more than twice the amount which is generally found in the air in the streets. This standard of purity is suggested in view of the fact that all the additional carbon dioxide found in the air of the tunnel has been produced by respiration, and is, therefore, of a more objectionable character than that produced by the combustion of fuel in the locomotives on other underground railways, or by the combustion of gas or oil for lighting purposes. London County Council Laboratory, Frank Clowes, November 20th, 1902. Chief Chemist. 3 Table I. Results of the Examination of the Air of the Central London Railway. No. Date, 1902. Place. Time. Inside tube. Outside tube. Organic matter, grammes of oxygen absorbed by 100,000 cubic centimetres of air. Percentage of humidity. Temperature in Centigrade degrees. Barometrical pressure. Carbon dioxide per cent. by volume. Temperature in Centigrade degrees. Barometrical pressure. Carbon dioxide per cent. by volume. Inside tube. Outside tube. Inside tube. Outside tube. 1 March 10 Oxford-circus station Down line 11.35 a.m. 19 768 0.105 8 767 0.035 2 „ 12 Oxford-circus station Up line 11.15 „ 19 772 0.097 10 772 0.042 0.0056 3 „ 14 Post Office station Down line 11.30 „ 19 769 0.090 13 767 0.038 0.0019 0.0020 4 „ 15 British Museum station Up line 11.30 „ 17 767 0.076 13 764 0.036 5 „ 17 Post Office lift 11.45 „ 16 775 0.109 14 775 0.043 0.0028 0.0024 6 „ 18 Bond-street station Down line 11.35 „ 18 772 0.094 13 772 0.043 0.0082 0.0015 7 „ 19 Marble-arch station „ 11.55 „ 19 767 0.092 15 764 0.043 0.0021 0.0061 8 „ 20 Lancaster-gate station „ 3.20 p.m. 19 752 0.074 10 750 0.033 9 „ 21 *Carriage Up line 11.40 a.m. 21 751 0.108 10 747 0.045 0.0026 0.0011 ]0 „ 22 Queen's-road station Down line 11.30 19 751 0.096 13 749 0.037 11 „ 24 Notting-hill-gate station „ 12.5 p.m. 18 758 0.083 10 756 0.045 0.0007 0.0016 12 „ 25 Bank station „ 11.0 a.m. 19 760 0.05 10 758 0.043 0.0018 0.0015 13 „ 26 Holland-park station „ 11.55 „ 17 771 0.077 10 769 0.044 0.0007 0.0026 14 „ 27 Shepherd's-bush station Up line 12.50 p.m. 18 765 0.079 15 703 0.038 0.0029 0.0014 15 April 2 Shepherd's-bush station Down line 12.30 „ 19 767 0.075 ... ... 0.038 0.0027 0.0007 16 „ 3 Chancery-lane station Up line 11.40 a.m. 18 764 0.085 12 762 0.045 0.0016 0.0017 17 „ 4 *Tunnel Down line 11.50 „ 19 769 0.082 11 767 0.037 0.0010 0.0006 18 „ 5 Holland-park station Up line 11.45 „ 16 766 0.063 10 762 0.038 19 „ 7 Notting-hill-gate station „ 12.5 p.m. 18 779 0.067 9 776 0.038 20 „ 8 *Carriage Down line 2.50 „ 20 775 0.111 7 773 0.036 0.0027 0.0018 21 „ 10 Queen's-road station Up line 12.5 „ 18 772 0.067 11 770 0.036 0.0005 0.0014 22 „ 11 *Bank station Down line 5.0 „ 19 769 0.103 ... ... ... 0.0012 0.0023 23 „ 14 Lancaster-gate station Up line 12.35 „ 18 769 0.082 13 767 0.048 0.0015 0.0027 24 „ 15 Marble-arch station „ 12.30 „ 19 756 0.086 14 753 0.049 0.0029 0.0012 25 „ 16 Bond-street station „ 12.40 „ 18 762 0.087 13 760 0.033 0.0050 0.0081 63.8 60.1 26 „ 17 Oxford-circus station „ 12.35 „ 19 763 0.095 17 761 0.032 0.0016 0.0031 67.4 59.0 27 „ 18 Carriage Down line 12.10 „ 20 765 0.106 14 764 0.031 0.0106 0.0005 64.1 71.5 28 ,, 22 Tottenham-court-road station „ 11.30 a.m 19 753 0.107 13 752 0.035 0.0021 0.0035 73.3 87.1 29 „ 23 British Museum station „ 11.30 „ 18 760 0.107 15 758 0.042 0.0011 0.0014 73.2 57.8 30 „ 24 Tottenham-court-road station Up line 12.25 p.m 20 767 0.094 ... ... ... 0.0009 0.0018 64.1 49.5 31 „ 25 Carriage Down line 11.45 a.m 20 766 0.118 18 765 0.046 0.0014 0.0024 60.2 48.5 32 „ 28 Chancery-lane station „ 11.40 „ 18 768 0.103 12 766 0.039 0.0017 0.0011 55.5 50.6 4 5 No. Date, 1902. Place. Time. Inside tube. Outside tube. Organic matter, grammes of oxygen, absorbed by 100,000 cubic centimetres of air. Percentage of humidity. Temperature in Centigrade degrees. Barometrical pressure. Carbon dioxide per cent. by volume. Temperature in Centigrade degrees. Barometrical pressure. Carbon dioxide per cent. by volume. Inside tube. Outside tube. Inside tube. Outside tube. 33 April 30 Post Office station Up line 11.50 p.m. 19 765 0.097 13 762 0.036 0.0049 0.0012 64.8 60.2 34 May 1 Bank station „ 12.5 a.m. 19 758 0.101 13 755 0.038 0.0012 0.0015 60.3 55.3 35 „ 5 Carriage Down line 11.15 a.m. 19 765 0.123 11 763 0.037 0.0005 0.0081 64.4 68.0 36 „ 6 Carriage „ 11.30 „ 19 771 0.131 8 768 0.034 0.0156 0.0024 60.3 62.3 37 „ 8 Carriage „ 11.30 „ 19 770 0.112 11 769 0.037 0.0029 0.0021 68.2 62.6 38 „ 9 Carriage „ 12.20 p.m 19 769 0.121 11 768 0.041 0.0024 0.0023 63.5 62.9 39 „ 12 Carriage 12.0 noon 18 761 0.119 10 760 0.032 0.0025 0.0008 72.7 79.1 40 „ 13 Carriage Up line 12.15 p.m. 19 763 0.106 9 761 0.032 0.0064 0.0014 63.1 71.5 41 „ 14 Carriage Down line 11.30 a.m. 19 762 0.133 11 761 0.033 0.0021 0.0062 60.3 54.5 42 „ 16 Tottenham-court-road station „ 12.10 p.m. 19 754 0.086 ... ... ... 0.0010 ... 42a „ 16 Tottenham-court-road station „ 5.0 a.m. 19 754 0.063 ... ... ... 0.0010 ... 43 „ 21 Carriage Up line 12.10 p.m. 20 772 0.112 12 770 0.031 0.0012 0.0006 60.1 54.8 44 „ 22 Carriage Down line 11.30 a.m. 20 773 0.107 13 771 0.033 0.0022 0.0034 62.1 60.2 45 „ 23 *Shepherd's-bush station Up line 11.30 „ 20 774 0.094 16 772 0.054 0.0010 0.0014 70.7 84.0 46 „ 26 Lancaster-gate passage 11.30 „ 19 774 0.077 16 772 0.035 0.0025 0.0027 66.0 54.4 47 „ 27 *Carriage Down line 11.20 „ 22 767 0.134 20 765 0.040 0.0016 0.0016 63.4 55.6 48 „ 28 Oxford-circus passage 12 midnight 18 758 0.076 18 757 0.033 0.0011 0.0007 68.1 63.4 49 „ 30 Chancery-lane station Down line 12.5 a.m. 20 761 0.074 ... ... ... 0.0016 ... 49a „ 30 Chancery-lane station „ 4.30 „ 19 758 0.045 ... ... ... 0.0007 ... 50 June 2 Tottenham-court-road passage 11.30 „ 19 769 0.111 19 767 0.038 0.0005 0.0015 72.9 67.8 51 „ 3 *Tunnel Up line 11.0 „ 21 768 0.104 18 767 0.039 0.0018 0.0017 69.1 77.0 52 „ 4 Tottenham-court-road station Down line 12.5 p.m. 20 768 0.104 15 766 0.050 0.0048 0.0015 79.4 86.8 53 „ 5 Lancaster-gate station „ 11.45 a.m. 20 767 0.093 ... ... ... 0.0039 0.0031 73.1 73.1 54 „ 6 Queen's-road station „ 12.15 p.m. 20 761 0.099 14 760 0.034 0.0155 0.0059 73.0 81.8 55 „ 8 Nottine-hill-gate station Up line 11.40 a.m. 19 760 0.088 11 759 0.034 0.0013 0.0013 60.1 68.6 56 „ 10 *Oxford-circus lift 11.10 „ 18 760 0.152 14 759 0.073 0.0042 0.0015 59.3 57.2 57 ,, 11 Holland-park station Up line 11.45 „ 19 761 0.073 15 759 0.033 0.0002 0.0012 64.0 66.0 58 „ 13 Oxford-circus station Down line 11.45 „ 20 751 0.098 12 750 0.033 0.0023 0.0027 70.8 86.5 59 „ 14 *Lancaster-gate passage 11.20 „ 18 758 0.078 11 757 0.039 0.0013 0.0019 77.0 85.8 60 „ 17 British Museum station Up line 11.20 „ 19 765 0.017 15 703 0.038 0.0039 0.0038 72.9 68.4 61 „ 18 *Tottenham-court-road station „ 11.20 „ 20 768 0.116 16 767 0.043 0.0022 0.0027 68.5 71.4 62 „ 19 Post Office passage 11.0 „ 20 762 0.102 20 759 0.041 0.0023 0.0021 70.7 53.2 63 „ 20 Queen's-road passage 12.15 „ 18 756 0.059 14 753 0.041 0.0020 0.0011 77.5 86.0 64 „ 30 Notting-hill-gate passage 11.30 „ 23 766 0.083 24 764 0.033 0.0016 0.0007 61.5 51.9 65 July 1 Holland-park passage 11.40 „ 21 764 0.063 19 763 0.039 0.0050 0.0013 75.9 82.8 66 „ 2 Marble-arch passage 12.30 p.m 22 771 0.093 16 770 0.035 0.0013 0.0026 69.6 62.1 67 July 3 Shepherd's-hush passage 11.50 a.m. 20 774 0.070 18 772 0.047 0.0014 0.0013 66.3 63.4 68 „ 4 Bond-street passage 12.15 p.m. 21 769 0.089 22 768 0.034 0.0009 0.0009 69.1 61.4 69 „ 7 British Museum passage 11.30 a.m. 21 769 0.098 24 768 0.036 0.0013 0.0009 78.8 64.8 70 „ 8 Chancery-lane passage 11.45 „ 22 770 0.073 24 768 0.031 0.0001 0.0037 78.0 59.5 71 „ 9 Lancaster-gate lift 11.30 „ 22 763 0.074 20 762 0.031 0.0009 0.0009 74.3 77.9 72 „ 10 Shepherd's-bush lift 11.15 „ 21 757 0.081 17 756 0.037 0.0010 0.0017 71.2 72.0 73 „ 11 Queen's-road lift 11.30 „ 21 767 0.080 16 768 0.041 0.0038 0.0026 83.5 66.7 74 Sept. 29 Lancaster-gate station Down line ... 11.50 „ 20 773 0.098 13 771 0.043 0.0007 0.0030 75 „ 30 Queen's-road station Up line 11.45 „ 20 764 0.076 14 762 0.044 0.0009 0.0033 76 Oct. 1 Nottine-hill-eate station „ 11.35 „ 21 761 0.085 15 760 0.039 0.0012 0.0004 64.3 61.0 77 „ 2 Oxford-circus lift 11.30 „ 17 763 0.136 12 764 0.030 0.0021 0.0018 77.1 69.3 78 „ 3 Bank lift 11.30 „ 18 767 0.104 8 766 0.039 0.0009 0.0020 72.2 72.4 79 „ 6 Carriage Down line 11.20 „ 19 760 0.123 10 759 0.034 0.0031 0.0015 72.9 88.6 80 „ 7 Chancery-lane station „ 11.30 „ 21 761 0.100 13 760 0.035 0.0009 0.0016 66.9 79.4 81 „ 8 British Museum station „ 11.45 „ 20 762 0.085 14 761 0.031 0.0005 0.0021 64.5 66.0 82 „ 9 Holland-park station Up line 12.0 noon 20 756 0.089 15 755 0.045 0.0028 0.0040 68.4 70.7 83 „ 10 Carriage Down line 11.15 a.m. 22 752 0.147 18 751 0.033 0.0014 0.0020 73.7 71.7 84. „ 13 Marble-arch station „ 11.25 „ 20 769 0.089 14 768 0.032 0.0022 0.0018 85 „ 14 Bond-street station „ 11.50 „ 20 762 0.079 14 760 0.040 0.0009 0.0022 73.1 75.4 86 „ 15 Shepherd's-bush station Up line 11.35 „ 20 756 0.071 16 753 0.037 0.0010 0.0024 68.5 70.8 87 „ 16 Carriage Down line 11.20 „ 20 751 0.096 13 750 0.033 0.0013 0.0018 68.7 62.3 88 „ 24 Oxford-circus station Up line 12.10 „ 21 778 0.103 ... ... ... 0.0009 88a „ 24 Oxford-circus station „ 4.35 „ 21 778 0.044 ... ... ... 0.0001 Results of the Examination of Samples of Air collected on Other Railways. April 19 City and South London Railway. Londonbridge station 11.30 a.m 18 767 0.076 May 7 Metropolitan Railway. Empty carriage between Edgware-road and Portland-road 11.30 „ 12 768 0.60 „ 15 Metropolitan Railway. Empty carriage between Baker-street and Gower-street 11.45 „ 14 756 0.288 4 „ 29 City an South London Railway. Empty carriage 11.45 „ 19 761 0.141 June 12 District Railway. Empty carriage between Mansion House and Temple 11.30 „ 16 754 0.151 6 Table II. Carbon dioxide in the Air of the Stations on the Central London Railway in volumes per 10,000 volumes of air— Date, 1902. Station. Time. Down line. Up line. Air outside station. March 25th Bank 11.0 a.m. 10.5 ... 4.3 April 11th „ 5.0 p.m. 10.3 ... ... May 1st „ 12.5 „ ... 10.1 3.8 March 3rd Post Office 11.30 a.m. 9.0 ... 3.8 April 30th „ 11.50 „ ... 9.7 3.6 April 28th Chancery-lane 11.40 „ 10.3 ... 3.9 May 30th „ 12.5 „ 7.4 ... ... May 30th „ 4.30 „ 4.5 ... ... April 3rd „ 11.40 „ ... 8.5 4.5 October 7th „ 1.1.30 „ 10.0 ... 3.5 April 23rd British Museum 11.30 „ 10.7 ... 4.2 October 8th „ 11.45 „ 8.5 ... 3.1 March 15 th „ 11.30 „ ... 7.6 3.6 June 17th „ 11.20 „ ... 9.7 3.8 April 22nd Tottenham-court-road 11.30 „ 10.7 ... 3.5 June 4th „ 12.5 p.m. 10.4 ... ... May 16th „ 12.10 a.m. 8.5 ... ... May 16th „ 5.0 „ 6.3 ... ... May 24th „ 12.25 p.m. ... 9.4 ... June 18th „ 11.20 a.m. ... 11.6 4.3 March 10th Oxford-circus 11.35 „ 10.5 ... 3.5 June 13th „ 11.45 „ 9.8 ... 3.3 October 24th „ 12.10 „ ... 10.3 ... October 24th „ 4.35 „ ... 4.4 ... March 12th „ 11.15 „ ... 9.7 4.2 April 4th „ 12.35 p.m. ... 9.5 3.2 March 18th Bond-street 11.35 a.m. 9.4 ... 4.3 April 16th „ 12.40 p.m. ... 8.7 3.3 October 14th „ 11.50 a.m. 7.9 ... 4.0 March 19th Marble-arch 11.55 „ 9.2 ... 4.3 April 15 th „ 12.30 p.m. ... 8.6 4.9 October 13th „ 11.25 a.m. 8.9 ... 3.2 March 20th Lancaster-gate 3.20 p.m. 7.4 ... 3.3 May 14th „ 12.35 „ ... 8.2 4.8 June 5th „ 11.45 a.m. 9.3 ... ... September 29th „ 11.50 „ 9.8 ... 4.3 March 22nd Queen's-road 11.30 „ 9.6 ... 3.7 April 10th „ 12.5 p.m. ... 6.7 3.6 June 6th „ 12.15 „ 9.9 ... 3.4 September 30th „ 11.45 a.m. ... 7.6 4.4 March 24th Notting-hill-gate 12.5 p.m. 8.3 ... 4.5 April 7th „ 12.5 „ ... 6.7 3.8 June 8th „ 11.40 a.m. ... 8.8 3.4 October 1st „ 11.35 „ ... 8.5 3.9 March 26th Holland-park 11.55 „ 7.7 4.4 April 5th „ 11.45 „ ... 6.3 3.8 June 11th „ 11.45 „ ... 7.3 3.3 October 9th „ 12.0 noon ... 8.9 4.5 April 4th Shepherd's-bush 1230 p.m. 7.5 ... 3.8 March 27th „ 12.50 „ ... 7.9 3.8 May 23rd „ 11.30 a.m. ... 9.4 ... October 15 th „ 11.35 „ ... 7.1 3.7 7 Table III. Carbon dioxide in the Air of the Passages on the Central London Railway in volumes per 10,000 volumes of air. Date, 1902. Passage to station. Time. Carbon dioxide. Air of passage. Outside air. June 19th Post Office 11.0 a.m. 10.2 4.1 July 8th Chancery-lane 11.45 a.m. 7.3 3.1 July 7th British Museum 11.30 a.m. 9.8 3.6 June 2nd Tottenham-court-road 11.30 a.m. 11.1 3.8 May 28th Oxford-circus 12.0 noon 7.6 3.3 July 4th Bond-street 12.15 p.m. 8.9 3.4 July 2nd Marble-arch 12.30 p.m. 9.3 3.5 May 26th Lancaster-gate 11.30 a.m. 7.7 3.5 June 14th Lancaster-gate 11.20 a.m. 7.8 3.9 June 6th Queen's-road 12.15 p.m. 5.9 4.1 June 30th Notting-hill-gate 11.30 a.m. 8.3 3.3 July 1st Holland-park 11.40 a.m. 6.3 3.9 July 3rd Shepherd's-bush 11.50 a.m. 7.0 4.7 Table IV. Carbon dioxide in the Air of the Lifts and Tunnels of the Central London Railway, in volumes per 10,000 volumes of air. Date, 1902. Lift or tunnel. Time. Carbon dioxide. Air of lift or tunnel. Outside air. Lifts. *October 3rd Lift at the Bank station 11.30 a.m. 10.4 3.9 *March 17 th Lift at the Post-office station 11.45 „ 10.9 4.3 *June 6th Lift at the Oxford-circus station 11.10 „ 15.2 ... *October 2nd Ditto ditto 11.30 „ 13.6 3.0 July 9th Lift at the Lancaster-gate station 11.30 „ 7.4 3.1 July llth Lift at the Queen's-road station 11.30 „ 8.0 4.1 *July 10th Lift at the Shepherd's-bush station 11.15 „ 8.1 3.7 Tunnels. April 4th Tunnel, on platform of front carriage. Down line 11.50 „ 8.2 3.7 June 3rd Tunnel, on platform of front carriage. Up line 11.0 „ 10.4 3.9 * Crowded lifts. Table V. Carbon dioxide in the Air of the Carriages on the Central London Railway in volumes per 10,000 volumes of air. Date, 1902. Carriage on up or down line. Time. Carbon dioxide. Air of carriage. Outside air. *March 21st Carriage on tip line 11.40 a.m. 10.8 4.5 April 8th Carriage on down line 2.50 p.m. 11.1 3.6 *April 18th „ 12.10 „ 10.6 3.4 *April 25th „ 11.45 a.m. 11.8 4.6 *May 5th „ 11.15 „ 12.3 3.7 *May 6th „ 11.30 „ 13.1 3.4 *May 8th „ 11.30 „ 11.1 3.7 May 9th „ 12-20 p.m. 12.1 4.1 †May 12th Carriage on tip line 12.0 noon 11.9 3.2 †May 13th „ 12.15 p.m. 10.6 3.2 May 14th Carriage on down line 11.30 a.m. 13.3 3.3 *May 21st Carriage on up line 12.10 p.m. 11.2 3.1 May 22nd Carriage on down line 11.30 a.m. 10.7 3.3 May 27 th „ 11.20 „ 13.4 4.0 *Oct. 6th „ 11.20 „ 12.3 3.4 Oct. 10th „ 11.15 „ 14.7 3.3 †Oct. 16th „ 11.20 „ 96 3.3 * Smoking carnage. t Empty carriage. 8 Table VI. Maximum and Minimum Quantities of Carbon dioxide in volumes per 10,000 volumes of Air collected at the undermentioned places on the Central London Railway— Place. Air of Railway. Fresh air outside the placea named. Maximum. Minimum. Maximum. Minimum. Bank station 10.5 10.1 4.3 3.8 Post Office station 9.7 9.0 3.8 3.6 Chancery-lane station 10.3 4.5 4.5 3.5 British Museum station 10.7 8.5 4.2 3.1 Tottenham-court-road station 11.6 6.3 4.3 3.5 Oxford-circus station 10.5 4.4 4.2 3.2 Bond-street station 9.4 7.9 4.3 3.3 Marble-arch station 9.2 7.4 4.9 3.2 Lancaster-gate station 9.8 7.4 4.8 3.3 Queen's-road station 9.9 6.7 4.4 3.4 Notting-hill-gate station 8.8 6.7 4.5 3.4 Holland-park station 8.9 6.3 4.5 3.3 Shepherd's-bush station 7.9 7.1 3.8 3.7 Of all stations 11.6 6.3 4.9 3.1 Passages to and from stations 10.2 5.9 4.7 3.1 Lifts 15.2 7.4 4.3 3.0 Tunnels, on platforms of front carriage 10.4 8.2 3.9 3.7 In carriages 14.7 9.6 4.6 3.1 Table VII. Carbon dioxide in the Air of Railways other than the Central London Railway in volumes per 10,000 volumes of air. Date, 1902. Place of collection. Time. Carbon dioxide air of carriage or station. April 19th City and South London Railway. London-bridge station 11.30 a.m. 7.6 May 29th Empty carriage 11.45 „ 14.1 May 7th Metropolitan Railway. Empty carriage between Edgware-road and Portland-road 11.30 „ 16.0 May 15th Metropolitan Railway. Empty carriage between Baker-street and Gower-street 11.45 „ 28.8 June 12th District Railway. Empty carriage between Mansion-house and Temple stations 11.30 „ 15.1 London County Council Laboratory, November 20th, 1902. Frank Clowes, Chief Chemist. 9 PART II.—REPORT BY THE MEDICAL OFFICER OF HEALTH. I present the report prepared by Dr. Andrewes in pursuance of his instructions to investigate twelve samples of air from different points in the Central London Railway, and to compare them bacteriologically with twelve similar samples taken at the same times from the fresh air outside. This investigation has been spread over four months, and has necessitated the detailed study microscopically and in culture of nearly 600 colonies arising in the plate cultures. Each of the twelve observations involved the making of four plate cultures, the organisms in the sample taken and in the control sample from the external air undergoing incubation in gelatine at 20° C., and also in agar-agar at 37° C. Two additional experiments were made with a view to determining whether anaerobic organisms were present in the air of the tube; these two experiments yielded negative results. As regards the total number of micro-organisms found, the average, i.e., average of twelve examinations of five litres of air, in the tube air was 44'1, while the control samples of fresh air gave an average of 33"9—the range in the tube air being from 14 to 103, and in the fresh air samples from 2 to 93. The highest averages, Dr. Andrewes notes, were found in the carriages and lifts, i.e., in the most crowded places examined, while the platforms and passages came out actually better than the fresh air, and the tunnels were only a little worse. There was thus a direct correspondence between the amount and concentration of the human traffic and the number of organisms in the air. Dr. Andrewes concludes that, so far as the total number of micro-organisms is concerned, the Central London Railway does not compare unfavourably with conditions known to exist in inhabited rooms generally. On turning to the relative proportion of organisms growing at 20° C. and 37° C. in the tube air and fresh air respectively, a difference is apparent. The tube air contains rather more than twice as many " mesophil organisms," i.e., organisms growing at the higher temperature, as the fresh air, and the average " mesophil ratio," i.e., the proportion of organisms growing at the higher, to the organisms (other than moulds) growing at the lower temperature, was in the case of fresh air 10'6 per cent., and in that of tube air 17'9 per cent. The difference is not a great one, and the number of observations not large enough to justify much stress being laid upon it; moreover, it appears that it was due, in the main, to the fact that sarcinse, which are almost invariably mesophil organisms, were more abundant in the tube air than in fresh air. Sarcinse are common air organisms, they are non-pathogenic, and there is no sufficient proof that the species found in the tube air had a human origin. Dr. Andrewes compares his bacteriological finding in each instance with the chemical results obtained by Dr. Clowes. On the whole the number of bacteria was in correspondence with the degree of chemical impurity testified to by the samples ; there were, however, occasional discrepancies, and it is clear that chemical examination alone cannot be taken as a trustworthy guide to the bacterial contamination of the air. In all, 58 species of bacteria, streptothrices and yeasts were identified in the colonies examined ; they included 26 micrococci, 24 bacilli, 3 streptothrices, and 5 yeasts. There were in addition some 10 or 12 species which could not be identified and several moulds. None of the bacteria identified were species which possess pathogenic property. As noted already, the most striking differences between the tube air and fresh air was the relative preponderance in the former of sarcinse; again, the genus streptothrix occurred in tube air twice or thrice as frequently as in fresh air. The species of micro-organisms found in the tube air were in the main identical with those occurring in the fresh air. In summarising his results, Dr. Andrewes concludes that while micro-organisms are present in tube air in a somewhat greater proportion (13 to 10) than in fresh air, the excess is not so considerable as to cause the tube air to compare unfavourably with the conditions known to exist in inhabited rooms generally, and although there was considerable excess of organisms capable of growing at the temperature of the body, this excess was due to non-pathogenic sarcinse and allied species, and no pathogenic organisms were found in the tube air. Dr. Andrewes adds a word of caution with regard to the observed absence of pathogenic species from the 600 or so colonies which he examined, pointing out that it may be safely inferred that the distribution of such organisms in air must be extremely sparse, and that while the method which he employed in his investigation was excellently adapted to the study of the general bacterial flora of the air, it was ill-adapted to the recognition of given pathogenic organisms on account of the small volume of the samples examined. He observes that what is needful is, in the first instance, that special methods for the recognition of individual species should be devised, and that these methods should be then employed upon very large volumes of air. Shirley F. Murphy, Medical Officer of Health. Public Health Department, 8, St. Martin's-place, W.C., November 20th, 1902. [2] 10 Report by Dr. Andrewes on the Micro-organisms present in the Air op the Central London Railway. On March 8th, 1902, I was instructed, through the medical officer of the London County Council, to conduct an investigation into the bacteria present in the air of the Central London Railway. My instructions were—To investigate twelve samples of air taken from different points in the Central London Railway, and to compare them, bacteriologically, with twelve similar samples taken at the same times from the fresh air outside; to enumerate the bacteria present, and, as far as possible, to determine the species to which they belonged, employing, if need arose, suitable means to test the pathogenic properties of any suspicious forms found. After consultation with the medical officer and with the chemist to the Council, I commenced the work on March 14th. The authorities of the Central London Railway were good enough to place every facility at my disposal for carrying on the investigation. The large amount of time requisite for the growth of the various cultures obtained, and for their determination, caused the work to be spread over some four months, which, indeed, was of some advantage, as it enabled comparisons to be made under varying seasonal conditions. Method.—The method employed was, in principle, that introduced by Frankland, viz., the aspiration of a known volume of air through a plug of glass wool, which retains all micro-organisms and can subsequently be distributed through a suitable cultivating medium in a glass capsule. This method has been used by Haldane, Laws and others with good results, and from my own experience I can speak of it as simple and reliable. In my earlier experiments I used coarsely pulverised glass wool alone, but I found, as others have found, that the addition of a small quantity of very finely powdered cane sugar gave a more coherent and satisfactory plug, and one not liable to charring during sterilisation if the temperature were not allowed to rise beyond 150° C. I employed straight glass tubes about five inches in length, without any constriction. A suitable amount of the powdered glass wool and sugar was introduced into these, and compressed by glass rammers into a coherent plug about a quarter of an inch long. The coherence of each plug was tested by forcibly aspirating air through it with a syringe. The ends of the tube were plugged with cotton wool, one plug being introduced into one end, and two, an inner and an outer, into the other. The tubes were then sterilised for an hour and a half in a dry-air steriliser at 13u°-150° C., and preserved in a bottle plugged with sterile wool. For aspiration I used a large and well-made brass syringe fitted at the nozzle with a twoway cock. The capacity of the syringe was 425 cubic centimetres, so that llf syringefuls represented very closely 5 litres of air. I graduated the stem of the piston, so that quarter syringefuls could be measured accurately. I found this apparatus more convenient and portable than a water aspirator, and I believe it to be equally accurate. The method of using it was as follows— The tube containing the glass-wool plug was supported by two brass clips attached to rubber suckers. The latter, when wetted, adhered firmly to any smooth wall or window. When no suitable surface was at hand I attached them to a glass plate placed in a convenient situation. The end of the tube provided with two cotton-wool plugs was attached by four feet of rubber tubing to one of the nozzles of the syringe; this enabled me to stand at some distance from the apparatus. The single cotton-wool plug at the free end of the tube was now removed with sterile forceps and placed in a sterile capsule during the process of aspiration. A syringeful of air was then sucked slowly through the tube. The air, entering its open end, passed first through the glass-wool plug, next through the inner of the two cotton-wool plugs at the attached end, and then through the outer cotton-wool plug. When the syringe was full, the tap of the two-way cock was turned and the air expelled through the other nozzle. The tap was turned back, and a second syringeful aspirated through the tube, and in this way llf syringefuls of air were drawn through the glass-wool plug. The cotton wool was now replaced in the free end of the tube; the sample was duly labelled and returned to its bottle for transport to the laboratory. I found that tlie process of aspirating 5 litres of air took about eight minutes. The samples thus collected were treated in the laboratory in the following way—(1) The outer of the two cotton-wool plugs in the end of the tube which had been attached to the syringe was removed, and the inner plug was quickly transferred with sterile forceps to a culture tube of broth. Had any micro-organisms failed to be arrested by the plug of glass wool and sugar they must have been caught in this inner cotton-wool plug, which thus served as a test of the efficiencv of the filtration. In the ipajoritv of cases the broth tube in which it was placed remained quite sterile, indicating that all micro-organisms had been arrested. In those cases in which any growth occurred in the broth, it occurred after several days, and was almost always limited to the presence of a single species of bacterium or mould, indicating that only a single individual had failed to be arrested. I have, therefore, every confidence that the cultures made from the glasswool plugs fairly represented the real numbers of the organisms present in the 5 litres of air aspirated. (2) A warmed sterile Petri capsule was now taken from the steriliser, and into it the melted sterile culture medium (gelatin or agar-agar) was poured. The remaining cotton-wool plug, i.e., the plug at the distal end, was removed from the sample tube, and the ends of the latter passed through the flame of a Bunsen burner. With a sterilised glass rammer the plug of pow dered glass wool and sugar was then forced out into the culture medium; it always came out as a. solid cylindrical mass, which could easily be broken up with a sterile platinum wire and evenly distributed through the melted culture medium. The sugar dissolved, and the tiny particles of glass presented no obstacle to the counting of the bacterial colonies which subsequently arose. When the culture medium had set firmly, the plates were put in the incubator—in the case of the gelatin plates at 20° C., in the case of "the agar-agar plates at 37° C. Here they were incubated for four days, and the colonies were then counted. The period of four days was selected 11 after some experience as the most suitable for the following reasons—Moulds were often found sporulating in two days, and the spores disseminated from such gave rise, if the plate were kept too long, to secondary colonies which vitiated the results. The large mould colonies tended also to overgrow the bacterial colonies in their neighbourhood and prevent satisfactory sub-cultures. I satisfied myself that the count on the fourth day was a reasonably fair one by repeating the count, in many cases on the fifth and sixth days, aud although I found that a few fresh colonies became apparent on these later days, yet they seldom formed five per cent, of the total. Inasmuch as the object was to compare different samples of air, it is plain that this comparison could be effectually carried out by counting all the plates after a uniform time had elapsed, provided that this time were such as to allow the great majority of the colonies to have developed. On only two occasions was I obliged to relax this rule of counting finally on the fourth day; these were in June, when the unseasonably cold weather had caused the temperature of the cool incubator, from which the gas was turned off in summer, to fall to 16° C., much retarding the growth of the colonies. On these occasions the count was taken on the fifth and sixth days respectively, which, as I estimated from the rate of appearance of the colonies, corresponded fairly with the fourth day uruder normal conditions. In counting the colonies, a map was made of each plate, every colony being numbered for future reference. (3) Having determined the total number of colonies, subcultures were made to determine their nature, and from these sub-cultures a number of further cultures were usually requisite upon different media. Where the number of colonies in a plate did not exceed 20 or 30, every colony was sub-cultured. Where the numbers exceeded this, the quantity of sub-cultures would have become unmanageable, and I therefore marked out a half, or sometimes even a quarter, of the plate and sub-cultivated every colony in this, making from the rest of the plate, cultures only from such colonies as appeared manifestly diverse from those which I had already taken. The total number of colonies microscopically and culturally studied in the series of twelve complete observations was nearly 600. Each complete observation involved the making of four plate cultures. I was anxious to determine, if possible, whether bacteria could be found, in the air of the railway carriages or elsewhere, to which a probable origin from human sources could be ascribed. It is well known that a very large proportion of the bacteria of the air and of water are species incapable of growing at the temperature of the human body. Pathogenic organisms, however, grow more rapidly and better at the body temperature than at the ordinary air temperature. It was therefore plain -that, whilst I must rely upon the colonies arising in gelatin plate cultures incubated at 20° C., for the total number of organisms present in a given volume of air, I should have a better chance of discovering the presence of pathogenic organisms by incubating agar-agar plates at 37° C. I hoped, too, that some interesting data for the comparison of the railway air with the fresh air above might be obtained by finding the ratios between the numbers of organisms capable of growing at blood heat, with the total numbers present—a line of observation not so far attempted, to my knowledge, in air investigations. I therefore, in each experiment, took two samples of railway air, each of 5 litres, and two similar samples from the fresh air. In each case one sample was incubated in gelatin at 20° C., and one in agar-agar at 37° C. In only one experiment, and that by inadvertence, did I fail to carry out this plan; this was in experiment IX., where I accidentally made two gelatin plates from the two samples of tunnel air taken. The two plates served, however, for the comparison of two different sections of the tunnel. I selected 5 litres, as the volume of each sample, in preference to 10 litres, because the smaller number of organisms obtained proved more manageable, and because, with the larger amount, the plates would have been often so overgrown with moulds as to render sub-cultures very difficult. The number of organisms in 5 litres was, moreover, as will be seen, quite sufficient for all practical purposes of comparison. I conducted two additional experiments, in the course of my investigations, with a view to determining the presence of anaerobic organisms in the air of the railway. In these I aspirated, in each case, 10 litres of air through glass wool and sugar plugs, as above described, and transferred the plugs to culture tubes containing glucose-broth (2 per cent, glucose). These were enclosed in " Buchner tubes," deprived of free oxygen by pyrogallic acid and caustic potash, and were then incubated at 37° C. After the lapse of three or four days the cultures were examined, and sub-cultures, both aerobic and anaerobic made from them. In neither of these experiments did I find any evidence of the presence of anaerobic organisms, and I therefore made no more. I varied the place of collection of the samples as much as possible. The twelve experiments •were distributed as follows—Three samples were taken from different station platforms, two from the passages leading from the platforms to the lifts and stairway, two from the lifts themselves as they were going up and down with passengers, three from the carriages in actual use, and two from the air of the tunnels. The last-named were taken from the front platform of the carriage immediately behind the engine, shut off by doors from the carriage and exposed to the tunnel air only. The fresh-air samples were taken at various places near the line of route of the railway, and at various heights above the ground. Quiet spots were selected for choice, as in crowded thoroughfares throngs of people were apt to collect to witness the proceedings, and this might have vitiated the results. In all cases great care was taken to collect fair samples of the air under every-day working conditions, and to avoid abnormal and disturbing influences. The details of the twelve observations are as follows—I have added to each the proportions of carbon dioxide and organic matter found in the same air at the same time, the data being kindly furnished to me by Dr. Clowes. The CO2 is stated as a percentage—the organic matter as grammes of oxygen absorbed by 100,000 c.c. of air. I.—On March 14th, 1902, two samples, each of 5 litres of air, were taken on the down platform of the Post Office station at 11.30 a.m. Trains were passing regularly, but there were not many 12 passengers at the time. The temperature was 66° F., and the barometer on the platform stood at 30'3 inches. The carbon dioxide in the air was "09 per cent., and the organic matter '0019. Immediately afterwards two similar fresh-air samples were taken from a scaffold in Newgate-street, over the station at a height of some 50 feet above the level of the street, well away from any obvious source of contamination. It was a fine, dry day, slightly cloudy, with a light S.W. wind. Temperature 55° F., barometer 30" 17 in. The carbon dioxide in the air amounted to "038 per cent., and the organic matter was '0020. The numbers of bacteria and other organisms found after incubation was as follows— Railway air.—Five litres incubated in gelatin at 20° C. yielded 27 colonies. These were made up of 14 bacteria, 1 streptothrix, 3 yeasts, and 9 moulds. Five litres incubated in agar-agar at 37° C. yielded 7 colonies, all bacterial. The following species were identified in this 10 litres of air—Micrococci: Sarcina lutea, sarcina alba, staphylococcus epidermidis albus, staphylococcus cereus albus, staphylococcus cereus flavus, micrococcus cremoides, micrococcus citreus, micrococcus versatilis. Bacilli: B. mesentericus vulgatus, B. lactis innocuus, B. helvolus, B. latericius, and a non-pathogenic pseudo-diphtheria bacillus. Yeasts: Saccharomyces cerevisiae and torula alba liquefaciens. Streptothrix: Str. albido-flava. Moulds: Penicillium glaucum, aspergillus glaucus, aspergillus flavus, aspergillus fumigatus, and aspergillus niger. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 60 colonies, made up of 34 bacteria, 1 yeast, and 25 moulds. Five litres incubated in agar-agar at 37° C. yielded five colonies, consisting of two bacteria, one streptothrix, and two moulds. The following species were identified in this 10 litres of air—Micrococci: Staphylococcus epidermidis albus, staphylococcus cereus flavus, M. cremoides, M. orbicularis, M. citreus, M. lactis, and a species of coccus undetermined. Bacilli: B. mesentericus vulgatus, B. helvolus, B. lactis innocuus, and B. arborescens non-liquefaciens. Yeasts: An o'idium, of which the exact species could not be determined. Streptothrix: Str. chromogenes. Moulds: Mucor mucedo, penicillium, glaucum, aspergillus fumigatus, niger and glaucus. II.—On March 17th similar samples were taken at 11.45 a.m. in one of the lifts at the Post Office-station. It made six or seven journeys up and down while the samples were being taken, carrying only a moderate number of passengers. The temperature in the lift was 61° F., and the average barometric pressure 30'52 in. The carbon dioxide in the air was '109 per cent., and the organic matter "0028. Fresh air samples were then taken in the public garden behind the Post Office buildings, known as the " Postmen's Park." The samples were taken on a quiet seat, close to Little Britain, about two feet from the ground. Hardly any people were in the garden. It was a cloudy, dull day, with a light W. wind. No rain had fallen for two days. The temperature was 57° F., and the barometer 30'5 in. The carbon dioxide in the air was '043 per cent., and the organic matter 0024. The following were the results after incubation— Lift air.—Five litres, incubated in gelatin at 20° C., yielded 39 colonies made up of 20 bacteria, 5 yeasts, and 14 moulds. Five litres incubated in agar-agar at 37° C. yielded six colonies, of which one was a mould and the rest bacteria. The following species were indentified in this 10 litres of air—Micrococci: Sarcina lutea, sarcina alba, staphylococcus pyogenes albus, staphylococcus cereus albus and flavus, M. candicans, M. citreus, and M. lactis. Bacilli: B. mesentericus vulgatus. Yeasts: Saccharomyces cerevisiae, torula alba, and a species of oidium. Moulds: Penicillium glaucum, aspergillus fumigatus, and two undetermined species. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 27 colonies made up of 23 bacteria and four moulds. Five litres incubated in agar-agar at 37° C. yielded eight colonies, all of them bacterial. The species identified from this 10 litres of air were as follows—Micrococci: Sarcina lutea, sarcina alba, M. cremoides, M. citreus, M. candicans, and M. lactis. Bacilli:, B. luteus, B. lactis innocuus, B. xerosis, B. domesticus, and two undetermined species. Mould: Penicillium glaucum. III.—On March 21st similar samples were taken at 11.45 a.m. in a smoking carriage full of passengers, between the Bank and British Museum stations. The temperature in the carriage was 70° F., and the barometer stood at 29'57 in. The carbon dioxide was '108 per cent, and the organic matter '0026. The fresh air samples were taken at 12.15 p.m. on the roof of the school buildings of St. Bartholomew s Hospital, about 100 feet above the ground.. It was fine, after much rain on the previous day, and there was a brisk S.W. wind. The temperature was 50° F., and the barometer stood at 29'4 in. The carbon dioxide was 045 per cent., and the organic matter 0011. The results were as follows— Air of smoking carriage.—Five litres, incubated in gelatin at 20° C., yielded 61 colonies, viz., 51 bacteria, 1 yeast, and 9 moulds. Five litres incubated in agar-agar at 37° C. yielded seven colonies, all bacterial. From this 10 litres of air the following species were identified—Micrococci: Sarcina lutea, sarcina alba, staphylococcus cereus albus and flavus, micrococcus rosettaceus, M. lactis, M. cremoides, M. citreus, M. orbiculatus, and two undetermined species. 13 Bacilli: B. luteus, and B. eta. Yeast: Torula alba. Moulds: Penicillium glaucum and an undetermined species. Fresh air.—Five litres, incubated in gelatin at 20° C., yielded 27 colonies, of which 12 were bacteria, 4 yeasts, and 11 moulds. Five litres, incubated in agar-agar at 37° C., yielded seven colonies, viz., two bacteria, four streptothrix, and one mould. The species identified from this 10 litres were as follows:—Micrococci: Sarcina flava, staphylococcus epidermidis albus, and M. lactis. Bacilli: B. ochraceus, B. helvolus, B. lactis innocuus, and an undetermined species. Yeasts: Torula alba, torula rosea, and an undetermined species. Streptothrix: Str. Forsteri. Moulds: Penicillium glaucum and an allied species. Also an undetermined species of mould. IV.—On April 4th similiar samples were taken of the air in the tunnels between the Bank and Lancaster Gate stations. The air was aspirated only while the train was travelling in the tunnels, not while it was stopping at the stations. The time was 11.45 a.m. The tunnel temperature was 67° F., and the barometer stood at 30.27 in. The tunnel air contained .082 per cent. carbon dioxide, and the organic matter was .0010. Corresponding fresh air samples were then taken under a tree on the grass in Kensingtongardens at 12.10 p.m. A circle of children who assembled to witness the proceedings were kept as much as possible to leeward. It was a fine, sunny day, with a moderate W. wind. Temperature 51° F. Barometer 30'2 in. There was .037 per cent. carbon dioxide in the air, and the organic matter was .0006. The results were as follows— Tunnel air.—Five litres, incubated in gelatin at 20° C., yielded 18 colonies, viz., 10 bacteria and 8 moulds. Five litres incubated in agar-agar at 37° C. yielded only two colonies, viz., a coccus and a streptothrix. The species identified in this 10 litres of air were the following—Micrococci: Sarcina lutea, staphylococcus pyogenes albus, staphylococcus cereus flavus and albus, M. rosettaceus, M. concentricus and an undetermined species. Streptothrix: Str. Forsteri. Moulds: Penicillium glaucum, aspergillus glaucus, and a mould of undetermined genus. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 18 colonies, of which 7 were bacteria and 11 moulds. Five litres incubated in agar-agar at 37° C. yielded no colonies at all; the plate remained permanently sterile. The species identified in the gelatin plate were the following—Micrococci: Staphylococcus cereus flavus, and micrococcus coronatus. Bacilli: B. vaculatus, B. helvolus, B. lactis innocuus. Yeast: Torula rosea. Moulds: Penicillium glaucum, a mucor and at least two species of which I was unable to determine the genus. V.—Samples were taken in a non-smoking carriage, towards the rear of the train. The time was 2.45 p.m. The carriage was half empty. The temperature in the carriage was 68° F., and the barometer stood at 30.5 in. The carbon dioxide amounted to .111 per cent. and the organic matter was .0027. Fresh air samples were then taken in Hyde Park, far out on the grass, and remote from any people, about 9 inches above the ground. It was a dull, cloudy, cold day, with a light E. wind. The temperature was 45° F., and the barometer stood at 30.43 in. There was .036 per cent. carbon dioxide in the air, and the organic matter was .0018. The results were as follows— Air of railway carriage.—Five litres incubated in gelatin at 20° C. yielded 27 colonies, made up of 13 bacteria, 1 streptothrix, 1 yeast and 12 moulds. Five litres incubated in agar-agar at 37° C. yielded 9 colonies, viz., 8 bacteria and 1 streptothrix. The following species were identified in this 10 litres of air—Micrococci: Sarcina lutea, sarcina flava, staphylococcus cereus albus and flavus, M. candicans, M. citreus, M. lactis, and M. flavus. Bacilli: B. xerosis, B. lactis innocuus, and an undetermined species. Yeast: Saccharomyces cerevisiæ. Streptothrix: Streptothrix Forsteri and streptothrix chromogenes. Moulds: Penicillium glaucum, aspergillus glaucus, and aspergillus flavus. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 17 colonies, of which 3 were bacteria, 1 a yeast, and 13 moulds. Five litres incubated in agar-agar at 37° C. yielded only 1 colony, a mould. The species identified in this 10 litres of air were as follows—Micrococcus: M. lactis. Bacilli: B. luteus. Yeast: Torula alba. Moulds: Penicillium glaucum, aspergillus glaucus, numerous colonies of black moulds, of which I could not determine the genus, and at least three other species. VI.—On April 11th samples were taken on the down platform of the Bank Station, at 5.10 p.m. It was one of the busiest times of the day; the City men were hurrying home. The platform was crowded, and loaded trains were going off at short intervals. The samples were taken at the west end of the platform, where there were few people, but a strong draught was blowing directly from the crowd to the apparatus. Temperature 67° F., barometer 30.12 in. The carbon dioxide was 103 per cent., and the organic matter was .0012. Fresh air samples were taken previously, at 4.50 p.m., on the steps of the Royal Exchange, 14 just inside the railings. A small crowd of people collected around, and had to be moved on by the police. There was a light shifting N. wind. It had been raining, and was still just spitting with rain, and was warmer after a cold morning. The temperature was 55° F., and the barometer was 30.05 in. The organic matter was .0023. The results were as follows— Air on station platform—Five litres incubated in gelatin at 20° C. yielded 41 colonies made up of 30 bacteria, 7 streptothrix, one yeast, and 3 moulds. Five litres incubated in agar-agar at 37° C. yielded 16 colonies, viz., 14 bacterial and 2 streptothrix colonies. The organisms identified from this 10 litres of air were as follows—Micrococci: Sarcina lutea, sarcina flava, staphylococcus cereus albus and flavus, M. candicans, M. aurantiacus, M. lactis and M. flavus. Bacilli: B. helvolus and B. fulvus. Yeast: Torula alba. Streptothrix: Str. Forsteri, Str. chromogenes, Str. albido-flava and an undetermined species. Moulds: Penicillium glaucum, aspergillus glaucus and aspergillus flavus. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 44 colonies, of which 40 were bacteria and 4 moulds. Five litres incubated in agar-agar at 37° C. yielded 5 colonies, viz., 4 bacteria and 1 mould. The species identified from this 10 litres of air were the following—Micrococci: Sarcina lutea, sarcina flava, staphylococcus cereus albus and flavus, diplococcus citreus conglomeratus, M. candicans, M. lactis, M. citreus, M. albicans tardissimus, M. aurantiacus and M. concentricus, Bacilli: B. lactis innocuus, B. luteus, B. subochraceus, B. latericius, B. arborescens and an undetermined species. Moulds: Penicillium glaucum, aspergillus flavus and an undetermined species. VII.—On May 23rd samples were taken on the up platform at Shepherd's Bush station at 11.40 a.m. A moderate amount of traffic was going on, but the samples were not taken at a very crowded part of the platform. Temperature 68º F. Barometer 30.46 in. The carbon dioxide was .094 per cent. and the organic matter .0010. Fresh air samples were taken in the porch at the exit from the lifts in a small street at the side of the station. They were taken at a spot freely exposed to the street air, but two or three lifts full of people came up during the process. It was a dull, damp day, and there had been a good deal of rain during the preceding night and up to 8 a.m. Temperature, 60° F. Barometer, 30.4 in. Light W. wind. The carbon dioxide in the air was .054 per cent. and the organic matter .0014. The results were as follows— Platform air.—Five litres incubated in gelatin at 20° C. yielded 112 colonies, viz., 106 bacteria, 4 streptothrix and 2 moulds. Five litres incubated in agar-agar at 37° C. yielded 1 colony only, a bacterium. The species identified from this 10 litres of air was as follows—Micrococci: Sarcina alba, staphylococcus cereus flavus, M. cremoides, M. candicans, M. coronatus, M. flavus, M. citreus, M. rosettaceus, M. albicans tardissimus, M. concentricus and M. roseus. Bacilli; B. latericius, B. ochraceus, B. helvolus, B. luteus and B. carneus. Streptothrix; Str. chromogenes and albido-flava. Moulds : Two species of penicillium—penicillium glaucum and another. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 93 colonies, viz., 87 bacteria, 1 streptothrix, 1 yeast and 4 moulds. Five litres incubated in agar-agar at 37° yielded 1 colony only—a mould. The species identified from this 10 litres of air were the following—Micrococci: Sarcina alba, staphylococcus cereus flavus and albus, M. rosettaceus, M. aurantiacus, M. flavus and diplococcus citreus conglomeratus, with an undetermined species. Bacilli; B. latericius, B. erythromyxa, B. helvolus, B. fulvus, B. lactis innocuus, B. aeris minutissimus, and an undetermined species. Yeast: Torula alba. Streptothrix: Str. albido-flava and an undetermined species. Moulds: Penicillium glaucum, aspergillus glaucus, and a mould of undetermined genus. VIII.—On May 27th samples were taken at 11.20 a.m. in a non-smoking carriage about the middle of a train as it was travelling from the Bank to the British Museum station. The carriage was full, but not crowded. Temperature in carriage 72° F., barometer 30.22 in. The carbon dioxide in the carriage air was .134 per cent., and the organic matter was .0016. Fresh air samples were taken at 11.45 a.m. in the open space in front of the British Museum. It was a fine bright day, with a few clouds and a moderate west wind. It had been fine warm weather, without rain for four days previously. The temperature was 66° F., and the barometer stood at 30.10 in. The carbon dioxide percentage was .040, and the organic matter .0016. The results were as follows— Carriage air.—Five litres incubated in gelatin at 20° C. yielded 103 colonies, viz., 90 bacteria, 1 yeast and 12 moulds. Five litres incubated in agar-agar at 37° C. yielded 4 colonies, all bacterial. The following species were identified in this 10 litres of air—Micrococci: Sarcina lutea, sarcina flava, sarcina alba, staphylococcus cereus albus and flavus, M. candicans, M. coronatus, M. citreus, M. flavus, M. aurantiacus, M. rosettaceus and M. albicans tardissimus. Bacilli: B. luteus and B. lactis innocuus. Yeast: Torula alba. Moulds: Penicillium glaucum and a closely allied species, aspergillus glaucus and a species of mucor. Fresh air.—Five litres, incubated in gelatin at 20° C., yielded 17 colonies, viz., 13 bacteria, 1 streptothrix and 3 moulds. 15 Five litres incubated in agar-agar at 37° C. yielded 1 colony only—a bacterium. The following species were identified in this 10 litres of air—Micrococci: Sarcina alba, sarcina flava, staphylococcus cereu3 flavus and M. citreus. Bacilli: B. helvolus, B. latericius, B. fulvus and B. lactis innocuus. Streptothrix: Str. Forsteri. IX.—On June 3rd samples were taken of the tunnel air between Shepherd's-bush and the Marble-arch station. They were taken from a platform behind the engine, as in observation IV., and only while the train was travelling. One sample was taken between Shepherd's-bush and Notting-hill stations, another between Queen's-road and the Marble-arch stations. The tunnel temperature was 70° F., and the barometer stood at 30.25 in. The carbon dioxide in the tunnel was .104 per cent, and the organic matter was .0018. The time was 11.15 a.m. Fresh air samples were taken at 11.40 a.m. under a tree in Hyde-park. It was a dull damp day following a rainy night. There was a light west wind. Temperature, 64° F. Barometer, 30.20 in. The percentage of carbon dioxide in the air was .039, and the organic matter was .0017. The results were as follows— Tunnel air.—Owing to an unfortunate inadvertence both 5 litre samples of this air were incubated in gelatin at 20° C. They serve, therefore, for the comparison of the air in two different sections of the tunnel. Sample A (taken between Shepherd's-bush and Notting-hill) yielded 14 colonies, viz., 10 bacteria. 2 yeasts and 2 moulds. Sample B (taken between Queen's-road and the Marble-arch) yielded 19 colonies, viz., 10 bacteria, 1 yeast and 8 moulds. The following species were found in the 10 litres of tunnel air—Micrococci: Sarcina lutea, sarcina alba, staphylococcus cereus albus, M. cremoides, M. candicans, M. citreus, diplococcus luteus and diplococcus citreus conglomeratus. No bacilli. Yeasts: Torula alba and saccharomyces cerevisiæ. Moulds: Penicillium glaucum, aspergillus glaucus, a species of mucor and 2 species of undetermined genera. Fresh air.—Five litres incubated in gelatin at 20° C. yielded only 2 colonies, both bacterial. Five litres incubated in agar-agar at 37° C. yielded 3 colonies, viz., 2 bacteria and a streptothrix. The species found in this 10 litres of fresh air were as follows—Sarcina aurantiaca, Micrococcus rosettaceus, Bacillus lactis innocuus and an undetermined species of streptothrix. X.—On June 10th samples were taken in one of the lifts at Oxford-circus station at 11 a.m. as it was going up and down. There were fair numbers of passengers, but the lift was not crowded. Temperature, 66° F. Average barometric pressure, 29.92 in. The carbon dioxide was .152 per cent, and the organic matter .0042. The fresh air samples were taken in the doorway of the Oxford-circus station, i.e., on the pavement of Oxford-street itself, constituting a fair sample of Oxford-street air at a busy time of day. A considerable crowd collected and had at times to be dispersed. The time was 11.15 a.m. It was a fine but cloudy day with a moderate north-west wind. Hardly any rain had fallen for two days. The street temperature was 58° F., and the barometer stood at 29.87 in. The carbon dioxide in the air was .073 per cent. and the organic matter .0015. The results were as follows— Lift air.—Five litres incubated in gelatin at 20 C. yielded 73 colonies, viz., 64 bacteria, 2 yeasts and 7 moulds. Five litres incubated in agar-agar at 37° C. yielded 14 colonies, of which 1 was a streptothrix and the rest bacteria. The species determined from this 10 litres were the following—Micrococci: Sarcina flava lutea and alba, and an undetermined species of sarcina, staphylococcus cereus albus and flavus, M. candicans, M. lactis and M. flavus. Bacilli: B. helvolus, B. luteus, B. fulvus, B. aquatilis, B. lactis innocuus, B. aeris minutissimus and an undetermined bacillus. Yeasts: Torula alba and saccharomyces cerevisiae. Streptothrix: Str. Forsteri. Moulds: Penicillium glaucum and an allied form; also mucor mucedo. Fresh air.— Five litres incubated in gelatin at 20° C. yielded 45 colonies, viz., 39 bacteria and 6 moulds. Five litres incubated in agar-agar at 37° C. yielded only 2 bacteria. The species found in this 10 litres were as follows—Micrococci: Sarcina lutea and flava, staphylococcus cereus albus and flavus, diplococcus citreus conglomeratus, M. concentricus, M. rosettaceus, M. citreus, M. citreus agilis, M. albicans tardissimus and M. flavus, with a coccus which I could not determine. Bacilli: B. helvolus, B. luteus and B. carneus. Moulds: Penicillium glaucum and an allied species. XI.—On June 14th samples were taken in a passage at Lancaster-gate station, close to the bottom of the staircase, and not much above the level of the railway. Nearly all the passengers were going up by the lifts, so there was very little traffic in the passage. The time was 11 a.m. The thermometer was 64° F., and the barometer 29.85 in. .078 per cent. carbon dioxide was found in the air, and the organic matter was .0013. Fresh air samples were then taken by the fountains in Kensington-gardens under a dripping chestnut-tree. It was pouring with rain; nearly an inch of rain had fallen during the preceding 24 hours. Temperature 52° F. Barometer, 29.8 in. There was scarcely any wind; what there was was N.W. .039 per cent. carbon dioxide was found in the air, and the organic matter was .0019. The results were as follows— Passage air—Five litres incubated in gelatin at 20° C. yielded 16 colonies, viz., 13 bacteria, 1 yeast and 2 moulds. 16 Five litres incubated in agar-agar at 37° C. yielded 5 colonies, all of which were bacterial. The following species were identified in this 10 litres of air—Micrococci: Sarcina alba lutea and flava, staphylococcus cereus flavus, M. candicans, M. flavus, M. lactis. Bacilli: B. subtilis, B. mesentericus fuscus, B. mesentericus ruber, B. luteus, B. arborescens, B. lactis innocuus, and an undetermined bacillus. Yeast: Torula alba. Moulds: Penicillium glaucum, and an allied species. Fresh air—Five litres incubated in gelatin at 20° C. yielded 13 colonies, viz., 10 bacterial colonies, 1 yeast and 2 moulds. Five litres incubated in agar-agar at 37° C. yielded not a single colony of any sort. The following species were identified in this 10 litres of air—Micrococci: Sarcina lutea and flava, with an undetermined species of coccus. Bacilli: B. fulvus, B. subochraceus, B. arborescens, and B. aeris minutissimus. Yeast: Torula rosea. Moulds: Aspergillus glaucus and a species of mucor. XII.—On June 19th samples were taken at 11 a.m. in a branch passage near the foot of the stairs at the Post Office station. There was no direct traffic past the apparatus, but passengers were passing to the lifts within 20 feet, and a moderate current of air was passing from them to us. The temperature was 68° F., and the barometer 30 in. The percentage of carbon dioxide in the air was .102; the organic matter was .0023. Fresh air samples were then taken on a scaffold above the station in Newgate-street, about on a level with the top storeys of the adjacent houses, and well above the ordinary street traffic. It was a bright, sunny day and dry. No rain had fallen for two days, and there was a moderate S.E. wind. Temperature, 69° F.; barometer, 29.86 in. The carbon dioxide in the air was .041 per cent., and the organic matter was .0021. The results were as follows— Passage air.—Five litres incubated in gelatin at 20° C. yielded 24 colonies, of which 17 were bacteria, 2 yeasts and 5 moulds. Five litres incubated in agar-agar at 37° C. yielded 5 colonies, of which 1 was a streptothrix and the rest bacteria. The following species were identified from this 10 litres of air—Micrococci: Sarcina lutea, and an undetermined species of sarcina, staphylococcus pyogenes albus, staphylococcus cereus albus, M. cremoides, M. concentricus, M. orbicularis, M. flavus, M. albicans tardissimus, and diplococcus citreus conglomeratus. Bacilli: B. pyocyaneus, and two bacilli which I could not identify. Yeasts: Torula alba and torula rosea. Streptothrix: Str. chromogenes. Moulds: Penicillium glaucum and an allied species, aspergillus glaucus and aspergillus fumigatus, with a mould belonging to an undetermined genus. Fresh air.—Five litres incubated in gelatin at 20° C. yielded 44 colonies, of which 23 were bacteria, 3 yeasts, and 18 moulds. Five litres incubated in agar-agar at 37° C. yielded 8 colonies, all of which were bacterial. The following species were identified in this 10 litres of air—Micrococci: Sarcina alba, a species of streptococcus, staphylococcus cereus flavus and albus, M. cremoides, M. flavus, M. albicans tardissimus, M. aurantiacus, M. citreus and diploccocus citreus conglomeratus. Bacilli: B. helvolus, B. subochraceus, B. latericius, B. aeris minutissimus, B. fulvus, B. arborescens, B. mesentericus ruber or an allied species, and three bacilli which I was unable to identify. Yeasts: Torala alba liquefaciens, and a species of oidium. Moulds: Penicillium glaucum, aspergillus glaucus, and several forms, the genera of which I could not determine. This concludes the detailed record of the experiments. Before tabulating and discussing the results, I will describe the two abortive experiments in which I endeavoured to demonstrate the presence of anaerobic bacilli in the air of the Central London Railway. XIII.—On May 23rd, 10 litres of air were aspirated through a tube such as I ordinarily used, in a smoking carriage in the rear of a train as we travelled between Holland-park and Lancaster-gate stations. There were plenty of passengers, but the carriage was not crowded. The glass-wool and sugar plug was placed in a broth tube containing 2 per cent. of glucose, and incubated anaerobically at 37° C. for 3 days. It was then examined, but no micro-organisms could be found microscopically. An aerobic subculture on agar-agar yielded a single colony of an aerobic sporing bacillus. The original culture was then further incubated aerobically and became turbid with the growth of a motile sporing bacillus. XIV.—On May 27th, 10 litres of air were similarly aspirated, on the up platform of the Bank station at 11.10 a.m. Very few people were on the platform. The plug was treated as in the preceding experiment and yielded no growth at all. After 4 days, subcultures were made aerobically on agar-agar and anaerobically as a stab culture in glucose gelatin. No growth occurred in either. The original culture was then further incubated under aerobic conditions, but no growth occurred. There was thus no evidence at all of the presence of strictly anaerobic bacilli in these two experiments. I will now endeavour to classify and tabulate the results of the twelve observations, in order that they may be rendered more intelligible. I will deal first with the total number of organisms found in the different samples examined, irrespective of the species to which they belong. 17 Table showing total numbers of colonies per 5 litres of air examined. Samples from Central London Railway. Corresponding fresh air samples. Growing in gelatin at room temperature. Growing in agar-agar at body temperature. Growing in gelatin at room temperature. Growing in agar-agar at body temperature. Railway carriages— Observation III. 61 7 27 7 „ V. 27 9 17 1 „ VIII. 103 4 17 1 Average 63.6 Average 6.6 Average 20.3 Average 3 Platforms— Observation I. 27 7 60 5 „ VI 41 16 44 5 „ VII. 112 1 93 1 Average 60 Average 8 Average 65.6 Average 3.6 Passages— Observation XI. 16 5 13 0 „ XII. 24 5 44 8 Average 20 Average 5 Average 28.5 Average 4 Lifts— Observation II. 39 6 27 8 „ X. 73 14 45 2 Average 56 Average 10 Average 36 Average 5 Tunnels— Observation IV. 18 2 18 0 „ IX. 14 and 19 — 2 3 Average 17 Average 2 Average 10 Average 1.5 Total averages 441 69 33.9 3.4 Conclusions. A.—As concerns the total number of micro-organisms found. Owing to the fact that a large majority of the organisms present in the air do not grow at the body temperature, the totals must be taken from the gelatin plates incubated at the room temperature. The true totals must be higher than those indicated in the table, for not only did I fix the arbitrary limit of four days for counting the colonies, but many organisms were doubtless present, incapable of growing in the media employed. The numbers which I found agree fairly with those previously found by other observers, though they are somewhat higher than those which have commonly been recorded. Differences in method, and especially in the date at which the colonies were counted, may explain this. As regards the number of micro-organisms in the fresh air of London, I may quote the figures given by Mr. J. Parry Laws in his report on sewer air investigations to the London County Council in 1893. He found in August, September and October an average of 25.8 organisms in 5 litres of air, the number varying from 11 to 59.5. But in January, February and March he found an average of only 57 organisms per 5 litres, his highest count being 9.5. My higher average of 33.9 is probably chiefly due to the fact that it includes several samples taken in crowded thoroughfares. The highest number of organisms I found in fresh air was at the outlet of the lifts at Shepherd'sbush station (93 in 5 litres). The next highest (60) was in Newgate-street on a rather windy day, followed by Oxford-street (45), and the steps of the Royal Exchange (44). My lowest figures were obtained in the quiet parts of Kensington-gardens and Hyde-park, where the number once sank as low as 2 organisms in 5 litres. The figures are in fact in complete general accord with the well-established principles that micro-organisms abound in the air in proportion to the amount of traffic going on in the vicinity, that they are increased by wind and diminished by rain. Turning now to the air of the Central London Railway, it is apparent that the same general principle holds good. In the foregoing table I have classified the results in accordance with the places where the samples were collected. The highest averages are found in the railway carriages, closely followed by the platforms and lifts (63.6, 60 and 56 organisms per 5 litres, respectively). In the passages and tunnels the numbers sink to 20 and 17. There is a direct correspondence between the amount and concentration of the human traffic and the number of micro-organisms in the air. It will be seen that I found the absolute number of micro-organisms present in the air of the Central London Railway greater, on the average, than in the fresh air, but not much greater—only as [3] 18 13 to 10. Twice they were less than in the fresh air and twice equal; four times they were somewhat greater and four times much greater. The differences were especially marked in the cases of the carriages and lifts, i.e., the most crowded places examined. The platforms and passages come out actually better than the fresh air; the tunnels, perhaps unfairly compared with the relatively pure air of a park, are only a little worse. So far, therefore, as the total number of micro-organisms in the air go, the Central London Railway does not compare unfavourably with the conditions known to exist in inhabited rooms generally. Turning now to the figures in the second and fourth columns of the preceding table, those dealing with the micro-organisms capable of growing at the temperature of the human body, it will be seen that the difference between the air of the railway and the fresh air is very much greater. The railway air contains rather more than twice as many such organisms as the fresh air; the total averages are 69 and 3.4 per 5 litres respectively. The excess of such organisms over those found in the fresh air is seen in the averages from carriages, platforms, passages, lifts and tunnels alike, and is an almost constant feature of the individual observations as well as of the averages. Only once did the number of colonies in the fresh air agar-agar plate incubated at 37° C. exceed the number in the corresponding plate from the railway air; once, too, they were equal. This fact struck me at once as perhaps of some importance and worth further investigation. The attention which has hitherto been paid to the bacterial flora of the air is very slight; practically all that has been attempted is an enumeration of colonies in gelatin plates. The term "psychrophil" is sometimes used to denote bacteria whose optimum temperature for growth is about that of the air, and which cannot grow at all at the body temperature. The term "mesophil" is used for those organisms whose optimum temperature is about that of the human body; but most of these can also grow, though more slowly, at air temperature. With "tliermophil" bacteria we are not here concerned. The foregoing table shows very plainly the well-established fact that the great majority of the air bacteria belong to the psychrophil group. I hoped, by the simple method which I had adopted of incubating similar samples at 20° and at 37° C., that the ratio of mesophils to psychrophils yielded by the figures obtained might give more valuable information than a bare enumeration of colonies in gelatin plates. For pathogenic bacteria all belong to the mesophil group, and one might expect to find bacteria derived from human sources, even if not pathogenic, to belong chiefly to the mesophils. In this I hope I have carefully analysed all my results, excluding the moulds altogether as confusing the issue; I have worked out the percentage of mesophils for all my observations, both on fresh air and on railway air. The result was disappointing, probably because the volume of air taken in each sample was too small, and the number of observations too few. The variations in the mesophil percentage proved so great that I fear no reliable inferences can be drawn from them. The figures, such as they are, are these— Fresh air—(I exclude one observation, No. IX., because the number of mesophils which happened to grow in the agar-agar plate actually exceeded the total in the gelatin plate—3 and 2 respectively. With such small numbers no result of any value can be obtained.) With this exception, and excluding moulds altogether, the average percentage of mesophil organisms was 10.6. The extremes of the different observations were 0.0 and 37.5 per cent. Railway air—(In observation No. IX. no comparison could be made because both samples of air were accidentally incubated at 20° C.) The remaining 11 observations yielded a mesophil percentage of 17.9, the extremes of the different observations being .9 and 66.6 per cent. The difference between 10.6 and 17.9 per cent. is not a great one, and the number of observations is too small to allow me to lay much stress on it. On further investigation of the matter I discovered another fact which from the point of view of public health appears to me still more to minimise the value of the mesophil percentage. This fact is the very large number of sarcinæ I found in the railway air, as will be seen later in the table of species identified. Sarcinæ are the commonest of air organisms. I identified them no less than 106 times in the course of these experiments. For some reason, which I am not at present able to explain, they were very much more abundant in the railway air than in the fresh air—as 87 to 19. They are almost invariably mesophil, and they practically account for the excess of mesophils in the railway air. Yet, so far as I am aware, we have no really sufficient grounds for attributing to them a human origin. What their natural breeding places may be we do not know, and it would be a matter of some interest to determine it. But we know that they are non-pathogenic, and that they are not amongst the commonest human saprophytes. They are common, it is true, in the lungs and the stomach, but the species found in the air are not those which are so abundant in these situations. The common air sarcinae, sarcina lutea, sarcina flava and sarcina alba, are practically known as air organisms only. They are at times found in cultures from the mouth and throat, but it is as likely that they get into the throat from the air, as into the air from the throat. While, therefore, I think it possible that future researches on the lines 1 have mentioned may add a new feature to the practical utility of bacteriological air examination, I fear I cannot claim any serious importance for these limited observations on the mesophil-ratio. Before leaving the subject of the total number of micro-organisms in the air, it will be well to examine the relation between these numbers and the other evidences of organic contamination. On every occasion on which I took samples, Mr. Dick, for the chemist to the Council, took samples for chemical examination. I am therefore able to give figures enabling this comparison to be made, Dr. Clowes having been so good as to furnish me with his results as to the carbon dioxide and organic matter present in the air. I have embodied our joint results in a diagram from which the variations in the three evidences of air contamination can be more readily appreciated than from tables of figures. The observations have been arranged in their chronological order, without any classification as to the source of the samples, as this renders the variations more sudden and striking. The thick, single line indicates the number of micro-organisms, including moulds, found in 5 litres of air. The DIAGRAM showing the simultaneous variations in the number of microorganisms, the proportion of carbon dioxide and the amount of organic matter in the air of the Central London Railway, in the twelve observations made Number of Organisms CO 2 Organic Matter ( The figures regarding the Carbon dioxide and the, organic matter were furnished by the Chemist to the Council. The numbers of microorganisms are from my own simullaneous observations 19 dotted line indicates the amount of carbon dioxide present, and the finer double line the amount of organic matter. A consideration of the curves shows that there is, as might be expected, a general correspondence in the three evidences of contamination. The carbon dioxide and organic matter vary together fairly uniformly, and if it were not for Observations VII. and VIII., the number of micro-organisms would fairly vary with them. In these two observations, however, and especially in No. VII., the number of micro-organisms is disproportionately high, and it must be inferred that bacterial contamination of the air, though as a rule parallel to chemical contamination, may yet vary quite independently as the result of special conditions. Wind or strong draughts for example might be expected to raise the number of micro-organisms in the air, while lowering the degree of chemical impurity. I cannot, however, explain the high numbers of bacteria found in Observations VII. and VIII. in this manner, as there were no particularly strong draughts noticeable on these occasions. On the whole the correspondence in the curves in the diagram is greater than I anticipated, but although this is so, it is plain from the occasional discrepancies that chemical examination alone cannot be taken as a trustworthy guide to the bacterial contamination of the air. B.—As concerns the species of micro-organisms found. I pass now from the total numbers of organisms found in the air to the actual species identified. The identification of the species in so large a number of colonies was an infinitely more laborious matter than the enumeration of the colonies, and the labour was much increased by the fact that many of the common air organisms are imperfectly described. Indeed I met with several species to which I could attach no name at all, and in many other cases the identification was only approximate. My method of procedure was to make a sub-cultivation from the original colony, and if it proved, as was occasionally the case, to be impure, to separate the diSerent species by the usual approved methods until I had pure cultures. These were then examined microscopically, stained and unstained, in order to determine the group to which the species belonged. Subcultures were then made on different media, gelatin, agar-agar, potato, broth, milk, etc., and were incubated at 20° C. and 37° C. The colour, mode of growth and other characters of the species were thus determined, and by comparison with the descriptions in standard text books and monographs, the species could as a rule be satisfactorily identified. In many cases, however, further tests had to be employed. In the case of a series of six different yeasts, the power of fermenting grape sugar was kindly determined for me by Mr. WoodSmith. In the case of bacilli resembling bacillus coli communis, in addition to testing the power of coagulating milk, 1 had to test the power of gas formation in glucose-gelatin, the production of indol, and the reduction of neutral red. Flagellum staining was resorted to in one or two cases. The bacilli belonging to the diphtheroid group were grown on serum, and tested by Neisser's method of staining, and their power of acid formation in glucose broth was also determined. One colony, which in some respects resembled the diphtheria bacillus, was tested on a guinea pig, but proved quite harmless. This was the only instance in which the inoculation test appeared to me necessary, as in no other case (excepting the common pyogenic skin cocci and bacillus pyocyaneus) was any organism found which resembled any known pathogenic species. Table of species found (excluding moulds) with their occurrence. No. of cola. met with in the c.l.r. No. of cols. in fresh air. No. of cols. met with in the c.l.r. No. of cols in fresh air. Streptococcus sp — 1 Bacillus vaculatus — 1 Staphylococcus pyogenes albus 2 — „ carneus ... 1 1 „ epidermidis albus 2 2 „ pyocyaneus 1 — „ cereus flavus 20 16 ,, ochraceus 1 1 „ „ albus 21 6 „ aquatilis 1 — Micrococcus cremoides 7 4 „ helvolus 4 11 „ candicans 16 6 „ latericius 4 4 „ rosettaceus 7 6 „ luteus 8 6 „ coronatus 3 1 „ domesticus — 1 „ versatilis 1 — „ eta 2 — „ flavus 15 8 „ fulvus 2 5 „ citreus conglomeratus 2 6 „ subochraceus — 4 ,, aurantiacus 3 7 „ arborescens 1 4 „ roseus 1 — ,, erythromyxa — 1 „ citreus 16 11 „ aeris minutissimus 1 4 „ orbicularis 1 1 „ lactis innocuus 10 20 „ lactis 11 10 „ arborescens non-liquefaciens — 1 „ orbiculatus 1 — „ concentricus 3 2 „ pseudo diphtheria (two species) 3 1 „ albicans tardissimus 14 3 „ citreus agilis — 1 „ xerosis 2 3 Diplococcus luteus 1 — Streptothrix Forsteri 6 5 Sarcina aurantiaca — 1 „ chromogenes 5 1 „ lutea 44 6 „ albido-flava 7 1 „ flava 22 8 Saccharomyces cerevisiæ 8 — alba 21 4 Torula rosea 1 3 Bacillus subtilis 1 — „ alba 8 3 „ mesentericus vulgatus 2 1 „ ,, liquefaciens 1 1 „ „ fuscus 1 — Oidium sp. 1 3 „ „ ruber 1 1 (Note.—The determination of some of the species in the foregoing list is to be taken as approximate only, for the reasons given in the text.) 20 In the preceding table I have enumerated all the species of bacteria, streptothrices and yeasts which I could certainly or approximately identify, and indicated the number of colonies in the railway air and in the fresh air which were referred to each species. The total number of colonies from which cultures were made was between 500 and 600. The number of species identified was 58, viz., 26 micrococci, 24 bacilli, 3 streptothrices and 5 yeasts. In addition to these there were some 10 or 12 species which baffled my efforts at determination, and of which most have probably not been described. It will be seen that I have omitted moulds from the table. By far the commonest mould met with was penicillium glaucum, and not far behind it came another penicillium, closely allied, but of a more ashy-grey tint. The genus aspergillus was also common, the usual species being aspergillus glaucus, though aspergillus flavus, aspergillus fumigatus, aspergillus niger and other species were sometimes found. The genus mucor was much less common. In addition to these genera were a number which I could not determine. I made many sub-cultures, and examined them in various ways, but I abandoned the attempt to name them, partly because I could not find any work in which they are adequately described, and partly because it did not appear of any great importance to name them. As regards total numbers, I found moulds somewhat more abundant in the fresh air than in that of the Central London Railway. My figures show 107 mould colonies from the fresh air as against 94 from that of the railway. As regards the proportion of moulds to bacteria, I find that my results give a much lower proportion of moulds than that usually accepted as present in the air. Taking the totals from the gelatin plates incubated at 20° C., I found in the railway air, out of a total of 574 colonies, 93 moulds, or 16.2 per cent. In the fresh air, out of a total of 407 colonies, 101 were moulds, or 24 8 per cent. The highest proportion of moulds was met with in a sample of fresh air from Hydepark, where it reached 76.4 per cent. of the total, while in the two samples taken from a scaffold in Newgate-street it reached 41.3 per cent. In the air of the Central London Railway the proportion twice reached 44.4 per cent., and was once as low as 1.8 per cent. The comparatively low average percentage of moulds may be due to the fact that I habitually made my final count on the fourth day of incubation for reasons which I have already given. As regards the species of moulds found respectively in the air of the Central London Railway and in the fresh air, I have only to record that the majority of the species which I was unable to identify were found in the fresh air. The species of penicillium, aspergillus and mucor were distributed more or less indiscriminately. As regards the bacteria, the most striking fact brought out in the above table is the very great relative preponderance of sarcinae in the air of the railway, to which I have already alluded, and which I am unable to explain. I am not aware of any published statistics dealing with the relative numbers of different bacterial species in pure and in vitiated air; so far as I know, no such observations have been previously made. The fact, therefore, must for the present stand alone. It may prove of some value as a test of atmospheric contamination, or it may not. But the mere presence of large numbers of these non-pathogenic sarcinae can hardly be, in itself, harmful. Much the same criticism may be applied to the lesser, but still marked preponderance, in the railway air of the organisms which I have designated staphylococcus cereus flavus, staphylococcus cereus albus and micrococcus flavus. These organisms are closely related to the sarcinae, and differ from them mainly in their inability to form the typical bales and packets which characterise the genus sarcina. This property varies, however, on different media, and it is quite possible that some of the colonies I have tabulated under the above headings were really sarcinæ. Indeed, I was able to correct several errors of this sort. Attention may further be drawn to the genus streptothrix, which occurred in the railway air between twice and thrice as frequently as in the fresh air. Little remains to be said of the other species found, which, for the most part, occurred in small numbers. By far the greater number were present indiscriminately in the railway air and in the fresh air. Eleven species were found in the railway air only, and eight in the fresh air only. I was struck by the chemical inactivity of the vast majority ot the micro-organisms present in the air. Of the various yeasts tested only one species could ferment sugar, and of a large number of bacterial colonies which I had occasion to test I did not find one which yielded gas in glucose-gelatin shake-cultures, or which was capable of causing the lactic acid fermentation in milk. A word of comment and criticism is required in conclusion as to my failure to demonstrate pathogenic species in the air. My attention was so constantly directed to their discovery that I feel tolerably sure that none were overlooked in the 600 or so colonies which I examined. The absence of streptococci was a surprise to me in view of their abundance in the human mouth. The solitary species I found was in the fresh air in Newgate-street; it formed no acid and did not coagulate milk. The white pyogenic coccus (staphylococcus pyogenes albus) was found twice, and the allied staphylococcus epidermidis albus four times. These are common on the human skin, and may well have had a human, or at least an animal origin. Bacillus pyocyaneus, rarely pathogenic to man, was once found in a passage of the Central London Railway. I have classed as bacillus pseudo-diphtheriæ two, if not three, species of diphtheroid bacilli, all of which were submitted to the usual tests. They were not the diphtheria bacillus, nor were they Hoffmann's bacillus nor bacillus xerosis, so I have been content to class them vaguely. The xerosis bacillus, which may have had a human origin, was met with five times. Bacillus coli communis, which I confidently expected to meet with from its abundance in horse-dung —so common an ingredient in street dust—was never once found, though every colony at all resembling it was carefully tested. The probable explanation of this approximate failure to find not only pathogenic organisms but even the commoner saprophytic organisms of the mouth and intestine is, in my opinion, to be found in the method which I was obliged to employ. In order to compare different samples of air as to bacterial contamination, the obvious and only method was to determine the number and the varieties of the bacteria present in known volumes of air. The task would have been impossible had I not employed a very limited volume for each estimation—in this case 10 litres for each sample examined. The primary problem was in essence a botanical one, and I do not regret the method I used, because the 21 foundations of our knowledge concerning the bacterial flora of the air must be thus laid, and they are only beginning to be laid. Had pathogenic bacteria been present in any numbers in the 240 litres of air which altogether was submitted to analysis, they would almost certainly have been detected. But from what is known as to the distribution of pathogenic organisms in other media, water for example, it may safely be inferred that their distribution in air must be extremely sparse. So long as our knowledge of the distribution of bacillus coli communis in water was confined to the examination of plate cultivations made from a single cubic centimetre of the water sample, we remained in comparative ignorance. But improved methods, directed to the recognition of this particular organism, have shown that it is far more widely distributed than was at first imagined. We now take 1000 cc. of the water, concentrate the bacteria in it into small compass, and make cultures in a medium which favours the growth of this special bacillus while hindering the growth of other organisms. Methods of this nature will have to be evolved and applied to the examination of air if we are to learn anything of the distribution of pathogenic organisms in it. And special methods will have to be evolved for the recognition of each particular pathogenic organism. The method which I employed in the foregoing investigation was, I believe, excellently adapted to the study of the general bacterial flora of the air. But it was probably very ill adapted to the recognition of given pathogenic micro-organisms on account of the small volumes of air to which I was necessarily confined. It will be needful in the future, when once the general nature of the bacteria present in the air is well established, to devise special methods for the recognition of the more important species pathogenic to man, and to employ these methods upon very large volumes of air. The bacteriological examination of air is, in fact, in its infancy, but those principles which have advanced our knowledge as to the bacteriology of water may be expected to prove equally fruitful in this field also. I have felt compelled to pass this criticism upon my own results, lest any undue stress should be laid upon the absence of important pathogenic bacteria from the list of species which I succeeded in isolating from the air of London generally, and that of the Central London Railway in particular. Had I not done so others would doubtless have done it for me. The general results of the investigation may be summarised in the following propositions— (1.) Micro-organisms were found present in the air of the Central London Railway in a somewhat greater proportion than in the fresh air outside. Taking all the results together, the exact proportion was as 13 to 10. (2.) The number of micro-organisms found was high in proportion to the concentration of human traffic; highest in the railway carriages, platforms and lifts. Elsewhere I found it low. (3.) The air of the railway does not, in it bacterial content, compare unfavourably with that known to exist in inhabited rooms generally. (4.) No pathogenic germs, other than those commonly present as saprophytes upon the normal body, were detected in such small volumes of the air as could be submitted to analysis under the conditions of the investigation. (5.) The number of organisms capable of growing at the temperature of the human body was considerably greater in the air of the Central London Railway than in the fresh air, but the excess was due to non pathogenic sarcinae and allied species. (6.) The number of micro-organisms in the air of the railway was found generally proportional to the degree of chemical contamination, but this rule was subject to striking exceptions. (7.) The species of micro-organisms found were in the main identical with those occurring in the fresh air. Frederick W. Andrewes, M.D., F.R.C.P., D.P.H. St. Bartholomew's Hospital, July 31st, 1902. London County Council. TECHNICAL EDUCATION BOARD. Reports on the Medical Examination of County Scholars, 1902-3. The following reports upon county scholars who were elected in the year 1902-3 have been prepared by the Board's Medical Officers, Dr. Leslie Thorne Thorne and Dr. May Dickinson Berry— I.—Report upon the boys by Dr. Leslie Thorne Thorne. At the medical examination of the scholars, held under the direction of your Board in September, 1902, and January, 1903, 348 junior, 72 intermediate, and 23 training college scholars presented themselves. Analysis of the physical examination of 348 junior scholars. General appearance.—132 good, 123 fair, 72 rather delicate, 19 delicate, and 2 very delicate. Previous illnesses.—269 had had measles, 71 whooping cough, 72 scarlet fever, 56 chickenpox, 18 bronchitis, 16 diphtheria, 13 mumps, 9 influenza, 8 croup, 8 pneumonia, 3 ringworm, 2 pleurisy, 2 congestion of the lungs, 2 jaundice, 2 rheumatism, 1 small-pox, 1 appendicitis, and 1 colie. Table of heights and weights. Age 10. Age 11. Age 12. Total number examined 4 85 259 ft. in. ft. in. ft. in. Average height 4 8 4 7¾ 4 8½ Number 10 per cent. above average — 2 9 „ 20 „ ,, „ — — 1 „ 10 „ below „ — 1 6 „ 20 „ „ „ — — — st. lb. st. lb. st. lb. Average weight 5 9 5 l½ 5 7 Number 10 per cent. above average — 16 46 „ 20„ „ „ — 5 19 „ 10 „ below — 15 32 „ 20 „ „ „ — 5 6 Circumference of chest at forced inspiration. Inches. Number of cases. Percentage of total cases. 24 to 25 3 .8 25 „ 26 18 5.3 26 „ 27 63 18.1 27 „ 28 121 34.8 28 „ 29 69 19.8 29 „ 30 52 15.0 30 „ 31 15 4.3 31 „ 32 5 1.4 32 „ 33 2 .5 Degree of chest expansion. Inches. Number of cases. Percentage of total cases. 1 20 5.7 2 196 56.3 3 119 34.2 4 13 3.7 [T.N. 1102 2 Lungs.—Two cases, or 1.26 per cent., showed signs of slight bronchitis, but there was no serious chest trouble. Heart.—In 30 cases, or 8.6 per cent., the heart was affected; of these, 5 suffered from shortness of breath and 9 from albuminuria. Classified technically, the varieties of heart affections were—10 cases of mitral regurgitation, 6 of mitral stenosis, 6 of simple hypertrophy, probably nephritic, 4 of simple hypertrophy with albuminuria, 2 of mitral regurgitation and stenosis, 1 of aortic regurgitation, and 1 of mitral regurgitation and pulmonary stenosis. In only one of the above was the affection serious enough to be a cause of present invalideism, but to minimise the risk of future trouble in the other cases it was highly important that the instructions, as to recreations and callings to be avoided in these particular cases, should be followed out by the parents to whom these instructions are sent. As at previous examinations, there was present in a large number of cases an indefinite presystolic apex murmur unaccompanied by any signs of heart trouble, which I am convinced is due to circulatory disturbance produced by nervous excitability, and is of no definite import. Only in one case of heart affection was there a definite history of rheumatism, and none had suffered from chorea. Spine.—There were no cases of spinal disease. Eyes.—8 scholars, or 2'2 per cent., were affected with colour blindness. Of these, 3 suffered from confusion of colours, i.e., imperfect colour vision, and 5 were definitely colour blind. Acuteness of vision.—In 71, or 20.4 per cent., vision was below "army standard" (one-third perfect vision). Of these, only 23 were wearing glasses. In 8 of the 71, the vision of one eye only was below "army standard," the vision of the other being perfect. Of the 348 junior scholars, 158, or 45.4 per cent., had perfect vision. Throat and nose.—115 scholars, or 36.4 per cent., had enlarged tonsils, adenoids, or both. Of these, 95 had enlarged tonsils, 8 enlarged tonsils and adenoids, and 12 adenoids. 38, or 33'0 per cent., had more or less defective hearing, and 25 of these required treatment to prevent increasing deafness, but in the remaining 77 the abnormality was very slight, and of no import. Hearing.—72 scholars, or 20.6 per cent., suffered from defective hearing. Of these— In 48 the hearing was fair (the tick of a watch could not be heard at more than 2 feet). In 18 „ „ poor ( „ „ „ „ „ 1 foot). In 6 „ „ bad ( „ „ „ „ „ 4 to 6 inches). Of the 72 scholars who suffered from defective hearing, 38 suffered from enlarged tonsils, adenoids, or both, 2 from nasal obstruction, 3 had discharge from their ears, and 3 had had discharge at some previous time. With reference to the effect of adenoids upon the hearing and mental condition of boys, Dr. Wilbert gave, in the "Deutscher Medicinisch Wochenschrift" of 5th February, 1903, his experience in the examination of 231 boys suffering from this complaint. He found that 27 per cent. were affected in their hearing, 16 per cent. not being able to hear whispered speech at a distance of one metre. With regard to the mental condition, he found that of 26 children who were described as bad scholars, 22 had adenoids, and that of the 84 boys, forming the bottom 12 in each class, 65 suffered in this way. I do not hesitate to quote the above in this report, as I am convinced that, from an educational point of view, it is of great interest. It is worthy of remark that among the 1,890 boys who have taken county scholarships and been examined by me during the last five years, only 96, or under 6 per cent. of the whole number, have shown any signs of adenoids in the naso-pharynx, and none of these have been bad cases. Urine.—52, or 14.9 per cent. of the junior scholars had albumen in the urine. In 31 of these there was only a trace; 15 had been examined twice, with an interval of three months between the examinations, and in 5 no albumen was present on the second occasion. In 12 there was a fair cloud; 5 had been examined twice, with an interval of about three months between the examinations, and in 3 no albumen was present on the second occasion. In the remaining 9 there was a heavy deposit of albumen; 4 had been examined twice, with an interval of about three months between the examinations, and in one of these no albumen was present on the second occasion. In those cases, 20 in number, in which albumen was present in the urine on two separate occasions, some organic kidney mischief is probably present. Skin.—One scholar had ringworm, and immediate steps were taken to inform his parents of the fact. Nervous system.—Three scholars were rather badly affected with stammering. Other cases of deviation from the normal.—One scholar had a congenital hernia on the right side, and one gave a definite history of a tendency to hæmophylia. Analysis of the physical examination of 72 intermediate and commercial scholars. General appearance.—36 good, 24 fair, 3 rather delicate, and 9 delicate. Previous illnesses.—59 had had measles, 19 whooping cough, 19 scarlet fever, 8 chicken-pox, 3 mumps, 3 congestion of the lungs, 2 diphtheria, 2 typhoid fever, 1 rheumatism, 1 croup, 1 influenza, and 1 ringworm. 3 Table of heights and weights. Age 13. Age 14. Age 15. Age 16. Total number examined 2 28 39 3 ft. in. ft. in. ft. in. ft. in. Average height 4 ll¾ 5 3 5 4½ 5 5 Number 10 per cent. above average — — 1 — „ 20 „ „ — — — — „ 10 „ below average — 2 2 — ,, 20 „ ,, — — 1 — st. lb. st. lb. st. lb. st. lb. Average weight 6 0 7 5½ 8 0 7 6 Number 10 per cent. above average — 7 12 — „ 20 „ „ — 4 4 — „ 10 „ below average — 8 12 — „ 20 „ „ — 1 6 — Circumference of chest at forced inspiration. Inches. Number of cases. Percentage of total cases. 25 to 26 1 1.4 26 „ 27 1 1.4 27 „ 28 2 2.8 28 „ 29 4 5.6 29 „ 30 11 15.3 30 „ 31 15 20.8 31 „ 32 5 6.9 32 „ 33 14 19.4 33 „ 34 7 9.7 34 „ 35 9 12.5 35 „ 36 2 2.8 36 „ 37 1 1.4 Degree of chest expansion. Inches. Number of cases. Percentage of total cases. 1 2 2.8 2 13 18.0 3 39 54.2 4 18 25.0 Lungs.—There were no cases of lung disease. Heart.—In 4 cases, or 5.6 per cent., the heart was affected. One of the scholars affected was short of breath and one had albuminuria. Technically classified, the heart affections were of the fallowing varieties:—2 of mitral regurgitation and 2 of mitral stenosis. Spine.—One boy suffered from lateral curvature of the spine due to partial paralysis and shortening of one leg. Eyes.—Two of the intermediate scholars suffered from colour blindness. Acuteness of vision.—Of the 72 scholars 31, or 43.0 per cent., had perfect vision. In 22 cases, or 30.5 per cent., the vision was below "army standard"; 16 of them were wearing glasses, in one of these only one eye was affected. Throat and nose.—34 cases, of 47.2 per cent., had enlarged tonsils, adenoids, or both. Of these, 3 had adenoids, 2 had enlarged tonsils and adenoids, and 29 had enlarged tonsils, but in only two of these latter were the tonsils hypertrophied to an extent to require treatment. Seven in all of the 34 cases required operative treatment. Of the above 34, 12, or 16.6 per cent., had defective hearing. Hearing.—23 scholars, or 31.9 per cent., had defective hearing. In 10 the hearing was fair, In 3 „ „ poor, and in 10 „ „ bad. Out of the 23 cases suffering from more or less defective hearing, 12 had adenoids, enlarged tonsils, or both, 2 had discharge from their ears, and 2 had had discharge at some previous time. Urine.—18 scholars, or 25 per cent., had albumen in the urine. In 11 of the cases there was only a trace; all but one of these had been examined a second time, at an interval of three months, and only in 3 cases was albumen found on the second occasion. 4 In 3 there was a fair cloud, but none of these cases showed presence of albumen at the second examination. In 4 there was a thick cloud, and of these albumen was present in 2 on the second occasion. Nervous system.—Three of the intermediate boys suffered badly from stammering, an affliction which would exclude them from any Government appointment. Advice as to occupation.—On the reports of those scholars suffering from colour blindness, defective vision, heart or kidney mischief, advice was given as to the pastimes and occupations it would be well for them to avoid, and the probability of some of them not being able to obtain posts for which physical examinations had to be passed, was, mentioned. The number of children who are found to be suffering from defective hearing, defective eyesight, or adenoid growth in the naso-pharynx, undetected and therefore untreated, among a class of boys who, being winners of scholarships, are probably above the average London schoolboy in physical as well as mental powers, makes it evident that great good could be done, and much irretrievable and permanent harm prevented, by a more general medical inspection of schoolboys than is now the custom. Analysis of th« physical examination of 23 training college scholars. General appearance.—19 good, 4 fair. Lungs.—There was no case of lung disease. One lad, whose brother died of consumption, had signs of an old abscess under one arm, but was at the time of examination in good health and fairly robust. Heart.—One scholar had slight mitral regurgitation, and 5 had hæmic murmurs, but there was no heart disease of import. Spine.—There was no case of spinal disease. Eyes.—There was no case of colour blindness. Acuteness of vision.—In 18 cases the vision was normal, in 2 it was below "army standard." but in both these glasses were worn. Throat and nose.—3 scholars had somewhat enlarged tonsils, and one had had adenoids removed. One scholar was suffering from chronic laryngitis. One of the scholars with enlarged tonsils had defective hearing. Hearing.—2 scholars suffered from defective hearing. In 1 the hearing was fair, and in 1 „ „ poor. The latter had had a discharge from both ears in childhood. Urine.—In 3 cases there was a faint cloud of albumen in the urine, one of these had had scarlet fever. General Remarks.—The physical condition of these scholars was, on the whole, decidedly satisfactory, being superior to that of the junior and intermediate scholars, as may be seen by comparing the statistics of general appearance and acuteness of vision and hearing in the three classes. The only scholar who suffered from anything likely to interfere with his career as a teacher was one who had chronic laryngitis. Instructions were given as to this being treated, and the lad will be re-examined later. Leslie Thorne Thorne, 26th June, 1903. Medical Examiner. II.—Report upon the girls by Dr. May Dickinson Berry. At the medical examination held in September, 1902, and January, 1903, 247 junior and 29 intermediate scholars presented themselves. Analysis of the physical examinations of 247 junior scholars. General appearance.—140 good, 100 fair, 7 delicate. Previous illness.—223 had had measles, 150 whooping cough, 61 scarlet fever, 16 diphtheria, 20 bronchitis, 8 pneumonia, 2 pleurisy, 4 croups, 2 tuberculous peritonitis, 2 jaundice, 1 rheumatic fever, 1 convulsions. Table of heights and weights. Age 10. Age 11. Age 12. Age 13. Total number examined 4 32 165 46 ft. in. ft. in. ft. in. ft. in. Maximum height 4 6 5 2 5 3 5 5 Minimum „ 4 4 4 0 4 2 4 0 Average „ 4 5 4 7 4 9 4 10 Number 10 per cent. above average — 5 6 1 „ 20 „ „ „ — — — — „ 10 „ below „ — 3 7 1 „ 90 „ „ „ — — — — St. lb. st. lb. st. lb. st. lb. Maximum weight 5 3 6 13 8 6 7 13 Minimum „ 4 7 3 9 3 12 3 10 Average „ 4 11 5 1 5 6 5 11 Number 10 per cent. above average 1 10 44 10 „ 20 „ „ „ — 4 26 7 „ 10 „ below „ — 7 48 17 „ 20 „ „ „ — 3 22 5 5 Circumference of chest at forced inspiration. Inches. Number of cases. Percentage of total cases. 24 to 25 2 .8 25 „ 26 13 5.3 26 „ 27 24 9.7 27 „ 28 62 25.1 28 „ 29 57 23.1 29 „ 30 45 18.2 30 „ 31 22 8.9 31 „ 32 12 4.9 32 „ 33 8 3.2 33 „ 34 2 .8 Degree of chest expansion. Inches. Number of cases. Percentage of total cases. 1 to 2 10 4.0 2 „ 3 123 49.8 3 „ 4 99 40.1 4 „ 5 14 5.7 5 „ 6 1 .4 Lungs.—There was no case of lung disease. Heart.—In two cases there was a distinct valvular murmur indicating mitral regurgitation. In neither case was there any history of previous disease to which the cardiac affection could be attributed, and in neither case was the general health in any way affected. There were no cases of anaemic murmurs. Spine.—In 28 cases, nearly 10 per cent., there was some tendency to lateral curvature of the spine, but in none did this amount to permanent bony deformity. A course of gymnastics was recommended in most of these cases. Extremities.—Four children had slight flatfoot, 2 had bow legs, and one rickety curving of the tibiae, all slight in degree. One scholar had some congenital contraction of the little fingers ; this was also of a slight degree. Nervous system.—A tendency to slight twitching of the fingers was. noticed in 9 cases, otherwise no abnormalities of the nervous system were observed. Eyes.—There was no case of colour blindness. Acuteness of vision.—105 children, nearly 43 per cent., possessed perfect vision. 39, i.e, 15 per cent., were below "army standard." In 15 of these one eye only was below this standard, the other eye being normal or defective to a less degree. 11 had glasses already, 20 were recommended to consult an oculist. There were two cases of strabismus, one corrected by glasses, the other, as yet, without treatment. Throat and nose.—There was one case of adenoids and 10 of enlarged tonsils. In none of them was any deafness present. Three cases were advised to have treatment. Hearing.—In 9 cases the hearing was below normal. In one case a watch which should have been heard at 20 inches was audible at 2 only on either side. The deafness followed severe earache 1½ years ago and is not likely to increase. Slight deafness was known to exist, but it is not noticeable in ordinary conversation, and is not likely to interfere seriously with her success in life. In another case the watch was inaudible even in contact on one side, but on the other side the hearing was normal, and neither the girl nor her relations were aware of the existence of any deafness. In the other cases the defect in hearing was of slight degree, and was present on one side only. One case was advised to have treatment from an aurist. Urine.—Albumen was found in the urine in 36 cases, 14.5 per cent. 23 of these were examined twice; 19 of these had albuminuria on both occasions. All these scholars were in good health, and none showed any other symptoms of kidney disease. Analysis of the examination of 29 intermediate scholars. General appearance.—Good 18, fair 8, delicate 3. Previous illness.—28 had had measles, 16 whooping cough, 7 scarlet fever, 7 bronchitis, 1 diphtheria, 2 rheumatic fever, 2 croup, 1 pneumonia, and 1 jaundice. 6 Table of heights and weights. Age 13. Age 14. Age 15. Total number examined 2 11 15 ft. in. ft. in. ft. in. Maximum height 5 1 5 5 5 5 Minimum „ 5 1 4 5 5 0 Average „ 5 1 5 1 5 2 Number 10 per cent. above average — — — „ 20 „ „ „ — — — „ 10 „ below „ — 1 — „ 20 „ „ „ — — — st. lb. st. lb. st. lb. Maximum weight 7 10 7 13 9 11 Minimum „ 7 7 5 7 6 4 Average „ 7 8 6 13 7 13 Number 10 per cent above average — 2 3 „ 20 „ „ „ — — 2 „ 10 „ below „ — 3 3 „ 20 „ „ „ — 1 — Circumference of chest at forced inspiration. Inches. Number of cases. Percentage of total cases. 28 to 29 2 7.0 29 „ 30 2 7.0 30 „ 31 5 17.1 31 „ 32 5 17.1 32 „ 33 7 24.2 33 „ 34 5 17.1 34 „ 35 1 3.5 35 „ 36 1 3.5 36 „ 37 1 3.5 Degree of chest expansion. Inches. Number of cases. Percentage of total cases. 1 to 2 2 7.0 2 „ 3 7 24.1 3 „ 4 17 58.6 4 „ 5 3 10.3 Lungs.—There was no case of lung disease. Heart.—There was one case of mitral regurgitation, probably the result of rheumatic fever some years previously. This girl was also examined when a junior scholar. The heart appears to be in the same condition as on that occasion, and the general health is not impaired. Spine.—One girl had slight lateral curvature of the spine. Eyes.—There was no case of colour blindness. 20 cases, 69 per cent., had perfect vision. In 4, i.e., 13.8 per cent., the vision was below "army standard," in one case one eye only being affected. One only possessed glasses; the other three were recommended to see an oculist. Throat and nose.—Four girls had slightly enlarged tonsils. Hearing.—In one case there was deafness on one side, the watch being heard on contact only. This girl had had otorrhœa in childhood, and had had an operation upon the mastoid. Urine.—There were 4 cases, 13.8 per cent., of albuminuria. Three of these were examined on two different occasions, and in all these the albumen was present at both examinations. The general health was good in every case. Remarks.—The results of these examinations are very similar to previous ones, and show, on the whole, a satisfactory condition of general physique in the scholars examined. The large number of cases of weak back muscles, causing a tendency to lateral curvature, suggests that more ought to be done in the way of physical exercise and gymnastics in elementary schools for girls. 7 Report on Training College students. 34 students were examined; all there were passed. The general standard of health was, on the whole, satisfactory. 26 students were classed as of good general appearance, 8 as fair and none as delicate. There were 9 cases of defective vision; these were all cases of errors of refraction, which had already been corrected satisfactorily by glasses. In 4 cases some albumen was present in the urine; in 3 the amount was slight and the condition, in my opinion, of no importance; in the fourth there was considerable albuminuria. This student was carefully examined and the urine tested on two subsequent occasions, a mere trace and no albumen being found respectively. As the microscopical examination showed no evidence of kidney disease, I came to the conclusion that the albuminuria was not due to organic disease and that the girl might be allowed to enter the college. May Dickinson Berry, Medical Examiner. 116, St. Martin's-lane, W.C., July, 1903.