r* LCC 12 London County 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 1903. (Printed by order of ike Council, 19th July, 1904.) PRINTED BY JAS. TRUSCOTT AND SON, LTD., LONDON, E.C. - «-? i "e. ^ i 7- St J*/-* //r, S^h?<£c- London County Council. Report of the Public Health Committee submitting the report ot the Medical Officer of Health of the County of London for the year 1903. In submitting the medical officer's report for 1903, we are glad to state that the London death rate from all causes per 1,000 living has further declined to 15'2, the lowest on record. The medical officer points out that the remarkably low death rate for that year was not peculiar to London, and that it appears probable that some general cause, such as favourable meteorological conditions, was largely responsible for the phenomenon. The infant mortality rate has also declined, and both in the period 1893—1902 and in 1903 was lower in London than in any of the principal English towns except Bristol. The rate is, however, unfortunately, far higher than it ought to be, and we are giving the subject our anxious consideration. The number of marriages in London in 1903 was 40,215, giving an annual rate of persons married of 17*4 per persons living, a slight decrease in the rate (17"8) for 1902. The steady decline in the birth rate has continued, that for 1903 being 28'4 per 1,000 living, the lowest rate recorded in London since the institution of civil registration. The number of cases of small-pox noticed in London in 1903 was 416 as compared with 7,796 in 1902, and 1,700 in 1901, the deaths from this disease in these three years being respectively 13, 1,314, and 229. It will thus be seen that, although the severe epidemic with which London was visited in the last few months of 1901 and the early part of 1902 was practically at an end at the close of August, 1902, a number of cases have since been from time to time reported. We have continued our efforts to minimise the spread of the disease in common lodging houses and seamen's lodging houses, and, when requisite, such houses have been visited daily by a medical expert specially employed for the purpose. In some instances it has been necessary for the Council, as on past occasions, to pay for the board and lodging of destitute occupants of such houses who had been in contact with cases of this disease, this course being taken in order that these " contacts " might be kept under observation. Measles still continues the cause of deplorable mortality, no fewer than 2,046 deaths in London being attributed to this disease in 1903. The Council has, on our advice, made an order, which came into operation on 1st April, 1903, applying to measles certain sections of the Public Health (London) Act, 1891. This order has the effect, while not making the disease notifiable, of placing it on a level in other respects with the dangerous infectious diseases specified in the Act. It is too early yet to gauge the results of the order, but we hope it will have a good effect in impressing upon those charged with the custody of children the necessity of taking proper precautions against the spread of the disease, especially having regard to the fatal effects which often ensue from the exposure of sufferers from this malady before they have fully recovered from it. We are pleased to observe that in 1903 there was a considerable reduction in the number of cases of scarlet fever, diphtheria, and enteric fever in London, as compared with the preceding year. The case mortality from diphtheria also showed a progressive decline during the preceding ten years. The result of investigations made by Dr. Hamer into exceptional prevalences of enteric fever in London at the close of 1903 pointed to infected fish as the source of the outbreaks in question (Appendix I.) T he deaths from influenza and bronchitis were also considerably below the annual average of the preceding ten years. The medical officer points out the rapidity with which influenza may increase from small to epidemic proportions and calls attention to the fact that the mortality from this disease has usually attained its maximum in the late autumn and winter months. Phthisis was the cause of 7,124 deaths in London in 1903, as against 7,424 in 1902. The deaths registered under the heading " Cancer " still increase. 4,695 deaths were ascribed to this cause in 1903, the annual average of the preceding ten years being 3,964. There were no cases of bubonic plague in London in 1903, but the Council's arrangements for dealing, in case of necessity, with " contacts" have been maintained, and prompt action was taken with regard to suspected cases. The spread of enteric fever from the consumption of oysters and other shell fish which have been exposed to sewage contamination has been the subject of reports which we have from time to time made to the Council, and the fourth report of the Royal Commission on Sewage Disposal suggests measures which should be adopted with a view to minimising this danger. The Council has, on our advice, urged the Local Government Board to promote legislation to give effect to these recommendations of the Royal Commission. Watercress has also been held to be a source of danger when gathered from polluted sources, and we are now engaged in making a thorough investigation into this subject. The question of the purity of the milk supply of London has recently excited public attention, and we think it right to remind the Council that in 1902 it made an unsuccessful attempt to obtain from Parliament powers to deal more effectively with milk which had been exposed to infection. The Council has, on our recommendation, decided to make a further attempt in the session of 1905 to obtain these powers, which we think are urgently needed in the interests of the London public. 2 Inquiry has been made by Dr. Hamer into the conditions under which aerated waters are manufactured, with the result that many possible sources of pollution were found, and in particular instances it was ascertained that risk of contamination was not adequately guarded against (Appendix III.). The desirability of legislation to give sanitary authorities powers of control in this matter has been represented by the Council to the Local Government Board. With the object of obtaining information as to the condition of houses originally built for one family but now inhabited by several families, we directed the medical officer to make inquiry on the subject. Of such houses there are a very great number in London, and their sanitary fitness for their altered use is a matter involving the sanitary condition of large numbers of people. The enquiries, which were made by Ur. Young, were necessarily rather limited in extent, but may be taken as fairly typical. They showed how in a very large proportion of such houses scarcely any alterations had been made to adapt them to their altered use (Appendix II). The means were very inadequate for a proper supply of water, and for the preparation of cooked food, and in many other important respects they were defective. The subject is receiving our serious consideration. We have also devoted much attention to the question of the enforcement throughout London of the by-laws regulating houses let in lodgings. We feel this to be a matter of primary importance to the public health and to the well-being of the people, and should like to see much larger use made by the sanitary authorities of tho powers which they possess for this purpose. This question is intimately connected with that of the adequacy of the sanitary staffs of the metropolitan boroughs, and we have from time to time had before us returns showing the number of sanitary inspectors in proportion to the population. The return published in 1903 (Appendix IV.) shows some increase in the total number of inspectors in London. The needs of particular districts have been the subject of special inquiries, the results of which have in several instances been to secure an increase in the number of sanitary inspectors. We observe with satisfaction that the medical officer states that the record of the year 1903 shows on the whole satisfactory progress in the administration by the sanitary authorities of their powers in relation to factories and workshops ; also that throughout London alterations and improvements were effected in many bakehouses to meet the requirements of sanitary authorities for the purposes of certification, and in other cases underground bakehouses were disused or closed. Steps are also being taken to ameliorate the conditions under which work in laundries is done, especially with respect to the drainage of floors. As regards the inspection of homes of outworkers, the medical officer emphasises the importance of a sufficient staff of sanitary inspectors. More activity is also being displayed by the sanitary authorities with regard to the inspection of pi-emises where food is prepared for sale, and we observe that in more than one of the annual reports of the local medical officers it is stated that premises on which working men obtain their food are maintained in better condition, especially as to cleanliness, than are those from which food is supplied to persons better circumstanced in life. We have spared no effort to bring the common lodging-houses in London up to a proper standard both as regards sanitation and safety in case of fire. The new licensing powers obtained by the Council in 1902 have enabled it to require improved conditions at a large number of houses, and we hope shortly to be in a position to say that all the common lodging-houses in use in London have been made suitable for the purpose as regards the number, health, safety, and convenience of the occupants. Henry Jephson, Chairman. County Hall, Spring-gardens, S.W., lbth December, 1904 TWELFTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. TABLE OF CONTENTS. Part I.— page Population 5 Marriages 5 Births 6 Deaths 6 Rates of mortality in the several metropolitan boroughs 9 London mortality in 1903 compared with the mortality in the decennium 1891-1900 10 Infant mortality 11 Deaths from certain diseases and groups of diseases 12 Principal epidemic diseases 13 Smallpox and vaccination 15 Measles 20 Scarlet fever22 Scarlet fever and elementary schools 24 Age and sex distribution 24 Diphtheria 25 Diphtheria and elementary schools 28 Age and sex distribution 29 Whooping cough 29 Typhus 30 Enteric fever 31 Age and sex distribution 35 Diarrhoea 36 Erysipelas36 Puerperal fever 37 Influenza, bronchitis and pneumonia 38 Phthisis 39 Cancer 41 Bubonic plaguo 43 Meteorology 43 Part II.— Dairies, cowsheds and milkshops 44 Offensive businesses 46 Nuisances 47 Smoke nuisances 47 Flooding of basements 47 Housing of the Working Classes Act 48 Representations under Part I. of the Housing of the Working Glasses Act 48 Schemes under Part I. of the Act 49 Schemes undertaken by the County Council under Part II. of the Act 49 Schemes undertaken by district authorities under Part II. of the Act, the County Council contributing to the cost 49 Proceedings of the County Council under Part III. of the Act 49 Erection of dwellings by the Council in connection with clearances under other Acts50 Proceeaings in respect of houses represented under Part II. of the Act as unfit for human habitation 52 Death rates of persons resident in the County Council's dwellings53 Housing of the Working Classes Act, 1903 53 Houses let in lodgings 53 Houses adapted as tenement houses 57 Common lodging-houses 57 Seamen's lodging houses 61 Customs and Inland Revenue Acts, 1890 and 1891 61 Underground rooms62 The admininistration of the Factory and Workshop Act62 Inspection of food, etc.71 Ice cream 71 Unsound food 71 Manufacture of aerated waters 72 Disinfection72 Shelters 73 Mortuaries 73 Water supply 74 The London Equalisation of Rates Act, 1894 75 Sanitary officers76 Medical officers of health of metropolitan boroughs in 1903 77 Appekdicbs— I.—Report on prevalences of enteric fever in London at the close of 1903. II.—Report on houses adapted as tenement houses. III.—Report on the manufacture of aerated waters in London. IV.—Report on the sanitary staffs of the metropolitan boroughs. 4 LIST OF DIAGRAMS. FACING PAGE Diagram I.—Marriages, 1851-1903 5 II.—Births, 1851-1903 5 „ III.—Deaths (all causes), 1841-1903 7 „ IV.—Seasonal curves based on notified cases of infectious disease (14 years, 1890- 1903) 13 „ V.—Smallpox, deaths, 1841-190315 VI.—Measles, 1841-190320 „ VII.—Scarlet fever; deaths, 1859-1903 22 „ VIII.—Scarlet fever; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 22 „ IX.—Scarlet fever; monthly notifications and case mortality, 1891-1903 23 „ X.—Diphtheria and croup ; deaths, 1859-1903 25 „ XI.—Diphtheria; admissions to and deaths in hospitals of the Metropolitan Asylums Board, per cent, of the total cases and deaths in London 25 „ XII.—Diphtheria; monthly cases and case mortality, 1891-1903 26 „ XIII.—Whooping cough; deaths, 1841-1903 29 „ XIV.—Typhus; deaths, 1869-1903 31 „ XV.—Enteric fever; deaths, 1869-1903 32 „ XVI.—Enteric fever ; weekly notifications, 1903, and mean weekly notifications, 1890-1903 32 ,,XVII.—Enteric fever ; monthly notifications and case mortality, 1891-190233 „ XVIII.—Diarrhoea, dysentery, and cholera; deaths 1841-1903 36 Diagram I. Marriages. Diagram II. Births. REPORT OF THE MEDICAL OFFICER OF HEALTH. 1903. PART I. Population. The population of the administrative county of London, estimated to the middle of the year 1903. was 4.613.812. The population of each of the metropolitan boroughs, as constituted by the London brovernment Act of 1899, estimated to the middle of 1903, is shown in the following table— Metropolitan Boroughs. Estimated population, 1903. Metropolitan Boroughs. Estimated population, 1903. Metropolitan Boroughs. Estimated population, 1903. Paddington 146,032 Stoke Newington 52,069 Bermondsey 129,801 Kensington 178,409 Hackney 224,082 Lambeth 307,711 Hammersmith 115,803 Holborn 57,845 Battersea 173,422 Fulham 147,780 Finsbury 99,717 Wandsworth 249,678 Chelsea 74,169 City of London 24,539 Camberwell 265,562 City of Westminster 179,052 Shoreditch 117,513 Deptford 112,537 St,. Marylebone 131,234 Bethnal-green 130,028 Greenwich 99,824 Hampstead 85,197 Stepney 302,153 Lewisham 136,405 St. Pancras 235,716 Poplar 169,550 Woolwich 121,478 Islington 339,137 Southwark 207,369 Marriages. The number of marriages in the administrative county of London in 1903 (52 weeks) was 40.215. trivins an annual rate of persons married of 17-4 per 1,000 living. The marriage rate in successive periods has been as follows— 1851-60 ... 20.6 1893 ... 17.2 1899 ... 18-6 1861-70 ... 20.3 1894 ... 17.0 1900 ... 18.0 1871-80 ... 19.0 1895 ... 17.2 1901 ... 17.6 1881-90 ... 17.5 1896 ... 18.0 1902 ... 17.8 1891 ... 17.7 1897 ... 18.5 1903 ... 17.4 1892 ... 17.4 1898 ... 18.8 The accompanying diagram (I.) shows the marriage rate in each year since 1850 in relation to the mean marriage rate of the period 1851-1903. In the year 1903 among the males 3'8 per cent, married were under 21 years of age, and among the females 13'7 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 minors per cent, of total marriages. Period. London. England and Wales. Males. Females. Males. Females. 1851-60 2.8 11.9 5.7 18.0 1861-70 3.6 14.6 6.8 20.1 1871-80 4.7 16.9 8.0 22.0 1881-90 5.5 18.9 6.8 20.7 1891 4.9 17.4 5.9 19.0 1892 5.2 17.7 5.9 18.7 1893 4.7 16.8 5.6 18.1 1894 4.7 16.8 5.5 18.1 1895 4.4 15.9 5.2 17.4 1896 4.9 16.1 5.3 17.4 1897 4.6 16.2 5.1 17.0 1898 4.8 16.3 5.1 16.8 1899 4.5 15.8 5.0 16.5 1900 4.5 15.5 5.1 16.3 1901 4.4 15.0 5.0 16.0 1902 4.0 14.1 4.7 15.4 6 Births. The number of births registered in the administrative county of London in 1903 (52 weeks) was 130,906, giving a birth-rate of 28-4 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 1903 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 31.01 1899. 29. 71 1861-70 35.4 1894 30.1 1900 29.11 1871-80 35.4 1895 30.61 1901 29.01 1881-90 33.2 1896 30.21 1902 28.51 1891 31.81 1897 30.11 1903 28.41 1892 30.91 1898 29.71 The accompanying diagram (II.) shows the London birth-rate in each year since 1850 in relation to the mean birth-rate of the period 1851-1903. The following table shows the birth-rate in the several metropolitan boroughs in 1903 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 3,303 22.7 19.8 Kensington 3,567 20.0 19.5 Hammersmith 2,989 25.9 21.0 Fulham 4,789 32.5 24.1 2Chelsea 1,516 20.5 18.8 Westminster, City of 3,018 16.9 15.4 2St. Marylebone 3,984 30.4 26.8 Hampstead 1,456 17.1 17.0 2St. Pancras 6,339 27.0 21.1 Islington 8,983 26.6 20.8 Stoke Newington 1,091 21.0 17.8 Hackney 6,182 27.7 23.0 2Holborn 1,631 28.3 23.3 2 Finsbury 3,693 37.1 28.2 London, City of 338 13.8 14.6 Shoreditch 3,905 33.3 25.7 Bethnal-green 4,627 35.7 28.1 2Stepney 11,329 37.6 29.6 Poplar 5,832 34.5 27.6 Southwark 6,717 32.5 24.2 Bermondsey 4,201 32.5 25.6 'Lambeth 9,080 29.6 23.5 Battersea 4,961 28.7 21.6 Wandsworth 6,722 27.0 23.4 Camberwell 7,311 27.6 22.8 Deptford 3,379 30.1 23.3 Greenwich 2,716 27.3 23.6 Lewisham 3,563 26.2 22.7 Woolwich 3,684 30.4 23.3 London 130,906 28.4 232 Deaths. The number of deaths in the administrative county of London in 1903 (52 weeks) was 69,737, giving an annual death-rate of 15'2 per 1,000 living. The London death-rate in successive periods has been as follows— 1 The rates for these years relate to the Administratire County of London ; the rates shown for the periods prerious to 1891, relate to the Registration County of London. 2 Lying-in hospitals are situated in these districts. The corresponding figures for England and Wales are as follows— 1851-60 34.2 1893 30 .7 1899 29 .1 1861-70 35.2 1894 29 .6 1900 28 .7 1.871-80 35.5 1895 30 .2 1901 28 .5 1881-90 32.5 1896 29 .6 1902 28.6 1891 31.4 1897 29 .5 1903 28 .4 1892 30.4 1898 29 .3 Diagram III. Deaths (All Causes).- 7 All causes—Death-rates per 1,000 living. 1841-50 . 24.8 1892 20.31 1898 18.41 1851-60 23.7 1893 21.01 1899 19.61 1861-70 24.4 1894 17.41 1900 18.61 1871-80 22.5 1895 19.51 1901 17.11 1881-90 20.5 1896 18.21 1902 17.21 1891 21.01 1897 17.81 1903 15.21 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1903 is shown in diagram III The following table has been prepared for the purpose of comparing the death-rate of London with those of other English towns having populations which exceeded 200,000 persons at the census of 1901 The columns showing "death-rates corrected for age and sex distribution" have been obtained by multiplying the crude death-rates by the "factors for correction" published by the Registrar-General in the annual summary for 1903— Towns. Estimated population middle of 1903. Crude death-rate per 1,000 living. Death-rate per 1,000 living (corrected for age and sex distribution). 1893-1902. 1903. 1893-1902. 1903. London 4,613,812 18 92 15.72 19.9 16.5 Liverpool 716,810 23.9 20.5 25.6 21.9 Manchester 553,486 23.1 19.7 25.8 22.0 Birmingham 533,039 20.5 17.8 22.1 19.2 Leeds 443,559 19.6 16.6 21.4 18.1 Sheffield 425,528 20.1 18.6 21.7 20.1 Bristol 338,895 17.6 14.3 18.1 14.7 Bradford 283,412 18.1 16.4 20.0 18.1 West Ham 281,894 18.4 15.3 19.7 16.4 Hull 249,639 19.2 169 19.7 17.3 Nottingham 245,985 18.5 16.9 19.5 17.8 Salford 226,480 23.1 19.0 25.5 21.0 Newcastle 222,241 21.1 19.2 22.8 20.7 Leicester 220,272 17.4 14.2 18.6 15.2 London had therefore (comparing the corrected death-rates) in the decennium 1893-1902 a lower death-rate than any of these towns except Bristol, West Ham, Hull, Nottingham and Leicester, and in 1903 a lower death-rate than any except Bristol, 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 cities3— All causes—Death-rates per 1,000 living Towns 1893-1902. 1903. Towns. 1893-1902. 1903. London 18.92 15.72 St Petersburg 27.0 23.8 Paris 19.8 17.9 Berlin 18.3 16.5 Brussels 17.5 15.2 Vienna 21.3 18.6 Amsterdam 16.6 14.0 Rome 19.3 19.8 Copenhagen 18.0 15.9 New York 20.2 18.2 Stockholm 17.3 144 It will be seen that in the period 1893-1902 the London death-rate exceeded that of any of these towns except Paris, St Petersburg, Vienna, Rome, and New York, while in 1903 it was lower than that of any except Brussels, Amsterdam, and Stockholm. The death-rate for London in 1903 is the lowest on record. It will be seen, however, from the tables published in the report that the low death-rate has not been peculiar to London; indeed, 1 These death rates are fully corrected for institutions, i.e., by the exclusion of deaths of persons not belonging to but occurring in institutions situated within London, and by the inclusion of deaths of persons belonging to London but occurring in London institutions situated outside the Administrative County. 2 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals and Lunatic Asylums outside the County of London, but excluding deaths of non-Londoners in the Willesden Workhouse, the London Fever Hospital, the Metropolitan Asylums Board's Hospitals and the Middlesex County Lunatic Asylum, within the County of London. 3 All death-rates in this report relating to foreign cities are calculated upon figures published by the Registrar-General. 8 in the case of the large provincial towns shown in the table on page 7, there has been a large percentage diminution in the death-rate of 1903 when compared with that of the preceding decennium in almost every instance, the greatest percentage diminution being in that of the Bristol death-rate, viz., 18-8 per cent., and the smallest in that of the Sheffield death-rate, viz., 7-4 per cent. In the case of the foreign towns (see table, page 7), the diminution in the death-rates has also been of a marked character, the only instance of increase being in that of Rome, where the decennial aeatn-rate tor was iy-<3, while tnat tor 1DU3 was 19-8, an increase of per cent. The percentage decreases in the death-rate of 1903 in the large provincial and foreign towns compared with those obtaining in the decennium 1893-1902 are shown in the following table— English Towns. Percentage decrease (—) in 1903 death-rate compared with that of 1893-1902. Foreign Towns. Percentage decrease (—) increase (+) in 1903 death-rate compared with that of 1893-1902. London - 16.9 per cent. Paris - 9.6 per cent. Liverpool - 14.5 ,, Brussels - 13.1 ,, Manchester - 14.7 ,, Amsterdam - 15.7 ,, Birmingham - 13.1 ,, Copenhagen - 11.7 ,, Leeds - 15.4 ,, Stockholm - 16.8 ,, Sheffield - 7.4 ,, St. Petersburg - 11.9 ,, Bristol - 18.8 ,, Berlin - 9.8 ,, Bradford - 9.5 ,, Vienna - 12.7 ,, West Ham - 16.8 ,, Rome -+ 2.6 ,, Hull - 12.2 ,, New York - 9.9 ,, Newcastle - 8.7 ,, Salford - 17.6 ,, Nottingham - 9.2 ,, Leicester - 18.3 The fact that the low death-rate of 1903 obtained over a very wide area, and that the fall compared with recent years was of a marked character, is strongly suggestive of some general cause, such as favourable meteorological conditions, being largely responsible for the phenomenon. In my annual report for 1894, when the death-rate for London was exceptionally low, I discussed the effect on the London death-rate of the changes in the age and sex constitution of the population which had occurred since 1841. Having regard to the fact that the death-rate for 1903 is the lowest on record, and that nearly ten years have elapsed since I last discussed this question, it is of interest to examine again the effect of these changes on the London death-rate, and for this purpose the following table has been prepared. In explanation of this table, it may be stated that the corrected death-rates shown in column 3 are the products of the crude average rates shown in column 2, and " factors for correction" calculated by applying to the recorded death-rates in London in the decennium 1891-1900 at each age period, populations enumerated in the successive census years 1851, 1861, 1871, 1881, 1891 and 1901. The age and sex constitution of the population in 1851 has been assumed to be constant over the period 1846-1855, that of 1861 over the period 18561865 and similarly for each period shown in the table. On this assumption the percentage excess of the death-rates in each period over that of 1896-1903 is shown in column 5, and a comparison of column 5 with column 4 shows that, although the present age and sex constitution of the London population is more favourable to low death-rates than that of preceding periods, the proportion of the decline in the death-rate due to the altered age and sex constitution of the population is so small that for comparative purposes it may be disregarded— Crude Corrected Uncorrected death- Corrected death-rates Period average annual rates per cent, excess per cent, excess over death-rates. death-rates. over 1896-1903. 1896-1903. 1 2 3 4 6 1846-1855 25 .10 24.88 37.6 35.8 1856-1865 23.56 22.99 29.2 25.5 1866-1875 23 .62 22 .93 29.5 25.2 1876-1885 21.58 21.02 18.3 14.7 1886-1895 20.10 20.03 10.2 9.3 1896-1903 18.24 18.32 - - The following table shows the crude death-rates and the death-rates corrected for differences in the age and sex constitution of the several metropolitan boroughs during the year 1903. The mean death-rates for the years 1901-2' are also shown for the purpose oi comparison— 1 Owing to the changes consequent upon the London Government Act, 1899, the death-ratea in the present metropolitan boroughs cannot be shown prior to the year 1901. Crude and corrected death-rates per 1,000 persons living, in the County of London, and the several metropolitan boroughs. Area. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure (London, 1,000) 1901-2. 1903. 1901-2. 1903. 1981.2. 1903. England and Walet 18.19 — — — — London 17.31 1.5107 17.2 15.2 18.1 16.0 1000 1000 Paddington 17.10 1.06398 14.5 13.2 15.4 14.0 851 875 Kensington 17.05 1.6710 15.3 13.9 16.3 14.8 901 925 Hammersmith. 17.47 1.04144 16.7 14.1 17.4 14.7 961 919 Fulham 17.09 1.4623 16.5 13.9 17.3 14.5 956 906 Chelsea 17 .57 1.03552 17.3 15.3 17.9 15.8 989 987 Westminster, City of 15 .97 1.13926 16.0 13.6 18.2 15.5 1006 969 St. Marylebone 16 .93 1.07466 17.5 16.4 18.8 17.6 1039 1100 Hampstead 16.19 1.12378 10.7 10.0 12.0 11.2 663 700 St. Pancras 17 .40 1.04563 18.4 16.2 19.2 16.9 1061 1056 Islington 17.53 1.03788 16.2 14.3 16.8 14.8 928 925 Stoke Newington 17 .42 1.04443 13.3 12.6 13.9 13.2 768 825 Hackney 17.45 1.04264 15.4 13.9 16.1 14.5 890 906 Holborn 16.39 1.11007 20.7 18.6. 23.0 20.6 1271 1287 Finsbury 17 .40 1.04563 22.2 20.3 23.2 21.2 1282 1325 City of London 16 .56 1.09867 20.2 14.6 22.2 16.0 1227 1000 Shoreditch 17.29 1.05228 21.3 19.4 22.4 20.4 1238 1275 Bethnal-green 17.98 1.01190 20.6 18.2 20.8 18.4 1149 1150 Stepney 17.40 1.04563 20.7 18.0 21.6 18.8 1193 1175 Poplar 17.61 1.03316 19.7 18.2 20.4 18.8 1127 1175 Southwark 17.38 1.04684 21.4 18.1 22.4 18.9 1238 1181 Bermondsey 17.60 1.03375 20.8 18.4 21.5 19.0 1188 1187 Lambeth 17.63 1.03199 17.3 15.2 17.9 15.7 989 981 Battersea 16.94 1.07403 15.7 14.2 16.9 15.3 934 956 Wandsworth 17.29 1.05228 13.4 12.4 14.1 13.0 779 812 Camberwell 17.53 1.03788 16.4 13.7 17.0 14.2 939 887 Deptford 17.31 1.05107 16.5 14.9 17.3 15.7 956 981 Greenwich 17.84 1.01984 15.3 13.3 15.6 13.6 862 850 Lewisham 17.64 1.03141 13.3 11.1 13.7 11.4 757 712 Woolwich 17.00 1.07024 14.8 13.5 15.8 14.4 873 900 Ihe followin metropolitan borouj g table shows the number of deaths2 occu *hs of the Administrative County of Londoi rring at sever a during the y »1 ages ii ear 1903 l each of the (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 ageg. Paddington 389 119 44 16 16 584 31 16 22 38 109 178 204 246 249 194 60 1,931 Kensington 513 152 52 27 23 767 46 26 40 39 124 210 270 294 339 247 80 2,482 Hammersmith 417 . 78 22 22 11 550 30 28 27 37 85 118 175 179 225 141 38 1,633 Fulham 627 155 56 27 19 884 50 21 35 41 127 185 180 208 184 125 26 2,069 Chelsea 214 58 18 14 8 312 13 13 17 13 69 98 122 169 156 124 27 1,133 W estminster, City of 370 107 35 28 19 559 23 22 38 58 174 255 304 323 340 272 68 2,436 St. Marylebone 379 118 75 18 17 607 37 17 29 41 131 182 259 308 304 190 56 2,161 Hampstead 129 31 11 4 5 180 18 7 17 20 46 87 96 100 124 123 34 852 St. Pancras 848 281 106 77 37 1,349 71 32 60 65 236 349 420 443 415 300 68 3,808 Islington 1,131 330 110 62 43 1,676 91 48 79 119 299 386 498 546 578 125 113 4,858 Stoke Newington 131 41 17 8 2 199 8 4 10 18 43 46 55 77 92 89 16 657 Hackney 738 225 90 43 29 1.125 83 25 64 66 187 233 292 316 381 268 79 3,119 Holborn 159 55 15 15 5 249 16 7 7 24 90 111 145 143 147 84 22 1,045 Finsbury 501 157 50 39 19 766 32 19 38 34 102 182 224 226 223 128 30 2,004 London, City of 47 7 1 3 1 59 5 1 3 7 17 44 59 54 60 49 12 370 Shoreditch 668 189 61 37 20 975 45 29 38 41 119 199 252 217 228 112 9 fi 2,281 Bethnal-green 654 217 A QA 85 -t oa 41 21 1,018 55 33 35 44 129 183 223 240 217 160 C\J 44 2,381 Stepney 1,ODO 4oU loU 107 58 2,393 90 51 85 122 347 486 519 540 468 276 67 5,444 Poplar 897 299 100 79 53 1.428 76 43 45 55 165 238 264 292 292 169 31 3,098 Southwark 995 274 95 55 32 1,451 72 54 63 90 266 337 413 388 353 228 44 3,759 Bermondsey 662 171 64 38 31 966 56 33 50 59 134 213 230 248 221 145 34 2,389 Lambeth 1,144 284 113 58 28 1 627 101 58 82 87 251 416 480 516 534 395 115 4,662 Battersea 668 190 60 37 30 985 56 29 47 62 170 202 227 262 225 160 42 2,467 Wandsworth Camberwell 739 908 195 249 90 91 34 41 27 30 1,085 1,319 76 70 60 41 54 63 68 70 157 212 223 300 283 354 314 379 351 422 319 315 97 79 3,090 3,624 JJeptiord. 463 129 52 29 24 697 41 19 30 40 78 138 149 162 172 134 32 1,692 Greenwich 345 91 41 19 13 509 36 16 22 30 61 93 132 132 149 100 41 1,321 Lewisham 330 76 33 22 15 476 35 25 34 42 79 112 124 167 208 174 43 1,519 Woolwich 394 92 30 20 13 549 30 25 22 49 110 143 146 185 216 132 37 1,644 London 17,028 4,850 1,797 1,020 649 25.344 1,393 802 1,156 1,482 4,117 5,947 7,099 7,674 7,876 5,578 1.461 69,929 All death-rates in this report relating to metro politian See footnote (1)2 page 7.boroughs are fully corrected for institutions (see footnote ('), page 7). 2 1 9 10 London mortality in 1903 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 1903. The figures for the year 1903 are fully corrected for institution deaths (see footnote ('), page 7), 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 deathrate 1891-1900. Uean death-rate 1903. Difference per cent. Mean deathrate 1891-1900. Mean death-rate 1903. Diffeience per cent. 0— 71.97 54.12 —24.8 61.99 46.44 —25.1 5— 4.97 3.02 —39.2 5.17 3.17 —38.7 10— 2.46 1.92 —22-0 2.48 1.84 —25.8 15— 3.47 2.74 —21.0 2.94 2.42 —17.7 20— 4.59 3.51 —23.5 3.46 2.66 —23.1 25— 7.36 5.81 —21.1 5.65 4.32 —23.5 35— 14.22 11.25 —20.9 10.68 8.66 —18.9 45— 23.14 19.83 —14.3 17.12 14.24 —16.8 55— 40.68 34.73 —14.6 31.01 24.28 —21.7 65— 77.78 67.02 —13.8 63.44 52.18 —17.7 75— 154.13 127.57 —17.2 134.56 111.08 —17.4 85 and upwards 284.10 269.19 — 5.2 265.77 236.48 —11.0 All ages 20.88 16.55 —20.7 17.88 13.91 —22.2 It will be seen from this table that the rate of mortality in 1903 was considerably lower than that of the period 1891-1900 at each age-period of life and for each sex. 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, 18911900— Table I. Mean future lifetime of males and females in qroups 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 .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 1903, 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 1903. The number of lives gained in the latter period is also shown, and the figures in the la3t 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. 11 Table 11. Age-groups. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1903. Gain (+) or loss (—) of lives in the year 1903 by fluctuations of mortality. Gain ( + ) or loss (—) of " life capital" in the year 1903 by fluctuations of mortality. Males. 0— 18,146 13,646 + 4,500 + 225,720 5— 1,113 676 + 437 + 21,802 10— 520 405 + 115 + 5,245 15— 737 583 + 154 + 6,354 20— 1,015 776 + 239 + 8,855 25— 2,780 2,195 + 585 + 18,164 35— 4,060 3,213 + 847 + 20,311 45— 4,595 3,938 + 657 + 11,662 55— 4,912 4,193 + 719 + 8,880 65— 4,351 3,749 + 602 -I- 4,804 75— 2,670 2,210 + 460 + 2,259 85 and upwards 503 477 + 26 + 79 All ages 45,402 36,061 + 9,341 + 334,135 Females. 0— 15,616 11,698 4 3,918 + 210,240 5— 1,169 717 + 452 + 24,173 10— 534 397 + 137 + 6,754 15— 696 573 + 123 + 5,528 20— 917 706 + 211 + 8,571 25— 2,515 1,922 + 593 + 20,393 35— 3,371 2,734 + 637 + 17,129 45— 3,801 3,161 + 640 + 12,826 55— 4,446 3,481 + 965 + 13,442 65— 5,018 4,127 + 891 + 7,930 75— 4,080 3,368 + 712 + 3,823 85 and upwards 1,106 984 + 122 + 389 All ages 43,269 33,868 + 9,401 + 331,198 Total 88,671 69,929 + 18,742 + 665,333 It will bo seen from the preceding table that during the year 1903, compared with the decennium 1891-1900, there has been a saving of 18,742 lives, representing a gain to the community of GG5,333 years of " life capital." Infant mortality. Tha deaths of children under one year of age in the administrative county of London during 1903 (52 weeks) numbered 16,978, being in the proportion of 130 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 1903 ... ... ... ... ... 1301 The following table enables comparison to be made of the infant mortality in London and other large English towns— 1 See footnote (') page 7. Deaths under one year of age per 1,000 births. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 1581 1311 Bradford 168 148 Liverpool 189 159 West Ham 169 146 Manchester 188 169 Hull 176 162 Birmingham 188 159 Nottingham 185 165 Leeds 179 153 Salford 202 167 Sheffield 186 182 Newcastle 173 165 Bristol 144 116 Leicester 187 160 London had, therefore, both in the period 1893-1902 and in 1903 a lower infant mortality than any of these towns except Bristol. Deaths from certain diseases and groups of diseases. The following table from the Annual Summary of the Registrar-General shows the diminution or excess in the year 1903 under certain of the more important headings in the list of causes of death, as compared with the corrected annual average of the preceding 10 years— Cause of death. Diminution in 1903. Excess in 1903. Smallpox 186 - Measles 494 - Scarlet fever 422 - Typhus - - Influenza 635 - Whooping cough 434 - Diphtheria 1,417 - Pyrexia (origin uncertain) 4 - Enteric fever 272 - 1 See footnote (2i, page 7. 2 See footnote ('), page 7. 12 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, 1903. Deaths under one year of age per 1,000 births, 1903. Paddington 392 119 Kensington 518 145 Hammersmith 422 141 Fulham 606 127 Chelsea 216 142 Westminster 372 123 St. Marylebone 382 96 Hampstead 128 88 St. Pancras 841 133 Islington 1,136 126 Stoke Newington 130 119 Hackney 736 119 Holborn 155 95 Finsbury 498 135 London, City of 46 136 Shoreditch 669 171 Bethnal-green 654 141 Stepney 1,569 138 Poplar 896 154 Southwark 993 148 Bermondsey 662 158 Lambeth 1,132 125 Battersea 666 134 Wandsworth 735 109 Camberwell 902 123 Deptford 452 134 Greenwich 345 127 Lewisham 327 92 Woolwich 398 108 London 16,978 1302 It will be seen from the foregoing table that the rate of infant mortality was highest in Shoreditch (171) and lowest in Hampstead (88). The infant mortality in London during each of the four quarters of the year 1903 was as follows—first quarter, 127 ; second quarter, 102; third quarter, 139; and fourth quarter, 152 per 1,000 births. London. Diagram IV. Notified Cases of Infectious Disease (14 years: 1890—1903). The mean fine represents an average week/y number of22 cases The mean fine represents an aver-aye weekly number of S3 cases 13 Cause of death. Diminution in 1903. Excess in 1903. Diarrhœa 710 — Pneumonia 504 — Phthisis and other tuberculous diseases (including scrofula) 1,322 — Cancer — 603 Premature birth 174 — Diseases of nervous system 1 2,286 — Diseases of circulatory system Diseases of respiratory system 4,199 — Diseases of urinary system — 47 Childbirth and puerperal septic diseases 101 — Accident 547 — Homicide 10 — Suicide — 86 All other causes 1,840 — Net diminution or excess 14,821 — Comparison can be made of certain causes of death in metropolitan boroughs by reference to the following table. The death rates shown in the table are fully corrected for deaths in institutions (see footnote ('), page 7), 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 ou pages 40 and 42. Death-rates per 100,000 living from all causes, and from various causes, in each of the metropolitan boroughs, 1903 (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 27 4 68 7 37 7 17 105 14 110 125 801 1,322 Kensington 17 7 52 6 49 12 16 124 7 132 146 823 1,391 Hammersmith 22 5 46 7 34 23 30 147 11 124 126 835 1,410 Fulham 40 5 45 7 28 15 20 139 14 120 120 847 1,400 Chelsea 19 9 55 4 66 5 12 150 15 143 143 907 1,528 Westminster, City of 27 6 41 6 56 6 14 167 16 110 119 792 1,360 St. Marylebone 28 5 63 11 61 8 24 189 26 137 179 916 1,647 Hampstead 9 5 77 8 41 2 25 72 7 76 76 602 1,000 St. Pancras 83 6 63 7 38 14 20 182 20 158 112 913 1,616 Islington 37 7 51 7 50 12 22 141 16 112 131 846 1,432 Stoke Newington 46 13 44 10 56 6 21 127 23 83 90 743 1,262 Hackney 51 6 50 4 36 17 29 128 26 103 94 848 1,392 Holborn 29 3 48 16 36 14 26 292 21 169 213 940 1,807 Finsbury 69 4 50 6 35 13 27 223 17 175 228 1,163 2,010 London, City of 12 4 45 1 2 45 8 20 163 16 110 200 873 1,508 Shoreditch 88 3 40 6 39 27 38 231 25 139 178 1,127 1,941 Bethnal-green 65 8 52 3 32 18 32 212 24 182 190 1,013 1,831 Stepney 57 7 47 6 25 13 26 214 29 194 153 1,031 1,802 Poplar 96 10 47 4 32 19 32 173 21 143 196 1,054 1,827 Southwark 41 2 61 7 30 29 32 239 27 210 152 983 1,813 Bermondsey 41 11 58 3 25 22 42 172 46 198 168 1,055 1,841 Lambeth 43 8 59 7 36 17 29 138 23 122 123 910 1,515 Battersea 61 7 41 7 37 12 19 132 17 128 121 841 1,423 Wandsworth 42 9 52 6 45 8 18 93 18 79 84 784 1,238 Camberwell 31 9 42 5 40 17 20 122 18 110 125 826 1,365 Deplford 58 7 54 5 32 9 15 138 17 104 131 934 1,504 Greenwich 29 2 38 7 31 12 18 113 19 106 95 853 1,323 Lewisham 26 8 54 10 23 5 28 83 10 76 84 707 1,114 Woolwich 21 7 40 2 35 12 18 145 21 105 110 837 1,353 London 44 7 52 6 38 14 24 155 20 131 133 892 1,516 Principal Epidemic Diseases. The number of deaths in the administrative county of London from the principal epidemic diseases, viz.—Smallpox, measles, scarlet fever, diphtheria, whooping-cough, typnus, enteric and ill-defined fevers and diarrhœa, during 1903 (52 weeks) was 8,088, giving an annual deathrate of 1.75 per 1,000 living. 1 For purposes of comparison deaths from infective endocarditis are included under this heading. * For the purposes of the tables on pages 41 and 42 "Cancer" includes the deaths from carcinoma and sarcoma which are here separately distinguished. 14 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 1891 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 1903 1.751 It will be seen from the following table that London in the period 1893-1902 had a lower death-rate from these diseases than any of the undermentioned English towns except Bristol, Bradford, Nottingham, and Newcastle ; and in 1903 had a lower death-rate than any except Leeds, Bristol, Bradford, Newcastle and Leicester. The following table shows that the London death-rate from the first six of these principal epidemic diseases, viz.—small-pox, measles, scarlet fever, diphtheria, whooping-cough, and fever, was, in the period 1893-1902, exceeded only by that of St. Petersburg, and in 1903 was higher than that of any except St. Petersburg and New York— Principal epidemic diseases—Death~rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 2.642 1.772 Bradford 2.15 1.36 Liverpool 3.43 2.51 West Ham 3.55 2.65 Manchester 3.32 2.54 Hull 3.15 2.19 Birmingham 3.02 2.32 Nottingham 2.53 2.01 Leeds 2.77 1.76 Salford 4.19 2.86 Sheffield 3.35 3.10 Newcastle 2.30 1.22 Bristol 1.99 1.08 Leicester 3.03 1.46 Six principal epidemic diseases—Death rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 1.842 1.132 St. Petersburg 3.19 2.44 Paris 0.97 0.57 Berlin 1.22 0.74 Brussels 0.80 0.71 Vienna 1.32 0.70 Amsterdam 0.80 0.58 Rome 1.12 0.83 Copenhagen 1.12 0.53 New York 1.52 1.22 Stockholm 1.24 0.63 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 1903— Metropolitan borough. Deaths in 1903. Death-rate per 1,000 living, 1903. Metropolitan borough. Deaths in 1903. Death-rate per 1,000 living, 1903. Paddington 191 1.31 Shoreditch 340 2.91 Kensington 278 1.56 Bethnal-green 290 2.23 Hammersmith 185 1.61 Stepney 712 2.36 Fulham 327 2.21 Poplar 505 2.97 Chelsea 84 1.13 Southwark 412 1.99 Westminster, City of 179 1.00 Bermondsey 265 2.04 St. Marylebone 210 1.61 Lambeth 530 1.70 Hampstead 49 0.58 Battersea 343 1.98 St. Pancras 448 1.92 Wandsworth 401 1.62 Islington 489 1.44 Camberwell 359 1.36 Stoke Newington 76 1.46 Deptford 246 2.19 Hackney 397 1.77 Greenwich 173 1.73 Holborn 83 1.44 Lewisham 131 0.95 Finsbury 231 2.31 Woolwich 133 1.10 London, City of 21 0.85 London 8,088 1.751 1 See footnote(1) page 7. 2 See footnote (2) page 7. Diagram V. — Small Pox — Mean death rate 1841-1303. 224 per million. 15 It will be seen, from the foregoing table that the death-rate from the principal epidemic diseases was highest in Poplar (2.97) and lowest in Hampstead (0.58). The death-rates from these diseases in London during each of the four quarters of the year 1903 were as followfirst quarter, 1.83; second quarter, 1.54; third quarter, 2.17; and fourth quarter, 1.48 per 1,000 living. Smallpox and Vaccination. The deaths from smallpox in the administrative county of London numbered 13 in 1903 (52 weeks), and 3 deaths were attributed to cowpox 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 1896 0.0021 1861-70 0.28 1897 0.0041 1871-80 0.46 1898 0.0001 1881-90 0.14 1899 0.0011 1891 1900 0.0011 1892 0.0071 1901 0.0511 1893 0.0401 1902 0.2821 1894 0.0201 1903 0.0031 1895 0.0121 In this table where — is in&erted no deaths occurred. The smallpox death-rate in each year since 1840 in relation to the mean smallpox deathrate of the period 1841-1903 is shown in diagram V. During the complete years in which the notification of infectious diseases has been obligatory, the number of cases of smallpox (uncorrected for errors in diagnosis) 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 1903 416 0.090 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 1893-1902 the London death-rate exceeded that of any except Birmingham, Bradford, "West Ham and Hull, while in 1903 it was smaller than the death-rates of all these towns except West Ham— Smallpox death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.042 0.002 Bradford 0.07 0.04 Liverpool 0.02 0.19 West Ham 0.11 — Manchester 0.01 0.05 Hull 0.08 0.02 Birmingham 0.05 0.02 Nottingham 0.00 0.01 Leeds 0.01 0.05 Salford 0.01 0.03 Sheffield 0.00 0.01 Newcastle 0.00 0.04 Bristol 0.02 0.01 Leicester 0.01 0.10 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. The following table shows that the London smallpox death-rate in the period 1893-1902 was. higher than that of any of the undermentioned foreign towns except Paris, St. Petersburg and New York, and in 1903 was exceeded by the rates of Paris, Brussels, Amsterdam, and St. Petersburg— 16 Smallpox death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.041 0.001 St. Petersburg 0.10 0.12 Paris 0.05 0.01 Berlin 0.00 — Brussels 0.01 0.22 Vienna 0.00 — Amsterdam 0.00 0.01 Rome 0.01 0.00 Copenhagen 0.00 — New York 0.04 0.00 Stockholm 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005; wnere no death occurred — is inserted. Ihe following table shows the smallpox cases and deaths and death-rates in 1903, and the case-rates in 1903, and the decennium 1893-1902 in the several metropolitan boroughs included in the administrative county— Metropolitan borough. Cases, 1903. Case-rate per 1,000 living. Deaths, 1903. Death-rate per 1,000 living. 1903. 1893-1902. 1903. Paddington 5 0.2 0.0 — — Kensington 5 0.2 0.0 — — Hammersmith 7 0.2 0.1 — — Fulham 11 0.2 0.1 — — Chelsea 7 0.1 0.1 — — Westminster, City of 45 0.3 0.3 3 0.02 St. Marylebone 4 0.6 0.0 — — Hampstead 1 0.1 0.0 — — St. Pancras 31 0.4 0.1 — — Islington 12 0.2 0.0 — — Stoke Newington 2 0.2 0.0 — — Hackney 4 0.3 0.0 — — Holborn 2 1.0 0.0 — — Finsbury 2 0.4 0.0 — — London, City of — 0.3 — — — Shoreditch — 0.4 — — — Bethnal-green 3 0.6 0.0 — — Stepney 26 0.7 0.1 4 0.01 Poplar 28 0.6 0.2 2 0.01 Southwark 40 0.4 0.2 — — Bermondsey 7 0.4 0.1 — — Lambeth 73 0.2 0.2 4 0.01 Battersea 37 0.3 0.2 — — Wandsworth 29 0.1 0.1 — — Camberwell 19 0.3 0.1 — — Deptford 2 0.2 0.0 — — Greenwich 4 0.3 0.0 — — Lewisham 1 0.1 0.0 — — Woolwich 6 0.4 0.0 — — Port of London 3 — — — — London 416 0.3 0.1 13 0.002 In this table 0.0 indicates that the cases were too few to give a rate of 0.05; where no cases occurred — is inserted. The following table shows the number of cases of smallpox notified in London in each week of the year 1903, and diagram IV. shows the seasonal curve of smallpox based on the notified cases in London during the 14 vears 1890-1903— Smallpox—Notified cases, 1903. Week ended No. of cases notified. Week ended No. of cases notified. Week ended No. of cases notified. January 10 3 May 16 n September 12 6 „ 17 3 „ 23 18 „ 19 9 „ 24 3 „ 30 9 „ 26 2 „ 31 5 June 6 23 October 3 1 February 7 4 „ 13 9 „ 10 2 „ 14 1 „ 20 14 „ 17 1 „ 21 5 „ 27 9 „ 24 24 „ 28 1 July 4 6 „ 31 13 March 7 3 „ 11 29 November 7 6 „ 14 1 „ 18 6 „ 14 16 „ 21 2 „ 25 13 „ 21 7 „ 28 4 August 1 7 „ 28 4 April 4 3 „ 8 6 December 5 2 „ 11 5 „ 15 8 „ 12 4 „ 18 21 „ 22 15 „ 19 4 „ 25 10 „ 29 10 „ 26 8 May 2 12 September 5 9 January 2, 1904 4 „ 9 15 1 See footnote (2), page 7. 2 See footnote (1), page 7. 17 Smallpox, after having attained a maximum prevalence in March, 1902, had declined steadily throughout the summer, and during the concluding months of the year only a few cases —not exceeding ten in any particular week—were notified. In the first fourteen weeks of 1903 the disease continued at this low ebb in London, the largest number of cases notified in any one week not exceeding five. During this period smallpox was prevalent to a much more considerable extent in some of the large provincial towns ; thus, 4,200 cases of the disease were notified up to and including April 25th from these large towns—with an aggregate population of some 14½ millions—while only 74 cases were notified during the same period in London. It is not surprising to find, therefore, that the information forthcoming as to the cases notified shows that infection was repeatedly imported into London from various parts of the country, and it was also introduced from time to time from abroad. A large common lodging-house, Victoria Home, in Stepney, became involved in January, this house being one which had been attacked in the preceding year, but the disease did not spread to any considerable extent. Two cases were notified from this house on 29th January, one in a " billposter," the other in a man who had been " walking round with the unemployed "; both these men were unvaccinated. Close watch was kept upon the house, and early morning visits were made, with the object of examining the lodgers, by the Council's officers. Only one further patient was removed—on 17th February—from Victoria Home, though one other case, that of a man found dead on 3rd March, on the pavement in Wentworth-street was also possibly infected by lodgers from that house; this death was returned at the inquest as due to " hæmorrhagic smallpox." The wife of a keeper of a seamen's lodging-house and a man who had tramped in from a common lodging-house in Essex were also attacked during the early weeks of the year. In March one of the cases notified was that of a man who had been travelling about the country with horses, and who had recently come from Maidstone to Battersea, thence to Peterboro', Norton, Bromley, Romford, Gravesend, and the St. Olave's Union Casual Ward, from which lastnamed place he was removed to hospital with smallpox. In the week ending 18th April, an increase in the weekly number of cases notified occurred, and double figures were in each week the rule rather than the exception throughout the summer months. During April and May several cases occurred in West, North-West, and Soutli-West London, in connection with which there arose the suspicion that infection had beeu contracted in one or other of the villages or towns on the roads leading from the west country into London ; in particular, persons who had tramped into London from Chertsey, Croydon, Miteham, Uxbridge, Kingston and Wallington, and several of whom had been engaged in fruit and flower selling, may be referred to as having probably introduced infection into a common lodging-house in Surrey lane, Battersea, into one in Kilburn-lane, and into two or three common lodging-houses and tenement houses in Notting-dale, Kensington, while Rowton House, Vauxhail, in which a number of cases occurred during May or June, was also probably, in the first instance, infected from this same source. In May and June a localised outbreak of the disease occurred among persons living in certain streets in the north of Poplar, and infection in upwards of a score of instances was traced to an original case of the disease affecting a patient who had contracted smallpox while in Bath. This man returned to London on 18th April from the Mineral Water Hospital at Bath, where cases of smallpox had occurred. He went to the London Hospital on 20th April, and was then informed that he was suffering from smallpox, but during the temporary absence of the medical attendant he escaped. I sent at once to each medical officer of health a description of this man, and on the following day Dr. Alexander informed me that the patient had been removed from an address in Poplar. In other instances it transpired that infection had been introduced from Harrow, from Kent, and from Northampton. Another case notified was that of a man who had been working at a smallpox hospital in Dublin, and two others who were attacked had been employed in the erection of a temporary smallpox hospital in Durham, which was in proximity to a hospital containing smallpox convalescents. Later in the year infection was traced in particular instances to Wiltshire, to Cardiff, and to Russia. During June a case was removed from a common lodging-house, 16 and 17, Dorset-street, another from 112, High-street, Deptford, and one from 12 and 14, Gray-street, Lambeth. Careful watch was kept on these houses by the Council's inspectors, and during May and June Dr. Priestley had under close observation the inmates of Rowton House, Vauxhall, in which over 20 cases occurred. As noted in 1902, though to a less extent than in that year, confusion between chicken-pox and smallpox not infrequently occurred, and, as in 1902, it was frequently found that the most considerable prevalences of disease were those which were the outcome of failure to recognise the fact that smallpox was in question. Smallpox was mistaken for typhus in at least one instance, again, a patient is reported to have been for a fortnight treated for ringworm by a medical practitioner, and in mimerous instances attacks of smallpox were traceable to individuals who had had a few spots of which they thought nothing. In at least one case infection was traced to a visit to the hospital ships, the patient when there having refused to be revaccinated ; in two or three instances it was supposed by the patient that infection was contracted in an out-patient room or in an omnibus where he or she had sat next to some person unknown who had an eruption upon the face. In one instance the belief was confidently entertained that the disease was contracted at the Lord Mayor's Show. Attacks among disinfectors and others in the employ of borough councils were not a marked feature of the smallpox of 1903, as had been the case in the preceding year; a veterinary [3] 18 surgeon and a policeman were, however, numbered among the sufferers. Several laundry workers, ironers, etc., were among those notified, as were also a dealer in second-hand clothes, a rag and bone sorter, a carriage examiner, and a scrubber at an infirmary ; while a group of cases was connected apparently with a pawnbroker's shop. At least three hairdressers were attacked, in one instance the disease was detected by a medical man whom the barber was in the act of shaving. As in 1902, waiters and waitresses, and also persons associated with public-houses, figure among tke patients, a public-house manager and at least two potmen being attacked. The only considerable outbreak in a common lodging-house occurred in October, at 8, Great Charlotte-street. A lodger there developed a smallpox rash, on 4th October, and tbe smallpox rash became developed in persons who were probably infected by this man on 18th October in five cases, on the following day in one case, on the 20th in six cases, on the 21st in one case, on the 22nd in one case, on the 23rd in two cases, and on the 24th in one case; the majority of these persons were living in or had lived at the particular common lodging-house. Dr. Millson, the medical officer of health of Southwark, by means of a gratuity of 2s. 6d. to each lodger, persuaded 60 of tbe 80 residents in the house to be vaccinated. Tbe Council caused early morning medical inspection to be made of the inmates of this and other common lodging-houses in Southwark. The services of Mr. Bingham were secured for this purpose on 23rd October, and on the 25th he found a man suffering from smallpox at 8, Great Charlotte street, and notified the case. No further cases occurred among common lodging-house residents, though two further cases in which the rash appeared on 4th and 5th November were notified in Southwark, and these persons may have been infected from the house in question. A lodger at another common lodging-bouse in Westminster Bridge-road was also probably infected from the same source. At a later date a man who had been residing at 6, Betterton-street, Holborn, a common lodging-house, developed smallpox at 33, Great Peter-street, Westminster, and infected a fellow lodger in that house; this latter case was detected in the course of inspection by Mr. Bingham and at once removed to hospital. Many of the annual reports give particulars of the cases of smallpox which occurred in the districts to which they relate. The following are the more important events mentioned— Paddington.—Four cases in the borough; one was a tramp in a common lodging-house in Kilburn-lane. Kensington.—Six cases occurred, all in common lodging-bouses; four of these and another outside London are believed to have been due to infection from the inmate of a common lodginghouse in Crescent-street, whose disease was not recognised. Fulham.—Ten cases occurred; one was a man who contracted the disease while tramping in Kent, and who on return home infected three members of his family; another was infected while engaged in the construction of a temporary smallpox hospital at Durham. Chelsea.—Six cases occurred; one bad worked at the above-mentioned hospital. Westminster.-—Forty-five cases occurred in the borough. An unvaccinated child whose illness had been mistaken for chicken-pox gave rise to several cases, wbile other cases occurred in a pawnbroker's shop, at which the child's mother was known as a customer, although she denied having entered the shop. A group of 18 cases were found to have been due directly or indirectly to a bargeman who had been at a wharf adjoining Millbank. Hampstead.—One case occurred in the person of an Italian, the disease being contracted abroad. St. Pancras.—Twenty-six cases occurred in the borough. The earliest cases of the disease were a group of three due to infection from a child whose illness was mistaken for chicken-pox. Two cases occurred among persons engaged in a laundry to wbich the linen from an antecedent case of smallpox had been sent. Finsbury.—One case occurred in the borough, the inmate of a common lodging-house. Holborn.—One case occurred in the borough, a man who had tramped from Manchester, and who was removed from the casual ward. Shoreditch.—One case occurred, a man in the Holborn Union Workhouse, who had been admitted from Holborn. Stepney.—Eighteen cases occurred in the borough, three of which were removed from common lodging-houses. A case occurred in the St. George's Workhouse. The woman who washed his clothing was infected, and subsequently another woman was infected by her. One other case occurred in the workhouse a fortnight after the first. Poplar.—Twenty-five cases were notified in the borough, but others occurred which had not been notified. A man infected in Bath, and who was walking about until his illness was recognised, gave rise to a considerable group of cases in the neighbourhood, and attacks of smallpox traceable to this source occurred in other districts. Southwark.—Forty cases occurred in the borough, fifteen of which were in a common lodging-house in Great Charlotte-street due to a drapers' assistant suffering from the disease who had been lodging in the house. Lambeth.—Seventy-two cases occurred in the borough, twenty-five of which occurred in Rowton House, Vauxhall. Account of other small groups of cases is given in the report. Battersea.—Thirty-three cases occurred in the borough. Most of the cases are included in eight groups. Wandsworth.—Twenty-four cases occurred in the borough, fourteen of these were primary cases, or first cases in houses, and all but one were infected in other parts of London. Ten cases were subsequent to other known cases, four of these being due to unrecognised cases. 19 Camberwell.—Eighteen cases were notified in the borough ; one was an imported case, a group of others occurred in connection with the Remand Home at Camberwell-green ; a further series of cases occurred in Dragon-road and two isolated cases occurred. Deptford.—Two cases occurred, one in a common lodging-house. Woolwich.—Six cases occurred in the borough, three were inmates of the workhouse. The steps taken by the London County Council in 1903 related especially to the inspection of the inmates of common lodging-houses which were invaded by smallpox, and aimed at securing the immediate removal of any lodgers who were attacked, and the continued residence in the houses of the lodgers who had been exposed to infection, so that these lodgers could be under daily inspection. Altogether 16 common lodging-houses were invaded, and 33 cases of smallpox occurred among the inmates. Mr. Bingham was employed by the Council in the inspection of the inmates of these houses from 23rd October to the 3rd December. During the year medical officers of health forwarded to the Council's Public Health Department particulars of cases of smallpox which occurred in their districts, and this information was at once communicated by the department to all medical officers of health in London. The order requiring chicken-pox to be notified expired on the 6th January, and was not renewed during the year. In the several districts the procedure followed by medical officers of health in the preceding year was continued. Recognise'd cases of smallpox were removed to hospital; effort was made to discover any cases of unrecognised smallpox in association with those which were notified, and persons known to be directly exposed to smallpox infection were offered vaccination, ard were kept under observation until the period of incubation had expired. In Southwark, as already stated, pecuniary inducement was offered to the inmates of common lodging-houses. Owing to the prevalence of the disease being smaller than in 1902, in a large number of cases the soiirce of infection of particular cases was discovered. The report of the Statistical Committee of the Metropolitan Asylums Board for the year 1903 contains a tabular statement showing the condition as to vaccination of smallpox patients received into hospital, from which the following table has been prepared— Admissions. Deaths. A. Vaccinated class— (A1) Half and upwards of half square inch total area of cicatrices 182 4 (A2) One-third but less than half ditto 25 3 (A3) Less than one-third ditto 34 — (A4) Areas not recorded 4 — Total of vaccinated class 245 7 B. Doubtful class 23 1 C. Unvaccinated class 87 4 Grand totals 355 12 London vaccination returns. 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 1901 are not yet available, but it will be noted that since 1898 the proportion has declined— Year. Children not finally accounted for (including cases postponed, and for which "certificates of exemption" were granted) percent, of total births. Year. Children not finally accounted for (including casea 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 1901 25.2 20 Measles. The deaths from measles in the administrative county of Londou during 1903 (52 weeks) numbered 2,046, as compared with 2,360 in 1902. The death-rates from this disease per 1,000 living in 1903 and preceding periods have been as follows— Measles— Death-rates per 1,000 living, 1851-60 0.53 1896 0.821 1861-70 0.58 1897 0.431 1871-80 0.51 1898 0.691 1881-90 0.64 1899 0.481 1891 0.431 1900 0.431 1892 0.791 1901 0.431 1893 0.381 1902 0.511 1894 0.761 1903 0.441 1895 0.601 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1903 is shown in diagram VI. If the London measles death-rate be compared with the death-rates of the following large English towns, it will be seen that in the period 1893-1902 the London death-rate exceeded the death-rate of all except Manchester, West Ham, Salford and Newcastle, and in 1903 it exceeded all except Manchester, Sheffield, West Ham and Salford— Measles—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.552 0.452 Bradford 0.36 0.05 Liverpool 0.50 0.18 West Ham 0.62 0.49 Manchester 0.75 0.63 Hull 0.53 0.42 Birmingham 0.44 0.36 Nottingham 0.35 0.39 Leeds 0.53 0.28 Salford 0.86 0.58 Sheffield 0.53 0.79 Newcastle 0.58 0.05 Bristol 0.45 0.03 Leicester 0.36 0.34 The following table shows that the measles death-rate in London both in the period 1893-1902 and in 1903 exceeded that of any of the undermentioned foreign towns except St. Petersburg— Measles—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.552 0.452 St. Petersburg 0.56 0.69 Paris 0.30 0.17 Berlin 0.20 0.18 Brussels 0.28 0.15 Vienna 0.52 0.22 Amsterdam 0.24 0.24 Rome 0.36 0.13 Copenhagen 0.20 0.12 New York 0.22 0.14 Stockholm 0.17 0.24 The following table shows the deaths and death-rates from measles in 1903 (52 weeks) in each of the metropolitan boroughs— Metropolitan borough. Deaths in 1903. Death-rate per 1,000 living, 1903. Metropolitan borough. Deaths in 1903. Death-rate per l,0(i0 living, 1903 Paddington 40 0.27 Shoreditch 102 0.87 Kensington 34 0.19 Bethnal.green 85 0.66 Hammersmith 27 0.23 Stepney 173 0.57 Fulham 62 0.42 Poplar 161 0.95 Chelsea 14 0.19 Southwark 83 0.40 Westminster, City of 49 0.27 Bermondsey 51 0.39 St. Marylebone 37 0.28 Lambeth 130 0.42 Hampstead 8 0.09 Battersea 108 0.62 St. Pancras 193 0.83 Wandsworth 107 0.43 Islingtou 125 0.37 Camberwell 81 0.31 Stoke Newington 24 0.46 Deptford 62 0.55 Hackney 113 0.51 Greenwich 28 0.28 Holborn 18 0.31 Lewisham 34 0.25 Finsbury 69 0.69 Woolwich 25 0.21 London, City of 3 0.12 London 2,046 0.441 1 See footnote (1), page 7. 1 See footnote (2), page 7. Diagram Vl. —Measles— Mean deathrate 1841 -1903. 570 per million. 21 In the distribution of measles mortality in London throughout the year 1903 the highest death-rate obtained in Poplar (0.95) and the lowest in Hampstead (0.09). The measles deathrates in London in the four quarters of the year were as follows—First quarter, 0.58; second quarter, 0.66; third quarter, 0.21; and fourth quarter, 0.33 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 (see footnote (1) page 7). Measles (365 days). Age-period. 0— 1— 2— 3— 4— under 5 5— 10— 15 and upwards. All ages. Paddington 7 18 13 — 1 39 — — — 39 Kensington 5 16 6 1 1 29 1 — — 30 Hammersmith 8 9 2 4 1 24 I — — 25 Fulham 12 27 12 5 1 57 1 — l 59 Chelsea 3 7 1 — 2 13 1 — — 14 Westminster, City of 14 19 9 2 4 48 1 — — 49 St. Marylebone 9 15 9 2 1 36 — — l 37 Hampstead 3 4 — — 1 8 — — — 8 St. Pancras 38 88 30 18 11 185 10 — — 195 Islington 30 58 23 10 3 124 1 1 — 126 Stoke Newington 4 9 6 3 1 23 — — i 24 Hackney 17 49 23 10 7 106 8 — — 114 Holborn 3 5 5 1 1 15 2 — — 17 Finsbury 18 30 9 10 1 68 1 — — 69 London, City of — 2 — — 2 1 — 3 Shoreditch 32 39 15 10 4 100 3 — — 103 Bethnal-green 21 43 11 5 3 83 1 — — 84 Stepney 47 70 31 16 6 170 3 — — 173 Poplar 38 64 20 22 12 156 5 — l 162 Southwark 14 46 10 5 5 80 5 — — 85 Bermondsey 12 26 7 4 1 50 3 — — 53 Lambeth 25 60 30 14 2 131 2 — — 133 Battersea 27 48 8 9 9 101 4 — 1 106 Wandsworth 25 45 17 5 3 95 8 2 — 105 Camberwell 17 38 15 6 1 77 3 — 1 81 Deptford 15 27 10 7 4 63 2 — — 65 Greenwich 5 9 9 4 2 29 — — — 29 Lewisham 6 15 7 3 2 33 2 — — 35 Woolwich 3 11 5 2 2 23 1 — 1 25 Loudon 458 897 343 178 92 1,968 70 3 7 2,048 The year 1903 was, as judged by mortality, a year of comparatively low measles prevalence. As stated in the last annual report, the order of the London County Council extending to measles certain sections of the Public Health Act came into force on the 1st of April, 1903. Measles is thus made subject to the law relating to the prevention of infectious disease, except the requirement of notification. It is probable that the Council's order may be the cause of more complete information being given by school teachers to medical officers of health concerning children who are absent from school either because these children are themselves suffering from measles or because they live in houses in which other persons are suffering from this malady. The extent to which the information thus obtained fell short of completeness as to occurrences of measles among children attending elementary schools during the year 1903 evidently differed much in the several districts. Dr. Reginald Dudfield expresses the opinion that, so far as Paddington is concerned, it is believed that nearly all such cases were reported when they occurred during term time. During the holidays, however, the chief source of information, that of the school, was necessarily wanting. On the other hand, Dr. Bond states that, apart from information derived from the registrars of deaths, he was only informed of cases in six houses in Holborn, although measles was prevalent, and in no case did he receive information from the schools. To what extent it is possible, under existing conditions, to limit the spread of measles cannot vet be stated, but it is interesting to note that there is evidence in a number of reports that the new powers for dealing with measles are regarded by medical officers of health with satisfaction, although this opinion is not unanimous. There is, however, much recognition of the value of these powers as an educational influence in teaching parents not only that measles is a dangerous infectious disease, but that they should make efforts to prevent children suffering from measles from being brought in contact with other children. The extension of the powers of the Public Health Act to measles has in some instances led the medical officer of health to urge the notification of measles. The question whether the spread of measles through school attendance can be best limited by closure of schools, or by excluding children from affected houses, is being studied by Dr. Kerr, the medical officer of the late School Board, and by Dr. Davies, the medical officer of health of "Woolwich, precise information being obtained as to the number of children in the Woolwich schools who have previously had measles, and the number who are still liable to attack. Account will be found in Dr. Kerr's report for the year 1903, of the steps which are being taken in this matter. Dr. Kerr expresses the opinion that it may reasonably be expected that much may be done to postpone attacks in children to a later age. 22 The annual reports show that schools, or parts of schools, were closed on account of measles prevalence among the pupils in the following districts—"Westminster, Islington, the City, Shoreditch, Bethnal Green, Poplar, Lambeth, Wandsworth, Lewisham and Woolwich. In a number of reports reference is made to the decision of the Board of Education to discontinue, as from 31st March, 1903, the special epidemic grant which has hitherto been allowed to schools for loss of income in any particular year, owing to the ordinary grant being reduced through diminished attendances while the expenditure on staff and maintenance remain unaltered. The opinion is generally expressed by medical officers of health that the discontinuance of the epidemic grant is to be regretted. The Board gave as a reason for this decision that the amounts paid on this head to individual schools had, as a rule, been inconsiderable, and that administrative difficulties had arisen in connection with the grant. Scarlet Fevee. The cases of scarlet fever notified in the administrative county of London during 1903 (52 weeks) numbered 12,531, compared with 18,252 in 1902. The number of deaths registered from this cause was 361 in 1903 (52 weeks), compared with 560 in 1902. The London rates in 1903 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 –1 –1 1871-80 0.60 –1 –1 1881-90 0.33 –1 –1 1891 0.142 2.7 5.1 1892 0.272 6.4 4.3 1893 0.372 8.6 4.3 1894 0.222 4.3 5.2 1895 0.192 4.5 4.2 1896 0.212 5.7 3.7 1897 0.172 5.1 3.0 1898 0.132 3.8 3.4 1899 0.092 4.1 2.2 1900 0.082 3.1 2.6 1901 0.132 4.1 3.2 1902 0.122 3.9 3.1 1903 0.082 2.7 2.9 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859-1903 will be seen on reference to diagram VII. The monthly case-rate and case-mortality in each of the years 1891-1903 in relation to the mean of the whole period is shown in diagram IX. The seasonal curve of scarlet fever based upon the cases notified in the 14 years 1890-1903 is shown in diagram IV., page 13. It will be seen from the following table that in the period 1893-1902 the London scarlet fever death-rate was exceeded by the death-rates of all the undermentioned English towns, except Leeds, Bristol, West Ham, Hull and Newcastle ; and in 1903 was exceeded by all, except West Ham, Hull and Leicester— Scarlet fever—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.173 0.083 Bradford 0.20 0.10 Liverpool 0.32 0.27 West Ham 0.16 0.07 Manchester 0.23 0.17 Hull 0.17 0.03 Birmingham 0.22 0.27 Nottingham 0.19 0.14 Leeds 0.16 0.25 Salford 0.37 0.25 Sheffield 0.19 0.22 Newcastle 0.14 0.12 Bristol 0.1l 0.15 Leicester 0.20 0.07 The following table shows that the London scarlet fever death-rate was, in the period 1893-1902, lower than that of any of the undermentioned foreign towns except Paris, Brussels, Amsterdam and Rome, while in 1903 it exceeded that of any except Copenhagen, St. Petersburg, Berlin and New York— Scarlet fever—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.173 0.083 St. Petersburg 0.59 0.29 Paris 0.06 0.05 Berlin 0.27 0.17 Brussels 0.05 0.01 Vienna 0.20 0.07 Amsterdam 0.03 0.01 Rome 0.01 0.02 Copenhagen 0.20 0.08 New York 0.23 0.20 Stockholm 0.24 0.03 1 The Infectious Disease (Notification) Act came into force in 1889. * See footnote (1) page 7. * See footnote(2) page 7. Diagram VII. —Scarlet Fever.— Mean deathrote 1859 -1903 499 per millon. Diagram VIII. Number of deaths occurring in hospitals of the Metropolitan Asylums Board per cent of total deaths in London 1873-1903. Number of admissions to hospitals of the Metro" Asylums Board percent of total cases notified in L ondon 1890-1903. Diagram ix. — Scarlet Fever. — Mean Case-mortality Mean notifications. 1831-1303. 1831-1903 - 3 .7 °/o 1,535 per month 23 The following table shows the scarlet fever cases and deaths, and death-rates in 1903, and the case-rates in 1903, and the decennium 1893-1902 in the several metropolitan boroughs— Metropolitan Borough. Cases, 1903. Case-rate per 1,000 living. Deaths, 1903. Death-rate per 1,000 living, 1903. 1893-1902. 1903. Paddington 417 3.8 2.9 10 0.07 Kensington 335 3.4 1.9 14 0.08 Hammersmith 316 4.0 2.7 8 0.07 Fulham 406 5.2 2.8 8 0.05 Chelsea 209 4.1 2.8 2 0.03 Westminster, City of 352 3.4 2.0 9 0.05 Marylebone 414 3.7 3.2 17 0.13 Hampstead 174 3.6 2.0 4 0.05 Pancras 658 5.0 2.8 23 0.10 Islington 867 5.0 2.6 24 0.07 Stoke Newington 87 4.5 1.7 — — Hackney 667 5.5 3.0 21 0.09 Holborn 144 4.2 2.5 5 0.09 Finsbury 293 5.2 2.9 11 0.11 London, City of 73 4.1 3.0 1 0.04 Shoreditch 259 4.4 2.2 7 0.06 Bethnal-green 392 5.7 3.0 12 0.09 Stepney 878 5.3 2.9 21 0.07 Poplar 450 5.0 2.7 19 0.11 Southwark 512 5.3 2.5 18 0.09 Bermondsey 401 5.4 3.1 25 0.19 Lambeth 745 4.4 2.4 23 0.07 Battersea 474 5.8 2.7 7 0.04 Wandsworth 821 4.2 3.3 17 0.07 Camberwell 666 4.7 2.5 13 0.05 Deptford 502 6.0 4.5 18 0.16 Greenwich 164 4.6 1.6 9 0.09 Lewisham 463 4.0 3.4 11 0.08 Woolwich 390 5.3 3.2 4 0.03 Port of London 2 — — — — London 12,531 4.7 2.7 361 0.08l It will be seen from the foregoing table that the scarlet fever death-rate in 1903 was highest in Bermondsey (0.19) and lowest in Stoke Newington (—). The scarlet fever death-rates obtaining in London during the four quarters of the year were as follow—first quarter 0.09; second quarter 0.07; third quarter 0.08, and fourth quarter 0.08 per 1,000 living. The low fatality (2.9 per cent.), and probably also the low case-rate (2.7 per 1,000) are indicative of the mild character of the disease which prevailed in 1903. With disease of this nature the difficulty of finding explanation for the occurrence of cases which are recognised is very great, inasmuch as mild and unrecognised cases must often give rise to cases in which the symptoms are sufficiently pronounced for the purposes of recognition, the cause infection being thus undiscoverable. In a population like that of London the chances of exposure to unidentified cases must be much greater than in sparsely inhabited districts. It is therefore interesting to note that Dr. Newman was able to trace exposure to an antecedent case in 90 of the 283 cases occurring in Finsbury in 1903, and similarly Dr. McCleary found, in 96 cases out of 448 cases occuring in Battersea, a history of personal contact with a previous case of scarlet fever. In the majority of the reports no reference is made to any large diffusion of the disease which might be characterised as an outbreak, but in a few instances the disease has spread among the children in an institution. Thus in Bermondsey 18 cases occurred in the Parish-street Workhouse, St. Olave; in Lambeth 26 cases occurred among the children in the Licensed Victuallers' school ; in Chelsea 82 cases occurred in the Duke of York's school. Of outbreaks associated with dav schools may be mentioned the occurrence of a number of cases among children attending the infants' department of Alverton-road Board school, Deptford, which was closed from 7th July to the end of the summer holiday ; and the occurrence of a number of cases among the children attending the St. Luke's Church school, Poplar, which was also closed. In a few reports reference is made to attendance at school as being the probable cause of other cases. Dr. Kenwood states that in Stoke Newington, in 12 cases, school was believed to be the place where the disease was contracted, and Dr. Newman writes that the disease was traceable to school attendance in 15 cases. The only outbreak which was attributed to milk occurred in Wandsworth. Dr. Caldwell Smith states that cases occurred in houses supplied by a particular milk, as follows—One in the last week of August, another on the 1st September, one on the 2nd, two on the 5th, five on 1 See footnote (1), page 7. 24 the 7th, and one on the 9th. The men engaged in the London dairy supplying the milk were in good health, but it was found that the sister of a lad who attended to the refrigerator on one of five farms supplying the daily with milk was suffering from scarlet fever. The supply of milk from this farm was stopped until the Kith September. When it was again supplied scarlet fever again appeared among the consumers, viz., two cases on the 25th September, three cases on the 28th, two on the 29th and two on the 30th. Dr. Caldwell Smith then advised the milk seller to Pasteurise the milk, keeping it separate from other supplies, after which no further cases occurred. In March of 1902 the Metropolitan Asylums Board, at the request of the Society of Medical Officers of Health, made arrangements for communicating to London medical officers of health immediately before their discharge from hospital the names of patients who had been received from these officers' districts. In this way medical officers of health are able to keep under observation the households which thus receive the patients, and note whether subsequent cases occur. This system is especially desirable in view of a proposition to detain patients in the hospitals for shorter periods than has hitherto been the practice. The results will be awaited with interest. As in previous years, " return " cases from time to time occurred, i.e., persons developed the disease within a short period of the return to their homes of patients discharged from the hospitals. Some of the annual reports show such cases to have occurred as follows: In Fulham there were 20 such cases within 14 days of the return of the first cases ; in Stoke Newington there were 3 such cases ; in Finsbury the relatives attributed 14 cases to the return home of antecedent scarlet fever or diphtheria patients ; in Shored itch there were 12 cases, in G of which the evidence was very strong that the returned patient was the cause of the infection, in the remaining 6 the evidence was doubtful ; in Stepney 15 primary cases, on their return home, gave rise to 24 return cases; in Bermondsey, Dr. Brown states, the proportion of return cases to cases admitted was, in 1901, 3 per cent., in 1902, 2.2 per cent., in 1903,1.5 per cent.; in Wandsworth there were 50 return cases; in Greenwich 8; in Lewisham 41; and in Woolwich 10 cases, due to the return home of 4 cases. Some of the patients who were believed to have given rise to subsequent cases were observed to have discharge from nose or ears or some amount of desquamation. Scarlet fever and elementary schools. The summer holiday of the London School Board schools began in 1903 on Thursday, the 23rd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 24th August, i.e., at the beginning of the 34th 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— Scarlet fever—Notified cases, 1903. 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 (27th to 30th) 123 810 157 — — — Four weeks of holiday influence (31st to 34th) 163 612 127 + 32.5 — 24.4 — 19.1 Four weeks following weeks of holiday influence (35th to 38th) 124 789 174 — 23.9 + 28.9 + 37.0 The effect of school closure during the summer holidays in interrupting the autumnal rise of the disease in London is conspicuously shown in diagram IV., page 13, which may well be compared with the corresponding diagram for enteric fever, in which this interruption is absent. Proportion of cases of scarlet fever removed to hospital. It will be seen from diagram VIII. that the proportion of cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board was slightly greater in 1903 than in the preceding year. Scarlet fever—Age and sex distribution. The following table shows the cases, deaths, case-rates, death-rates and fatality of scarlet fever at the several ages and for each sex in London during the year 1903. 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 this 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 was greatest among males of one year of age, and among females under one year of age— Diagram X. —Diphtheria.— Mean deathrate 1859-1303 Mean deathrate 1853-1903 412 per millon 276 per mllion. Diagram XI. Deaths occurring in the hospitals of the Metropol" Asylums Board per cent of total deaths in London 1888-1303. Admissions to hospitals of the Metropolitan Asylums Board per cent of total cases notified in London 1690-1903. 25 Scarlet fever1, 1903. 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 6,059 179 3.0 278 8 6,472 182 2.8 266 7 0— 90 8 8.9 161 14 80 10 12.5 144 18 1— 303 29 9.6 612 59 265 22 8.3 535 44 2— 497 32 6.4 992 64 441 30 6.8 884 60 3— 592 30 5.1 1,214 62 623 35 5.6 1,262 71 4— 689 24 3.5 1,443 50 724 19 2.6 1,524 40 5— 2,264 42 1.9 1,011 19 2,508 49 2.0 1,109 22 10— 912 3 0.3 432 1 939 5 0.5 436 2 15— 340 5 1.5 160 2 344 5 1.5 145 2 20— 182 4 2.2 82 2 253 3 1.2 95 1 25— 149 2 1.3 39 1 225 4 1.8 51 1 35— 32 — — 11 — 57 — — 18 — 45— 5 — — 3 — 10 — — 5 — 55 and upwards 4 — — 2 — 3 — — 1 — Diphtheria. The cases of diphtheria notified in the adminstrative county of London in 1903 (52 weeks) numbered 7,738, compared with 10,731 in 1902. The number of deaths registered from this cause in 1903 was 740, compared with 1,159 in 1902. The diphtheria case-rates and death-rates in 1903 and preceding periods are shown in following table— Period. Death-rate per 1,000 living. Case-rate per 1,000 living. Case-mortality per cent. 1861-70 0.18 –2 –2 1871-80 0.12 –2 –2 1881-90 0.26 –2 –2 1891 0.313 1.5 22.5 1892 0.443 2.0 22.2 1893 0.743 3.2 23.3 1894 0.613 2.6 23.6 1895 0.523 2.6 20.4 1896 0.593 3.1 19.3 1897 0.503 3.0 17.0 1898 0.393 2.7 14.8 1899 0.433 3.1 14.2 1900 0.343 2.7 12.8 1901 0.293 2.7 10.9 1902 0.253 2.3 10.8 1903 0.163 1.7 9.6 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859-1903 is shown for diphtheria and for diphtheria and croup combined in diagram X. The monthly case-rate and case-mortality in each of the years 1891-1903 in relation to the mean of the whole period is shown in diagram XII. The seasonal curve of diphtheria, based on the number of cases notified, in London during the 14 years 1890-1903, is shown in diagram IV., page 13. 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 1893-1902 the London rate exceeded the rates of all these towns, except West Ham and Leicester, while in 1903 it was lower than the rates of any except Leeds, Sheffield and Leicester— Diphtheria—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.484 0.164 Bradford 0.12 0.19 Liverpool 0.23 0.23 West Ham 0.65 0.26 Manchester 0.20 0.24 Hull 0.16 0.31 Birmingham 0.26 0.26 Nottingham 0.10 0.26 Leeds 0.34 0.15 Salford 0.32 0.38 Sheffield 0.44 0.09 Newcastle 0.16 0.17 Bristol 0.24 0.35 Leicester 0.50 0.13 1 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. 2 See footnote (1), page 22. 3 See footnote (1), page 7. 4 See footnote (2), page 7. [4] 26 The following table shows that the London diphtheria (including croup) death-rate in the period 1893-1902 exceeded that of any of the undermentioned foreign towns except Stockholm, St. Petersburg, and New York; and in 1903 was higher than that of any except Stockholm, St. Petersburg, Vienna and New York— Diphtheria (including croup)—Death-rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.501 0.171 St. Petersburg 0.89 0.48 Paris 0.23 0.15 Berlin 0.41 0.13 Brussels 0.13 0.10 Vienna 0.45 0.24 Amsterdam 0.17 0.11 Rome 0.10 0.07 Copenhagen 0.27 0.14 New York 0.66 0.59 Stoikholm 0.57 0.22 The following table shows the diphtheria cases, deaths and death-rates in 1903 and the case-rates in 1903, and the decennium 1893-1902 in the several metropolitan boroughs— Metropolitan borough. Cases, 1903. Case-rate per 1,000 living. Deaths, 1903. Death-rate per 1,000 living, 1903. 1893-1902. 1903. Paddington 150 2.2 1.0 15 0.10 Kensington 180 1.7 1.0 24 0.13 Hammersmith 166 1.9 1.4 17 0.15 Fulham 294 3.6 2.0 24 0.16 Chelsea 98 2.8 1.3 4 0.05 Westminster, City of 186 1.6 1.0 15 0.08 St. Marylebone 228 1.9 1.7 26 0.20 Hampstead 86 1.7 1.0 10 0.12 St. Pancras 522 2.7 2.2 37 0.16 Islington 458 2.4 1.4 42 0.12 Stoke Newington 40 2.1 0.8 7 0.13 Hackney 545 3.4 2.4 48 0.21 Holborn 52 2.3 0.9 8 0.14 Finsbury 129 3.2 1.3 11 0.11 London, City of 27 2.0 1.1 2 0.08 Shoreditch 154 2.8 1.3 22 0.19 Bethnal.green 242 3.6 1.9 27 0.21 Stepney 543 3.3 1.8 58 0.19 Poplar 425 3.9 2.5 60 0.35 Southwark 354 3.5 1.7 23 0.11 Bermondsey 174 3.1 1.3 18 0.14 Lambeth 346 2.5 1.1 29 0.09 Battersea 314 3.0 1.8 29 0.17 Wandsworth 532 2.3 2.1 44 0.18 Camberwell 365 3.6 1.4 34 0.13 Deptford 456 3.7 4.1 45 0.40 Greenwich 208 2.8 2.1 27 0.27 Lewisham 278 2.8 2.0 21 0.15 Woolwich 184 2.4 1.5 13 0.11 Port of London 2 — — — — London 7,738 2.8 1.7 740 0.162 It will be seen from the foregoing table that the diphtheria death.rate in 1903 was highest in Deptford (0.40) and lowest in Chelsea (0.05). The diphtheria death-rate in London in each of the four quarters of 1903 was as follows—First quarter, 0 21; second quarter, 0-15, third quarter, 0-13; and fourth quarter, 0-16 per 1,000 living. To enable the variations in diphtheria prevalence in the several metropolitan boroughs to be more clearly appreciated the following table has been prepared. This table shows the comparative case-rates of each borough in each of the years 1891-1903 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— 1 See footnote 2), page 7. 2 See footnote (1), page 7. DiagramxII. —Diphtheria.— Mean Case-mortality Mean notifications. 1891~1903. 1831-1903- 17.0 % 858 per month 27 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. 1903. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 Fnlham 61 58 78 126 139 99 109 145 135 178 174 126 118 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 47 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 Holborn 52 89 79 61 66 61 104 102 46 70 104 87 53 Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 City of London 59 130 60 49 51 74 71 60 68 89 96 161 65 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 Bethnal-green 154 230 181 168 143 114 144 100 89 115 133 104 112 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 Sonthwark 71 72 116 113 86 106 102 151 207 141 100 113 100 JBermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 London 100 100 100 100 100 100 100 100 100 100 100 100 100 With the continued decrease in the case-rate and in the case mortality of diphtheria, as manifested by the statistics of 1903, only a few localised outbreaks of this disease, all due to school attendance, occurred during the year. In Paddington 10 cases occurred among children attending the St. Michael's school, which was closed in consequence, with the result that no further cases appeared. In Chelsea 9 cases occurred among the children in the Duke of York's school. In Finsbury 7 cases occurred among the children of the Brewer-street school and 10 among those of the Moreland-street school. Dr. Newman, as the result of inquiry, was able to establish a relationship between these two occurrences. In Wandsworth a special prevalence was observed, in Streatham particularly, among the children attending the Eardleyroad school. Examination of material from the throats of children attending the school was made by the medical officer of the School Board, and several cases of the disease were thus discovered and isolated. The cases in Streatham were largely due to attendance at school of unrecognised cases of diphtheria; closure of the school was not found to be necessary. In Deptford prevalence of diphtheria among the children attending the Alverton-street Board school led to closure of the infants' department from 7th July to the end of the summer holiday. In Camberwell the Infants' National school at Dulwich was closed for three weeks for the same reason. The appreciation of the part played in the dissemination of diphtheria by unrecognised cases of the disease, or by "carrier cases," must inevitably lead to fuller examination of persons who have been in contact with those who have liad attack of diphtheria which is recognised and notified. Fortunately, in respect of diphtheria, bacteriological methods are able to be utilised for this purpose, and the more completely this system of examination of "contacts " is carried out the more thorough will be the control over extension of diphtheria. In a community like that of London, with its vast population, and with its divided administration, the difficulties which stand in the way of complete success are no doubt great. They do not, however, prevent steps being taken which will largely reduce diphtheria prevalence, and especially extension of the disease, due to the attendance at school of children who are infective, but present no clinical symptoms of the disease. In the last annual report account was given of the results obtained by Dr. Brown, the medical officer of health of Bermondsey, in his examination of the inmates of houses in which cases of diphtheria were known to have occurred. In his anmial report for the year 1903, Dr. Brown supplies information as to his procedure and the results obtained in similar examinations made during that year. Dr. Brown's experience may well be given in his own words— "During the first nine months of the year the contacts were generally the children of all ages and occasionally the mothers of those families in which diphtheria occurred. During the last three months this plan was slightly modified and more systematised, inasmuch as the examination of contacts was practically limited to those attending school, the remaining ones only being examined if they showed sore throat. The plan of procedure is as follows—On the notification of a case of diphtheria, the inspector 28 visits the house and sees that the necessary precautions of removal, disinfection, etc., are duly carried out. He then requests the parents to send up those children attending school to the town-hall during the second week after removal of the case, to have their throats examined by the medical officer. If no diphtheria bacilli are found, the headmaster and parents are notified that the children may return to school at once, but if they are found, a request is sent to the headmaster to exclude them until further examination. The parents are at the same time notified of this, and asked to bring the children to their medical attendant for an antiseptic gargle, and requested to bring them up for a second bacteriological examination in 14 days. If, of course, any of these "contacts" at the time the inspector calls, or during the subsequent period, develop sore throats, the parents are advised to call in their medical attendant at once. Before carrying out this plan I consulted the medical officer of the School Board as to its feasibility, and got encouragement and promise of help from him. The Board has now appointed an assistant medical officer, who, when he sees any particular school or class attacked or threatened with an outbreak of diphtheria, visits and examines the suspicious cases bacteriologically, and immediatelv notifies the medical officer of health if diphtheria bacilli are found. These two plans so far have worked very well, and I have experienced, as yet, no difficulty in carrying out my part, and hope to see it before long adopted all over London and applied to all schools. I, of course, see difficulties in following it very completely in a district like Bermondsey if there was anything like a large epidemic or a very large number to be examined. If such, unfortunately, took place, the only plan would be to appoint a temporary assistant to examine throats. Another difficulty would be if all the cases had to be visited, but the parents so far have shown themselves willing to co-operate by bringing their children to the town-hall, when the advantages of the early warning of an impending attack were explained to them. The number of contacts examined during the year was 193, belonging to 64 families. Of these 20 were found to have diphtheria bacilli in their throats, and of these, three developed sore throats and were notified as diphtheria." The use of antitoxin for prophylactic purposes is mentioned in a few of the reports of medical officers of health. Thus Dr. Newman reports that antitoxin was used in Finsbury in several cases, both for prophylactic and therapeutic purposes. Dr. Priestley states that antitoxin has been distributed gratuitously by the Lambeth Borough Council for use both as a remedy and a prophylactic during 1903, 45 vials having been so distributed within the borough. The medical officers of health of Stoke Newington and Lewisliam recommend its use for prophylactic purposes, and arrangements have been made in Lewisham for the free supply by the borough council of this material "where it is thought desirable to give injections as a protective agent." In 18 annual reports the results are given of bacteriological examination of material from the throats of persons suspected to be suffering from diphtheria. Of 1,382 cases thus examined the results of 355 cases were positive, or 25'7 per cent. The number of "return cases" are stated in a few of the reports to have occurred as follows—Holborn, one; Shoreditch, one; Stepney, two; Wandsworth, eleven; Lewisham, twelve; and in Woolwich six cases, all of which were attributed to infection from one child. As a result of the arrangements made by the Metropolitan Asylums Board for every medical officer of health to be informed of the discharge from hospital of patients admitted from their districts, the homes of such persons have been brought under medical observation at the time of the return of the patient. Dr. McCleary states that "the first intimation of discharge was received from Battersea, on 15th March, and since then it has been a duty of the lady sanitary inspector to visit the homes to which recovered patients are to return, and to advise the mothers to take certain precautions, for instance, not to allow the child to sleep with other children soon after his return. She also ascertains to what school it is proposed to send the patient, and a letter is then addressed to the head teacher requesting that the child be excluded from school for a fortnight after his return home. This procedure appears to have been beneficial." Diphtheria and elementary schools. The summer holiday of the schools of the London School Board began on Thursday, the 23rd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 24th August, i.e., the beginning of the 34th week. If the number of cases in the four weeks preceding and four weeks subsequent to the weeks most subject to holiday influence be compared, the following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. It will be observed that the decrease in the number of cases notified during the period of holiday influence and the increase in the subsequent period is most marked at the school age— Diphtheria—Notified cases, 1903. 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 (27th to 30th) 96 420 138 — — — Four weeks of holiday influence (31st to 34th) 84 287 101 —125 —317 —268 Four weeks following weeks of holiday influence (35th to 38th) 96 350 94 + 14-3 + 22-0 — 69 The interruption of the autumnal rise during the period of the summer holiday, previously referred to in the case of scarlet fever, is equally conspicuous in the case of diphtheria, as will be seen on reference to diagram IV., page 13. Diagram XIII. Whooping Cough. 29 Proportion of cases of diphtheria removed to hospital. It will be seen from diagram XI. that the proportion of cases of diphtheria admitted to the hospitals of the Metropolitan Asylums Board was slightly greater in 1903 than in the preceding year. 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 1903. The incidence of attack at "all ages" was, as in preceding years, greater on females than on males. The death. rate and fatality were also higher among females than among males at "all ages." In the age. groups adopted for the purposes of this 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 females of one year of age. The fatality was greatest both among males and females under one year of age— Diphtheria}, 1903. 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 3,613 349 9.7 166 16 4,125 413 10.0 169 17 0— 98 31 31.6 175 55 78 25 32.1 140 45 1— 281 63 22.4 567 127 249 77 30.9 502 155 2— 379 68 17.9 757 136 324 71 21.9 649 142 3— 442 47 10.6 906 96 430 66 15.3 871 134 4— 440 47 10.7 922 98 445 39 8.8 937 82 5— 1,130 76 6.7 504 34 1,402 109 7.8 620 48 10— 366 9 2.5 173 4 474 15 3.2 220 7 15— 169 3 1.8 80 1 187 2 1.1 79 1 20— 102 2 2.0 46 1 170 1 0.6 64 0 25— 137 2 1.5 36 1 231 2 0.9 52 0 35— 52 — — 18 — 96 — — 30 — 45— 10 — — 5 — 25 2 8.0 11 1 55 and upwards 7 1 14.3 4 1 14 4 28.6 5 2 Whooping Cough. The deaths from whooping cough in the administrative county of London in 1903 numbered 1,627, compared with 1,876 in 1902. The death-rates from this disease in 1903 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 0.342 1861-70 0.88 1896 0.652 1871-80 0.81 1897 0.422 1881-90 0.69 1898 0.482 1891 0.682 1899 0.3S2 1892 0.582 1900 0.432 1893 0.542 1901 0.352 1894 0.492 1902 0.402 1903 0.352 The death-rate in each year in relation to the mean death-rate of the period 1841.1903 is shown in diagram XIII. It will be seen from the following table that the London whooping-cough death-rate was in the decennium 1893.1902 greater than the death-rates of any of the following large English towns except Liverpool, Manchester, Birmingham, "West Ham, Salford, and Newcastle, and in 1903 it was exceeded by the death-rates of Liverpool, Manchester, Sheffield, "West Ham, Nottingham, and Salford— 1 See footnote (1), page 25. 2 See footnote (1), 1 age 7. 30 Whooping cough—death-rates per 1,000 living. Towns. 1893.1902. 1903. Towns. 1893.1902. 1903. London 0.451 0.351 Bradford 0.32 0.32 Liverpool 0.53 0.4,3 West Ham 0.49 0.59 Manchester 0.50 0.39 Hull 0.38 0.09 Birmingham 0.50 0.17 Nottingham 0.33 0.39 Leeds 0.39 0.27 Salford 0.61 0.42 Sheffield 0.41 0.61 Newcastle 0.45 0.23 Bristol 0.39 0.20 Leicester 0.32 0.16 The following table shows that the London whooping-cough death-rate both in the period 1893.1902 and in 1903 considerably exceeded that of any of the undermentioned foreign towns— whooping-cough—death-rates per 1,000 living. Towns. 1893.1902. 1903. Towns. 1893.1902. 1903. London 0.451 0.351 St. Petersburg 0.22 0.28 Paris 0.14 0.08 Berlin 0.29 0.23 Brussels 0.14 0.11 Vienna 0.09 0.13 Amsterdam 0.27 0.13 Rome 0.06 0.09 Copenhagen 0.34 0.13 New York 0.18 0.09 Stockholm 0.20 0.12 The following table shows the deaths from whooping cough and the death-rates in the several metropolitan boroughs during the year 1903— Metropolitan borough. Deaths in 1903. death-rate per 1,000 living, 1903. Metropolitan borough. Deaths in 1903. death-rate per 1,000 living, 1903. Paddington 54 0.37 Shoreditch 44 0.38 Kensington 90 0.51 Bethnal-green 42 0.32 Hammersmith 30 0.26 Stepney 108 0.36 Fulham 46 0.31 Poplar 80 0.47 Chelsea 29 0.39 Southwark 68 0.33 Westminster, City of 34 0.19 Bermondsey 41 0.32 St. Marylebone 56 0.43 Lambeth 126 0.41 Hampstead 16 0.19 Battersea 81 0.47 St. Pancras 91 0.39 Wandsworth 89 0.36 Islington 153 0.45 Camberwell 72 0.27 Stoke Newington 19 0.37 Deptford 45 0.40 Hackney 67 0.30 Greenwich 37 0.37 Holborn 18 0.31 Lewisham 6 0.04 Finsbury 54 0.54 Woolwich 27 0.22 London, City of 4 0.16 London 1,627 0.352 It will be seen from the foregoing table that the whooping-cough death-rate was highest in Finsbury (0.54) and lowest in Lewisham (0.04). The whooping-cough death-rate in London in each of the four quarters of the year 1903 were as follows—First quarter, 0.66; second quarter, 0.39; third quarter, 0.19; and fourth quarter 0.18 per 1,000 living. Typhus. Three deaths from typhus in the administrative county of London occurred during the year 1903. The death-rates from this disease in 1903 and previous periods were as follows— Typhus. Period. death-rate per 1,000 living. Period. death-rate per 1,000 living. 1871-80 .055 1897 .0002 1881-90 .008 1898 .0012 1891 .0022 1899 .0002 1892 .0032 1900 .0002 1893 .0012 1901 .0012 1894 .0012 1902 — 1895 .0012 1903 .0012 1896 .0012 III this table .000 indicates that the deaths were too few to give a rate of .0005; where — is inserted no death occurred. 1 See footnote (2), page 7. 2 See footnote (1), page 7. Diagram XIV. Typhus Fever. — 31 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1903 is shown in diagram XIV. The three deaths registered from this disease occurred in Bermondsey. During the year 1902 only four persons in London were certified to be suffering from typhus fever. In the early part of the year 1903, however, a number of cases of recognised typhus occurred in London, viz., in January 1 case, February 2 cases, March 6 cases, and in April 9 cases. The case in January was that of H. D., a fishmonger's assistant, aged 25, living in Jamaicaroad, Bermondsey, who was removed to hospital on the 27th on the supposition that he was suffering from enteric fever. The source of his infection could not be ascertained. The next case was that of S. E., aged 16, a tailor's porter, who lived in Stevens-street, Bermondsey, and worked in Cheapside. He became ill on the 4th of February and the source of his infection was not known. This case was followed by a group of cases occurring in the same district in February, March, and April. A special report of Dr. Brown, the medical officer of health of Bermondsey, gives particulars of these cases. A girl, E. M., aged 9, living at 14, Warford-place, was removed to hospital on the 28th February on the supposition that she had scarlet fever, and died on the 8th March from what was believed to be pneumonia. She attended the St. Joseph's School, Paradise-street, and was last there on the 23rd February. The source of infection was unknown. Her illness was followed by that of another girl, N. C., aged 5, the daughter of a potman living at a public-house in Neptunestreet, attending the same school, and who may have met E. M. in the playground. This child sickened on the 3rd March and was removed on the 12th March. A third family attacked, the children of which attended St. Joseph's School, lived in Donne-place, Bermondsey. The first recognised case was W. R., aged 23, a dock labourer, who was removed on the 7th April. His illness had been preceded by that of his brother, S. R., aged 8, who was ill between March 16th and 21st, but who was not at the time known to have typhus. W. R.'s illness was followed by that of a sister, E. M. R., aged 5, removed on the 14th April, and S. R., aged 15, a brother, removed on the 29th April. Of the family of E. M., already mentioned, there were attacked M. M., aged 2, and E. M., aged 7, sisters, and I. M., aged 11, brother of E. M., the first two sickened on the 20th and the last on the 21st March. They were all removed on the 30th. The two former attended St. Joseph's Infants' School. E. M., aged 35, the mother of the family, was removed on the 3rd April, and W. M., aged 6, another of her children, was removed on the 19th April. Another case occurring in Bermondsey was that of a woman, S. L., aged 29, who lived in Aylton-street. She was a trousers finisher, working for a maker in East London, and she used to go to the Neptune-street public-house for beer. She was attacked on the 8th March and removed on the 14th. Another family attacked, the children of which attended St. Joseph's School, lived in Salisbury-street, Bermondsey. The first case recognised to be typhus was R. D., aged 18, a vanguard, removed on 7th April. Dr. Brown found that his brother, J. 1)., aged 8, was ill about the 6th March with diarrhoea. R. D.'s attack was followed by that of his sister, J. D., aged 15, and his mother, M. A. D., aged 44, both removed to hospital on 10th April. Another case, not known to be related to the other Bermondsey cases, was that of E. E., aged 33, living in Jamaica-road, who was attacked on 5th April. She was engaged in housework at home. Her sister aged 29 had an illness, said to be influenza, from the 15th to the 22nd March. This sister worked in her father's office in James-place. Cases occurring in other districts were W. M., a tailor, aged 43, living in Booth-street, Whitechapel, attacked on the 20tn February with what was thought to be enteric fever. He was removed to hospital on 25th February, where his disease was later recognised to be typhus ; also N. G., aged 19, a tailor's machinist, living in Boundary-street-buildings, Bethnal-green, and working in Philip-street, Stepney, who was attacked on the 28th March, and removed to hospital on the 3rd April. His illness had been, before his removal to hospital, thought to be enteric fever. With respect to the Bermondsey cases, Dr. Brown visited the schools where the patients and relatives attended and asked the teachers to inform him of all cases of suspicious illness. The school closed for the Easter holiday early in April, and Dr. Brown recommended that the school should not be reopened until the 11th May. The school and its contents were disinfected. The members of infected families were removed to the shelter of the borough council, and, as a matter of fact, five or six of those who were attacked first developed the disease in the shelter, and were thus isolated from the beginning of their illness. It is interesting to note that of the cases not connected with the Bermondsey groups three were connected with the tailoring trade, viz., in February, S. E., living in Stevens-street, Bermondsey, and M. L., living in Booth-street, Whitechapel, and in April, N. G., a tailor's machinist, living in the Council's Cookham-buildings, Boundary-street, and working in Philip-street, Stepney. Further, among those mentioned in the Bermondsey groups was the case of S. L., living in Aylton-street, Bermondsey, a trousers finisher for an East-end tradesman occupying premises in Commercial-road, E. Enteric Fever. The number of cases of enteric fever notified in the administrative county of London during 1903 (52 weeks) was 2,339, compared with 3,407 in 1902. The deaths from this disease numbered 368 in 1903, compared with 537 in 1902. 32 The rates per 1,000 living in 1903 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 l l 1881.90 0.19 l l 1891 0.22 0.8 15.6 1892 0.102 0.6 17.2 1893 0.162 0.9 18.4 1894 0.142 0.8 18.1 1895 0.142 0.8 17.0 1896 0.132 0.7 17.6 1897 0.132 0.7 18.0 1898 0.122 0.7 18.3 1899 0.172 1.0 17.0 1900 0.162 1.0 16.6 1901 0.1l2 0.7 15.6 1902 0.122 0.7 15.8 1903 0.082 0.5 15.7 The death-rate in each year since 1868 in relation to the mean death-rate of the period 18G9.1903 is shown in diagram XV. The monthly Case-rate and case mortality in each of the years 1891.1903 in relation to the mean of the whole period is shown in diagram XVII. The seasonal curve of enteric fever based on the number of cases notified in London during the 14 years 1890.1903 is shown in diagram IV page 13. The following table shows the death rate from enteric fever in 1903 and the Case-rates in 1903 and the decennium 1893.1902 obtaining in each of the metropolitan boroughs— Metropolitan borough. Cases, 1903. Case-rate per 1,000 living. Deaths, 1903. death-rate per 1,000 living, 1903. 1893.1902. 1903. Paddington 44 0.6 0.3 7 0.05 Kensington 66 0.6 0.4 9 0.05 Hammersmith 59 0.6 0.5 9 0.08 Fulham 80 0.6 0.5 15 0.10 Chelsea 13 0.7 0.2 4 0.05 Westminster, City of 71 0.7 0.4 14 0.08 St. Marylebone 67 0.8 0.5 13 0.10 Hampstead 29 0.6 0.3 2 0.02 St. Pancras 88 0.9 0.4 14 0.06 Islington 131 0.8 0.4 23 0.07 Stoke Newington 35 0.6 0.7 5 0.10 Hackney 271 1.1 1.2 36 0.16 Holborn 54 0.8 0.9 5 0.09 Finsbury 52 0.9 0.5 10 0.10 London, City of 14 1.0 0.6 3 0.12 Shoreditch 99 1.0 0.8 13 0.11 Bethnal-green 59 1.0 0.5 12 0.09 Stepney 199 1.0 0.7 27 0.09 Poplar 93 1.3 0.6 17 0.10 Southwark 122 0.8 0.6 23 0.11 Bermondsey 76 0.9 0.6 12 0.09 Lambeth 136 0.7 0.4 23 0.07 Battersea 89 0.8 0.5 17 0.10 Wandsworth 101 0.6 0.4 18 0.07 Camberwell 103 0.6 0.4 17 0.06 Deptford Greenwich 31 44 0.8 0.8 0.3 0.4 4 1 0.04 0.01 Lewisham 49 0.5 0.4 10 0.07 Woolwich 42 0.7 0.3 5 0.04 Port of London 22 — — — — London 2,339 0.8 0.5 363 0.082 The foregoing table shows that among the several metropolitan boroughs the enteric fever death-rate was highest in Hackney (0.16) and lowest in Greenwich (0.01). The enteric fever death-rates in London in each of the four quarters of the year 1903 were as follows—First quarter 0.07; second quarter 0.04; third quarter 0.07; and fourth quarter 0.14 per 1,000 living. 1 See footnote (1), page 22. 2 See footnote (1), page 7. Diagram XV. Enteric Fever. Diagram XVI. Enteric Fever. Diagram XVII. Enteric Fever. 33 There was diminished prevalence of enteric fever in 1903, the number of cases notified being less than that in any year since the year 1889, when notification became obligatory, and in »o far as deaths are concerned, the deaths in proportion to population were less than in any year since 1869, when deaths from enteric fever were first separately classified. The diminished prevalence in 1903 is well shown by the upper curve in diagram XVII., relating to notified cases, from which it will be seen that the nearest approach to the conditions obtaining in 1903 since notification has been obligatory occurred in the year 1892. So far, however, as the distribution of cases throughout the year is concerned, diagram XVI. shows that this did not exhibit marked deviation from the normal. Among the articles of food which are mentioned as causes, or possible causes, of the cases which occurred are shellfish, watercress, ice-creams, water, and milk. The extent to which contaminated shellfish is productive of enteric fever in London cannot be determined. In some of the instances recorded in the reports for 1903 and in preceding reports there is evidence of shellfish being consumed by certain members of households and being followed, at a time which corresponds with the incubation period of the disease, by the occurrence of enteric fever among those who had partaken of the shellfish, and limited to people who had so partaken. In other cases there is the additional evidence that the shellfish had been received from a source suspected to be contaminated, for the reason that enteric fever had occurred in other families who had received shellfish from that source. In other cases the evidence does not amount to more than the fact that a particular person suffered from an attack of enteric fever after eating shellfish some period before the attack which is within the limits of the period of incubation. The number of cases in London actually due to the eating of infected shellfish is necessarily problematical. This question was thus reported on by the Royal Commission on Sewage Disposal in 1903— After carefully considering the whole of the evidence on this point, we are satisfied that a considerable number of cases of enteric fever and other illness are caused by the consumption of shellfish which have been exposed to sewage contamination; but, in the present state of knowledge, we do not think it possible to make an accurate numerical statement, at any rate, as regards the whole country. In certain towns the subject has received much consideration, and the medical officers of health have been at considerable trouble to collect all available data, but we doubt whether this practice has been universally adopted throughout the country. Moreover, an examination of the figures which have been placed before us as regards those towns in which the subject has been most carefully studied shows that there may be occasional errors. Indeed, the witnesses themselves recognised that absolutely accurate figures are not obtainable. Isolated cases of enteric fever have been ascribed to shellfish where the patient had eaten shellfish obtained from a contaminated source, at a period prior to the manifestation of the disease corresponding with the incubation period, and no other source of infection was discovered. We are far from denying that such isolated cases may have been due to contaminated shellfish, but when we remember the numerous unexplained cases of enteric fever we feel that the possibility of some of them being due to other causes cannot be altogether excluded. Further, if the figures are accepted as correct in those cases in which careful records have been kept, we have not the means of applying them to other towns. The extent of illness properly ascribed to shellfish would depend partly on the proportion of the population who were consumers of shellfish, and on the degree of contamination of the shellfish supplied to the particular town. There can, however, be no doubt that the evil is sufficiently grave to demand a remedy. The consumption of shellfish in connection with the occurrence of enteric fever is mentioned in several of the annual reports, from which the following information is derived— Paddington.—Probable cause of infection, oysters 4 cases, cockles 6 cases, mussels 2 cases, winkles 1 case. Several cases of enteric fever believed to be due to eating polluted cockles occurred in a family visiting Leigh-on-Sea. A group of cases occurred within a few days of each other in two neighbouring streets; shellfish (cockles or mussels) had been eaten by the sufferers which had been purchased from a hawker who admitted having procured them from Leigh-on-Sea. Kensington.—In a few of the cases there was ground for suspicion that the illness had been caused by the eating of shellfish—oysters in seven of the cases. Fulham.—Three cases, probably due to shellfish. Chelsea.— One case, probably due to consumption of cockles at Southend. Westminster.—"In fifteen cases there appeared to be a direct connection with the eating of shellfish (thirteen oysters, one mussels, one cockles)." Dr. Allan states that the occurrence of a case of enteric fever in Westminster and several in other parts of London having possible connection with the consumption of oysters in Westminster led him to communicate to the Fishmongers' Company the names of the merchants supplying the Westminster tradespeople. He was informed by the company "that they had watched certain beds at Emsworth, known to be polluted, had seen oysters removed from them and traced them to Portsmouth and to London (to a merchant supplying Westminster dealers). Those sent to London were sent under a designation implying that they came from a pure source." The oysters were seized by the Company. Dr. Allan adds that the Emsworth beds referred to adjoin those from which oysters were taken which had given rise to a well-known outbreak of enteric fever in Winchester. St. Pancras.—Dr. Sykes gives particulars of the attack of five members of a family by enteric fever. The first person attacked was the father, who had a fortnight before eaten oysters. Four children were subsequently attacked, the disease being communicated from person to person. Stoke Newington.—Dr. Kenwood states that the evidence in one instance pointed strongly to the eating of oysters as a cause. Holborn.—" In four instances there was strong evidence that the disease was caused by eating shellfish, and in several others there was great probability that shellfish was the cause of the disease." Finsbury.—Dr. Newman mentions the eating of shellfish, oysters, cockles, etc., as a probable cause of fourteen cases. [5] 34 The City.—Dr. Collingridge states that five cases were brought to his knowledge in which infection was attributed to oysters and four in which it was attributed to mussels. Samples of oysters which had been laid down in South Deep and from the "Pollard" bed at Whitstable, which thus came under suspicion, were reported by Dr. Klein to be sewage-polluted. Dr. Collingridge reports that an undertaking was received from the chairman of the company supplying the latter oysters to "discontinue the sale of any oysters (including 'natives') from the Pollard layings at Whitstable during the remainder of the season, and sell only off the 'Ham' ground." This latter is, Dr. Collingridge says, in deep water, some miles from the shore, and apparently free from pollution. Mussels which came under suspicion came from Hadleigh Ray, Leigh-on-Sea, and were sold in accordance with instructions received from the Fishmongers' Company, viz., to caution purchasers to boil them for three and a-half minutes. Samples were reported by Dr. Klein to be sewage-polluted. Dr. Collingridge states that he has received written undertakings from the two proprietors of these layings, in the one case not to expose Hadleigh mussels for sale without giving him due notice of their intention to do so, and in the other not to have any more up until Dr. Collingridge considers them free from contamination. The occurrence of cases of enteric fever which were attributed to the eating of cockles from Leigh-on-Sea led to examination by Dr. Klein of cockles which had been cooked by the cocklers with a view to sterilisation. The samples thus examined, Dr. Collingridge writes, "showed evidence of sewage pollution, and that in the process of cooking the temperature had not been high enough to ensure devitalisation of sewage bacilli, thus clearly showing the impossibility of relying upon any arrangement with irresponsible fishermen to carry out precautions necessary to protect the public health." The Fishmongers' Company had endeavoured to compel the discontinuance of the practice of laying cockles in the Leigh-creek, and to ensure more complete cooking, and now, in view of Dr. Klein's report, they excluded the Leigh cockles from the London markets. Shoreditch.—Five cases associated with the eating of shellfish occurred, one had eaten cockles at Southend and another at Leigh-on-Sea. Poplar.—Four cases occurred, two after eating oysters and one each after eating mussels and cockles respectively. Souihwark.—" In quite a fourth of the cases the evidence was so strong in favour of shellfish being the cause that it could not be reasonably discarded. In one group of cases the shellfish was purchased from a particular stall." Bermondsey.—In three cases attack followed the eating of mussels, and in one case cockles. Lambeth.—" There was a history in twenty cases (15 per cent.) of shellfish having been eaten by the patients notified one to three weeks previous to the disease developing." Wandsworth.—" Twelve cases were in all probability caused by eating infected oysters, 7 by mussels, 2 by cockles, 1 by winkles." Deptford.—" Five of the cases reported were traced to the consumption of shellfish (oysters and cockles)." Greenwich.—The patient had eaten shellfish within the incubation period of the disease in the following cases-—mussels 2, oysters 2, mussels and oysters 1, shell-fish 1. Woolwich.—Two cases were attributed to eating oysters, 1 to periwinkles, 1 to crayfish and crabs bought and cooked at Hull. In one instance an outbreak of the disease is believed to have been due to local contamination of a water supply. This outbreak occurred in Fulham, Dr. Jackson's report showing that cases of enteric fever occurred in streets on each side of the portion of Greyhound-road, running between Ancill-street and Field-road, comprising an area of about 20 acres, with an approximate population of 4,000. In this area cases of enteric fever were reported as follows—6 in the week ending June 27th, 16 in the week ending July 4th, and 4 in the week ending July 11th. During the next six weeks 5 other cases occurred. Possible causes, such as milk, shellfish, icecreams, fried-fish, etc., could be excluded. The water supply of this area, in which the cases of enter fever occurred and of three other streets, was received from a particular water-main, the water being on constant supply. Dr. Jackson states that "no information could be obtained from the company respecting the supply having been intermitted at a time corresponding with the infection of the patients, but I was positively assured by several residents in the district affected that the water was shut off for a short time about Whitsuntide. If such were the case, it is quite conceivable that some specifically infected sewage may have been sucked into a defective communication pipe, and it may be noted that on the evening of Thursday, May 29th, we experienced one of the heaviest of last year's storms by which the sewers were surcharged and the basements in that locality flooded to a depth of two to three feet, so that the risk of sewage being drawn into a defective empty pipe would be increased, as the subsoil would be soaked with it.'' Since Dr. Hamer found certain outbreaks of enteric fever in London in 1900 to be associated with the consumption of fried-fish, attention has been directed to this subject, and in December of 1903 groups of cases occurred for the most part in Holborn, Westminster and Southwark, the persons attacked having eaten fried-fish obtained from local vendors at a period before their attack which corresponded with the incubation period of the disease. The Holborn and Westminster cases were investigated by Dr. Bond and Dr. Allan, the medical officers of health of those districts. They were further inquired into by Dr. Hamer, who subsequently, by study of the distribution of notified cases of enteric fever in London in certain selected areas during a number of years, found that there was frequently a distinct tendency to the grouping of cases, and that the localities in which the groups occurred were in the main occupied bv poor persons by whom fried-fish was largely consumed. This behaviour of enteric fever appeared to be of sufficient interest to put on record, and hence Dr. Hamer has discussed the subject in a report which was presented to the Public Health Committee, and is appended to this report (see appendix I.). 35 In a number of instances the fact is mentioned that the persons who were attacked had, within the incubation period of the disease, eaten ice-creams or watercress. In Hackney two localised outbreaks of the disease were attributed by Dr. Warry to the eating of watercress. The first of these, which comprised 48 notified cases, occurred within a period of eight weeks, from the second week in June to the week ending the 25th July, in an area bounded by a circle of one-third mile radius, the centre of the circle being situated in the Clarence-road, opposite Pembury-grove; the second outbreak of 62 notified cases occurred in a period from the first week in August to the week ending the 29th August, in an area bounded by a circle of half-mile radius, of which the centre was situated near Orchard-street, adjoining Well-street. Inquiry as to the food supply of the population in these areas enabled Dr. Warry to exclude as possible sources of infection all articles of food usually thought of in connection with such outbreaks, except watercress. He found, however, that during the first period watercress eaters suffered 4.6 times as much as those who did not eat watercress, during the second period more than twice as much, and during the whole epidemic over three times as much. Dr. Warry submitted for bacteriological examination a number of specimens of watercress purchased in Hackney, the source of some of which were known, and also water from beds at West Ham, which he had reason for thinking were the source of watercress which had been supplied in the areas of enteric fever incidence. All these samples were found to contain organisms of the intestinal type. This report was communicated to the Public Health Committee of the County Council. The Committee, as far back as 1900, had their attention directed to the pollution of watercress beds in London, and they now decided that inquiry should be made concerning watercress beds outside the county. Dr. Wellesley Harris also submitted, for bacteriological examination by Dr. Klein, samples of water from the River Pool, which receives the effluent from the Croydon Sewage Farm. Dr. Klein found that the watercress grown at Southend-lane and supplied by the River Pool was sewage polluted. Dr. Harris states that it is proposed to construct additional filter beds to improve the quality of the Croydon effluent. The only cases of enteric fever attributed to milk during the year occurred at Eltham. There were three such cases, the patients, with some few others at Mottingham, receiving their milk from a farm in that village. The outbreak was investigated on behalf of the inhabitants of the locality by Professor Simpson who, Dr. Davies, the medical officer of Woolwich, reports, was of opinion that " the polluted condition of a small water-course running through a field in which the cows of the suspected farm were turned out offers sufficient explanation of the infectiousness of the milk. In several annual reports account is given of the communication of infection from person to person, and Dr. Bryett gives the particulars of cases occurring in Shoreditch among persons who had been hop-picking in Kent, where infection was first received, and the disease subsequently communicated from one person to another. The use of the Widal test for the diagnosis of enteric fever is mentioned in the annual reports relating to 17 districts. In these districts 566 such examinations were made, the result being positive in 31.6 per cent. Enteric fever—Age and sex distribution. The following table shows the cases, deaths, case-rates, death-rates, and fatality of enteric fever at the several ages and for each sex in London during the year 1903. The case-rate and death-rate at "all ages" was greater among males than among females, but the fatality was greater among females. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon males aged 15-20 and upon females aged 10-15. The greatest incidence of death was upon males aged 20-25 and upon females aged 35-45. The fatality was greatest among males aged 55 and upwards and among females aged 35-45. Enteric fever1, 1903. Age-period. Males. Females. Cases. Deaths. Case mortality per cent. Rates per 100,000 livirg. Cases. Deaths. Case mortality per cent. Rates per 102,000 living. Cases. Deaths. Cases. Deaths. All ages. 1,249 200 160 57 9 1,090 182 167 45 7 0— 1— 5 1 4 — 2— 14 — 3.8 21 1 10 1 4.4 18 1 3— 14 — 13 1 4— 19 1 18 — 5— 143 7 4.9 64 3 125 7 5.6 55 3 10— 188 11 5.9 89 5 158 14 8.9 73 6 15— 198 22 11.1 93 10 154 23 14.9 65 10 20— 189 42 22.2 86 19 162 27 16.7 61 10 25— 272 66 24.3 72 17 250 51 20.4 56 11 35— 143 31 21.7 50 11 117 38 32.5 37 12 45— 43 9 20.9 22 5 65 17 26.2 29 8 55 and upwards. 21 10 47.6 11 5 14 3 21.4 5 1 1 See footnote (1), page 25. 36 Diarrhoea. The deaths in the administrative county of London attributed to epidemic diarrhoea (infective enteritis) numbered 1,397 in 1903, while 1,561 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 (infective enteritis) 1,109 269 7 — 4 6 2 1,397 Diarrhoea and dysentery 1,059 206 15 48 61 127 45 1,561 Total 2,168 475 22 48 65 133 47 2,958 No accurate comparison of the deaths from epidemic diarrhoea for a long series of years in Loudon can be made, diagram XVIII., however, shows the deaths from cholera, dysentery and diarrhoea combined, in relation to the mean of the period 1841 1903 in each year since 1840. The following table shows that the London diarrhoea death-rate was, in the decennium 1893-1902, lower than the death-rate of any of the undermentioned large English towns except Bristol, and in the year 1903 was lower than that of any except Leeds, Bristol, Bradford, Newcastle and Leicester— Diarrhoea—Death rates per 1,000 living. Towns. 1893-1902. 1903. Towns. 1893-1902. 1903. London 0.801 0.641 Bradford 0.90 0.51 Liverpool 1.50 0.98 West Ham 1.25 1.11 Manchester 1.44 0.89 Hull 1.58 1.25 Birmingham 1.33 1.11 Nottingham 1.26 0.68 Leeds 1.14 0.63 Salford 1.67 0.98 Sheffield 1.49 1.27 Newcastle 0.82 0.58 Bristol 0.66 0.28 Leicester 1.48 0.60 The deaths and death-rate per 1,000 living in the year 1903 in each of the metropolitan boroughs are shown in the following table— Metropolitan Borough. Deaths, 1903. Death-rate per 1,000 living, 1903. Metropolitan Borough. Deaths, 1903. Death-rate per 1,000 living, 1903. Paddington 65 0.45 Shoreditch ... 152 1.30 Kensington 107 0.60 Bethnal-green 112 0.86 Hammersmith 93 0.81 Stepney 321 1.07 Fulham 172 1.17 Poplar 166 0.98 Chelsea 31 0.42 Southwark 197 0.95 Westminster, City of 55 0.31 Bermondsey 115 0.89 Marylebone 59 0.45 Lambeth 194 0.63 Hampstead 9 0.11 Battersea 101 0.58 Pancras 90 0.38 Wandsworth 126 0.51 Islington 121 0.36 Camberwell 142 0.54 Stoke Newington 21 0.40 Deptford 72 0.64 Hackney 112 0.50 Greenwich 71 0.71 Holborn 29 0.50 Lewisham 49 0.36 Finsbury 76 0.76 Woolwich 59 0.49 London, City of 8 0.33 London 2,925 0.642 It will be seen from the foregoing table that the diarrhoea death-rate was highest in Shoreditch (1.30) and lowest in Hampstead (0.ll). The diarrhoea death-rates in London in each of the four quarters of the year 1903 were as follows—First quarter 0-22 ; second quarter 0'23 ; third quarter 1.49 ; and fourth quarter 0.59 per 1,000 living. Erysipelas. The deaths from erysipelas registered in the administrative county of London during 1903 (52 weeks) numbered i83, the corrected annual average of the preceding 10 years being 213. 1 See footnote (v), page 7. 2 See footnote (1), page 7. Diagram XVIII. Diarrhoea, Dysentery and Cholera 37 The number of cases notified and the number of deaths registered from this disease since 1890 have been as follows— Erysipelas. Year. Cases. Case-rate per 1,000 living. Deaths.1 Death-rate per 1,000 living.  1891 4,764 1.13 214 .05 1892 6,934 1.63 292 .07 1893 9,700 2.26 424 .10 1894 6,080 1.40 221 .05 1895 5,660 1.30 179 .04 1896 6.436 1.43 207 .05 1897 5,794 1.31 184 .04 1898 5,169 1.16 165 .04 1899 5,606 1.25 213 .05 1900 4,762 1.06 182 .04 1901 4,604 1.02 171 .04 1902 5,536 1.19 183 .04 1903 4,372 0.95 183 .04 The number of cases of erysipelas notified and the Case-rate in the year 1903, together with the Case-rate in the decennium 1893.1902 for each of the metropolitan boroughs, are shown in the following table— Metropolitan borough. Cases, 1903. Case-rate per 1,000 living. Metropolitan borough. Cases, 1903. Case-rate per 1,000 living. 1893. 1902. 1903. 1893. 1902. 1903. Paddington 119 1.1 0.8 Bethnal-green 214 2.4 1.7 Kensington 177 1.2 1.0 Stepney 376 1.7 1.2 Hammersmith 109 1.0 0.9 Poplar 144 1.7 0.9 Fulham 116 1.1 0.8 Southwark 239 1.5 1.2 Chelsea 55 1.1 0.7 Bermondsey 182 1.5 1.4 Westminster, City of 111 0.8 0.6 Lambeth 231 1.1 0.8 St. Marylebone 177 1.7 1.4 Battersea 149 1.4 0.9 Hampstead 41 0.7 0.5 Wandsworth 235 1.2 0.9 St. Pancras 224 1.6 1.0 Camberwell 233 1.2 0.9 Islington 228 1.1 0.7 Deptford 134 1.4 1.2 Stoke Newington 30 0.8 0.6 Greenwich 73 1.3 0.7 Hackney 281 1.4 1.3 Lewisham 82 0.9 0.6 Holborn 90 1.9 1.6 Woolwich 58 0.9 0.5 Finsbury 106 1.8 1.1 Port of London I — — London, City of 10 1.0 0.4 London 4,372 1.3 1.0 Shoreditch 147 1.7 1.3 The relationship between erysipelas prevalence and season will be seen on reference to diagram IV., page 13. The seasonal curve is not unlike that of enteric fever, except that the variations from the mean are not so marked, the maximum in relation to the mean being smaller and the minimum greater. The following table shows the age and sex distribution of the notified cases of erysipelas in 1903— Age period. All ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 1,840 147 72 76 83 88 242 377 355 205 123 72 Females 2,532 181 73 106 172 179 331 432 440 306 217 95 Persons 4,372 328 145 182 255 267 573 809 795 511 340 167 The table shows, so fur as the figures relating to notified cases of this disease can be trusted in this connection, 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.2 The deaths in the administrative county of London in 1903 attributed to puerperal fever numbered 170, the corrected annual average of the preceding ten years being 216. The number of cases notified and the number of deaths registered from this cause sinca the year 1890 have been as follows— 1 See footnote (2), page 7. 2 Including deaths from puerperal septicaemia and puerperal pyaemia. 38 Puerperal fever. Year. Notified Deaths.1 cases. 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 1903 233 170 If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Tear. 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 .C5 1.81 .04 1.29 1901 .06 1.93 .04 1.40 1902 .07 2.34 .04 1.51 1903 .05 1.78 .04 1.30 Diagram IV., page 13, shows the seasonal curve of puerperal fever based on the notified cases of the disease in the 14 years 1890.1903. The irregularity of this curve is no doubt largely due to the smallness of the figures on which the curve is based. Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1902 numbered 1,073, fell to 644 in 1903, being 595 below the annual average of the preceding ten years. The deaths from bronchitis in 1903 numbered 5,240, being 3,232 below the annual average of the preceding ten years. The deaths from pneumonia numbered 5,826 in 1903 and were 305 below the ten years' average. The deaths from these diseases since 1889 have been as follows— Year. Influenza. Bronchitis. Pneumonia. Deaths.1 Corrected annual average for preceding ten yearn. 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 1903 644 1,238.6 5,240 8,471.9 5,826 6,131.5 1 See footnote (2), page 7. 39 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, 1890.1903. Number of weeks. 1890. 1891. 1892. 1893 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 49—52 2 6 81 28 546 58 49 56 71 52 342 46 56 99 51 Phthisis. The deaths from phthisis in the administrative county of London during 1903 (52 weeks) numbered 7,124. The Death-rates from this disease per 1,000 living in successive periods have been aa follows— 1851-60 2.86 1896 1.73l 1861-70 2.84 1897 1.781 1871-80 2.511 1898 1.79l 1881-90 2.091 1899 1.901 1891 2.021 1900 1.791 1892 1.89l 1901 1.711 1893 1.911 1902 1.641 1894 1.741 1903 1.601 1895 1.83l 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 publio 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— Metropolitan borough. Deaths, 1903. Death-rate per 1,000 living, 1903. Metropolitan borough. Deaths, 1903. Death-rate per 1,000 living, 1903. Paddington 155 1.06 Shoreditch 272 2.32 Kensington 223 1.25 Bethnal-green 272 2.10 Hammersmith 170 1.47 Stepney 633 2.10 Fulham 204 1.38 Poplar 294 1.74 Chelsea 116 1.57 Southwark 496 2.40 Westminster, City of 301 1.69 Bermondsey 225 1.74 St. Marylebone 240 1.83 Lambeth 430 1.40 Hampstead 63 0.74 Battersea 223 1.29 St. Pancras 428 1.82 Wandsworth 237 0.95 Islington 472 1.40 Camberwell 323 1.22 Stoke Newington 64 1.23 Deptford 152 1.35 Hackney 283 1.27 Greenwich 111 1.12 Holborn 181 3.14 Lewisham 114 0.84 Finsbury 227 2.28 Woolwich 176 1.45 London, City of 39 1.59 London 7,124 1.553 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— 1 See footnote (2) page 7. 2 The deaths occurring in the 53rd week of the years 1890, 1896 and 1902 are excluded from these figures. 2See footnote (1) page 7. 40 Crude and corrected Death-rates,1 per 1,000 persons living, in the County of London and the several metropolitan boroughs. Phthisis. Metropolitan Borough. Standard death rate. Factor for correction f r ape and sex distribution. Crude Death-rate. Corrected Death-rate. Comparative mortality figure. (London 1,000.) 1901.2. 1903. 1901.2. 1903. 1901.2. 1903. London 1.74 1.00000 1.63 1.55 1.63 1.55 1,000 1,000 Paddington 1.80 .96659 1.07 1.06 1.03 1.02 632 658 Kensington 1.78 .97419 1.33 1.25 1.30 1.22 798 787 Hammersmith 1.74 .99600 1.43 1.47 1.42 1.46 871 942 Fnlham 1.69 1.02786 1.37 1.38 1.41 1.42 865 916 Chelsea 1.83 .95018 1.56 1.57 1.48 1.49 908 961 Westminster, City of 1.95 .89205 1.84 1.69 1.64 1.51 1,006 974 St. Marylebone 1.85 .93836 1.91 1.83 1.79 1.72 1,098 1,110 Hampstead 1.75 .98862 0.88 0.74 0.87 0.73 534 471 St. Pancras 1.80 .96551 1.88 1.82 1.82 1.76 1,117 1,135 Islington 1.75 .99145 1.50 1.40 1.49 1.39 914 897 Stoke Newington 1.77 .97914 1.30 1.23 1.27 1.20 779 774 Hackney 1.68 1.02969 1.48 1.27 1.52 1.31 933 845 Holborn 1.97 .87894 2.91 3.14 2.56 2.76 1,571 1,781 Finsbury 1.72 1.01050 2.24 2.28 2.26 2.30 1,387 1,484 City of London 1.89 .91946 2.00 1.59 1.84 1.46 1,129 942 Shoreditch 1.66 1.04206 2.02 2.32 2.10 2.42 1,288 1,561 Bethnal-green 1.59 1.03984 2.06 2.10 2.25 2.29 1,380 1,477 Stepney 1.65 1.05281 1.99 2.10 2.10 2.21 1,288 1,426 Poplar 1.66 1.04772 1.75 1.74 1.83 1.82 1,123 1,174 Southwark 1.74 .99829 2.56 2.40 2.56 2.40 1,571 1,548 Bermondsey 1.65 1.05026 1.84 1.74 1.93 1.83 1,184 1,181 Lambeth 1.75 .99258 1.68 1.40 1.67 1.39 1,025 897 Battersea 1.69 1.02483 1.38 1.29 1.41 1.32 865 852 Wandsworth 1.72 1.01050 1.02 0.95 1.03 0.96 632 619 Camberwell 1.68 1.03522 1.49 1.22 1.54 1.26 945 813 Deptford 1.69 1.02969 1.15 1.35 1.18 1.39 724 897 Greenwich 1.67 1.04143 1.18 1.12 1.23 1.17 755 755 Lewisham 1.69 1.02543 0.98 0.84 1.00 0.86 613 555 Woolwich 1.70 1.01881 1.62 1.45 1.65 1.48 1,012 955 It will be seen from the foregoing table (comparing the corrected Death-rates) that in the period 1901.2 the phthisis Death-rate was highest in Holborn and Southwark (2.56) and lowest in Hampstead (0.87). In 1903 Holborn had the highest Death-rate (2'76) and Hampstead the lowest (0.73). The phthisis Death-rates in London in each of the four quarters of the year 1903 were as follows—First quarter 1.66; second quarter 1.47; third quarter 1.42; and fourth quarter 1.64 per 1,000 living. The following table shows the number of deaths from phthisis at several age-periods in each of the metropolitan boroughs. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the deceased had previously resided. (See footnote (1) page 7.) Phthisis (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddington 3 3 3 7 18 31 45 26 11 6 _ 153 Kensington 8 5 4 13 19 45 48 51 19 8 1 — 221 Hammersmith 8 1 4 11 10 31 42 32 17 14 — — 170 Fulham 5 7 4 11 16 51 50 36 20 5 — — 205 Chelsea 4 — 1 2 3 27 33 22 12 7 — — 111 Westminster, City of 4 1 4 7 17 66 97 49 31 18 5 — 299 St. Marylebone 8 2 6 7 18 42 57 60 33 14 1 — 248 Hampstead — — 1 7 6 12 17 12 3 2 1 — 61 St. Pancras 8 3 4 18 20 96 134 87 36 18 6 — 430 Islington 18 6 2 25 42 105 107 95 55 22 2 — 479 Stoke Newington — — — 3 6 19 15 14 6 2 — 1 66 Hackney 13 4 2 16 26 68 64 51 27 15 1 — 287 Holborn 3 1 3 3 5 39 39 49 19 4 4 — 169 Finsbury 10 3 3 11 10 39 56 51 29 8 2 — 222 London, City of 2 — — 1 5 5 9 9 6 3 — — 40 Shoreditch 10 1 6 14 14 53 69 70 29 5 — — 271 Bethnal-green 12 6 3 12 18 56 69 53 34 10 3 — 276 Stepney 25 2 8 18 58 139 168 136 70 17 5 — 646 Poplar 14 4 5 13 18 71 81 55 26 6 — — 293 Southwark 16 4 5 24 33 104 133 102 46 20 7 1 495 1 See footnote (1) page 7, 41 Age period— 0- 5- 10- 15- ' 20- 25- 35- 45- 55- 65- 75- 85 and up. All ages. Bermondsey 6 1 5 10 19 50 68 43 17 4 223 Lambeth 22 2 3 27 37 82 119 89 31 13 1 426 Battersea 11 2 2 15 20 55 59 39 18 7 1 229 Wandsworth 4 2 3 21 27 50 43 48 25 8 1 232 Camberwell 5 4 2 20 25 63 94 66 32 11 2 3^4 Deptford 3 3 3 8 15 34 48 22 13 5 1 155 Greenwich 7 2 4 7 11 18 25 22 13 3 1 113 Lewisham 4 — 2 8 14 22 33 13 11 5 1 113 Woolwich 3 1 2 3 21 36 40 37 24 8 1 176 London 236 70 94 342 551 1,509 1,862 1,439 713 258 46 3 7,133 The animal reports give evidence of extension in London of the adoption of measures designed for the control of tubercular disease. These measures include the voluntary notification, of phthisis, the giving of advice as to the precautions which should be taken in the house of the patient, especially as to the manner in which the sputum should be dealt with, and the disinfection of the house which has been occupied by the patient either after death or removal. A system of voluntary notification of phthisis has now. been adopted in the following districts, and the number of cases notified is shown in some of the reports, thus—Kensington (221), Hammersmith (143 since the 11th April, 1903), Fulham (171), Chelsea, Holborn, Westminster (124 since the 6th April), Hampstead (37), Stoke Newington (52), Finsbury (115), City (4), Southwark (307), Bermondsey (67 since the 24th April), Lambeth (339), Wandsworth (88), Greenwich (51), Woolwich (167). Thus, in more than half the sanitary areas of London this system existed in 1903, and in Holborn the borough council has since resolved to adopt the same course. In Islington a proposal for this purpose was rejected, but Dr. Harris expresses the hope that the matter will shortly be reconsidered. Incidental to notification are inquiries into the supposed source of the infection and into the family history of the patient. A few of the reports contain interesting information on both these points, and the subject is discussed in the reports of the medical officers of health of Westminster, Finsbury, Hampstead, Southwark, Bermondsey, Camberwell and Woolwich. The question of the provision of sanatoria is also discussed in a number of annual reports, and the Woolwich Borough Council has decided, as an experiment, to maintain two beds at the Peppardcommon Sanatorium in Oxfordshire. The beds are now occupied by two men removed from Woolwich. In a number of districts sputum was examined for tubercle bacilli at the cost of the local authority. The by-law of the London County Council prohibiting spitting in public places came into force on the 12th May, 1903. The by-law provides that "no person shall spit on the floor, side, or wall of any public carriage, or any public hall, public waiting room, or place of public entertainment whether admission thereto be obtained upon payment or not. Any person who shall offend against this by-law shall be liable for each offence to a fine not exceeding forty shillings." Any person can take steps for obtaining the enforcement of the penalty in the event of breach of the by-law. The words "any public carriage" would include a railway carriage. Dr. Collingridge includes in his annual report relating to the City an account of the steps taken on railway companies' premises in the City, and in railway carriages, to cleanse the premises and carriages and to exhibit cautionary notices against spitting. Cancer. The deaths from cancer in the administrative county of London during 1903 (52 weeks) numbered 4,695, the annual average of the preceding ten years being 3,964. The death-rates of this disease per 1,000 living in successive periods have been as follows— Cancer. 1851-60 .421 1896 .861 1861-70 .481 1897 .881 1871-80 .551 1898 .921 1881-90 .681 1899 .951 1891 .781 1900 .951 1892 .75l 1901 .931 1893 .801 1902 .991 1894 .791 1903 1.021 1895 .831 For the purpose of enabling the incidence of cancer on the several populations of the metropolitan boroughs 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-ratee since 1900 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 partially responsible for the differences in the crude death-rates obtaining in the several districts. 1 See footnote (2) page 7. [6] 42 Cancer. Crude and corrected Death-rates1 per 1,000 persons living in the County of London and the several metropolitan boroughs. Metropolitan boroughs. Standard death. rate. Factor for correction for age and S»'X distribution. Crude Death-rate. Corrected Death-rate. Comparative mortality figure (London 1,000). 1901.2. 1903. 1901.2. 1903. 1901.2. 1903. London 0.87 1.00000 0.90 0.93 0.90 0.96 1,000 1,000 Paddington... 0.98 0.89478 1.00 1.12 0.89 1.00 989 1,042 Kensington... 1.02 0.85622 1.00 1.07 0.86 0.92 956 958 Hammersmith 0.90 0.96811 0.85 0.86 0.82 0.83 911 865 Fulham ... ... 0.77 1.13828 0.82 0.80 0.93 0.91 1,033 948 Chelsea 1.03 0.84874 0.98 1.25 0.83 1.06 922 1,104 Westminster, City of 0.96 0.91348 0.95 1.03 0.87 0.94 967 979 Marylebone... 0.99 0.88571 1.07 1.34 0.95 1.19 1,056 1,240 Hampstead 0.92 0.94816 1.04 1.27 0.99 1.20 1,100 1,250 St. Pancras... 0.92 0.95229 0.96 1.07 0.91 1.02 1,011 1,062 Islington 0.90 0.96704 0.95 1.09 0.92 1.05 1,022 1,094 Stoke Newington ... 0.98 0.89387 0.88 1.09 0.79 0.97 878 1,010 Hackney 0.88 0.99341 0.84 0.89 0.83 0.88 922 917 Holborn 0.95 0.91924 1.04 1.00 0.96 0.92 1,067 958 Finsbury 0.84 1.04071 0.79 0.91 0.82 0.95 911 990 London, City of 1.06 0.82316 1.42 1.02 1.17 0.84 1,300 875 Shoreditch ... 0.79 1.10518 0.93 0.85 1.03 0.94 1,144 979 Bethnal-green 0.78 1.12077 0.84 0.86 0.94 0.96 1,044 1,000 Stepney 0.74 1.17976 0.70 0.78 0.83 0.92 922 958 Poplar 0.81 1.08327 0.79 0.83 0.86 0.90 956 937 Southwark ... 0.82 1.06350 0.85 0.98 0.90 1.04 1,000 1,083 Bermondsey 0.81 1.08462 0.81 0.86 0.88 0.93 978 969 Lambeth 0.92 0.95333 1.00 1.02 0.95 0.97 1,056 1,010 Battcrsea ... 0.79 1.10798 0.84 0.85 0.93 094 1,033 979 Wandsworth 0.88 0.99116 0.91 1.03 0.90 1.02 1,000 1,062 Camberwell 0.87 1.00483 0.96 0.86 0.96 0.86 1,067 896 Deptford 0.81 1.07396 0.89 0.92 0.96 0.99 1,067 1,031 Greenwich ... 0.88 0.99795 0.78 0.76 0.78 0.76 867 792 Lewisham ... 0.92 0.95333 0.97 0.87 0.92 0.83 1,022 865 Woolwich ... 0.78 1.11933 0.78 0.78 0.87 0.87 967 906 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 7.) Cancer (365 days). Age period— 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up. All ages. Paddington 1 1 - - 2 3 8 35 55 39 16 4 164 Kensington 3 1 . - . 3 18 32 49 57 26 2 191 Hammersmith . . . 1 1 3 7 29 27 23 8 1 100 Fulham 1 . . 1 5 13 21 28 36 11 2 118 Chelsea 1 . . 2 . 2 7 17 35 18 10 1 93 Westminster, City of 1 . . 4 . 7 21 43 48 39 19 2 184 St. Marylebone 3 1 . . 2 9 14 34 51 37 24 1 176 Hampstead . - . . . 2 11 25 20 30 17 3 108 St. Pancras 2 1 1 3 . 9 21 66 68 58 22 2 253 Islington 4 3 1 2 4 8 42 75 100 90 38 1 368 Stoke Newington . . . . . 1 3 7 15 17 14 . 57 Hackney 1 1 . 1 . 4 23 41 58 50 18 3 200 Holborn 2 — . . . 2 6 14 16 11 6 1 58 Finsbury . . . 1 1 4 10 28 23 17 6 1 91 London, City of . 1 1 . — — 2 8 4 6 2 I 25 Shoreditch — 1 1 2 — 2 12 28 27 20 7 . 100 Bethnal.arreen 1 . . 1 — 3 14 24 33 26 8 2 112 Stepney 2 1 2 2 — 10 42 67 46 44 20 1 237 Poplar _ _ 1 _ 1 4 12 35 42 27 18 1 141 Southwark 1 . . . — 11 20 58 65 35 10 3 203 Bermondsey — . . . 1 6 11 32 39 17 5 1 112 Lambeth 1 2 1 2 2 10 39 61 91 74 26 5 314 Battersea 2 — . 2 2 4 12 43 34 31 15 3 148 Wandsworth _ 1 1 1 1 7 24 53 . 81 56 29 4 258 Camberwell — _ — 1 1 8 21 44 70 51 28 4 228 Deptford . . . 1 . 1 11 29 29 20 11 1 103 Greenwich . 1 — 2 . 4 7 15 19 18 7 3 76 Lewisham 1 — . 2 1 . 11 18 33 35 16 1 118 Woolwich _ _ 1 _ 1 2 10 19 28 23 10 1 95 London 27 15 10 30 21 134 452 1,001 1,234 1,005 447 55 4,431 1 See footnote (1) page 7. 43 Bubonic Plague. During the year 1903 in no instance was any case of suspected bubonic plague brought to the notice of the Public Heath department of the Council. 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 1903 was 50.1° Fahrenheit, or 0.6 Fahrenheit above the average of the 50 years 1853.1902. The rainfall during the year amounted to 35.54 inches, or 11.0l inches above the average of the preceding fifty years. The temperature and rainfall in each month of the year 1903 are shown in the following table— Temperature of the air. Departure Rain. from Month. average of Absolute Absolute Mean for 50 years, Number of Amount maximum. minimum. month. 1853.1902. days it fell. collected. deg. F. deg. F. deg. F. deg. F. Inches. January 53.9 23.8 40.7 +2.2 18 2.13 February 58.3 26.2 45.0 +5.5 10 1.37 March 68.0 29.5 46.0 +4.3 18 2.20 April 60.2 28.4 44.3 —2.9 11 1.85 May 779 31.3 53.6 +0.5 15 1.95 June 84.8 37.1 55.8 —3.6 10 6.07 July 87.5 42.2 62.0 —0.4 13 5.27 August 77.5 44.2 60.3 —1.3 17 4.82 September 82.0 38.4 57.6 +0.4 15 2.24 October 68.5 36.5 52.7 +2.7 24 4.44 November 57.0 26.4 44.5 +1.3 16 1.93 December 52.8 25.2 38.3 —1.4 12 1.27 44 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 282 applications for licences, of which 277 were granted. The number of applications for licences received during the last ten years and the number granted are shown in the following table. It will be seen that the number of these premises in London is continually decreasing. No. of applications. No. of licences received. 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 1903 282 277 The cows in the London cowsheds were periodically inspected by Mr. W.F. Shaw, the County Council's veterinary inspector, and his assistant, with a view to certification under the Order of 1899 of any cow suffering from tuberculous disease of the udder. Thus, during 1903, there were four quarterly inspections of all the cows in the London cowsheds. The number of cows found by Mr. Shaw to be affected in one or another way is shown in the following table— Examination of cows for tubercular disease of the udder— Summary of Mr. Shaw's reports for the year 1903. 1st quarter. 2nd quarter. 3rd quarter. 4th quarter. Total number of cows examined 4,027 3,983 3,997 3,676 Affected with disease or defects of the udder 245 195 251 228 Affected with tubercular disease of the udder 3 3 3 — Suspected cases of tubercular disease of the udder 4 5 8 — Subjects of acute mastitis 30 22 37 19 Clinically affected with chronic induration of the udder 5 6 5 7 Atrophy of one or more quarters 140 98 117 112 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 26 34 44 43 Hypertrophied udders without induration — 2 4 3 Giving milk of poor quality, dried.off cows 31 20 36 35 Recovered or removed from premises 6 5 5 3 Mr. Shaw's reports also show the action taken for the elimination of tuberculous cows from the London cowsheds, thus— First quarterly report. Three cows affected with tubercular disease of the udder were removed from sheds for slaughter. Five cows with no signs of tubercular disease of the udder, but with visible signs of tuberculosis, were slaughtered— three at knackers' yards and two at public slaughter.houses; the carcase of one, being unfit for food, was destroyed. Second quarterly report. Three cows affected with tubercular disease of the udder were removed for slaughter. Five cows were suspected of being affected with tubercular disease of the udder. Twenty.two cows affected with acute mastitis, and cows showing signs of general tuberculosis, were kept under observation until recovered or removed for slaughter. Third quarterly report. Three cows were certified to be affected with tubercular disease of the udder— the supply of milk was prohibited until these cows were removed for slaughter. One cow, not affected with tubercular disease of the udder, but suffering from tuberculosis, were kept under observation until sent to the knacker's. Thirty.seven cows were affected with mastitis, and eight suspected cases of tubercular disease of the udder, and five of chronic induration of the udder were reported. All were kept under observation until recovered or removed for slaughter. Fourth quarterly report. Nineteen cows were affected with acute mastitis, and seven with chronic induration of the udder. All were kept under observation until they recovered or were removed for slaughter. Of six cows presenting clinical symptoms of tuberculosis two were sent to the knackers the day after 45 examination, one died in the shed the week after examination, and the carcase was sent to the knacker's, and three were sent for slaughter; of these, the carcase of one was passed as fit for food, the carcase of another was condemned, and the remaining animal was sold alive in a public market. The absence of any power to require the slaughter of a cow certified to be suffering from tubercular disease of the udder determined the London County Council to apply to Parliament for power to take possession of all such cows and to slaughter them. Further, the difficulty of always diagnosing with certainty tubercular disease of the udder led the Council to include in the powers they sought that of taking possession of a cow suspected to be so suffering, to slaughter it and to compensate the owner if on post.mortem examination the udder was not found to be affected with tubercular disease. Inspection of milkshop premises. The number of milkshop premises on the register of the several sanitary authorities and the number of inspections of such premises are shown in the majority of the annual reports. From these reports it would appear that there is great diversity of practice in the several boroughs with regard to the frequency of inspection of milkshops. In some boroughs inspection of these premises is only made about once a year, while in others inspections are made every few weeks. The subject evidently demands careful inquiry by each metropolitan borough council as to the efficiency with which this duty is being performed. The following table is compiled from statements in the annual reports of the medical officers of health— Metropolitan borough. No. on register No. of inspections, Metropoliian borough. No. on register, No. of inspections, 1903 1903. 1903. 1903. Paddington 174 210 Shoreditch 300 2,803 Kensington 238 Frequently Bethnal Green 342 1,783 Hammersmith 269 Periodically Stepney Unstated 1,340 Fulham 272 Unstated Poplar 365 Periodically. Chelsea 123 246 Southwark 413 597 Westminster, City of 303 313 Bermondsey 286 325 Hampstead 110 638 Battersea 225 Systematically Islington 674 573 Wandsworth 286 523 Stoke Newington 51 51 Camberwell 574 2,019 Hackney 346 1,025 Deptford 189 315 Holborn 167 812 Greenwich 158 175 Finsbury 261 400 Lewisham 148 626 City of London 553 Unstated Woolwich 154 154 In a number of the annual reports statements are made which show recognition of the need for the supply to London of milk which is unpolluted, and frequent reference is made to efforts to secure the protection of milk against contamination in the milkshop by requiring the milk vessels to be covered with muslin or other similar material. Many, however, would go beyond this requirement and would insist upon the milk being stored apart from such articles as are usually sold by the keeper of the " general shop " who, for the convenience of his customers, receives daily a few quarts of milk which he usually retails to them in halfpenny.worths. Under existing law every milk vendor is required to give notice to the sanitary authority that he is engaged in the sale of milk, and it is then the duty of the authority to enforce the regulations. Some medical officers of health view this method of administration with disfavour, and would claim for their authorities a right to determine whether or no milk shall be sold on the premises; in other words, they would desire to substitute for the system of registration a system of licence. So far as structural conditions are concerned they can usually be controlled by regulation which can precisely define those conditions which are deemed to be necessary. Beyond this, however, is the question of protection of milk against infection or contamination. There is complete agreement as to the need of preservation of the milk from conditions of dirt, and there is no doubt that premises in which a variety of goods are sold and in which from the nature of the other business or businesses carried on, the atmosphere must be frequently pervaded with dust, are unsuitable for the storage of milk, a material which is an excellent medium for the cultivation of micro.organisms. There is, therefore, much ground for insisting upon conditions of greater cleanliness in connection with the storage of milk than of other articles of food. Under the Dairies, Cowsheds, and Milkshops Order of 1885, it is illegal to occupy a dairy in which the lighting and the ventilation, including air space, and the cleansing, drainage, and water supply are not such as are necessary and proper, and this Order is administered by the London County Council. Under the Public Health (London) Act, all milk premises are included under the definition of "dairies," and hence the issue of a new Order under that Act would give power to the London County Council to apply a higher standard of requirement to all milk premises in London. There is no doubt that public opinion has, in respect of the conditions required for milk, advanced considerably in recent years, and probably the Council could, under a new Order, require conditions in advance of those which have, in past years, been enforced. It is, however, not in the milkshop, nor on the railway, that the chief source of contamination of milk occurs. The most frequent cause of contamination and that which the consumer has a right to demand shall as far as practicable be excluded from the milk, is the excremental matter of the cow which, through the befouled udder of the cow and the soiled hands of the milker, contaminates the milk at the time of milking. Many dairy farmers do not yet recognise the necessity 46 for cleaning the cows, for the washing of the milker's hands, and for the wearing of clean overalls, without all of which precautions the milk cannot be preserved from contamination. The enforcement of these conditions obviously most concerns the communities in which the milk is consumed; the difficulty which stands in the way of success is that the authorities which represent the consumers have no jurisdiction in such matter in the districts in which the milk is produced. The need for speedy identification of a farm, the milk from which is found to be causing infectious disease in London, has, in the past, been manifested on a number of occasions. Hence the desirableness of every medical officer of health knowing the sources of milk supply to his district and the channels by which the milk is supplied. An excellent effort has been made in this direction by Dr. Newman, the medical officer of health of Finsbury, from whose annual report the following paragraph is extracted— During the present year we have made inquiries respecting the source of the milk sold in Finsbury. In .1 general way, it may be said that vendors have three modes of obtaining milk. First, some 185 milk.sellers in Finsbury obtain their supply through milk contractors, who deal with more than a thousand country farms. There are 14 such wholesale contractors trading in the borough. Secondly, there are some 50 milk sellers who obtain their milk through other milk sellers in the borough from country farms. Thirdly, there are, perhaps, a dozen milk shops which obtain part or all their milk from town cow.sheds situated in the borough. Speaking generally, therefore, it may be said that about 235 of the 261 milk sellers in Finsbury obtain their milk wholly or partly from country cowsheds, whereas about a score obtain their milk wholly or partly from town cowsheds. We have a register in Finsbury of the sources of the milk of every milk seller, whether it be town or country, so that it would be practicable at any moment to trace a milk supply with some degree of accuracy. A register is also kept of all the milkshops in the borough, containing particulars of each in respect to general and particular sanitation management of milk trade, etc. The fourteen contractors deal with some 1,111 farms situated at varying distances from London. Offensive Businesses. In the year 1903 the County Council received 350 applications for licences for slaughterhouses and granted 346. The following table shows the number of applications received and the number of slaughter.houses licensed in recent years— Year. No. of applications received. No. of licences granted. Year. No. of applications received. No. of licences granted. 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 1897 460 460 1903 350 346 The number of slaughter.houses in each of the London boroughs and the frequency with which these slaughter.houses, in some of the districts, were inspected are shown in the following table— Metropolitan borough. No. on register, end of 1903. No. of inspections, 1903. Metropolitan borough. No. on register, end of 1903. No. of inspections, 1903. Paddington 8 770 Shoreditch 14 110 Kensington 12 regularly Bethnal.green 6 42 Hammersmith 12 fortnightly Stepney 12 36 Fulham 5 20 Poplar 20 periodically Chelsea 6 30 South wark 7 110 Westminster, City of 1 14 Bermondsey 3 22 Marylebone 11 233 Lambeth 32 constant Hampstead 5 175 Battersea 7 frequent Pancras 21 periodically Wandsworth 23 183 Islington 40 2,414 Camberwell 16 275 Stoke Newington 8 17 Deptford 6 57 Hackney 29 348 Greenwich 7 35 Holborn 2 28 Lewisham 17 169 Finsbury 5 100 Woolwich 11 44 City of London 8 Unstated A cow was seized in a slaughter.house in Camberwell, the carcase of which was unfit for human consumption. Prosecution by the borough council led to the man who sent the cow to the slaughter.house being condemned to six months' imprisonment and to the owner of the slaughter.house being fined five pounds and costs. The conviction of the man who sent the cow for slaughter was quashed on appeal on the ground that at the hearing of the case at the police.court the defendant had not been asked whether he would be tried there or at Quarter Sessions. The County Council, after full consideration of the case, decided to withhold the licence for the slaughter.house. 47 The only changes in the number of offensive trade premises, other than slaughterhouses, in London are a reduction in the number of tripe boilers' premises and tallow melters' premises, two of the former businesses and one of the latter being abandoned. The number of authorised offensive trade premises other than slaughterhouses, in London except those under the jurisdiction of the City Corporation, was at the end of the year— Fat melters 25 Tripe boilers 23 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 6 Manure manufacturers 4 Soap boilers 13 Tallow melters 10 Gut manufacturers 4 Gut scrapers 2 Animal charcoal manufacturers 1 104 In a few instances proceedings were instituted by the borough councils against persons thus employed, the offences being breaches of the County Council's by.laws for regulating the conduct of the business. Thus in Wandsworth a fat melter was fined five pounds and a firm of bone boilers and tallow melters was fined a similar amount, but on appeal the last penalty was remitted owing to the date of the alleged nuisance not having been stated. During the year the Council obtained powers under the L.C.C. (General Powers) Act, 1903, sec. 53, prohibiting any person from using any yard building or other premises within the county for receiving or keeping horses for slaughter unless he shall hold a licence from the Council for such purpose. Section 54 of this Act empowers the Council to make by.laws with respect to the mode of conveying the carcases of dead horses through and along the public streets. Nuisances. Smoke nuisances. In a number of the annual reports information is given as to the steps taken to abate nuisances arising from chimneys emitting black smoke. In Paddington there were 73 observations of 9 premises, and one notice was served; in Kensington there were several complaints; in Hammersmith 25 summonses were taken out; in Fulham 15 intimations and 8 statutory notices were served, and in two instances penalties were recovered; in Chelsea two nuisances were abated; in Westminster 52 complaints were received, 2,731 observations were made, 106 nuisances were reported, 68 preliminary notices and 18 statutory notices were served and prosecutions were instituted in two instances; in Marylebone 13 nuisances were abated; in Hampstead in 15 instances notices were served; in St. Paneras 8 complaints were dealt with and 118 smoke shafts inspected weekly, and in 31 instances notices were served; in Islington 28 notices were served; in Stoke Newington the chimneys on the register were watched; in Hackney 1,124 observations were made, 52 notices served, and prosecutions instituted in 4 instances; in Holborn there were 107 inspections and 20 notices served; in Finsbury 19 nuisances were abated; in the City 57 nuisances were abated; in Shoreditch nuisances from 13 premises were abated; in Bethnal.green 834 premises were observed; in Stepney 100 nuisances were abated; in Poplar 345 smoke nuisances were dealt with, 19G notices served, and prosecutions were instituted in 7 instances; in Southwark there were 404 observations, 80 nuisances found, 53 intimations and 24 statutory notices served, and in 9 instances prosecutions were instituted; in Bermondsey there were 173 observations, 56 nuisances reported, and in 5 instances prosecutions were instituted; in Lambeth there were 720 observations, 60 notices served, and in one instance a prosecution was instituted; in Battersea 126 smoke nuisances were observed, 100 notices were served, and 17 summonses taken out; in Wandsworth 26 notices were served; in Camberwell 58 nuisances were abated; in Deptford 34 nuisances were abated; in Greenwich there were 312 observations, and notices were served where nuisance was found; in Lewisham there were 3 nuisances, and notices served for each; in Woolwich 133 observations of smoky chimneys were made; nuisance from a chimney in the Royal Dockyard led to a communication being addressed to the chief superintendent, after which there was considerable improvement; in 10 instances complaints of smoke from certain South.Eastern Railway engines were sent to the traffic manager, with the result that there was improvement. Flooding of basements. In several of the annual reports reference is made to the flooding of basements with sewage in times of heavy rainfall. So far as the main drainage system is concerned the London County Council have within the last few years decided to spend a sum of £3,000,000 in duplicating the principal main outfall and intercepting sewers, and have carried out works or entered into contracts involving an expenditure of over £1,500,000, and are proceeding as rapidly as possible with the complete scheme, including the provision of additional storm.water sewers. 48 Housing of the Working Classes Act. The following is a summary of the proceedings taken by the London County Council and the metropolitan borough councils in connection with the housing of the working classes during the year 1903— Representations under Part I. of the Housing of the Working Classes Act. Back Church.lane area, Stepney.— This area was represented under the Act by the medical officer of health of Stepney in October, 1901. It comprises about two acres, and contains 206 houses, with several stables and sheds. The area consists of two parts, (a) the block of property bounded by Berner.street on the east, Back Church.lane on the west, Fairclough.street on the south, and Batty's.gardens on the north; (b) the block of property which comprises both sides of Gloucester.buildings, Boyd.street and Everard.street, and the nine houses from Everard.street to Gloucester.buildings which front Back Church.lane. Many of the houses in part (a) are two storeys in height, and some are damp and in bad repair. This part of the area had changed hands in 1901, and again recently at a greatly enhanced price. There was ground for anticipating that this part of the area would shortly be rebuilt for commercial purposes. Part (b) consists of six rows of small houses nearly all two storeys in height, practically worn out, and with cramped yard spaces in the rear. The population of the area amounted to 1,296 persons, of whom 1,258 were of the working class, mostly foreigners. The corrected death.rate of the whole area for the period 1898.1900 was 19'2 per 1,000, while the corresponding death.rate for the parish of St. George.in.the.East, in which the area is situated, was 26.9 for the period 1898.9. The Housing of the Working Classes Committee reported to the Council in March, 1903, that in view of the low death.rate, and the expectation of changes in the area, an improvement scheme was not necessary, and the Council, on the 10th March, resolved accordingly. On the 5th May the Committee reported that a letter had been received from the Secretary of State forwarding a communication from the Metropolitan Borough Council of Stepney to the effect that that council was of opinion that no further step should at present be taken, and that the council based its opinion on information that a large part of the area was about to be dealt with by private enterprise, and that some rehousing would take place thereon. Warner.street area, Holborn.— This area was represented by the medical officer of health of Holborn in 1901. It is about two acres in extent, and comprises some 120 houses and premises in Warner.street, Fleet.row, Summers.street, Little Bath.street, Back.hill, Eyre.street.hill, and Eyre.court. The houses generally are old and worn out, and in many cases have inadequate or no back yards. The streets are narrow and a large number are situated in courts whose only approach is by means of covered archways. The population of the area is about 1,170 persons, almost all of whom are Italians of the working class. The death.rate of this population from all causes was 29.2 per 1,000, or 30 higher than that of Holborn, the death.rate from phthisis being lower than that of Holborn. The Housing of the Working Classes Committee reported on the 10th November that in the course of their inquiries they had learned that by far the greater portion of the area was in the hands of the freeholders, who were developing it for commercial purposes. "This property comprises much of the interior of the area wherein the most insanitary conditions prevail, and the action that is being taken by the freeholders is resulting in the creation of fresh subsidiary interests and the erection of business premises." The Committee were of opinion that, in view of the change in the area from a residential to a commercial character, which is rapidly taking place, they were unable to advise the Council to incur the heavy expenditure which the carrying into effect of a scheme for dealing with the area would involve. The Council therefore resolved that an improvement scheme should not be made. Kilburn.vale area, Hampstead.— This area was represented in June, 1903, by the medical officer of health of Hampstead. It is about an acre in extent and is situated close to the Kilburn Station, and is bounded on the north.west by West End.lane,'.on the south.east by the premises of the London General Omnibus Company, on the north.east by Abbey.lane, and on the southeast by Providence.place, and comprises 60 premises and two disused cottages. The houses are mostly cottages, some with ample space in front and rear, while other houses have insufficient or no back vards. Many of the cottages are old, and some in bad condition. The population numbered 360, and the mean annual death.rates per 1,000 living for the period 1898.1902 compared with those of Hampstead and London were— Principal epidemic Infant All causes. diseases. Phthisis. mortality. Kilburn.vale area 18.9 3.3 1.7 217 Hampstead 11.3 1.1 0.8 109 London 18.2 2.4 1.8 155 The Housing of the Working Classes Committee reported that the evils which existed were not, in their opinion, such as to require an improvement scheme, and that if dealt with by scheme the area could not be considered of importance to London as a whole, 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. Park.street area, Southwark.— In 1903 the Council received a representation as to an area in and about Park.street, Southwark, concerning which the Housing of the Working Classes Committee stated in a report in December that the Committee were advised that the area will in all probability shortly be converted from residential cottages into commercial property, and that it appeared therefore undesirable that it should be dealt with under the costly provisions of Part I. of the Act. 49 Schemes under Part I. of the Housing of the Working Classes Act. In respect of schemes already undertaken progress was made in the purchase of property for the clearance of the areas and in the erection of dwellings. The following areas may be specially referred to— Garden.row scheme, Finsbury.— On the 27th January the Housing of the "Working Classes Committee reported that the Secretary of State had given his consent to the erection of dwellings on the Robey.street site for 490 persons, and on the 8th December the Council accepted a tender of £18,861 for the erection thereon of Wenlake.buildings, to consist of two blocks of five.storey balcony dwellings for 496 persons in 25 tenements of two rooms, 45 tenements of three rooms, 15 of four rooms, and one cottage of three rooms. Webber.row, King's Bench.walk and Wellington.place scheme.— On the 8th December the Council resolved to ask the Home Secretary to modify this scheme so as to place an obligation on the Council to provide for the accommodation of 2,500 persons in lieu of 903 persons as required by the scheme. Clare.market scheme.— On the 20th May the Housing of the Working Classes Committee reported that Siddons.buildings, Russell.court, were nearly completed. A portion of these buildings had been leased for the purposes of a home for working girls. On the 23rd June the Committee reported Stirling.buildings ready for occupation. The two buildings provide accommodation as follows— Siddons.buildings, 5 tenements of one room, 20 tenements of two rooms, and 15 tenements of three rooms; and Stirling.buildings, 4 tenements of one room, 8 tenements of two rooms, 18 tenements of three rooms, and 5 tenements of four rooms. Schemes undertaken by the Council under Part II. of the Act. Mill.lane scheme, Greenwich.— On the 3rd November the Housing of the Working Classes Committee reported that the erection of Carrington House, a lodging.house for men, was nearly completed. Schemes undertaken by district authorities under Part II., the Council contributing to the cost. King Johns.court scheme, Stepney.— On the 3rd February the Council approved plans submitted by the borough council for dwellings for 132 persons in 12 tenements of three rooms and 15 tenements of two rooms. The number of persons displaced by the scheme was 49. Fulford.street and Braddon.street scheme, Bermondsey.— On the 10th March the Council consented to a modification of this scheme so as to enable the borough council to clear the whole area at once and proceed with the erection of artisan's dwellings. On the 17th March the Council approved plans (subject to slight modification) submitted by the borough council, and which provided for the accommodation of 980 persons in the area. On the 17th November the Council gave consent for a modification of the scheme, which was found to be necessary so as to enable 980 persons to be accommodated on the area, instead of 550, as originally provided in the scheme. Proceedings of the Council under Part III. of the Act. Site on west side of Brixton.hill.— On the 17th February the Council decided to purchase for £7,000 a site on the west side of Brixton.hill, on which could be erected three blocks of five. storey buildings providing accommodation for 620 persons in 60 tenements of two rooms, 50 of three rooms, and 10 tenements of four rooms. Wedmore.street site, Upper Holloway.— On the 26th May the Council approved an estimate of £32,600 for the erection of Wessex.buildings by the Works Department. The buildings will consist of two blocks providing accommodation for 710 persons in 50 tenements of three rooms, 100 tenements of two rooms, and 5 tenements of one room. White Hart.lane estate, Tottenham.— On the 30th June the Council accepted a tender of £35,519 15s. for the erection of 141 cottages on section A of this estate. The average number of persons and cottages per acre are respectively 217.5 and 30.5. The cottages consist of three classes as shown in thei following table— Number, class and type. Number of persons provided for. Area of Living room. 1st bedroom. 2nd bedroom. 3rd bedroom. Parlour. Kitchen. Scullery. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. 8 1st class, type A 80 147 104 98 98 132 — 35 12 1st „ „ B 120 144 151 & 131 98 98 117&98 — 28 12 1st „ „ C 96 144 131 98 — 98 — 28 9 2nd „ „ A 54 158 112 146 — — 74 — 28 2nd „ „ B 168 146 115 96 — — 74 . 28 2nd „ „ C 224 146 115 96 96 — 74 — 8 3rd „ „ A 48 148 96 96 — — — 28 36 8rd „ „ B 216 144 96 96 — — — 28 1,006 On the 28th July the Council accepted from Sir Samuel Montagu, Bart., a sum of £10,000, and adopted a scheme for the allocation of this sum to about twenty.five acres of the White Hart. lane estate to be used for all or any of the following purposes— (a) the erection of lodging. houses; (6) the provision of gardens, trees and other amenities in connection with "lodging. houses "; (c) the maintenance of the houses, gardens, and trees. [7] 50 Totterdown.fields estate, Tooting.— On the 28th July the Council approved an estimate of £7,803 for the erection of 20 additional cottages on section B of this estate, the cottages, each of which will consist of living room, parlour, scullery, and three bedrooms, to be erected by the builders who had the contract for the other cottages at the same schedule of prices. On the same day the Council accepted an estimate of £120,317, and sanctioned expenditure up to that amount for building 414 cottages on the remainder of section B by the same builder on his undertaking to build them at a reduction of 1½ per cent. on prices contained in the contract for erection of cottages on section A. Norbury estate, Croydon.— On the 28th July the Council accepted a tender of £37,000 for the erection of 146 cottages on this estate. The following table gives the class and type of cottage proposed, and the amount of accommodation to be provided therein— Number, class and type of cottage. Number of persons provided for. Size of Parlour. Living room. 1st bedroom. 2nd bedroom. 3rd bedroom. Scullery. Bathroom. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. 6 1st class, type A 60 101 144 116 96 96 27 22 6 „ „ B 48 114 144 123 96 — 32 29 6 ,, ,,C 48 96 144 116 96 . 32 29 3 „ ,,B 30 96 144 116 100 96 18 . 3 „ „ E 24 96 144 116 96 — 18 — 18 2nd class, type A 180 96 144 100 108 96 30 — 10 „ „ B 80 — 144 96 96 96 64 — 10 „ „ C 60 — 144 96 96 — 64 — 27 „ „ D 216 . 144 96 104 96 36 — 27 „ „ E 216 . 144 104 100 96 36 — 6 3rd class, type A 36 — 144 96 96 — 30 — 24 „ „ B 144 — 144 96 96 — 30 — 146 1,142 Erection of dwellings by the Council in connection with clearances under other Acts. Rotherhithe.tunnel displacement.— On the 27th January the Council accepted a tender for the erection of the Swan.lane estate of Hythe, Seaford, and a portion of Winchelsea buildings for 670 persons in five tenements of four rooms, 55 tenements of three rooms, and 75 tenements of two rooms. On the 7th April the Housing of the Working Classes Committee reported Rye.buildings, Swan. lane estate, ready for occupation. These buildings contain 20 tenements of two rooms and 20 tenements of three rooms providing accommodation for 200 persons. On the 19th May the Housing of the Working Classes Committee reported Sandwich.buildings, Swan.lane estate, ready for occupation. These buildings contain the same number of two and three room tenements as in Rye.buildings. On the 28th July the Council approved working drawings, specification, bills of quantities and architect's estimate of £13,892 for the erection by the Works Department of Brightlingsea.buildings, on Ropemaker's.fields site, Wapping, the buildings to be of five storeys and to accommodate 340 persons in 65 tenements, 5 of four rooms, 35 of three rooms, 20 of two rooms, and 5 of one room. Long.lane and Tabard.street improvement.— On the 30th June the Council accepted a tender of £14,787 0s. 7d. for the erection of Barnaby.buildings, Leroy.street, Bermondsey, to meet the requirements of 291 persons displaced by the improvement, the buildings to consist of two five. storey blocks. These buildings will accommodate 400 persons in 40 tenements of three rooms, and 40 tenements of two rooms. School Board rehousing (Norfolk.street site).— On the 7th April the Council accepted a tender to build 14 cottages on this site. Greenwich electricity generating.station rehousing (Hughes.fields).— On the 28th July the Council accepted a tender of £23,119 for the erection of Drake, Raleigh, and Benbow buildings on three of four surplus plots of land acquired under the Hughes.fields scheme, Deptford. The buildings will provide accommodation for 660 persons in 8 tenements of four rooms, 74 tenements of three rooms, and 38 tenements of two rooms. Mare.street, Hackney, improvement.— On the 24th November the Council accepted a tender of £17,884 for the erection of Vallette.buildings, the buildings to consist of one block of five storeys providing accommodation for 416 persons in 39 tenements of two rooms, 34 tenements of three rooms and 7 tenements of four rooms. The annual reports of medical officers of health supply the following information concerning action taken under the Housing of the Working Classes Act. Paddington.— Negotiations for a site for the erection of houses were continued in 1903, and plans of dwellings were prepared but are not yet approved. Proposals to acquire houses and adapt them for the working classes were under the consideration of a committee. A private company has, within the last two years, commenced such operations within the borough. Hammersmith.— The report of the town clerk shows that buildings erected by the borough council under Part III. of the Act were ready for occupation on the 1st January, 1904. The buildings were erected on land abutting on Yeldham.road at a cost of £5,684 6s. 8d., and were very quickly let. 51 Fulham.— The Public Health Committee of the borough council had under consideration plans prepared by the borough surveyor for a block of buildings proposed to be built on the land belonging to the borough council in Townmead.road, on a portion of which the electric light station, dust destructor and disinfecting station have been erected, but no decision has as yet been arrived at. Chelsea.— The borough council decided in 1901 to acquire, at a cost of £13,350, the reversionary interest of Onslow.dwellings, and in 1902 acquired the leasehold interest for the sum of £5,000. These dwellings came into the possession of the borough council in 1903. No further special expenditure was required beyond the cost of supplying seventy.two kitchen ranges. During 1903 the borough council acquired, for £2,300, the freehold interest of six houses in Pond.place, included in the leasehold of Onslow.dwellings. The area of the land covered by these houses and their curtilages is 8,500 square feet. Sub.leases for these houses expire before the end of 1909. Contracts for the erection of dwellings on the Beaufort.street site at a cost of £53,756 were made in 1902, the cost per room being £92. Considerable progress was made in 1903 in the erection of the buildings. Westminster.— The erection of three blocks of dwellings in Regency.street has made good progress, and it was expected the buildings would be ready for occupation early in 1904. The medical officer of health reported on the number of persons who might properly occupy them, this number being 688 persons over ten years of age and 1,541 under ten years of age, or 2,229 in all. St. Marylebone.— Mr. Wynter Blyth states that no progress has been made in dealing with the Devonshire.place and Burne.street areas, but that Queen.street.buildings have been opened on the Portman estate, and a large block of dwellings will be erected in the district of Grove End.road on the Howard de Wahlen estate. Hampstead.— Dr. Littlejohn refers to the representation he made as to the Kilburn.lane area, and states that the Secretary of State had invited the observations of the borough council on the decision of the County Council not to make a scheme for the improvement of this area under Part I. of the Act. He gives account of proceedings under Part II., in respect of King's College.mews East, which ended in certain works of improvement being effected, and in respect of the Silver.street area, the houses of which were individually represented under Part II., and which he thought might be dealt with by scheme. The borough council were in communication with the County Council on this subject. St. Pancras.— Dr. Sykes states, in respect of area No. 1 (Somers Town area), that the houses in the part of the area west of Charlton.street and north of Drummond. street.lane were dealt with individually some years ago under the Public Health Act. In the case of the Chapel.grove scheme and Euston.place scheme plans and estimates were prepared by the Public Health Committee, but referred back for the purpose of report whether it would not be advantageous to let the sites to industrial or other dwellings companies for the erection of working.class dwellings. In respect of the Prospect.terrace and Brantome.place scheme agreement was come to with the Skinners' Company, as the governors of Tonbridge School, to whom the site of Brantome.place belonged; the opposition of the company being withdrawn, the order of the Local Government Board was confirmed in February, 1904. The foundation of working.class dwellings on the Great College. street site was laid in 1902, and the work was proceeding towards completion at the end of 1903. Hackney.— Reference is made to the closing of cottages in Priory.place, off Wall.street, under the Housing of the Working Classes Act. Holborn.— Dr. Bond states that since the Eyre.street area (Italian colony) was represented five houses in Eyre.street.hill have been replaced by warehouses and three other houses closed as inhabited houses and used entirely for the manufacture of ice.cream. He gives account of the progress made by the County Council in dealing with the Union.buildings area and the building on the Bourne estate and Herbrand.street sites, of the closure of seven houses under Part II. of the Act, and of numerous houses in the borough voluntarily demolished, rebuilt, etc. Finsbury.— Dr. Newman shows the result of representations he made to the owners of groups of insanitary houses in the borough referred to in his preceding report. Twelve houses on an area near Sermon.lane were demolished. Houses in Caroline.place and Kemp.place, Bakers.row, were much improved. The houses in Providence.place, Bakers.row, ten in number, were demolished. The houses in Eastern.place, out of Eastern.street, were much improved. A square of property bounded by York.road, Lever.street, and Hull.street, with courts in the interior, were also dealt with. It was arranged that the whole property should be rebuilt in two or three years, and the internal courts were demolished in 1903. In the above proceedings 33 houses were demolished and 186 persons were displaced, of whom 60 found accommodation in the borough and 73 elsewhere, mostly in the vicinity. The annual report also contains information of the number of houses closed and persons displaced in the borough in 1903; these included 59 houses and 593 persons by the County Council in connection with schemes under the Act; 21 houses and 133 persons by the action of the borough council, and 81 houses and 623 persons for commercial reasons, street widening, etc., making in all 161 houses and 1,349 persons. Of 758 persons displaced as the result of the action of the borough council or on account of houses being closed owing to street improvements, commercial invasion, etc., 391 found accommodation in Finsbury, 280 removed outside the borough, and 87 were not traced. Dr. Newman also gives account of the progress made in dealing with areas for which the County Council has made schemes. Shoreditch.— Twenty houses were closed as the result of sanitary notices and numerous houses occupied by the working classes were also closed, mostly for the erection of warehouses. Dr. Bryett estimates that some 600 persons will thus be displaced. 52 Stepney.— Dr. Thomas describes the Back.church.lane area, which he represented to the the Council in 1903 (see page 48), and states that on the Council declining to make a scheme for its improvement, sanitary notices were served for the improvement of the houses. He writes— The procedure under the Act must to a certain extent be made public. This gives opportunity to certain shrewd house speculators to buy the property, raise the rents, and by the time the local authority is ready to negotiate for its purchase the property is very much enhanced in value. This took place in the Back.church.lane area, but as the London County Council ultimately refused to proceed with the scheme, the speculators must have made a bad investment, especially as they were immediately called upon to carry out extensive sanitary repairs. If it had been proceeded with, this speculation would have rendered the property more expensive to purchase. With reference to the sufficiency of house accommodation in Stepney, he states that "the house famine in the borough two years ago forced up the rents abnormally high. Thia was one, if not the most important factor in the causation of overcrowding. For some reasons, there is, at the present time, plenty of house accommodation in the district. There are, of course, more empty houses in some parts than in others. One reason is the number of new houses that were built during the year, which included a number of large blocks of model buildings. A large number of these dwellings have been constructed during recent years. This is, however, far from being responsible for so many of the empty houses. Among the number of dwellings completed during the year was Mann's.buildings, which were erected in the insanitary area cleared by the late Limehouse District Board of Works, and known as Queen Catherine.court area." Poplar.— Proceedings were instituted by the County Council under the Building Act for dealing with Arnolds.buildings as a dilapidated and neglected structure. The hearing of the summonses was adjourned by the magistrate with a view to opportunity being given for the repair of the premises. These premises had been included in an area represented under Part I. of the Act, for which the County Council were not prepared to make a scheme. Closing orders under Part II. were obtained for seven houses in Prospect.place and Eagle.place, King.street, which had also been included in a representation under Part II., and the courts were boarded up. Southwark.— Dr. Millson gives particulars as to the Park.street area represented by him under Part I. of the Act (see page 48). Wandsworth.— The Housing Sub.Committee reported on proposals to erect houses on certain plots of land, some belonging to the borough council. It was not deemed practicable to utilise these sites for this purpose, but a proposal was adopted "to take a house in a populous and poor neighbourhood and fit slipper baths in most of the rooms, the use of which might be obtained at a very moderate cost." Lewisham.— Dr. Harris includes in his report particulars of a number of houses represented by him under Part II. of the Act, and of the results obtained, as well as an estimate of the number of dwellings in the borough and its divisions let at weekly rentals varying from 4s. to 13s. Of these there were in all 9,896. Woolwich.— The borough council's 25 new houses at North Woolwich were completed, and all but one occupied. 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, 1903— Metropolitan borough. Total number of houses concerning which the Council has received information that representations have been made from the 1/1/03 to the 31/12/03. 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 3 1 . 2 3 . . . . . — Camberwell . . . . — . — — . — — Chelsea . . . . . . . . . . . Deptford . . . . . . . . . . . Finsbury . . . . — — — — — — . Fulham — . . . — — — — — — — Greenwich . . . . . . . . . . . Hackney 6 6 . . 6 . . — — . . Hammersmith — . . — — — . — — — — Hampstead 52* — — — — — — — — — — Holborn 7 . 1 1 2 . 5 . 5 . . Islington . . . . . . . — . . — Kensington — . . — — — — — — — — Lambeth . . . . . . . . . — — Lewisham 14 3 . 8 11 3 . . 3 . . Paddington — — — — — — — — — — — Poplar 7 4 . . 4 3 . . 3 . . St. Marylebone 22 1 . . 1 20 . 1 21 . . St. Pancras 2 . 1 . 1 — l — 1 — . Shoreditch . . . . — . — — — — . Southwark . . . . — . — — — — . Stepney — — — — — — — — — . . Stoke Newington — — — . — . — . — . . Wandsworth . . . . . . — . — — . Westminster, City of . . . . . . . — — — — Woolwich 6 5 — 1 6 — — — — — . Total 119 20 2 12 34 26 6 1 33 . . * Further action postponed until the garden scheme at Wylde's farm has been inaugurated. 53 Death.rates of persons resident in the County Council's dwellings. The death.rates among tenants of the Council's dwellings for the year 1903 were calculated in the Public Health department and presented to the Council in March, 1904. The following death.rates relate to buildings which were occupied during the whole of the year 1903. The population thus dealt with comprised 12,835 persons, and the death.rate at all ages, after correction for age and sex distribution, was 118 per 1,000 compared with 15.2 per 1,000 for London. The following table enables the death.rates in these buildings, at several ages, to be compared with those of London. The death.rates from certain causes are also shown— Death rate per 1,000 living in Cause of death. Council's dwellings. London. All causes— All ages 11.8 15.2 Do. Ages 0.1 1497 152.6 Do. „ 0.5 37.2 49.5 Do. „ 5.20 1.2 2.6 Do. „ 20 and upwards 9.9 14.9 Principal epidemic diseases 1.64 l.75 Phthisis 1.48 1.55 Tubercular diseases other than phthisis 0.55 0.60 Bronchitis 0.55 1.13 Pneumonia 1.25 1.28 Housing of the Working Classes Act, 1903. The principal alterations of the law effected by this Act are— (a) The maximum period which may be sanctioned as the period for which money may be borrowed by a local authority is extended from sixty to eighty years. (b) Obligation is imposed upon any authority, company, or other person acquiring land under any Act or Order to comply with the provisions in the Schedule as to the provision of dwelling accommodation where 30 or more persons of the working classes may be displaced from occupation, and not to enter upon the dwellings so occupied until the Local Government Board have approved of a housing scheme, or have decided that such a scheme is not necessary. (c) Power is given to the confirming authority to enforce by mandamus the making and carrying out of a scheme after an inquiry directed by them under section 10 of the principal act. (d) The requirement for calling upon the owner to place the premises in repair before proceeding for a closing order is made unnecessary where the local authority is of opinion that the dwelling.house is not reasonably capable of being made fit for human habitation, or is in such a state that the occupation thereof should be immediately discontinued. Houses let in Lodgings. During the year magisterial decisions were given on various points affecting the application of by.laws relating to the regulation of houses let in lodgings. At the South.Western Police Court the magistrate held that an ordinary dwelling.house which had been altered by the addition of a kitchen and water.closet to each floor was subject to the by.laws. In the Court of Appeal in February, 1904, two cases were heard in which the question was considered of the validity of the by.law requiring the landlord to annually cleanse the house. The Court decided that this by.law was unreasonable on the ground that it did not provide for notice of the required cleansing to be given to the landlord. The County Council's by.law, which requires the provision of a water.closet for every twelve persons, was in December declared invalid by the High Court for a like reason. Hence the by.laws of London sanitary authorities will have to be amended in this particular, and the Council has taken the necessary steps for the amendment of its own by.law. In Appendix IV. will be found a statement showing the number of houses on the register in each metropolitan borough in the early part of 1904. Particulars of the steps taken in the several districts in connection with the regulation of houses let in lodgings are given in many of the annual reports, from which the following details are extracted— Paddington.— At the close of 1902, 586 houses were on the register, and 265 houses were added during 1903, the number of houses on the register at the end of that year being 851. Originally the work of supervising these houses was entrusted to district inspectors, but it has been found necessary to transfer this duty to two special inspectors. In three instances it was necessary to summon the landlord for not supplying the information required. In the 851 houses were 1,246 one.room tenements, 1,437 tenements of two rooms, 271 of three, 25 of four, 8 of five, and 1 tenement of six rooms. The number of families found to be overcrowded was 293, occupying 332 rooms, and comprising 1,281 persons, 754 aged ten years and upwards, and 527 below ten years of age. In 161 cases the overcrowding was abated by rearrangement of the sleeping accommodation, 37 families voluntarily removed to other rooms on being informed of the overcrowding, and 17 did so on service of notice. The remaining 78 families were under observation at the end of the year. The annual cleansing in April 54 necessitated 2,826 visits, and 9 summonses were taken out. In the 586 houses on the register, 396 cases of infectious disease are known to have occurred. The occupants of the 586 houses numbered 9,295, 6,512 under ten years of age, and 2,783 aged ten years and upwards. The attack rate of notifiable diseases in 1903 was 8.30 per 1,000, compared with 4.78 for the rest of the borough; the death.rates from "all causes" were 39.9 per 1,000 persons under ten years of age and 20 9 per 1,000 persons ten years and upwards. In the rest of the borough these rates were respectively 281 and 11.4. Kensington.— The number of houses on the register was 2,050. Hammersmith.— The total number of houses on the register was 1,818. During the year 261 notices were served, nearly all of which were complied with. Fulham.— New by.laws for houses let in lodgings were made by the Council and sanctioned by the Local Government Board in October. "In these by.laws the 'owner,' i.e., the person who receives, or is entitled to receive, the rack rent of the house, is made responsible for the annual cleansing of the premises, the condition of the drains, etc., in place of, as in the old by.laws, the 'landlord,' who was the person by whom the rooms were actually let, since in administering the by.laws it was found that the latter was frequently in such a finanical position as to be unable to comply with the requirements." "As originally submitted to the Board the by.laws only applied to such of the houses let in lodgings as were registered by the Council, but the Board objected to this on the ground that, as they were informed by the London County Council, it lent itself to lax administration." By.laws without an exemption clause were then submitted, but the Local Government Board were not prepared to assent to them, and a by.law was then made and approved by the Board exempting from the operation of the by.laws lodging. houses where the rent paid by each lodger for unfurnished rooms was 12s. a week and upwards, and for furnished rooms 15s. a week and upwards. Arrangements were made for the active administration of the by.laws, and one of the inspectors was instructed to devote himself entirely to this work. As a result of the decision in the case of Stiles v. Galinski, the work is in abeyance, but the Council has drafted the necessary amendment for submission to the Board. Westminster.— By.laws as to houses let in lodgings were approved by the Local Government Board, A clause exempts houses from the operation of the by.laws if the rent payable by the lodger is 15s. or upwards, exclusive of furniture, and 18s. and upwards inclusive of furniture. Dr. Allan states that the requirement as to cubic space is based on an extremely low standard; the limits are 300 cubic feet for each person over ten years of age for a room used exclusively as a sleeping apartment, and 400 cubic feet for rooms not exclusively so used, half this, space being required for children under ten years of age. Hampstead.— Dr. Littlejohn writes: "Arrangements were being made, as far as the staff would permit, to inspect tenement houses, when the town clerk advised that under the by.laws at present in operation the lime.washing of these places could only be enforced during the months of April and May every year, and further, that a house let in lodgings or occupied by members of more than one family was, by virtue of by.law 2, exempt from the operations of the by.laws, until the present landlord had been required to make a return in pursuance of by.law 5; the result being that a very large number of houses on the register were exempted owing to a change of landlord having taken place. Consequently no work has been accomplished under the provisions of the by.laws beyond requiring the landlord, in every case where there had been a change, to make the return required so that a proper inspection could be proceeded with in April and May of next year." Dr. Littlejohn states that the by.laws are unsatisfactory in other respects, especially in making the landlord, and not the owner, responsible for the limewashing and decorative work, and for the maintenance of the sanitary appliances of all kinds. St. Pancras.— During the year 42 tenement houses were measured for registration, and at the end of the year 1,838 were upon the register, 2,307 periodical half.yearly inspections were made, and 5,535 re.inspections after the service of notices. Islington.— At the end of the year there were 655 houses on the register, 122 more than at the end of the preceding year. There were 1,566 separate inspections and 6,841 re. inspections of, and visits to registered houses, resulting in 2,254 nuisances being abated in 1,049 houses. Dr. Harris expresses a strong opinion as to the need of appointment of an additional inspector to assist the inspector upon whom devolves the duty of inspecting registered houses. He states: "The Public Health Committee are now considering the whole position of the sanitary staff, and it is hoped that before very long the additional assistance will be obtained." In a special report to his authority on "the duties of sanitary inspectors," he refers to a return on "Sanitary officers," issued by the County Council, and states that an examination of this report "shows that in nearly every borough inspectors are being selected for special work, those with a special aptitude being chosen," and in a preface to his annual report he writes: "I am glad to know that your Public Health Committee are resolved that that portion of the Public Health (London) Act, 1891, dealing with tenement houses shall be firmly administered, and that an inspector, who shall devote the whole of his time, shall be appointed to inspect houses let in the northern part of the borough, as is already done in its southern district." Stoke Newington.— At the end of the year there were 180 houses on the register, 61 having been added during the year. Dr. Kenwood states that in the borough, more especially in the southern division, there is a considerable number of houses let in lodgings under circumstances and conditions which make it desirable, in the interest of personal and public health, that they should be registered and inspected at frequent intervals. Hackney.— During 1903, 135 houses let in lodgings were inspected. The chief defects noted and remedied were dirty rooms, passages, yard paving and dust.bins. 55 Holborn.. At the eng of the year 775 houses were registered, 439 in the Bloomsbury, and 336 in the Holborn division; 296 houses, all in the Holborn division, were added to the register during the year. All have been inspected from time to time and the by.law enforced New by. laws were enforced by the Local Government Board in August, 1903. The Board assented to the omission of the exemption clause. Finsbury.— During 1903 170 houses were inspected and placed on the register, making a total of 1,109 on the register. Houses in 120 streets and courts are now registered. The usual inspections were made and a number of notices served. In the spring, registered houses were cleansed. "Overcrowding has also been reduced in many registered houses, and there is a substantial improvement in their general sanitation." There are still a number of houses which ought to be registered, and these will be proceeded with in due course. Twenty.one summonses were issued for failure to cleanse; two were withdrawn; in fourteen there were convictions, and in five cases the summonses were dismissed. In these five cases the magistrate took the view that the by.law, which required the cleansing of houses in one and the same month, was unreasonable, but another magistrate shortly afterwards, who had his attention drawn to this decision, convicted for breach of the same by.law. In seven instances summonses were taken out for overcrowding; one was withdrawn, and in six there were convic'tions. Altogether in 98 cases, overcrowding was abated, a notice sufficing for the other cases. City of London.— The houses let in lodgings were re.surveyed; there were 366 on the register, comprising 1,175 tenements inhabited by 2,876 persons, or 2.45 persons per tenement. The notices served in respect of these houses numbered 419. Shoreditch.— The number of houses on the register was 233, 42 having been added during the year. Referring to correspondence between the County Council and borough council as to the administration of by.laws under section 94 of the Public Health (London) Act, Dr. Bryett points out that the number of tenements under five rooms shown in the Census Report contains many in blocks of artizans' dwellings which are, to all intents and purposes, blocks of separate houses, and could not, therefore, be registered, but that the borough council had informed the County Council that special instructions had been given to the sanitary staff with a view to securing the speedy registration of such houses as required to be brought under the by.laws. Dr. Bryett writes— In connection wiih the correspondence above referred to, it may be mentioned that the London County Council have been advised by Mr. C.A. Cripps, K,C., that section 94 of the Public Health (London) Act, 1891, which requires by.laws to be made and enforced, is imperative, and that there is no provision as to a power to exempt from the operation of the by.laws such houses as come within the definition of a lodging.house. When the Shoreditch by.laws were made, in 1891, an exemption clause was allowed by the Local Government Board. By this clause a lodging.house is exempt from the operation of the by.laws until the landlord of such lodging.house shall have been required to furnish the statement of particulars which is set forth in the fifth by.law. These particulars have to be furnished by the landlord within fourteen days of the receipt of a notice in writing from the clerk to the sanitary authority. This notice is sent only when it has been decided by the borough council to register a lodging.house. In view of the exemption clause, there appears to be a discretionary power as to what lodging.houses are to be registered in Shoreditch. The subject of the registrat ion of lodging.houses was considered by the late Shoreditch Vestry in 1896, and after a good deal of discussion it was decided to register houses which are occupied by members of more than one family in which the landlord doss not reside on the premises, and which are not kept in a proper sanitary condition, and the inspectors were accordingly instructed to report such houses for registration. In carrying out their instructions the attention of the sanitary inspectors is more especially directed to those houses which are observed to be recurrent sources of sanitary trouble. Bethnal.green.— From a report by the chief inspector it appears that the number of houses on the register was 365, comprising 922 tenements, the average number of persons to a tenement being 3.76. Since the appointment of an inspector "the regulations have been steadily enforced, and the most gross cases of overcrowding and indecent occupation dealt with." Night inspections were made to 41 houses, 11 cases of overcrowding and 18 of indecent occupation were discovered, chiefly among the alien population. Altogether there have been 2,429 inspections. The visits to tenement houses numbered 1,747; 299 were visited with a view to registration, and 296 were found suitable. The number of summonses issued was 39. Some defendants escaped conviction on a technicality, but in the main the proceedings were successful, and fines amounting to £21, with costs £15, were imposed. Of this total of £36 there was recovered £27 9s.; the other defendants either went to prison in default of payment or absconded. Stepney.— At the end of the year 2,649 houses were on the register. Two special inspectors devote the whole of their time to the administration of the by.laws. No other inspectors are thus employed except in the district of St. George, where the areas allotted for other purposes to each inspector are so small that it was thought advisable to allow the registered houses to be under their supervision. The two special inspectors made 8,802 visits during the year and served 2,096 notices for the abatement of nuisances. Overcrowding was abated in 613 tenements. Poplar.— The number of houses registered during the year was 207, making a total of 580 on the register. The number of houses registered and re.registemi during the year was 329. The number of rooms measured was 200. There were 153 night inspections. In 51 instances overcrowding was found and abated either by rearrangement of occupation_o_f the rooms or by removal of tenants from the premises. The number of rooms cleansed was 774, and the number of yard walls and waterclosets cleansed was 235. A temporary assistant inspector employed in these duties was re.appointed for a period of twelve months. The borough council desired to amend their by.laws so that thev should require cleansing of houses in April and November, instead of in April only. The Local Government Board were of opinion this might be 56 reasonable, but were prepared to assent to an amendment requiring a lodging.house to be cleansed in the first week of April and at such other times as the conditions thereof may render it necessary. Southwark.— There were 970 houses on the register at the end of the year 1902, 163 were registered in 1903, and 33 removed from the register, leaving 1,100 on the register at the end of 1903. There were 3,031 inspections and 5,373 re.visits to the registered houses, 3,456 entries made in the nuisance register, 1,020 intimation and 318 statutory notices served, 985 sanitary works completed, and 3,230 nuisances abated. Bermondsey.— In 1902 there were 206 houses on the register. During 1903 two houses were added and one removed, leaving 207 on the register at the end of the year. Lambeth.— There were 372 houses on the register, one being registered during the year. Dr. Priestley states that in practice it has been found difficult to enforce the annual cleansing by the landlord, and he is of opinion that there is necessity for the by.laws to be amended so as to make the owner, and not the landlord, liable. With respect to overcrowding, he states in a special report that while gross cases are dealt with under the Public Health Act, the enforcement of the by.law as to cubic space would, in his opinion, be " an unjust and severe action for a sanitary authority to take under conditions such as at present exist, more especially in the Inner Wards of Lambeth Borough." Battersea.— The number of houses on the register at the beg inning of the year was 82, and during the year 39 were added, making a total of 121, and the medical officer states that this number would have been greater had the revised by.laws been sanctioned during 1903. In March, 1903, the borough council submitted a new set of by.laws in which the term "landlord" was so defined as to mean the owner of premises, and the term keeper to mean the person letting the house in lodgings and receiving the profits of such letting. The standard of air space was raised to 400 cubic feet for an adult in a sleeping room and 500 cubic feet in a room used for living and sleeping, the corresponding figures for children under ten years of age being 200 and 250 cubic feet respectively. The Local Government Board accepted these provisions but objected to by.laws which contained no exemption clause. The borough council sought sanction to an exemption clause similar to that in the Bethnal.green by.laws, but the Board declined, and suggested the following clause, which was accepted by the borough council— "A lodging.house shall be exempt from the operations of these by.laws where the keeper resides on the premises, and where, in addition to such keeper and his family, there are not more than two persons lodging in such house." The revised by.laws had not been formally sanctioned at the end of the year. Dr. McCleary discusses the advantages of registration of houses let in lodgings, and shows the larger control the sanitary authority can exercise over such houses by making them subject to by.laws. With respect to overcrowding, dirty houses, etc., he writes: "In a registered house the sanitary authority can prosecute the landlord direct for a breach of the by.laws and apply for penalties. This procedure should be adopted in cases of overcrowding, unless there are very good reasons to the contrary. It has the effect of giving the landlord a pecuniary interest in the prevention of overcrowding, and converts him, practically, into a colleague of the sanitary inspector." Wandsworth.— The number of houses on the register was 200; 360 inspections were made and 192 notices served, of which 6 were for overcrowding. In a special report Dr. Caldwell Smith states that about 5,000 houses in the borough are let to tenants who in turn sublet, and he writes: "It is almost impossible for the by.laws to be carried out satisfactorily where this latter form of letting is in force, as the tenant who sublets is not in a position financially to carry out the requirements, and registration of these, as long as the by.law remains as at present, would be of no advantage. It always has been my practice to advise the committee to place houses on the register which are occupied by more than two families, but even in these the same difficulty as to the definition of 'landlord' has arisen. There are, however, a large number of houses let to members of more than one family, and which come under the by.law, which it would be advisable to place on the register when such are not kept in a sanitary condition. It has not been my practice to ask for houses to be placed on the register which are well looked after by the landlord, as I do not think anything would be gained by such registration." Camberwell.— There were 270 houses on the register at the end of 1902, and 30 were added during 1903, making a total of 300 on the register at the end of 1903. There were 1,172 inspections, 58 notices served, and 2 prosecutions for overcrowding; and 183 notices served and 4 prosecutions for other conditions. Deptford.— By.laws were sanctioned by the Local Government Board in November, 1902. There were 126 houses on the register at the end of 1903, 49 having been registered during the year. There were 134 inspections. Two notices were served for overcrowding. The medical officer of health anticipated that many houses would be put on the register during 1904. Greenwich.— The medical officer of health reports— "The by.laws prepared by this council have during the year received the sanction of the Local Government Board, and the various forms and notices required under these by.laws are in course of preparation. No houses have been placed upon the register during the year, and with the present staff it will be practically impossible to make any satisfactory attempt to deal with this large question. The Public Health Committee now have under consideration a report dealing with the question of an increase to the permanent staff." 57 Lewisham.— There were 29 houses on the register at the end of 1902, none were registered during the year, and 14 were removed from the register, leaving 15 on the register at the end of 1903. There were 324 inspections in 1903 and 21 notices were served for nuisances. Woolwich.— There were 132 houses on the register at the commencement of the year, 42 were recommended for registration, of which 28 were registered, 7 were removed from the register, and 20 demolished, leaving 133 on the register at the end of the year. The houses were all inspected either quarterly or half.yearly, and the number of notices served was 132. One prosecution for refusal to fill up the form failed on the technical ground that the owner was not the landlord under the by.laws. In 17 instances overcrowding was abated. Dr. Davies states that during the year he made an inspection of 51 houses which had been recommended for registration during the three previous years, "but which had not been registered because they were reduced to occupation by one family, or overcrowding or dirty conditions were remedied, or the conditions were not thought bad enough to justify registration."He found that 43 of these houses were still occupied by two or more families, 28 of these were in a dirty condition, and overcrowding existed in 12. "Such a result," he writes, "shows conclusively that this class of house requires to be dealt with in a special way. Fourteen of these houses were ordered by the committee to be placed on the register." He further states that he inspected a large number of houses on the register and found their conditions markedly superior to those referred to above. Houses adapted as tenement houses. During 1903 Dr. Young made inquiry as to the extent to which houses originally constructed for one family were adapted for use by several families when subsequently let in tenements. In numerous instances he found that no alteration had been made, and that the only water supply available for all the families was derived from a tap in the back.yard or in the wash. house on the ground or basement floors. As a rule water.closet accommodation had been provided, usually in the back.yard, in the proportion of one water.closet to every 12 persons, so as to comply with the requirements of a by.law made by the London County Council under the Public Health (London) Act 1891. Provision for washing clothes was generally, but not always, made by the use as a wash.house of the ground floor room of a back addition or a room in the basement or an outhouse in the back.yard. Frequently, moreover, the only opportunity for cooking was a stove of the ordinary bedroom type which had been put into the house when it was originally constructed. The results of Dr. Young's inquiries are embodied in a report which is appended. (See Appendix II.) Common Lodging.houses. The administration of the Common Lodging Houses Acts devolved upon the Council in 1894. New by.laws governing common lodging.houses came into force on the 1st October, 1903. In the following table will be seen the number of houses registered, the authorised number of lodgers, and the number of convictions, with the penalties inflicted, during each year since 1894— Year. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties, and costs. * No. of deaths. No. of cases of infections 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 . 87 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 28,037½ 35,225 2,133 16 15 96 3 — 102 166 1902 491 28,970½ 40,512 1,449 22 21 98 4 . 120 686 1903 470 28,893 33,402 4,790 6 6 26 11 . 98 53 In the year 1903 proceedings before the magistrate were instituted in six instances, resulting in six convictions, the penalties amounting to £18 9s., with costs amounting to £8 2s. In addition to the number of inspections mentioned in the table there were 826 day and 122 night visits to houses suspected of being used as common lodging.houses. The number of cases of notifiable infectious disease reported in common lodging.houses was as follows— Smallpox, 33; erysipelas, 12; diphtheria, 5; enteric fever, 2; scarlet fever, 1; total, 53. As mentioned in my last annual report, the Council obtained powers under its General Powers Act, 1902, for the annual licensing of common lodging.houses. The Act received the Royal assent on 31st July, 1902, and on the 1st January, 1903, notices were served upon the keepers of all the known common lodging.houses in the administrative county calling upon them to apply for a licence. * The number of deaths referred to in the above table includes only those brought to the notice of the Council's inspectors. The actual number when correction is made for deaths in infirmaries and other institutions is very much greater. [8 ] 58 Before the passing of this Act the Council's powers with respect to common lodging.houses were more limited, and there was no means of compelling a keeper to provide for the safety, of the lodgers in case of fire. Advantage was taken of the larger powers granted by the Act to improve the sanitary condition of many common lodging.houses, and to ensure that proper provision was made for the safety of the lodgers in the event of fire. For this purpose every common lodging.house was visited and reported upon with special reference to its suitability, capacity, and general sanitary condition, and every room in each house was remeasured. Lists of requirements were prepared and sent to the respective keepers, together with a draft apportionment showing the number of persons for which the several rooms would be apportioned. The new apportionment in many cases had the effect of considerably reducing the registered accommodation. The requirements included the removal of unsatisfactory water.closet and lavatory fittings, in place of which the keepers were called upon to provide new water.closets conforming to the by.laws, proper fixed lavatory basins in slate slabs, glazed stoneware footbaths and washing troughs. Special attention was paid to the lighting and ventilation of the sleeping rooms and kitchens. In many instances the removal of partitions forming cubicles was insisted upon, thus improving the ventilation of the dormitories. At the present time, save for three houses only in which the conditions are exceptional, every common lodging.house in the county is now separately apportioned for single men, or single women, or married couples. The first annual licensing meeting was held on the 24th and 25th June, 1903. Adjourned meetings were held on the 3rd July and 14th October. At these meetings 512 applications for licences were considered. Of these 384 were granted, 88 adjourned until the 27th January, 1904, for the completion of the necessarv works. 11 withdrawn, and 29 refused. The following table shows the total number of known common lodging.houses in London on the 31st December, 1903, whether licensed or unlicensed, and the authorised number of lodgers in each case. The number of houses remaining on the register at the end of 1902 is added for the sake of comparison— Metropolitan borough. Remaining licensed on 31.12.03. Remaining unlicensed on 31.12.03. Total at end of year 1903. Total at end of year 1902. No. of houses added during 1903. No. of houses. Authorised No. of lodgers. Houses. Authorised No. of lodgers. Houses. Authorised No. of lodgers. Houses. Authorised No. of lodgers. Battersea 3 117 6 182 9 299 8 273 1 Bermondsey 3 115 3 772 6 887 5 789 1 Bethnal.green 16 712 1 71 17 783 18 781 1 Camberwell 5 230 1 313 6 543 9 609 . Chelsea 7 289 1 89 8 378 9 479 . Deptford 7 279 1 200 8 479 9 545 . Finsbury 6 363 1 98 7 461 7 471 . Fulham 2 60 — — 2 60 2 68 . Greenwich 6 178 — — 6 178 7 228 . Hackney 6 397 — — 6 397 8 426 . Hammersmith 8 179 1 292 9 471 9 550 . Hampstead — — — — — — 1 35 . Holborn 32 1,634 8 774 40 2,408 43 2,414 1 Islington 41 1,279 1 72 42 1,351 40 1,292 3 Kensington 29 819 1 43 30 862 33 1,019 1 Lambeth 7 460 1 167 8 627 9 688 — Lewisham 1 30 — — 1 30 1 30 . Marylebone 15 644 4 868 19 1,512 20 964 1 Paddington 8 264 — — 8 264 9 301 — Poplar 9 959 2 288 11 1,247 11 1,461 — St. Pancras 13 664 2 372 15 1,036 15 990 1 Shoreditch 7 472 5 262 12 734 13 761 . Southwark 38 2,152 14 1,826 52 3,978 56 4,086 2 Stepney 51 3,780 31 3,430 82 7,210 81 6,755 8 Stoke Newington 1 37 — — 1 37 1 37 — Wandsworth 10 218 — — 10 218 10 231 . Westminster, City of 19 1,036 3 687 22 1,723 24 1,891 — Woolwich 30 674 3 46 33 720 33 796½ — 380 18,041 90 10,852 470 28,893 491 28,970½ 20 In connection with the foregoing table, it should be noted that during the year 1903 a number of large Salvation Army shelters were included in the list of common lodging.houses, these shelters being held to be common lodging.houses within the meaning of the Acts as the result of the appeal Logsdon v. Booth, referred to in my annual report for 1899. From censuses taken of the number of persons sleeping in common lodging.houses on certain nights in June, 1897, June and October, 1902, and November, 1903, it may be estimated that about 4,000 beds are vacant every night. On the 14th November, 1903, when the accommodation for lodgers alone might be roughly estimated at 29,000, a census was taken for the purpose of classifying the total common lodging.house population, including deputies, their wives and families, according to age and sex. This census gave a total of 25,662 men, women, and children sleeping in common lodging.houses on the night in question, and of this 59 number nearly 500 persons belonged to the families of deputies. The results are tabulated below— Common Lodging.houses. Census taken— 14th November, 1903. Metropolitan borough. Age period. under 10 10. 15. 20. 25. 35. 45. 55. 65. 75 and upwards. All ages. Battersea Males 1 4 17 44 98 92 91 43 6 . 396 Females 1 — 1 3 15 18 6 5 . . 49 Bermondsey Males . 1 27 66 218 176 183 95 24 . 790 Females 1 1 1 3 Bethnal.green Males 1 1 16 79 167 168 133 81 19 10 675 Females 1 3 1 — 1 4 — 2 — . 12 Camberwell Males 1 — 9 65 104 131 87 60 5 2 464 Females 1 — — — — 1 2 — — — 4 Chelsea Males —' 1 17 28 50 77 82 37 33 4 329 Females 2 — — 5 9 8 10 8 — — 42 Deptford Males 3 — 13 69 101 80 101 54 8 — 429 Females 3 — — 1 — . 1 — — — 6 Finsbury Males 4 — 27 47 95 101 90 52 22 7 445 Females 1 — — . 2 4 — — — — 7 Fulham Males — — — 5 16 18 9 3 — — 51 Females 1 1 Greenwich Males — — 4 10 51 45 25 14 12 2 163 Females 2 — — — 1 1 — — — — 4 Hackney Males 1 . 3 22 79 84 70 36 8 2 305 Females 1 . . . — 2 1 . . . 4 Hammersmith Males — . 18 56 109 64 47 44 8 2 348 Females 1 . — 1 1 3 4 4 — 1 15 Holborn Males 3 1 20 157 354 549 421 255 68 10 1,838 Females 9 5 6 23 52 120 60 39 14 1 329 Islington Males 3 4 24 145 214 285 204 125 25 7 1,036 Females 7 — 1 12 30 33 20 10 4 2 119 Kensington Males 4 — 34 72 91 118 84 52 18 6 479 Females 1 2 19 39 63 62 38 17 14 1 256 Lambeth Males 1 3 28 71 133 128 107 46 13 — 530 Females 1 — 1 — — — 1 — — — 3 Lewisham Males — — — 2 7 6 5 3 1 — 24 Females — Marylebone Males — — 51 179 362 404 244 136 53 3 1,432 Females — — — — 18 9 16 7 1 1 52 Paddington Males 2 1 1 4 33 50 63 30 16 2 202 Females — — 2 4 12 7 5 3 — — 33 Poplar Males — 1 33 182 178 227 170 91 24 1 907 Females — — 1 — 1 1 2 2 — 7 St. Pancras Males — — 14 131 241 210 145 91 19 7 858 Females — — 2 16 37 38 . 1 3 . 106 Shoreditch Males — 4 30 76 122 169 120 62 31 3 617 Females 2 — 1 — 2 . — — — 1 6 Southwark Males 1 4 114 297 632 795 675 421 114 19 3,072 Females — 1 3 25 48 59 78 32 16 — 262 Stepney Males 23 23 149 510 1,208 1,482 1,170 678 166 19 5,428 Females 34 22 49 99 168 193 178 124 40 7 914 Stoke Newington Males — — 2 — 18 7 4 3 — — 34 Females 2 1 — — — — — 1 — — 4 Wandsworth Males 3 2 6 13 27 38 31 20 7 — 147 Females 2 2 — 1 8 9 5 2 — 1 30 Westminster, City of Males 2 2 61 205 371 394 371 225 109 10 1,750 Females 2 3 2 22 24 11 7 — 1 — 72 Woolwich Males 2 1 20 54 136 120 91 65 13 4 506 Females 3 — — 10 22 20 10 1 1 — 67 London Males 55 53 738 2,589 5,215 6,018 4,823 2,822 822 120 23,255 Females 76 39 89 261 515 605 455 258 94 15 2,407 Totals Persons 131 92 827 2,850 5,730 6,623 5,278 3,080 916 135 25,662 Death.rates from certain causes in common lodging.house population. During the year effort has been made to obtain particulars of all deaths occurring in London and institutions belonging to London among persons resident in or removed from common lodging.houses. Very few of these deaths actually occur in common lodging.houses, as the large majority occur in institutions, hospitals, workhouse infirmaries, etc. The male population at certain ages as enumerated on the 14th November. 1903, shown in the preceding table, has been applied to these deaths and death.rates at certain age.periods calculated therefrom. The rates have been limited to males, as the female population in London common lodging.houses is not sufficiently large to give reliable results. Objection can be urged on statistical grounds to the calculation of 60 rates upon the common lodging.house population of London, inasmuch as the persons comprised therein are largely of the nomadic class and its numbers are variable, but the figures are amply sufficient to show that the death.rate among this class is abnormal, and that the abnormality is especially marked in the case of particular causes of death. The fact has to be borne in mind in drawing any conclusions from these figures, that sufferers from chronic diseases such as phthisis and alcoholic subjects naturally gravitate to the common lodging.houses owing to inability to obtain remunerative employment, and the high death.rates obtaining cannot therefore be regarded as the result of the environment of the common lodging.house per se; the rates, moreover, are calculated upon the population actually residing in common lodging.houses, while among the deaths are included those occurring in public institutions among persons removed thereto from common lodging.houses. The following table shows the death.rates per 1,000 living from certain causes at certain ages in common lodging.houses during 1903, compared with the corresponding death.rates in London during 1901. The London rates for 1903 are not yet available, but the fact that the "all causes" death.rate for 1903 in London was considerably below that for 1901 makes it probable that the comparison would be still more unfavourable to the common lodging.house death.rates if the 1903 figures for London had been used in this connection— Death.rates per 1,000 males living from certain causes at certain ages in common lodging.houses during 1903 and in London during 1901. Cause of death. Age 25— Age 35— Age 45— Age 55— Age 65— All causes C.L.H. 15.24 22.62 42.56 66.30 144.30 London 6.74 12.76 21.79 37.82 70.42 Phthisis C.L.H. 6.89 12.49 20.27 16.29 11.49 London 2.65 4.30 5.01 4.12 2.72 Alcoholism (including cirrhosis of the liver) C.L.H. 1.04 1.27 1.78 3.79 5.11 London 0.17 0.61 1.17 1.39 1.36 Urinary diseases C.L.H. 1.26 1.09 3.57 4.17 14.05 London 0.22 0.67 1.28 2.91 5.88 Violence C.L.H. 0.63 0.72 1.78 1.89 5.11 London 0.64 0.92 1.43 1.77 2.36 Cancer C.L.H. 0.21 0.72 2.23 7.20 21.72 London 0.14 0.57 1.95 4.36 7.24 Other tubercular diseases C.L.H. 0.21 0.18 0.22 0.76 1.28 London 0.22 0.16 0.19 0.15 0.27 Circulatory diseases C.L.H. 1.46 2.35 4.46 7.58 24.27 London 0.68 1.34 3.82 8.93 19.04 Nervous diseases C.L.H. — — 1.78 2.27 5.11 London 0.21 0.53 0.91 1.70 3.56 Bronchitis C.LH. 0.21 1.09 2.01 11.36 30.66 London 0.08 0.36 1.18 4.28 11.54 Pneumonia C.L.H. 1.26 1.81 2.01 6.44 12.77 London 0.53 1.20 1.88 2.82 3.81 All other causes C.L.H. 2.07 0.90 2.45 4.55 12.77 London 1.20 2.10 2.97 5.39 12.64 The following table shows for London and the population residing in common lodging. houses the number of deaths from certain causes per 1,000 deaths from "all causes" at five age-periods. This table is a much better indication of the excessive mortality obtaining for certain causes of death among common lodging-house inmates than the preceding table, as the figures are not shown in relation to population against which, as has been previously shown, objection can be urged. Where the common lodging-house figure exceeds the corresponding figure for London the former is shown in Clarendon type. Table showing for London, and the population residing in common lodging.houses, the number of deaths from certain causes out of 1,000 deaths from all causes at five age periods. Cause of death. Age 25— Age 35— Age 45— Age 55— Age 65— C.L.H. London. C.L.H. London. C.L.H. London. C.L.H. London. C.L.H. London. All causes 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Phthisis 452 393 552 337 477 229 246 109 80 39 Alcoholism 68 26 56 48 42 54 57 37 35 19 Urinary diseases 82 32 48 52 84 59 63 77 97 84 Violence 41 95 32 72 42 65 29 47 35 33 Cancer 14 20 32 45 52 90 109 115 150 103 Other tubercular dis- 14 32 8 13 5 9 11 4 9 4 Circulatory diseases 96 100 104 105 105 176 114 236 168 270 Nervous diseases — 32 — 42 42 42 34 45 35 51 Bronchitis 14 11 48 28 47 54 171 113 213 164 Pneumonia 82 79 80 94 47 86 97 75 89 54 All other causes 137 180 40 164 57 136 69 142 89 179 Proportions in C.L.H.'s in Clarendon type are those in excess of the corresponding London proportions. 61 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 of October, 1901. During the year 1902, 114 houses had been measured and apportioned, and this number at the end of 1903 had been increased to 133. At the end of the year there were 102 houses under regulation. These houses are divided among the several metropolitan boroughs, as follows— Metropolitan borough. Houses. Lodgers. Poplar 31 452 Stepney 70 1,270 Woolwich 1 26 Total 102 1,748 During the year 1,956 day and 4 night visits were made to these houses by the Council's inspectors, and in a few instances notices were served for the remedying of dirty or defective conditions. Proceedings before the magistrates were instituted in two instances. In one case the summons was dismissed, and in the other the keeper was fined £1 10s., with 6s. costs. The number of cases of notifiable infectious disease reported in seamen's lodging.houses was as follows— Smallpox, 1; diphtheria, 2; measles, 1; erysipelas, 2; enteric fever, 1; total, 7. Customs and Inland Revenue Acts, 1890 and 1891. The following information as to proceedings under the Customs and Inland Revenue Act is contained in the annual reports of medical officers of health— Paddington.— Very few applications for certificate of exemption from inhabited house duty have been received for some years. One application was received in 1903 relating to four blocks of flats in Wymering-road, each block containing ten flats. The medical officer of health states that "it has been ascertained that before flats can come under the provisions of the section, they must be rated separately. It is not certain whether the same rule does not apply to tenement houses." Fulham.— Applications were made for certificates in respect of 605 dwellings, of which 455 were granted, 66 were given after certain specified works had been completed, and 84 were refused. Chelsea.— Applications were received in respect of 5 houses, comprising 103 dwellings, and 1 certificate was granted. Hampstead.— Certificates were granted in respect of 2 premises, comprising 26 dwellings, and refused in respect of 4 other premises, comprising 15 dwellings. Islington.— Applications were received in respect of 14 houses, comprising 113 dwellings, and 4 certificates were granted. Stoke Newington.— Applications were received and granted in respect of 3 houses, comprising 25 tenements. Hackney.— There were 19 applications for certificates of exemption of properties comprising 228 tenements, all of which were granted after any necessary works had been executed. Holborn.— Applications were received in respect of 13 premises, comprising 322 dwellings, and were granted in respect of 13 premises. In some premises works were required to be done antecedent to a certificate being granted, and in the case of Leather.lane.buildings the certificate was refused. Finsbury.— There were applications for certificates for 5 houses, comprising 60 dwellings, all of which were granted. Shoreditch.— Applications were received in respect of 24 houses, comprising 72 dwellings, and were granted for 42 dwellings. Southwark.— Applications were received and granted in respect of 15 houses, comprising 318 tenements. Bermondsey.— Applications were received and granted in respect of 6 houses, comprising 91 tenements. Lambeth.— Certificates were granted unconditionally in respect of 25 blocks of houses, comprising 355 tenements, and conditionally in respect of 20 blocks of houses comprising 360 tenements. In no instance was the certificate refused. Battersea.— Applications were received and granted in respect of 97 houses, comprising 105 dwellings. Wandsworth.— Applications were received in respect of 359 houses, comprising 508 dwellings. In 14 instances certificates were granted and in one instance refused. Camberwell.— Applications were received in respect of 9 houses, comprising 24 dwellings, and 5 certificates were granted. Deptford.— Applications were received in respect of 55 houses, comprising 97 tenements, and 93 certificates were granted. Greenwich.— No applications for certificates were received during the year. Lewisham.— Applications were received and granted in respect of 140 houses, comprising 280 tenements. Woolwich.— There was one application, viz., in respect of a house comprising 16 dwellings. This application was refused, as several of the dwellings were insufficiently lighted, and in none of the dwellings was there a bedroom containing 900 cubic feet, i.e., large enough for a father, mother, and two infants to sleep. G2 Since the Customs and Inland Revenue Act, 1890, came into force no Inhabited House Duty has been paid in respect of a house originally built or adapted by additions or alterations and used for the sole purpose of providing separate dwellings where the annual value was under £20, provided a certificate of the medical officer of health was obtained to the effect that the house was so constructed as to afford suitable accommodation for the occupiers, and that due provision was made for their sanitary requirements. By the Revenue Act, 1903, the provisions above mentioned were repealed (except as regards the certificate of the medical officer of health) and instead, where a house, so far as it is used as a dwelling.house, is used for the sole purpose of providing separate dwellings; (a) the value of any dwelling in the house not exceeding £20 is to be excluded from the annual value of the house for the purposes of Inhabited House Duty, (b) any dwelling in the nouse of the annual value of £20 and not exceeding £40 is reduced to 3d., and (c) any dwelling in the house exceeding £40 and not exceeding £60 is reduced to 6d. The exemption and reduction under (a) and (b) cannot be obtained unless the certificate of the medical officer of health as mentioned in the Act of 1890 is obtained. This provision, however, does not apply to (c). Underground Rooms. At the close of 1903 the Public Health Committee reported to the Council on the occupation of underground rooms in St. Pancras, and stated that enquiry made by the Council's medical officer had shown that upwards of 400 such rooms were illegally occupied which did not comply with the requirements of the Metropolis Local Management Act of 1855, and that these rooms were inhabited by over 1,000 persons. As the result of subsequent inquiry by the medical officer of health of the borough he found there were 640 rooms in which the conditions were practically irremediable, and he suggested that these rooms should be dealt with consecutively, " so as to avoid the serious effects of suddenly displacing a large population." Notices in respect of 50 rooms had been served on the 7th August, and it was proposed in December that 58 further notices should be served. The Council, on the recommendation of the Committee, decided to suggest to the borough council that it was desirable notices should be served at more frequent intervals so as to secure compliance with the law as soon as practicable. The annual reports of medical officers of health show that the illegal occupation of underground dwellings was discontinued in their boroughs as follows— Fulham, 4; Chelsea, 7; Westminster, 28; Hampstead, 3; St. Pancras, 36; Islington, 40; Holborn, 21; Finsbury, 27; Shoreditch, 2; Bethnal.green, 14; Stepney, 121; Southwark, 1; Lambeth, 72; Battersea, 55; Woolwich, 1. The Administration of the Factory and Workshop Act. In the last annual report I endeavoured to show the action taken in each London district under this Act, and I pointed out the need for some uniform method of statement which would enable the facts to be presented in such a way that estimate could be formed of the extent to which, and efficiency with which, this Act is administered in the several sanitary areas of London. With this object, in conference with H.M. Chief Inspector of Factories and the Metropolitan Branch of the Society of Medical Officers of Health, forms for statistical purposes were prepared. It was not felt that these forms could be regarded as finally complete, but rather that they might provisionally, and until experience had been gained of their use, serve the purpose in view. These forms were not, however, settled until the early part of the present year, and hence while some medical officers of health have been able to use them in the preparation of their annual reports, others were unable to do so. In some instances, however, these officers subsequently communicated to me the results of tabulation of their statistics in the manner which the forms indicated, and these have been used in this report. It need hardly be said that the use of forms for statistical statement is limited to those facts which lend themselves to such treatment, and does not in any way obviate the necessity for a full statement in the annual reports of the work done and of the experience of each officer in the administration of the Act. The record of the year shows on the whole satisfactory progress, when consideration is had for the very large number of premises which have thus come under the supervision of the sanitary authorities, and when it is recollected that every workroom in each workshop has to be measured in order that its cubic space may be ascertained, and that every year a number of workshops are disused, while others come into occupation. The amount of work which is involved in these preliminary steps is obviously very considerable, and when the subsequent routine inspection of the premises, remedy of defects, dealing with outworkers' premises, and other duties which have to be performed are taken into consideration, the need for the recognition by the sanitary authorities, of the magnitude of the work which devolves upon them and the provision of a staff of officers sufficient for the purpose, is evident. Evidence of the fact that success is attending the efforts of a number of sanitary authorities is found in several of the reports, and the following extract from the report of the medical officer of health of Islington may be quoted. Dr. Harris writes :— "It may safely be asserted that the administration of this Act in Islington has been satisfactory, and that all its requirements have been faithfully carried out. Formerly it was the rule that hardly a day passed that anonymous or signed complaints were not received from workers, now it is the exception, and, indeed, they are practically unknown; while on the other hand, testimony has been given of the great improvement that has been effected in every direction." Nevertheless, Dr. Harris feels it necessary to point out that the two inspectors, one male and one female, cannot, with the increase of the work, "much longer give the premises, which it is their duty to inspect, that adequate supervision which is so necessary, if inspection is to be 63 of any material service. Altogether they at present number 3,412, containing nearly 5,000 rooms, from which it will be seen that work as they may they cannot visit many of these places more than once, especially if they pay due attention to those workshops which require, and must have, continued supervision. It will, therefore, be necessary that the Council should consider how much further they will increase their staff for the purpose of executing their duties under the Act." Again, Dr. Allan, in his report on the inspection of outworkers' premises in Westminster, of which he received in the six months up to August 1st notice of upwards of 3,000, writes:— "Inspection of their houses has not been made except in so far as the inspectors have been able to include it in their ordinary work. I had 60 places specially examined, and in 17 instances it was necessary to take action, thereby showing the need of inspection; besides, such inspection is a statutory duty, and the Council may prevent work being given out to persona using places which are unsuitable." And again, Dr. Brown, writing of workshops in Bermondsey, states that he does not think that the number on the register (322) represents more than at most a third of the workshops which ought to be on the register, and he adds: "In this connection I trust the Council will see the wisdom of considering at an early date, if the Factory and Workshop Acts are to be efficiently administered, the appointment of at least one female sanitary inspector." In a return as to sanitary officers appended to this report (see Appendix IV.) it will be seen that Westminster has since appointed two female inspectors, and in a preface to his report, Dr. Harris states that the Islington Borough Council have under consideration the appointment of an additional inspector.* The return mentioned shows that inspectors are especially employed in connection with duties arising under the Factory and Workshop Act in the following twenty.three districts, in twenty.one of which female inspectors are employed in this work— Metropolitan borough. Male inspectors. Female inspectors. Metropolitan borough. Male inspectors. Female inspectors. Battersea 1 1 Lambeth - 1 Bethnal-green 1 — Lewisham 1 1 Camberwell — 1 Paddington 1 2 Chelsea — 1 Poplar — 1 Finsbury 1 1 St. Marylebone 1 1 Fulham - 1 St. Pancras 1 1 Hackney — 2 Southwark — 1 Hammersmith 1 — Wandsworth — 1 Hampstead 1 1 Westminster, City of — 2 Holborn — 1 Woolwich — 1 Islington 1 1 London, City of - 1 Kensington - 2 In the above districts in some instances other duties may also devolve upon the inspectors, but they are relieved of the general duties which usually devolve upon inspectors who have an area allotted for their supervision. In Bermondsey, Deptford, Greenwich, Shoreditch, Stepney and Stoke Newington, work arising under the Factory and Workshop Act is included with that of a general character which is undertaken by inspectors, to each of whom an area of the district is allotted for his supervision. Particulars of the number of workshop premises which have been added anew to the register, the number which has been removed from the register, and the number remaining at the end of the year may be shown in tabular form for the following boroughs— Metropolitan borough. Number of workshops on register. Added during 1903. Removed during 1903. Remaining at end of 1903. Laundries. Bakehouses. Other workshops. Laundries. Bakehouses. Other workshops. Laundries. Bakehouses. Other workshops. Paddington - 13 132 3 13 83 73 66 605 Fulham 50 1 130 2 5 16 48 68 200 Chelsea 3 — 130 — 3 16 22 44 457 Westminster, City of — 2 163 — 18 — — — — Hampstead 1 2 178 8 2 45 15 39 611 Islington 8 — 469 10 4 162 191 247 1548 Stoke Newington 2 — 22 — 1 — 19 25 71 Finsbury 4 1 345 4 5 55 30 62 1559 Shoreditch 2 — 93 3 6 40 33 76 †1100 Southwark 15 — 473 6 6 73 73 108 1736 Bermondsey — — 177 23 — 821 23 105 322 Battersea — 2 120 6 — 29 67 91 383 Wandsworth 30 11 495 8 12 183 129 155 1202 Deptford — 6 23 2 6 6 10 79 172 Greenwich — — 75 4 — 42 23 75 113 Lewisham 110 1 336 — 2 — 138 87 446 Woolwich 10 1 33 - 9 4 19 62 158 * One additional inspector for the inspection of hou.es let, in lodgings has since been appointed in Islington. † Including workplaces other than outworkers premises and places where food is prepared for sale. 64 The number of workshops on the register is shown in other reports, although the classification indicated in the table has not been adopted. Thus in Kensington there were 270 laundries, 111 bakehouses and 1,187 other workshops; in Westminster there were on the register some 2,037 workshops other than bakehouses; in St. Marylebone 2,291 workshops other than bakehouses; in St. Pancras 1,109, exclusive of laundries and bakehouses; in Hackney 913, exclusive of bakehouses; in the City 178 workshops; in Bethnal.green 582 workshops,, exclusive of bakehouses, were placed on the register during the year, the number of workshops on the register being 700; there were on the register in Stepney 1,655, including 102 laundries, and excluding bakehouses; in Poplar 40G workshops, including laundries, but exclusive of bakehouses; in Lambeth 1,049 workshops, including 36 laundries, and exclusive of 214 bakehouses; in Holborn there were 13 laundries, 37 bakehouses, and 191 other workshops, including a number of factories and workplaces. Information as to the number of factory laundries and factory bakehouses in the different boroughs is given in several annual reports. This number is shown in the following table— Metropolitan borough. Factory laundries. Factory bakehouses. Metropolitan borough. Factory laundries. Factory bakehouses. Paddington 6 40 Shoreditch - 2 Kensington 58 — Southwark 5 l Fulham 29 2 Bermondsey l l Chelsea — 1 Lambeth 8 — Westminster, City of — 1 Battersea 24 4 Hampstead 5 2 Wandsworth 58 8 Stoke Newington 6 3 Camberwell 62 — Holborn 1 1 Greenwich 4 2 Finsbury 4 - Woolwich 1 4 The number of inspections of workshops may also, for a number of districts, be shown separately for workshop laundries, workshop bakehouses, and other workshops as follows— Workshops. Metropolitan borough. No. of inspections. No. of notices. No. of prosecutions. Workshop laundries. Workshop bakehouses. Other workshops. Workshop laundries. Workshop bakehouses. Other workshops. Fulham 97 250 201 31 61 32 - Chelsea 34 115 827 — 6 26 - Hampstead 26 78 1,515 3 27 129 2 Islington 300 729 2,282 — 332 — 1 Holborn (a) 67 791 (a) 5 177 — Finsbury 10 248 1,716 — — 455 (b) 1 Shoreditch 92 710 3,236 10 57 382 — Southwark 120 588 928 57 — 442 1 Bermondsey 68 311 489 26 63 92 5 Battersea (a) (a) 3,369 57 69 103 — Wandsworth 374 1,446 1,933 39 25 246 4 Deptford 12 474 131 — — — — Greenwich 18 182 226 5 — 7 1 Lewisham 110 549 336 21 87 50 — Woolwich 41 142 311 7 11 31 - The following information as to inspections and proceedings is derived from other annual reports. In Paddington there were 2,468 inspections of factories, workshops, workplaces, etc., 211 notices were served, and there were two prosecutions. In Kensington there were 1,964 inspections of workshops by the female inspectors, and 240 notices were served; the male inspectors inspected premises under their supervision from time to time, and notices were served when requisite. In Westminster there were 562 primary and 917 subsequent inspections of workshops other than bakehouses, 9 notices were served, and there was one prosecution. In St. Marylebone the male inspector made 596 visits to workshops, etc., 456 to bakehouses; the female inspector made 1,371 re-inspections. In St. Pancras 838 inspections and 154 re-inspections of workshops were made by the male and female inspector, and by the female inspector there were 236 inspections and re-inspections of 89 laundries; the male inspector also made 197 inspections and 125 re-inspections of bakehouses; there were also 375 inspections and 76 re-inspections of factories; notices were served where necessary. In Stoke Newington "all the premises were inspected annually, and the bakehouses every six months, 83 notices being served. In Hackney the female (a) Workshops and laundries included under "other workshops." (4) Including total notices for all factories and workshops. 65 inspector made 135 first visits to workshops where women were employed, and 1,440 visits of re. inspection; the male inspector inspected 58 workshops where men were employed; as the result •of these visits notices were served, and there were three prosecutions. In the City there were 264 inspections and 1,364 re.inspections of various premises, and 355 notices were served. In Bethnal. green the various premises were visited at least twice in the year, the inspections numbering 1,394, notices being served where necessary. In Stepney 2,266 visits were made to the workshops; notices were served where necessary. In Poplar the female inspector made 610 inspections and 305 re. inspections, 143 notices were served and in one instance there was a prosecution; the male inspectors also inspected and served notices. In Lambeth there were 313 workshops visited and inspected, 163 were re-inspected by the female inspector, and 198 notices served. In Camberwell there were 1,552 inspections of workshops, 925 of bakehouses, and 322 of laundries. Air space and ventilation. In nearly all the reports which have been received the number of cases of overcrowding which have been found and dealt with are recorded. This condition appears to have been especially found in workrooms occupied by dressmakers, the requirement of labour in this work being of a fluctuating character, varying with season. Under these circumstances rooms at times become occupied by a much larger number of persons than their cubic capacity warrants, and indeed, other rooms and places, altogether unsuitable, are improperly brought into use. Dr. McCleary, writing of overcrowding in workrooms in Battersea, states that this was found in twelve instances, each of them on premises occupied by dressmakers, and that he had found bathrooms and even waterclosets used as workrooms. In other workrooms where trade is less seasonal, the measuring up of rooms and the exhibition of a card showing how many persons may occupy them, have evidently led to improvement. Dr. Reginald Dudfield states that the overcrowded workrooms found in Paddington, of which there were 31, were for the most part rooms which had not previously been measured, and Dr. Newman states that in Pinsbury, a central district, overcrowding is rare. "In 28 cases it had been necessary to issue notices. In other cases a slight rearrangement of workers has provided that each person shall have at least 250 cubic feet. In many of the large workshops the air space provided is liberal." In the matter of ventilation much difficulty has evidently been experienced through the unwillingness of the workpeople to allow means of ventilation to be maintained in operation. In numerous reports reference is made to this subject, and it is stated that openings which have been made for this purpose are frequently found to have been stopped up by the employees, an action often due, Dr. Kenwood states, to insufficient warming of the workshop. Dr. Collingridge expresses the opinion that the best remedy is the use of fans operated by electricity, and which, when properly fixed, cause a continuous change of air without producing draughts. The experience of Dr. McCleary in Battersea is that it is impossible to adequately ventilate many of the workshops in which sedentary occupations are carried on, especially tailoring and dressmaking, unless means are adopted to warm the incoming air. Reference is made to the question of warmth of workshops in many of the annual reports. The Factory and Workshop Act requires that the workshop shall be maintained at a reasonable temperature by means which do not interfere with the purity of the air. In the absence of any definition of what constitutes a reasonable temperature, proceedings were instituted by one of H. M. Inspectors of Factories in respect of certain workrooms in London having a temperature varying from 54 deg. to 61 deg. These workshops were heated by steam.pipes, and in some of them gas was burning. Dr. T. M. Legge, of the Factory Department of the Home Office, gave evidence to the effect that in workshops in which sedentary occupations were carried on the temperature should be from 60 deg. to 65 deg. The magistrate convicted, but the decision was reversed at the County of London Sessions. Gas stoves and oil stoves unprovided with the means for carrying off the products of combustion are frequently provided, and used for heating irons and other purposes. Dr. Allan found in Westminster, in 87 instances, means of ventilation were required for such stoves. He writes— These stoves, as well as gas jets, give off gases which are injurious to health, especially in rooms in which the ventilation is not well maintained. Breathing these products leads to headache, giddiness and anæmia. It is claimed for some stoves that a flue is not neces sary, as the products are in great measure consumed or condensed. Experiments made in the Government laboratory show that each of the five varieties tested (three gas and two oil stoves) gave off a certain proportion of carbonic monoxide, a very poisonous gas, as well as a larger quantity of carbonic acid gas. It is therefore of importance that special attention be given to the use of such stoves. It not infrequently happens also that gas burners are relied upon to afford warmth to rooms, and when such is the case it is almost always found that doors, windows, and other means of ventilation have been closed, thereby infringing the Act in two particulars. Sanitary accommodation. The annual reports show that sanitary accommodation in factories and workshops in proportion to the number of persons employed is being enforced in the several districts of London. It would appear from the annual reports that the standard of accommodation, i.e., the proportion of water-closets to the number of persons employed, is that specified in the Sanitary Accommodation Order of the Home Office, dated 4th February, 1903. This Order does not apply to London, but it provides a standard to which appeal may be conveniently made in determining what is to be deemed sufficient. In respect of the following districts the number of instances during the year in which sanitary accommodation was insufficient or unsuitable can be shown in tabular form; these conditions were practically all remedied— [9] 66 Sanitary conveniences. Metropolitan borough. Insufficient. Unsuitable. Not separate for the sexes. Paddington 5 43 17 Fulham 4 15 3 Chelsea 1 — — Hampstead 18 21 12 Islington 30 6 5 Stoke Newington — 3 — Holborn 3 86 8 Finsbury 17 304 18 Shoreditch 6 38 10 Bermondsey 40 30 11 Battersea 12 149 7 Wandsworth 54 49 15 Deptford 8 8 1 Greenwich 2 9 2 Lewisham 6 6 2 Woolwich 2 1 1 The proceedings in some other districts than those mentioned in the above table were as follows— In Kensington 33 new water-closets were provided and 107 improved; in Westminster there were 29 instances in which improved sanitary accommodation was provided; in St. Pancras in 99 instances water-closets were improved; in the City there were 188 improvements connected with water-closets, including 20 additional provided in workshops and 22 in factories; in Bethnalgreen 46 water-closets were cleansed and repaired; in Stepney 123 additional water-closets were provided, and in many the water supply was improved; in Poplar 21 water-closets were improved in workshops in which women were employed; in Southwark 66 water-closets were provided and 100 improved; in Lambeth separate accommodation was provided in 9 instances, and water. closets improved in numerous instances; in Camberwell improvements were effected in 44 instances, and in 3 insufficient accommodation was found and remedied. The Order of 1903 mentioned above makes certain requirements as to the position and other matters connected with sanitary conveniences. The medical officer of health of Paddington states that the provisions relating to exclusion from workrooms of the emanations arising from closets and urinals might be usefully enforced, but could not be universally applied, as they would entail reconstruction of many premises. The medical officer of health of Finsbury also speaks of difficulty in dealing with the subject of proper sanitary accommodation in workshops in a district like Finsbury in the midst of a transition period between a residential borough and an industrial borough. In the City, where the Corporation has adopted the standard of the Home Office Order, steps are being taken to secure suitable sanitary accommodation for women clerks employed in offices which are deemed to be workplaces. Dr. Collingridge states that complaints of insufficiency continue to be received, but that the owners of the premises have in each instance shown themselves willing to make such alterations and improvements as were required to secure the necessary accommodation. He comments on the absence of any statutory requirement of accommodation for washing hands, and states that owners of workshops have had their attention directed to this matter, and in many cases this accommodation has been provided. Bakehouses. Under the Factory and Workshop Act, 1901, no underground bakehouse could continue to be occupied after the 1st January, 1904, unless certified by the sanitary authority to be suitable as regards construction, light, ventilation, and in all other respects. Throughout London alterations and improvements were effected in many bakehouses during 1903 to meet the requirements of sanitary authorities for the purposes of certification, and in other cases underground bakehouses were disused. Information supplied by the annual reports as to the results of this provision shows that in Paddington certificates were refused in two instances; in Kensington no applications were refused, but in 6 instances the bakehouse was devoted to other use, in 5 instances gone out of use, and in 6 instances bakehouses above ground have been substituted, thus reducing the underground bakehouses from 95 to 78; in Hammersmith there are 42 underground bakehouses in use; in Fulham 55 underground bakehouses were in use, 5 have been closed, in one instance noncompliance with an order to supply electric light led to the application being refused, a prosecution followed, and the electric light was then provided; in Chelsea in 6 cases the bakehouse was disused, and in one instance the certificate was refused; in Westminster the number of underground bakehouses was reduced from 97 to 79; in St. Marylebone no application was received in respect of 7 underground bakehouses, the owners, having short leases, being unwilling to effect the necessary improvements; in Hampstead 3 bakehouses were closed; in Islington 4 were closed; in Stoke Newington 1 was closed; in Hackney 7 were closed, and a few others will be allowed to be continued for a few years without certification; in Holborn certificates were not granted in several cases. In Finsbury 6 underground bakehouses were closed; in the City, of 44 underground bakehouses 1 has been demolished and 16 closed or disused; in Shoreditch no application was received in respect of 6; in Bethnal Green 6 were closed and 3 have been disused for the purpose 67 of baking bread; in Stepney 4 bakehouses were discontinued and new ones constructed above ground, and in 21 instances the certificate was refused; in Poplar no application was received in respect of 3; in Southwark 6 were closed; in Bermondsey 6 were not in use at the time of the Act coming into operation, and in 2 other instances certificates were not granted; in Battersea in 15 instances the bakehouse was closed, in one instance in which the certificate was refused there was appeal to the magistrate, who upheld the decision of the borough council; in 9 instances other bakehouses were constructed by the owner; in Lambeth 7 were not certified, and are now closed; in Wandsworth in 7 instances no application was received, and in another instance the consideration of the alterations to be made was adjourned; in Camberwell 1 bakehouse was closed; in Deptford certificates were granted for 27 of 34 bakehouses; in Greenwich only 1 certificate had been granted at the end of the year, but certain bakers occupying underground bakehouses were continuing in occupation while providing new premises; in Woolwich 10 underground bakehouses have been removed from the register. The improvements in underground bakehouses which have been certified is testified to by many medical officers of health, the change in the condition of the bakehouse being greater in some instances than had been anticipated. There is, therefore, no doubt that the Act has served a useful purpose, and that the underground bakehouses of London are far more free from objection than formerly. Desire is, however, expressed in one or two of the reports for a power to make by.laws for the maintenance of wholesome conditions in the remaining bakehouses. The medical officer of health of Lambeth has included in his annual report a draft of by.laws which relate to the conduct of the business, and which, he believes, would be effective for this purpose. The medical officer of health of Battersea also points out the need for by.laws, which he thinks might well be made by tho County Council and enforced by the borough council. The number of bakehouses on the registers of 25 sanitary authorities, in 1903, both above ground and underground, are shown in the following table— Bakehouses in use at end of 1903. Metropolitan borough. Above ground. Under ground. Number of underground certified in 1903. Paddington 17 62 56 Kensington 33 78 78 Fulham 20 50 49 Chelsea 7 34 32 Westminster, City of 13 79 79 St. Marylebone 12 84 77 Hampstead 14 27 11 Islington 135 112 94 Stoke Newington 8 20 20 Hackney 53 69 54 Holborn 9 29 23 Finsbury 21 41 40 London, City of 12 27 27 Shoreditch 32 46 46 Bethnal-green 62 38 25 Stepney 116 70 70 Poplar 79 36 36 Southwark 60 42 42 Bermondsey 56 33 33 Lambeth 135 72 72 Battersea 42 42 31 Wandsworth 115 59 48 Camberwell 159 72 27 Deptford 45 34 27 Lewisham 64 23 23 Woolwich 38 24 24 An order made by the Home Secretary under section 3 (2) of the Factory and Workshop Act, 1901 came into force on the 1st January, 1904. This order modifies for persons employed in bakehouses the amount of cubic space which is required for every person— (1). As regards underground bakehouses, by the substitution of "500 cubic feet of space" to every person for "250 cubic feet of space to every person." (2). As regards bakehouses (other than such as are underground) where work is carried on at night by artificial light other than electric light, by substituting in respect of the period between 9 in the evening and 6 in the succeeding morning "400 cubic feet of space to every person" for "250 cubic feet of space to every person." Dr. Allan states that he finds it will affect only one or two bakehouses in Westminster, and only in each instance to the extent of one person employed occasionally. Laundries. The administration of the Factory and Workshop Act is especially needful for ameliorating the conditions under which work is carried on in laundries. These conditions are well 68 described, in his annual report, by Dr. McCleary, who states that from a health point of view the laundries are the most unsatisfactory of the Battersea workshops. He writes— "The atmosphere in the washing-room is hot and laden with impurities, the floor is constantly wet, and in the hand laundries the workers spend their day bending over a hot steaming wash-tub; the temperature in the ironing-rooms is often exceedingly high, and the drying-rooms, where the wet clothes are often thrown over lines stretched across the room over the workers' heads, are hot and damp." He states, moreover, that "the laundress lacks the protection against excessive hours of labour which the Factory Act affords other women workers. Not only may she work 60 hours a week,, exclusive of overtime, but as the period of legal employment may vary from day to day, and may even vary for each individual worker, the working of illegal overtime is hard to detect, and there is every reason to believe it is extremely common." He urges the need for further legislation, which should include— (1). The standard of cubic space per worker to be not less than 500 cubic feet. (2). Prohibition of underground workrooms and of the practice of hanging articles to dry over the heads of the workers. (3). Application to workshop laundries of the present provisions relating to factories for (a) providing fans or other means for regulating the temperature in the ironing-room and carrying away steam from the wash-house; and (6) separating heating stoves from the ironing.room and prohibiting the use of gas-irons emitting noxious fumes. (4). Application of the Factory Act to institution laundries and small exempted laundries. (5). Provision to be made for the disinfection, by boiling or otherwise, of all articles immediately on arrival at the laundry. (6). Alteration of the legal periods of employment so as to bring them into line with those obtaining in factories and workshops. So far as the existing law is concerned it is evident that much is being done to ameliorate the conditions under which work in laundries is done, especially with respect to the drainage of floors. Dr. Reginald Dudfield states that in Paddington a fair standard of cleanliness is maintained; drying grounds, the majority of which were previously unpaved and undrained, are gradually being put into proper condition, and the drainage of the floors of washing.houses is being improved; the provision of hoods over the coppers he has found to effect a great improvement, and in three cases a remedy was found for excessive temperature by the Home Office inspector. Again, Dr. Harris reports that laundries in Islington are much improved in condition, although, he adds, thev never can be rendered absolutely healthy because of the heat, steam, and nature of work. Writing of small laundries, Dr. Caldwell Smith states that in Wandsworth these have increased from 116 to 366. He states these are workplaces, and the need for their inspection is shown by the fact that 274 were found to be in dirty condition, and one to be insufficiently ventilated. For these conditions 34 notices under the Public Health Act were served for the abatement of nuisances, with the result that the conditions were remedied. Furriers' shops. The conditions under which furriers conduct their business in the City has been made the subject of inquiry during 1903. The presence of dust and clippings of fur, constitute, Dr. Colling. ridge writes, a special danger which may seriously affect the health of the workers. In the course of the year 57 such workshops were inspected and attention directed to the provision of adequate ventilation, the constant removal of refuse and the prevention of dust accumulation by covering the floors with smooth, impervious material. Dr. Collingridge states that hitherto little attention had been paid to these points, and many of these workshops were found to be dirty and sanitarily defective in other respects. The greater part of these defects were remedied by the end of the year. Places where food is prepared for sale. Many of the annual reports show that systematic inspection has been undertaken of places where food is prepared for sale. In more than one it is stated that premises on which working.men obtain their food are maintained in better condition, especially as to cleanliness, than are those where food is supplied to persons better circumstanced in life. The conditions frequently found and remedied were chiefly those of want of cleanliness and the accumulation of matter arising from the preparation of food. In some instances, as in the City and Southwark, water.closets were found to be approached from the kitchen or cooking.room. In Finsbury "some of the kitchens and cellars were in a disgraceful condition, and food prepared in them could not but be open to grave criticism." In Battersea a horse was found to be stabled in a cellar in which meat was chopped for sausages. In the City the kitchen was found, in 135 of 343 visited, to be situated in the basement. Referring to underground kitchens Dr. Collingridge claims that they should be dealt with on the same lines as underground bakehouses. He writes, "Without mechanical means, it is almost impossible to properly ventilate a kitchen placed in a basement. In many cases the ventilation has to be partially obtained by means of open gratings on the footway pavement, indeed, in some instances, nothing else can be had. As a consequence, mud, filth, and dust find direct access to the kitchens— indeed, it is a common thing to observe marks of expectoration through these gratings, one occupier even being obliged to exhibit a brass notice requesting the passer.by not to spit down one of the openings. Others attach movable trays beneath, but this only partly obviates the evil." He adds that much difficulty occurs in endeavours to provide separate sanitary conveniences for the two sexes where basement and ground.floors are used as a eating.house, in which both sexes are employed, and where the upper part is let as offices. On the recommendation of Dr. Collingridge, the City Corporation has decided to grant certificates to the occupiers of restaurants and above.ground bakehouses whose premises comply with a certain standard of sanitary requirement. The improvements effected by the several sanitary authorities are shown by the annual reports to include the insistence upon a higher standard of cleanliness, better condition of floors. better water-closet accommodation and drainage, the provision of hoods over gas stoves, and 69 the removal of numerous nuisauces. The reports bear testimony to the success which has attended the efforts made during 1903, but in several a desire is expressed for greater powers, such as the Council had desired to obtain from Parliament in the last session. The following table shows, for several districts in which the details can be stated in tabular form, the number of premises which were subject to inspection and the number of inspections and notices served. Places where food is prepared for sale. Metropolitan borough. On register at end of 1902. Added in 1903. Removed in 1903. On register at end of 1903. Number of inspections 1903 Number of notices, 1903. Number of prosecutions, 1903. Premises Rooms. Paddington 154 5 4 155 - - - - Fulham — 66 2 64 71 66 17 Chelsea — 50 — 50 50 100 - — Hampstead — 630 — 630 — 2,037 56 — Islington 326 — — 326 326 673 78 — Stoke Newington 23 — — 23 — — — — Holborn — — — 313 — 770 70 — Finsbury 325 32 13 344 576 1,186 180 — Southwark 210 — — 210 — 379 323 3 Bermondsey — 181 — 181 — 723 76 — Battersea 83 68 2 149 216 535 88 — Wandsworth 85 185 — 270 291 335 71 — Deptford — — — 54 64 54 — — Lewisham - 28 — 28 28 28 8 — Outworkers. The Factory and Workshop Act of 1901 provides that in certain trades, to be specified by the Home Secretary, the employers shall twice a year, i.e., on 1st February and 1st August, send to the sanitary authority lists of the outworkers employed therein. The sanitary authorities receiving these lists communicate to other authorities the addresses of outworkers living in their districts. The following trades have been specified by the Home Secretary— The making, cleaning, washing, altering, ornamenting, finishing and repairing of wearing apparel and any work incidental thereto. The making, ornamenting and finishing of lace, and of lace curtains and nets. Cabinet and furniture making and upholstery work. The making of electro-plate. The making of files. Fur-pulling. The making of iron and steel cables and chains. The making of iron and steel anchors and grapnels. The making of cart gear, including swivels, rings, coops, gem buckles, mullin bits, hooks, and attachments of all kinds. The making of locks, latches and keys. The number of lists received and the number of outworkers to which they relate, with other particulars, are shown for 17 districts in the following table— List of outworkers. Metropolitan borough. Number of lists received. Number of addresses. Notices prohibiting homework in unwholesome premises. Orders prohibiting homework in infected premites. Up to Feb. 1st, 1903. Up to Aug. 1st, 1903. Forwarded to other authorities. Received from other authorities. Number of lists. Number of outworkers Number of lists. Number of outworkers. Paddington 53 201 49 188 202 135 - - Fulham 12 35 13 41 36 111 — — Chelsea 21 192 12 185 454 26 — 1 Westminster, City of 175 5,746 247 3,655 517 334 — — Hampstead 42 124 52 178 172 24 — — Islington 68 770 70 787 841 919 — — Holborn 62 350 60 413 217 143 — - Finsbury 62 1,495 47 1,403 2,814 342 — — Stepney 28 206 474 1,559 317 2,563 — — Poplar 38 866 34 670 549 388 — — Southwark 13 71 116 617 206 211 — — Bermondsey 5 169 10 231 233 321 — — Camberwell 20 52 289 772 599 500 — — Battersea 5 68 10 88 33 96 — - Wandsworth 51 174 35 107 89 115 — - Deptford 38 169 27 166 164 345 — — Lewisham 36 48 40 60 30 46 — - Woolwich 51 273 51 212 51 60 — — 70 Many of the sanitary authorities keep registers of outworkers' premises. The following table shows for 18 districts the number of such premises on the register, and in the majority of cases the number of inspections and notices served— Outworkers' premises. Metropolitan borough. On register at end of 1902. Added in 1903. Removed in 1903. On register at end of 1903. Number of inspections, 1903. Number of notices, 1903. Number of prosecutions, 1903. Premises. Rooms. Paddington 82 30 19 93 298 - - - Fulham -[ 150 18 132 - 102 25 — Chelsea — - - 32 32 64 - - St. Marylebone 267 — 25 491 - 423 - — Hampstead 64 29 9 84 - 128 6 — Islington 600 500 - 1,100 1,100 511 - — Stoke Newington 150 - 34 116 - - — — Hackney — - — 1,736 - 139 — — Holborn 148 89 — 237 - 177 7 — Finsbury 258 326 83 501 - 302 13 — Southwark — - - 551 551 551 - — Bermondsey 252 93 - 345 - 205 31 — Battersea 134 44 - 178 178 356 7 — Wandsworth 208 115 6 317 317 190 14 — Deptford 164 230 7 387 387 254 - - Greenwich 79 36 - 115 - 115 5 — Lewisham 67 78 10 135 135 88 11 - Woolwich — 212 - - - 424 39 — It is evident from study of the reports relating to other districts that much the same course is adopted as in the districts included in the above table, but the information contained in these reports does not lend itself to tabular statement in the same way. Many of the reports refer to neglect of employers to send in the lists which are required, and it is observed that employers are frequently found to be under the impression that the lists are only to be sent when application is made for them. Difficulties of this sort will probably disappear in course of time as the requirements of the Act and Order become known. In particular cases (in Finsbury and Camberwell) summonses were taken out for such neglect. Such action will, especially if made generally known, provide the remedy which is needed. Some of the reports show the need for inspection of outworkers' premises, insanitary conditions being found and remedied. In some reports, moreover, reference is made to the prohibition by the sanitary authority of the giving out of work to outworkers in whose premises cases of infectious disease have occurred—a matter of considerable importance where tailoring and allied trades are carried on. In view of the large number of outworkers in London employed in some of the prescribed trades, it is evident that the effect of this order, if inspections follow, will be to ensure a higher standard of cleanliness and sanitary condition in numerous premises. A sufficient staff of sanitary inspectors is the first requirement for this purpose. Notices to H.M. Inspector of Factories. The medical officer of health is required to give notice to H.M. Inspector of Factories of any workshop in which anv woman, young person, or child is employed, and also of any failure to exhibit an abstract of the Act in such workshops. In addition to such notices are others which are given of workshops in which proper temperature is not maintained, and of the action taken upon communications which are received from H.M. Inspectors. The number of such notices is shown for most of the London districts in the followino table— Cases re-ported to H.M. Inspector. Metropolitan borough. Abstract not fixed. Acton taken in cases notified by H.M. Inspector. Other cases. Paddington 118 15 6 Kensington — — 64 Fulham 72 4 3 Chelsea 22 4 — Westminster, City of — — 4 Hampstead 70 — 27 St. Pancras — — 91 Islington 140 12 — Hackney — — 49 Holborn 74 — 2 Finsbury 40 78 26 City of London 14 — — Bethnal-green 37 — — Poplar 70 5 70 Southwark — — 14 Bermondsey 2 6 — Lambeth — 9 19 Battersea 76 6 — Wandsworth 70 13 115 Camberwell 37 1 3 Deptford 10 6 6 Greenwich 92 5 3 Lewisham 23 2 19 Woolwich 2 - 3 71 Inspection of Food, etc. Ice-creams. The London County Council (General Powers) Act, 1902, contains provisions which confer powers on the London sanitary authorities for requiring that ice-creams, for the most part sold from stalls in the street, shall be prepared under conditions which will not expose consumers to risk. A considerable outbreak of enteric fever in South-east London had been investigated on behalf of the Council by Dr. George Turner, now medical officer of the Transvaal, and had been shown by him to be due to the consumption of ice-creams made by Italian vendors under grossly insanitary conditions. Since that time cases of enteric fever have at various times been attributed to the same cause, and in 1902 Dr. Collingridge found that a number of telegraph boys had suffered from severe gastric disturbance due to the consumption of ice-creams manufactured on insanitary premises. Samples of the ice-creams in question had been examined bacteriologically by Dr. Klein, and of 23 such samples, 12 had been found to contain virulent bacteria, and in some cases to produce the death of guinea-pigs when injected beneath the skin of these animals. No outbreak of disease was attributed in 1903 to this cause, although in a few isolated instances, it was noted that, antecedent to an attack of enteric fever, the patient had eaten ice-cream. In respect of one of these occurring in the City, Dr. Collingridge expresses the opinion that the ice-cream, which was made under insanitary circumstances in Stepney, was the cause of the illness. The annual reports show that much use was made in London of the powers conferred by the Act of 1902. Premises were inspected on which ice-cream was manufactured, and various insanitary conditions were removed. In Finsbury, in which the Italian quarter is in part situated, "a determined effort has been made to supervise the ice-cream industry, not only in the Italian quarter, but throughout the borough." A register of such piemises is kept in nearly all, if not in all, districts of London, and each medical officer of health communicates to his colleagues any information he obtains from itinerant vendors as to the existence of such premises in their districts. In this way a fairly complete register of such places has been obtained. In a number of instances it was found that the icecream was stored in a bedroom, and in Fulham and Holborn penalties were recovered for this offence. In several districts itinerant vendors were prosecuted for failing to exhibit their names and addresses on their barrows. Several of the medical officers of health speak of the improved conditions under which ice-cream is now prepared as the result of these proceedings. In Paddington it was noted that there was "a great improvement in the cleanliness of the premises, utensils, towels, and washing water used in connection with the sale of ice-cream, and especially in the personal cleanliness of the street vendors"; and Dr. Harris states that on three occasions in Islington he was invited to inspect premises with a view of advising intending tenants as to their fitness for the manufacture of ice-cream. "In each instance an opinion adverse to their occupation was given, so that ultimately they went to other parts of the metropolis." The number of ice-cream premises on the register, and the number of inspections, etc., can be seen in tabular form for the following districts— Ice cream premises. Metropolitan borough. On register at end of 1902. Added in 1903. Removed in 1903. On register at end of 1903. Number of inspections, 1903. Number of notices, 1903. Number of prosecution!, 1903. Paddington 25 55 — 80 172 11 1 Fulham — 117 — 117 150 22 2 Chelsea — 60 — 60 120 — — Westminster, City of — — — 108 220 1 1 Hampstead 69 — — 69 84 — — Islington 183 — — 183 29 17 — Stoke Newington — 35 — 35 35 4 — Holborn 21 11 — 32 179 15 1 Finsbury 94 7 — 101 700 43 — Shoreditch — — — 64 64 15 — Stepney 89 — — 89 196 7 — Bethnal-green 53 11 3 61 61 22 — Southwark — — — 65 89 101 3 Bermondssy 68 — — 68 218 31 — Battersea 80 39 4 115 — 12 — Wandsworth 129 39 10 158 309 48 — Camberwell — 258 — 258 849 9 2 Deptford — 98 — 98 288 — — Greenwich 103 19 4 118 118 9 1 Woolwich — 17 2 64 192 4 — Unsound food. The annual report of Dr. Collingridge, the medical officer of health of the City of London, in which the Central Meat Market is situated, shows that the supply of meat to the market in 1903 amounted to 415,915 tons, the greatest amount on record in any one year. Of this meat, 1,142 tons were seized, of which 193 tons were diseased, 602 tons putrid, and 76 tons unwholesome. Dr. Collingridge states that on the 15th April, 1903, the Netherlands Government instituted a system of examination of meat with a view to preventing the export of any doubtful meat from Holland. Dr. Collingridge thus describes the system—"Pending legislation of a compulsory character the Netherland Government have introduced a system of voluntary inspection and 72 marking by Government officials, at a very small charge, of all meat intended for export." This action, he says, has led to improvement in the quality of the consignments of Dutch pork to the London market, and from information which Dr. Collingridge has received it would appear that 70 per cent, of the meat coming from Holland, chiefly pork, is thus examined and marked. Dr. Collingridge expresses the wish that "the Great Eastern Railway Company could see their way to fall into line with other carriers of meat from Holland, and refuse to ship any not bearing the guarantee of the Netherlands authorities." With reference to Servian mutton, Dr. Collingridge reports that this meat, as in the previous year, arrived in such bad condition that a large proportion was seized. Seventeen prosecutions were successfully instituted for sending bad meat to London, one for exposing unsound fish for sale and one for exposing unsound rabbits. In the markets in the borough of Finsbury, situated immediately outside the City markets, 83 tons of decomposed and 18 tons of diseased meat were seized, and 24 prosecutions were instituted in reference to meat which had been seized. In Islington, where systematic effort is made to examine meat in the slaughter-houses (and in this connection the number of inspections of slaughter-houses should be noted, see page 46), over two tons of diseased meat were seized. Dr. Harris states that "one butcher who, not residing in the borough, formerly killed a great many cattle, especially cows, at a slaughter-house in Roman-road, removed his slaughtering elsewhere, as the supervision was too strict; or, in other words, animals or parts of animals that were diseased were not allowed to be sold but were destroyed." He adds that "It is satisfactory to find that, whereas in former years, before an inspector of meat was appointed, very many persons used to come to the medical officer, complaining of the unsound food that had been sold them, such an event is now a rare occurrence, a fact which proves that the mere presence of a skilled inspector is sufficient to prevent dealers foisting unsound articles on their customers." Seizures of meat, though in less quantity, were made in the following districts—Paddington, Westminster, Hampstead, St. Pancras, Stoke Newington, Hackney, Holborn, Shoreditch, Bethnal-green, Stepney, Southwark, Bermondsey, Lambeth, Battersea, Wandsworth, Deptford and Woolwich. Prosecutions for the exposure of unsound meat for sale were instituted in several of these districts, and penalties recovered, in some instances the defendants being imprisoned. Other articles of food seized comprised, for the most part, fish, fruit, eggs and tinned goods. In Stepney samples of tinned salmon were found to be contaminated with tin, due to escape, within the tin, of the solder used in sealing it. The owners consented to surrender the whole consignment as trade refuse and to pay all expenses incurred in the destruction. A case of interest is mentioned in the report of the medical officer of health of Finsbury. The death of a man occurred after eating cheese from which was isolated "a body which gave marked reaction similar to those given by tyrotoxicon." Dr. Newman states that a few hours after the meal, at 10,30 a.m., the patient, a carman, was taken ill. "The symptoms of his illness consisted of frequent vomiting, extreme pallor, faintness, colic pains and profuse diarrhoea. The onset was sudden and the symptoms very severe. The patient reached home early in the afternoon and went to bed. His condition became steadily worse. He suffered from pains in the legs, loss of voice, griping pains in the stomach, and collapse. He died at midnight. An inquest was held, and I was present with Dr. Roe at the necessary autopsy. We found the body in a healthy condition throughout, except the stomach, which showed signs of acute poisoning." In 1903 the Local Government Board held a public inquiry as to the desirability of extending the powers of the port sanitary authority in the matter of unsound food over the wharves forming part of or abutting on the port. This inquiry resulted from a complaint from the London and India Docks Company, that the examination of food landed at the docks was of a more severe character than that of food landed at the wharves. The proposal was opposed by the London County Council and the riparian authorities who would be affected by such extension, and the Local Government Board, finally decided not to make the Order which had been sought. Manufacture of aerated waters. The conditions under which aerated waters are manufactured in London was the subject of inquiry by Dr. Hamer, who, for the purposes of his report, visited numerous premises in London in which this industry is carried on. This report was presented to the Public Health Committee, and submitted to the Council on the 23rd June, 1903. The Council, on the recommendation of the Committee, adopted the resolution—"That a "copy of the report be sent to the Local Government Board, with an expression of the opinion of "the Council that it is desirable that legislation should be promoted in order to enable sanitary "authorities to register makers of aerated waters, to inspect premises upon which aerated waters "are manufactured, and to prevent the manufacture of such waters under cond;tions likely to "give rise to contamination." Dr. Hauler's report is appended (see Appendix III.). Disinfection. The principal matters relating to disinfection mentioned in the annual reports of medical officers of health may be summarised as follows— In Westminster there are three stations, situated respectively at Horseferry-road, Commercial-road, and Denzell-street. In 1903 the Washington-Lyons apparatus at Dufours-place was removed to the Commercial-road station. Dr. Allan urges the need for a central disinfecting station in replacement of the three which now exist. In Lambeth the whole of the work of disinfection has been carried out at Wanless-road, where two Equifex machines are in use. In Battersea the need of a laundry for washing articles which have been disinfected is mentioned by Dr. McCleary, who hopes this provision will be made in the course of a year. Dr. Caldwell Smith writes that he anticipates the new disinfecting chamber which it is proposed to erect at 73 Tooting will meet the requirements of the borough for many years. In connection with this station it is proposed to construct a chamber for disinfection with formalin articles which cannot be disinfected in any other way. Dr. Roberts describes the apparatus which has been erected at Deptford and which was largely used in 1903. In Woolwich the apparatus has been removed from the dust destructor station to the electric light works in White Hart-road, and considerable improvements have been effected. Paddington and Kensington are the only authorities who rely upon the services of a contractor, and in both boroughs there is the intention to provide a station. During the present year I addressed letters to the London medical officers of health asking what processes were adopted in the various boroughs for the disinfection of rooms. From the information obtained it appears that in Paddington a formalin spray only is used, followed by stripping, etc., when thought necessary. In Kensington, sulphurous acid gas is used, excepting in cases of measles and consumption. In Hammersmith the room is sulphured and bedding removed ; the room is carbolised before the bedding is returned. In Fulham, fumigation with sulphur dioxide is adopted, and washing or spraying with bichloride of mercury (1-1,000). The walls are stripped. In Chelsea, tins of sulphur dioxide are in some cases used, and burning roll sulphur is used in other cases when more efficient disinfection is required. In St. Marylebone and Hampstead, sulphur dioxide is used; formalin is also used in the latter district. In St. Pancras the process is to spray with formalin, to fumigate with sulphurous acid gas from burning sulphur and to wash in soft soap all woodwork and furniture. In Islington the rooms are either fumigated or sprayed with formalin solution. In Stoke Newington, formic aldehyde is used as a gaseous disinfectant, and for washing the surfaces of rooms, corrosive sublimate; textile articles are disinfected by steam. In Hackney, sulphur is used. In Holborn, formic aldehyde is used in ordinary cases and sulphurous acid gas in cases of smallpox. In Finsbury, sulphur fumigation is used for vermin, etc., formic aldehyde, as a rule, for infectious disease, spraying with chloride of lime (1.2 per cent.) in all cases of phthisis and smallpox, and stripping and cleansing is done when necessary. In the City of London a formalin spray is used, and formalin vapour rarely. In Shoreditch. after the removal of textile articles, the floors, walls, and ceilings are sprayed with a 2 per cent, solution of betalvsol; in some cases fumigation with sulphur (one pound of sulphur to 1,000 cubic feet) is the method employed; occasionally both spraying and fumigation are resorted to; very rarely formic aldehyde is used for small spaces, such as the interior of vehicles; walls of rooms are stripped and cleansed after fumigating when necessary. In Bethnal-green, until recently, sulphur candles have been used for the disinfection of rooms; formic aldehyde is now being tried. In Stepney the rooms are sprinkled with a solution of carbolic acid and then fumigated with sulphur. In Poplar the rooms are sprayed with formalin. In Southwark after a case of infectious disease, with the exception of erysipelas, the room is first sprayed with formalin (3 ozs. to a gallon of water), the paper is then stripped off walls, the room is afterwards fumigated with sulphur and kept closed for 8 hours whilst under that process. In Bermondsey, formalin sprays (2 per cent. solution) are used; sulphur is only used in cases of verminous rooms. In Lambeth, as a rule, formic aldehyde solution (40 per cent. by volume) sprayed through an Equifex sprayer, is used. In Battersea, formic aldehyde or sulphur dioxide are used for fumigating, and formalin solution for spraying. In W andsxcorth and Deptford, sulphur and formalin are used. In Camberwell, fumigation is done by formalin, and after measles by sulphurous acid gas. In Greenwich sulphurous acid gas is generally used; formic aldehyde is only used in special and particular cases. In Lewisham the formalin spray is used. In Woolwich, fumigation is done with formalin tablets (25 per 1,000 cubic feet), and in cases of smallpox spraying with formalin (5 per cent, solution) is used in addition. Shelters. The decrease in the prevalence of smallpox in the year 1903 led to smaller use of shelters than in the preceding year. In several annual reports the number of persons or families received into the shelters during the year is stated, and it is thus learnt that in Fulham 7 persons were accommodated, in Chelsea 29, in Westminster 19, in St. Marylebone 30, in St. Pancras 211, in Islington 18, in Stoke Newington 1, in Hackney 148, in Finsbury 26, in the City 39, in Shoreditch 14, in Poplar 92, in Southwark 85, in Bermondsey 90, in Wandsworth 14, in Deptford 1, in Greenwich 10. In Paddington, Hampstead, Holborn, Lambeth, Camberwell, and Woolwich the shelter was not used during the year. In Battersea a shelter is being erected which will provide accommodation for three families, as well as a residence for the keeper of the mortuary in a two-storey dwelling on land adjoining the mortuary. In Kensington a site for the provision of a disinfecting station has not yet been decided upon. Mortuaries. The following information as to mortuaries is derived from the reports of medical officers of health. In Lambeth the need for a mortuary for the increasing population of the Norwood Ward has long been felt, and in 1903 negotiations for the acquisition of a site in the Windsor-road were in progress; Dr. Priestley describes the High-street mortuary as being inadequate, and says that what is wanted is a new mortuary and coroner's court on a new site, or the reconstruction of the existing mortuary buildings on the present site, a matter which is under the consideration of the Public Health Committee. By the amalgamation of the three districts of Bermondsey, Rotlierhithe, and St. Olave, the Bermondsey Borough Council became possessed of three mortuaries. Dr. Brown recommended the abandonment of the mortuary in St. Olave, which was accordingly demolished. In Poplar, the need of suitable mortuary accommodation has been felt, and the auestion of the selection of a suitable site has been under consideration, but no final decision has been arrived at. In the Borough of Wandsworth the mortuary at Clapham was improved, but no further step was taken in reference to the erection of a new mortuary and coroner's court in [10] 74 Wandsworth Parish as land was not available. The erection of a mortuary in Greenwich is in progress. There would appear to be an increasing use of mortuaries by the public for the temporary deposit of bodies pending burial. In the several districts the number of bodies received into mortuaries in 1903 was as follows—Paddington 304, and 4 infectious bodies; in Kensington 296, and 4 infectious; in Hammersmith 182, of which 4 were infectious; in Fulham 191, and 1 infectious; in Chelsea 107; in Westminster 393, and 1 infectious; in St. Marylebone 583, and 6 infectious; in Hampstead 74; in St. Pancras 424, and 4 infectious; in Islington 680, and 1 infectious; in Stoke Newington 37; in Hackney 394, and 10 infectious; in Holborn 130, and 13 infectious; in Finsbury 402 and 7 infectious; in the City 190; in Shoreditch 447, and 3 infectious; in Bethnal-green 385; in Stepney 690, and 3 infectious; in Southwark 471, and 4 infectious; in Poplar 428, and 5 infectious; in Bermondsey 190; in Lambeth 437; in Battersea 215, and 8 infectious; in Camberwell 318; in Deptford 95; in Greenwich 138; in Lewisham 116, and 2 infectious; in Woolwich 187. Water Supply. The following particulars as to the filtration works of the several water companies are extracted from the annual report of the water examiner appointed under the Metropolis Water Act, 1871— Subsidence reservoirs. Filters. Monthly rate of filtration per square foot per hour, 1903. Name of company. No. of days' supply. Area. Area per million gallons of average daily supply. Mean monthly average. Maximum monthly averages. Chelsea 16.0 8 .67 1.60 1.85 East London 59.5 31 .77 1.18 1.33 Grand Junction 3.4 24 1/4 1.43 .87 .98 Lambeth 15.9 14 3/4 .50 2.14 2.37 New River 4.2 16 5/6 .42 2.44 2.86 Southwark and Vauxhall 12.5 23 .74 1.45 1.90 West Middlesex 17.4 22 1/3 .97 1.28 1.47 The water examiner urges the necessity of all the water companies passing water drawn from the river into a storage reservoir before letting it on to the filter beds, and of the delivery of water from each filter into a distinct well so that distinctive examples may be obtained for examination, and failure in the efficiency of filtration may be traced to the particular filter which is at fault. Dr. Thorpe states that "the year 1903 has been a very exceptional one in respect to rainfal and by watching the effects of the heavy floods in the river Thames on the quality of the metropolitan water supply it has been possible to gain more definite information on this important subject in a single twelve months than could have been obtained by observations extending over many ordinary years." Dr. Thorpe's study of the subject leads him to the following conclusions— 1. That 16 to 18 days' storage is not sufficient, and that it should be increased so that the several works could, if necessary, entirely exclude the river water for at least 15 days, and still have water available for some weeks' supply. 2. That all water ought to be regularly stored before use and that storage should not be treated, as it is at present in some cases, as a mere reserve or standby. 3. That when the river is in flood the proportion of soluble organic impurity in the water is always high, and that merely excluding the top of a flood will not ensure a supply which, even after storage and Alteration, can be considered satisfactory in regard to colour and organic purity. 4. That when one flood follows another, after a short interval of time, it does not appear that the second flood brings down proportionally less organic impurity than the first, and this observation is also generally true with regard to a succession of floods. 5. That if the best use could be made of the Thames as a source of supply, in order to secure water which after storage and filtration should neither contain excessive amounts of organic matter nor have a marked high colour, it would often be necessary to altogether refrain from abstracting water when the "natural flow" at Teddington exceeded 2,000,000,000 gallons per day. 6. That in order to remedy the present state of affairs, it is very desirable that the Staines reservoirs, already constructed, should without delay be called into regular and systematic use. The effects of the rainfall on the water supply are commented on in the reports by Dr. Thorpe. In June Dr. Thorpe states the water was of"very high colour, and considerable organic contamination was supplied by the Thames companies possessing but little storage. In the case of the Southwark and Vauxhall Company, on the 19th June the "oxygen consumed probably represented an amount of total organic impurity which has not been exceeded in a London water during the last thirty-four years." Again, in November Dr. Thorpe reported that "the floods in the Thames valley during October had a greater general adverse effect on the quality of the London water than any of the earlier floods," the largest maximum amounts of organic impurities being 75 recorded in the Southwark, Grand Junction and Lambeth supplies, while the largest mean proportions were found in the cases of the Chelsea and West Middlesex waters. In the latter part of the year the Council's chemist found unusual results in the water supplied by the Kent Company. The London Equalisation of Rates Act, 1894. The Equalisation of Rates Act provides that the London County Council shall in each year form a fund equal to a rate of sixpence in the pound on the rateable value of London. The contribution from each parish to the fund is to be in proportion to its rateable value. The fund thus formed is to be distributed among the sanitary districts in proportion to their population. Where a sanitary district comprises two or more parishes, and the aggregate of the contributions from such parishes is less than the grant apportioned to the district, the difference shall be paid out of the fund to the sanitary authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish; and if it exceeds the grant 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 authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund an estimate of population on the 6th April 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 6th April, 1903, 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, 1904— District. Estimated population, 6th April, 1903. Equalisation charge, being exce?s of contribution over grant. Net grant, being excess of grant over contribution. £ s. d. £ s. d. Paddington 146,413 4,310 13 2 - - - Kensington 175,230 17,851 4 3 - - - Hammersmith 114.102 - - - 7,767 12 3 Fulham 146,990 - - - 12,638 19 3 Chelsea 71,653 4,587 11 10 - - - Westminster, City of 175,705 98,678 5 5 - - - St. Marylebone 129,730 14,022 7 5 - - - Hampstead 84,319 5,796 5 9 - - - St. Pancras 234,136 - - - 6,955 10 1 Islington 336,780 - - - 26,557 1 4 Stoke Newington 51,673 - - - 2,849 18 11 Hackney 220,161 - - - 19,447 1 3 Holborn 57,563 10,419 5 11 - - - Finsbury 102,352 1.556 3 1 - - - London, City of 25,641 117,076 14 - - - - Shoreditch 117,392 - - - 6,540 - - Bethnal-green 129,170 - - - 15,513 12 9 Stepney 295,211 - - - 30,027 7 2 Poplar 168,988 - - - 17,392 15 3 Southwark 202,883 - - - 13,699 17 2 Bermondsey 130,455 - - - 6,078 6 - Lambeth 304,588 - - - 20,310 7 2 Battersea 169,166 - - - 11,882 12 4 Wandsworth 254,327 - - - 15,457 - - Camberwell 262,069 - - - 25,934 8 7 Deptford 110,164 - - - 9,114 16 1 Greenwich 98,487 - - - 6,840 8 - Lewisham 141,161 - - - 8,350 19 3 Woolwich 129,215 - - - 11,895 4 6 Inner Temple 127 596 14 9 - - - Middle Temple 107 358 11 9 - - - 76 Sanitary Officers. Appended to this report (see Appendix IV.) will be found a return showing the number of sanitary inspectors employed in the various boroughs in the years 1903 and 1904, the figures relating to the year 1901 being based upon information received from the medical officers of health in the early part of that year. The return shows that whereas there were 301 sanitary inspectors employed in London in 1903, this number had increased in 1904 to 313, included in this number being 28 women. The increase in the total number of inspectors was indeed, in the main, due to the appointment of female inspectors who are largely engaged in the inspection of workshops employing female labour. The return gives particulars as to the duties performed by the inspectors in the several districts, as well as information as to the population inhabiting tenements of less than five rooms. Shirley-F. Murphy, Medical Officer of Health. To the London County Council. December, 1904. 77 Medical Officers of Health of Metropolitan Boroughs in 1903. Metropolitan borough. Medical officer of health. Battersea G. F. McCleary, M.D. Bermondsey R. K. Brown, M.D. Bethnal-green G. P. Bate, M.D. Camberwell F. J. Stevens, M.R.C.S. Chelsea L. C. Parkes, M.D. City of London W. Collingridge, M.D. Deptford H. W. Roberts, M.R.C.S. Finsbury G. Newman, M.D. Fulham J. C. Jackson. L.R.C.P. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead H. Littlejohn, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. o. Dudfield, M.D. Lambeth J. Priestley, M.D. Lewisham A. W. Hams, 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.R.C.S. 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. MAP SHEWING PRIMARY CASES OF ENTERIC FEVER NOTIFIED, During the period November 21st to December 5th, 1903. in the Area supplied wholly or in part by the Southwark and Vauxhall Water Company. N B.—The RED DOTTED LINE indicates the boundary of the area supplied by the Southwark and Vauxhall Water Company. The BLACK CROSS-HATCHING indicates the area supplied jointly by the Southwark and Vauxhall and Lambeth Water Companies. The RED DOTS indicate cases of enteric fever occurring in houses supplied by the Southwark and Vauxhall Water Company. The RED CROSSES indicate cases of enteric fever occurring in houses supplied by the Lambeth Water Company. Lonidon Counts Council. Public Health Department, 8, St. Martin's-place, W.C. April, 1904. Report by the Medical Officer presenting report by Dr. Hamer on prevalences of Enteric Fever in London at the close of 1903. (Ordered to be printed by the Public Health Committee.) Since the occurrence of the outbreaks of enteric fever in Southwark, Lambeth, and Kensal Town,* which were investigated by Dr. Hamer, whose report I presented to the Committee in January, 1901, the question has from time to time risen as to whether fish has again played a part in spreading the disease in London. In 1902 Dr. Allan, the medical officer of health of Westminster, called attention to a small group of cases in which there was some ground for supposing fish had been at fault.† Another case Dr. Allan reported was "believed to have been contracted from eating fried fish while staying at Old Ford." Dr. Newman, the medical officer of health of Finsbury, states that in that borough in 1902 there were eight cases of enteric fever, concerning which there was some evidence that they were caused by the consumption of fried fish. Dr. Bulstrode, medical inspector of the Local Government Board, has called my attention to references to the possible transmission of the infection of enteric fever by consumption of fried fish contained in reports by Dr. Annis, formerly medical officer of health of Huddersfield, now medical officer of health of Greenwich, and by Dr. A. S. Williamson, medical officer of health of the Urban District of Sandal Magna. The report of the third quarter of 1898 of the medical officer of health of Huddersfield contains the statement that out of a total of 29 cases of enteric fever several "appear to have had a common origin from a case occurring in the person of a fried fish shopkeeper, who, whilst suffering from the earlier stages of the illness, still attended to his business without apparently having a sufficient regard to cleanliness in all its details whilst conducting the same." Dr. Williamson's annual report for 1899 describes how the occurrence of a case of enteric fever in Heath-road, on June 17th, was followed from July 12th-14th by that of five other cases, three in separate houses (one of the three being that of the keeper of a fried fish shop), and two in the Heath-road house. Dr. Williamson writes: "At the house in Heath-road, of four children who had been customers (the parents never ate fried fish) three contracted the disease; in another house the patient was a lodger, and the only one in the house who had had fried fish; and in the other case the patient was also the only one in the house who had." The circumstances which led to Dr. Hauler's present inquiry were as follows—In the week ending December 5th, 1903, Dr. Bond, the medical officer of health of Holborn, raised question as to fish sold at two fried fish shops having caused enteric fever in his district, and he later prepared a special report on the outbreak which he forwarded to the Council. I was from the outset in communication with Dr. Bond and Dr. Allan (one of the shops held to be at fault was situated in Westminster), and Dr. Hamer, at my request, conferred with them on December 14th and succeeding days, and made inquiries as to the source of the fish sold at the implicated shops. Examination of the notification figures directed attention to undue prevalences of enteric fever in 1903 in other parts of London, and Dr. Hamer was afforded help by Dr. Millson, the medical officer of health of Southwark, in making inquiries in that borough, and later extended his investigations to other districts. It speedily became clear that a localised prevalence of enteric fever in Southwark, occurring a few weeks before the Holborn and Westminster cases, was in all probability due to consumption of fried fish, and it became necessary therefore to inquire as to the possibility of mischief being thus caused in other parts of London during the closing weeks of 1903. The localised outbreaks in Holborn and Southwark were on a smaller scale than the prevalences in 1900 had been, but it was by no means clear that they represented the whole of the cases due to distribution of infected fish in October, November and December, 1903. There were, in fact, three periods subsequent to attainment of the autumnal maximum, when the number of cases in some parts of London showed increase, one towards the end of October, another in the 51st and 52nd weeks, and an intermediate period. The tendency to grouping of cases in the * In the Southwark and Lambeth outbreaks fried fish was incriminated. In Kensal Town fish sold in the uncooked condition (wet fish) fell under suspicion. † "One patient was a fishmonger and three others were regular customers buying fried 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 * * * to attribute his illness to oysters eaten off a barrow in the East-end."—Annual Report, Medical Officer of Health of Westminster, 1902. 2 intermediate period was marked—it was in this period that the Holborn and Southwark groups occurred—and partly on account of this tendency to grouping these cases have been more particularly studied by Dr. Hamer. The first period presented groups of cases, but inquiry was not made as to these when they occurred, and difficulty was experienced in following the matter up after an interval of time. The third period, in which the increase (as, indeed, was the increase in the first period) was quite small, did not present marked grouping of cases. The abnormal incidence of enteric fever in the intermediate period examined was in part accounted for by the Holborn and Southwark groups already mentioned, and by groups in Stepney and Poplar, but an important contribution to the increase was furnished by South-West London as a whole, though more particularly by the portion of that area supplied by the Southwark and Vauxhall Water Company. In the absence of other explanation it has, therefore, been necessary to consider alternative hypotheses—one of water-borne infection, the other of infection by fish, as accounting for the exceptional incidence of the disease. Dr. Hamer discusses the topographical distribution of the cases and the time relations between the occurrence of flood in the river Thames and the exceptional prevalence of enteric fever in South-West London, and he points out that there are difficulties in the way of accepting the first hypothesis. An infected fish hypothesis, on the other hand, he finds, is consistent with the known facts as to exceptional prevalence of enteric fever in various parts of London in the intermediate period (43rd-49th weeks) of 1903, and no other adequate explanation of this prevalence is forthcoming. If this hypothesis be well founded it becomes a matter of interest to ascertain whether there is reason for suspecting infected fish has produced mischief in the past, for it is clear that if this cause were widely operative at the close of 1903, when indications of its existence were so little apparent save in two localities (Holborn and Southwark), it may readily have been a source of infection on numerous previous occasions without exciting notice. The three outbreaks attributed to consumption of fish in 1900 and in less degree those of 1903, were characterised by two features, both frequently met with in outbreaks due to food, to which Dr. Hamer directs special attention—the occurrence of multiple attacks in houses, and abnormality of age-incidence of the disease, persons at the ages 3-25 inclusive being attacked with special frequency. Examination of the notifications of enteric fever in the areas involved in these outbreaks showed that there were not wanting indications suggestive of the existence of the characteristic features in question at other times during the years 1896-1903 in these areas. This has led Dr. Hamer to examine spot-maps showing the distribution of cases of enteric fever in 1899 and 1900, a period in which there was excess of enteric fever in London beyond the average of recent years, and more particularly to study the notification records of further areas which enteric fever especially affected in those years, and he finds that the cases in these areas also present in greater or less degree the features above referred to, not only in 1899 and 1900, but also in other years. A number of charts have thus been examined, and it transpired in each instance in which these appearances were manifested that the further areas in question were occupied by poor persons by whom fried fish was largely consumed. The secondary cases occurring in these areas were in each instance distinguished (so far as it was possible to do this on the notification data which were for this purpose alone available), and the evidence pointed less to communication of the disease from person to person than to a common source of origin. The simultaneity of occurrence of an abnormal number of cases in widely separated areas also suggests some food supply as being at fault; while the abnormality of age-incidence, although possibly explicable on the ground of character of the populations invaded, was specially marked, in particular instances examined, at the times of the exceptional prevalences—a fact which is consistent with the food hypothesis. It should be noted, moreover, that so far as there is information on the subject, the cases now in question were not attributed at the time of their occurrence to any of the foods ordinarily credited with ability to produce enteric fever. The phenomena commonly met with in food outbreaks (occurrence of multiple cases and abnormal age-incidence) were found by Dr. Hamer, in his inquiry, always associated with the two conditions—poverty and fried fish eating, and it was impracticable, in the absence of precise inquiry at the time, to demonstrate in the case of these further areas that this article of food as apart from poverty stood in causal relationship with excessive fever prevalence; it was indeed found impossible to discover an area in London in which the one set of circumstances existed apart from the other. The appearances exhibited on the charts are sufficiently striking, however, to make it desirable that the future behaviour of enteric fever in the particular areas should be studied, and that henceforth attention should be directed to the possibility of fish acting from time to time as an infecting agent. Shirley F. Murphy, Medical Officer of Health. 3 Dr. Hamer's Report. During the first two weeks of December, 1903, Dr. Bond, the medical officer of health of Holborn, made inquiry concerning a group of cases of enteric fever in that borough, and found "the only article of food that had been eaten in common was fried fish obtained from two shops." One of these shops was in Westminster, and Dr. Bond communicated the facts observed by him to Dr. Allan, the medical officer of health of that city, who ascertained there was reason for concluding that fish purchased at the shop in question had been consumed by one or more persons recently attacked by enteric fever in Westminster, and he subsequently mentioned the suspicion entertained to the Council's medical officer. At Mr. Shirley Murphy's request I conferred witii Dr. Bond on December 14th, and was then informed by him that in most of the cases notified during the preceding fortnight he had elicited the history that shortly prior to attack the patient had consumed fried fish from one of two shops.* I conferred with Dr. Allan later in the day, and we visited the fried fish shop in Westminster. On succeeding days further inquiries were prosecuted, and with a view to learning whether the two shops received fish from a common source, I called upon Dr. Collingridge, the medical officer of health of the City of London, who gave me facilities for ascertaining the facts as to those portions of the two fish vendors' supplies which were obtained from Billingsgate. Meantime, it was found that in other parts of London there had recently been small exacerbations of prevalence of enteric fever, and these were made the subject of further investigation. Special attention was devoted to areas in Southwark, Camberwell, Battersea, Lambeth and Stepney, in which during the closing weeks of the year the behaviour of the disease presented unusual features. In Camberwell Dr. Stevens, the medical officer of health, had noted that almost all the invaded houses were supplied by the Southwark and Vauxhall Water Company. For the most part the houses involved in Camberwell were situated in portions of the borough in which water wa6 supplied exclusively by that company, hence the incidence of enteric fever upon houses so supplied was possibly explicable as resulting from the fact that the disease happened to affect a Southwark and Vauxhall supplied area. In Southwark, just over the borders of Camberwell, both the Southwark and Vauxhall and the Lambeth companies were supplying water; there were still, in fact, in parts of this district, as was the case nearly half a century ago, in the time of cholera prevalence in 1854, two "mutually interfused" populations living in the same streets having other circumstances in common, but one obtaining water from the Lambeth and the other from the Southwark and Vauxhall Company. The investigation of the Southwark cases was therefore undertaken in the first instance with a view to throwing light upon the question of water supply. I accordingly called upon Dr. Millson, the medical officer of health of Southwark, who placed the services of one of the officers of his department at my disposal, and we commenced a visitation of infected houses. It then soon became clear that there had recently been a well-defined localised prevalence of enteric fever in an area immediately to the east of Walworth-road. Detailed inquiries as to the water supply of this area were at once instituted, and this duty was undertaken by two of the Council's inspectors, Messrs. Perry and Swinson. As my own inquiry progressed it became clear the evidence to hand strongly pointed to the conclusion that the localised prevalence referred to above was attributable to the consumption of fried fish obtained from a particular shop. It was therefore a matter of much interest to find that the houses in the near neighbourhood of this shop constituted as it were an island of buildings exclusively supplied with Southwark and Vauxhall water, while surrounding houses were supplied some by the Southwark and Vauxhall Company and some by the Lambeth Company. Thus, on the assumption that an infected article of food had been distributed from this shop and had caused the localised prevalence, the involvement of the water of one company to the almost complete exclusion of that of another was at once explained; the area in question being a Southwark and Vauxhall supplied area, the fact that houses deriving water from this company were especially attacked, may be regarded as a mere coincidence. It will, however, be seen in the sequel that, the Southwark outbreak apart, there was reason for concluding that the behaviour of enteric fever in other parts of the Southwark and Vauxhall Company's area of supply had been exceptional, and that some special cause of enteric fever had operated in South-West, London during November and December. In point of fact, further inquiry led to the entertainment of a strong suspicion that infected fish had been somewhat widely distributed in London during this period, but that a considerable proportion of the whole amount had been sold in South-West London. Again, on reviewing the facts ascertained, the further suggestion presented itself that enteric fever might have been intermittently caused at various times during recent years in numerous widely separated parts of London by the agency in question. The reasons for entertaining this suspicion are briefly set out in section (d) of this report. In sections (a) and (b) the Holborn and Southwark outbreaks, respectively, are dealt with, and in section (c) the behaviour of enteric fever in South-West London during November and December, 1903, is referred to. * Reference may here be made to the question as to the extent to which fried fish is consumed in certain localities in London. Inquiry in Southwark in 1900 showed, taking an area bounded by a circle with a radius of aquarterof a mile, having as its centre a fried fish shop, that 42 per cent. of the population bad, shortly prior to the time of inquiry, eaten fried fish from the particular shop, 16 per cent, had eaten fried fish obtained from other sources and 42 per cent. had not eaten fried fish at all. The area chosen in Southwark was one in which fried fish was consumed to a quite exceptional extent, and it may be assumed that the percentage of persons eating fried fish from a particular shop, viz. 42 per cent. would be very unlikely to be exceeded in any area of the same size and configuration elsewhere. 4 (а) The Holborn outbreak.—This outbreak has been made the subject of special report by Dr. Bond, and is referred to by Dr. Allan in his monthly report for December, dealing with statistics relating to the fourth quarter of the year 1903. A statement of particulars of the cases is appended (See Appendix I.); briefly the facts may be analysed as follows. Between November 21st and December 7th, 17 persons commenced to sicken with enteric fever within, an area, partly in Holborn and partly in Westminster, bounded by a circle of a quarter mile radius and having at its centre a fried fish shop in the latter district. One of the patients denied having partaken of fried fish, the date of attack in this person was consistent with the case being regarded as secondary to a previous case in the same house; in another instance no history of having eaten fried fish was obtained, but this case was apparently imported into the area, and infection was presumably contracted in North London. Of the remaining 15 cases, 10 had, at about the time when infection presumably occurred, eaten fried fish obtained from the shop taken as the centre of the area; another probably did so also, and three more ate fried fish which was possibly obtained from this shop. The remaining patient had at about the time when infection must have occurred eaten fried fish purchased at a shop situated north-east of the centre of the area, and four o'ther patients (included in the 15) had been supplied with fish from this second shop (these four included the three whose having been supplied from the first shop was not a matter of certainty). In view of these occurrences the suggestion presented itself that there had been community of origin of the fish sold at the two shops; inquiry was made as to this, but while the possibility was not negatived the information obtained did not demonstrate a common source of supply. Both fishmongers, at the time when infective material must be assumed to have been introduced into Holborn and Westminster, had bought plaice at Billingsgate, and both had in the main been supplied with this fish from a particular port, but nothing beyond this was ascertainable so far as community of original source was concerned. It was definitely stated by both the vendors that there had been no intercommunication between their retail establishments, and though both on occasion had been supplied with fish from Grimsby sent direct to King's-cross, the middlemen concerned in supplying the fish did not, so far as could be learned, belong to the same firm, nor were their businesses in any ascertainable way related to one another. (б) The Southwark outbreak.—Particulars as to individual cases constituting this localised prevalence of the disease are appended (See Appendix II.). These cases occurred in an area surrounding a small fried fish shop, and for the most part the invaded houses were within a few hundred yards of the shop. In an area bounded by a circle of a quarter mile radius with this shop as centre, there occurred between October 17th and 31st 14 cases, in nine of which there was a history that the patient had in all probability eaten fried fish obtained at this shop, at about the date when he or she must have been infected, while four others are quite likely to have done so.* The incidence upon consumers of fried fish from a particular shop in this small outbreak was thus very striking, and further, the age-incidence of the disease was noteworthy, young persons being specially affected. It has been mentioned that most of the sufferers (12 out of 14, in fact) lived in houses supplied by the Southwark and Vauxhall Water Company. It has also been pointed out that the central portion of the area, in which the majority of the cases occurred, was found to be supplied exclusively by that company. The possibility of pollution of a local main presents itself, but no reasons for supposing such pollution had occurred were forthcoming. The circumstances as regards water supply generally, however, will be further considered in connection with the behaviour of enteric fever in surrounding parts of London at the close of the year 1903. Inquiries made as to milk, shellfish, ice-cream and watercress yielded negative results. The question of use of a swimming bath was also considered, but in only five of the 14 cases was there a history of having visited this bath, and this proportion was not larger than might a priori have been anticipated, having in view the ages of those attacked; again, if pollution of the water of the bath had been responsible for the outbreak, it may be assumed that the disease would have extended over the entire area inhabited by persons who used the swimming bath referred to, and would not have been limited, as was actually the case, to a particular portion of that area. Having regard to all these facts, and considered in the light of the history of enteric fever prevalences in London in 1900, the case against fish in this Southwark outbreak must be regarded as a very strong one. (c) The behaviour of enteric fever in London at the close of the year 1903.—When it was ascertained that localised outbreaks of enteric fever occurring in November in Holborn and Southwark were in all probability attributable to the consumption of fried fish, attention was naturally directed to the behaviour of the disease in London as a whole at this time. It was found that the number of weekly notifications of enteric fever, having attained a maximum in the 40th week of the year (the week ending 10th October), had fallen sharply in the 41st week, and again slightly in the 42nd week; in the 43rd and 44th weeks there was a small rise, the notifications in the 45th and 46th weeks were, however, somewhat smaller in number, and then in the 47th and 48th weeks a notably increased prevalence declared itself; after this the notifications fell off again as the end of the year approached. The small rise referred to above in the 43rd and 44th weeks coincided in point of time with the Southwark outbreak, and may thus be thought of as being accounted for by that outbreak ; the considerable rise in the 47th and 48th weeks corresponded * In one instance only was the information to the effect that fried fish from this shop had not been consumed; the sufferer, a lad of 12, stated that some days before his illness commenced he bought fried potatoes at a fried fish shop (not the shop in question), but he denied ever having eaten fried fish. It may be noted that the fried fish shop in this instance supplied far fewer persons with fish than did the shop in Southwark, referred to in footnote on p. 3. The percentage of persons obtaining fried fish from the latter shop being 42 (See footnote on preceding page), it maybe taken for granted that the corresponding figure for the shop now in question would not exceed 15 or at most 20 per cent. DIAGRAM Shewing cases of Enteric Fever notified in the several Water Companies' Areas during the 34th to 52nd weeks of the year 1903 (N.B.—The hatched portions of the diagram indicate the number of cases in each area, probably attributable to a special cause, the effects of which were manifested during the 43rd to 49th weeks). No. of Week. GRAND JUNCTION WEST MIDDLESEX CHELSEA NEW RIVER EAST LONDON KENT LAMBETH SOUTHWARK & VAUXHALL Week Ending Martin Hood.8cLark:in,Lith.London,W.C 5 roughly speaking in time with the Holborn outbreak, but as this latter outbreak was only a small one it could in no case explain the increase in the figures for London as a whole in those weeks. In view of the possibility entertained in the first instance that Southwark and Vauxhall water had been at fault, it was deemed desirable to study the distribution of enteric fever throughout London during the closing weeks of the year in relation to water supply. The results obtained may be quoted, as they give a general idea of the topographical distribution of the disease. Each case, it should be stated, is referred to the week in which the day on which it was notified falls. It was found that north of the Thames some small but noteworthy irregularities had presented themselves. The extent of these variations will be seen on reference to the diagram facing this page, which shows that— (i.) In those parts of North-West London supplied by the Grand Junction, West Middlesex and Chelsea Companies, following the fall after the attainment of maximum prevalence in the 38th—40th weeks, there was a slight rise, culminating in the 44th week, and another slight rise in the 50th week. (ii.) In those parts of North and Central London supplied by the New River Company, following upon a maximum prevalence attained in the 39th and 40th weeks, there was a rise in the 42nd-44th weeks, and further a short sharp rise in the 48th and 49th weeks. This last-mentioned rise was due to the Holborn outbreak already referred to. (iii.) In East London there were some marked irregularities, particularly there may be noted the rise in the 43rd week, partially accounted for by a group of cases in NorthEast London, and the rise culminating in the 46th week, due in the main to three groups of cases, one in Poplar and two in Stepney. A further rise in the closing weeks of the year will also be observed. Turning now to the south side of the river it transpires that— (i.) In those parts of South-East London supplied by the Kent Company there was no specially noteworthy irregularity of incidence of enteric fever; the maximum was attained in the 40th week and this corresponds fairly well with the time of occurrence of the ordinary seasonal maximum of the disease. (ii.) In those parts of South and South-West London supplied by the Lambeth Company a maximum was attained in the 40th week, and there was then a slight rise of prevalence in the 42nd and 43rd and again in the 47th and 48th weeks of the year. (iii.) In those parts of South-West London supplied by the Southwark and Vauxhall Company a remarkable increase in prevalence was manifested between the 43rd and the 49th weeks. On comparing the curves for the areas supplied by the several water companies it will be seen that three periods of exceptional prevalence may be roughly marked out in the closing weeks of the year. One toward the end of October is marked in East London, but is also traceable in the charts of the New River and Lambeth areas. Another occurring in the 51st and 52nd weeks is marked in the New River and East London areas. A third (intermediate) prevalence was that developed during the 43rd-49th weeks of the year, when the Southwark and Holborn outbreaks occurred which have already been discussed. It is this intermediate prevalence to which attention will now be more particularly directed and interest specially centres upon the areas supplied by the Southwark and Vauxhall and East London Companies, the rise in the New River Company's area being already sufficiently accounted for by the Holborn outbreak. Taking first the East London area, there were in Stepney two definitely localised prevalences, the one comprising four cases in Whitechapel, the other a group of seven cases in the east of Stepney, confined to a circumscribed area surrounding the point where the Regent's Canal passes from Mile End Old Town into Limehouse. To these cases, and to a group of four cases in one house in Poplar, further reference will be made later (See area xvii. referred to on pages 7 and 8). On examination of the area supplied by the Southwark and Vauxhall Company (which includes an area in part supplied by the Lambeth Company) the cases well be found to bave a much more generalised distribution. The accompanying map shows the cases notified during a portion of the period included in the 46th-48th weeks when the prevalence was at its height. Between 21st November and 5th December inclusive 74 cases were notified from houses within the area bounded by a red line. One of these cases was returned from hospital owing to error in diagnosis, and three more occurred in a block of dwellings from which a number of cases of enteric fever had already been notified during preceding weeks. Omitting these four case9 there remain 70 cases, 62, indicated by red dots, removed from houses suppHed with Southwark and Vauxhall water, 8, indicated by red crosses, from houses supplied with Lambeth water. Having in view the ordinary behaviour of enteric fever in London at this time of year, it may be assumed that rather more than half these cases must be looked upon as due to some superadded cause over and above the causes normally operative. But if some 25 or 30 cases, due to such ordinary causes, be more or less uniformly distributed over the area, and then, in addition, 40 or 45 further cases due to special causes be distributed, the question as to whether or no the total cases will show evidence of a tendency to grouping will be necessarily complicated by the 25 or 30 cases scattered more or less uniformly over the area. Having this consideration in view it is necessary to examine the distribution of the cases shown on the map somewhat more closely. It will be noted, then, that Bermondsey and portions of Southwark, Lambeth, Battersea and Wandsworth near the river, all thickly populated areas, are almost free from cases; on the other hand, there is suggestion of grouping of cases— (i.) In North Camberwell, in the neighbourhood of the Grand Surrey Canal, and more particularly of its southern extension into Peckham (8 cases). 6 (ii.) In Lambeth. (6 cases) on either side of South Lambeth-road, and again, in this borough and in the adjoining parish of Clapham (8 cases), near the southern end of Clapham-road. (iii.) In Battersea (6 cases) in the neighbourhood of Battersea-park-road. (iv.) In Wandsworth (5 cases) near the point where Garratt-lane approaches the county boundary. (v.) In Newington there is suggestion of grouping in two or three localities, but it must be borne in mind that in the Borough of Southwark, of which that parish forms part, there had been increased prevalence of the disease in weeks preceding the time now under consideration, and some of the cases notified in the latter periods (over and above the three cases excluded as already mentioned) may have been secondary cases. Two groups of three cases are particularly noteworthy, one to the south-east of Kennington-park, on the borders of Newington and Lambeth, and one near the southern end of Walworth-road, and to these attention will be further directed later. (See 3rd and 4th paragraphs from bottom of this page.) The question of age and sex distribution, as well as that of the topographical distribution of cases at this period, may be thought of as possessing importance in connection with inquiry as to the nature of the superadded cause of enteric fever operating in South-West London during the period in question. Examination of the returns shows that of the 70 cases on the map 40 were males and 30 females, and that 45 were under and 25 were over 25 years of age. These results do not deviate widely from the normal; there is, however, some slight tendency for younger ages, and more particularly for persons aged 15-20, to suffer unduly. Two hypotheses naturally present themselves as possible explanations of the superadded cases—(i.) That in the 40 or 45 cases in question infection was water borne ; (ii.) that the cause (infected fish), to which the Southwark and Holborn prevalences have been ascribed, had been operative just prior to the 47th and 48th weeks in two or three areas in South-West London. In connection with the first hypothesis, it may be noted that during late October and early November the River Thames was in flood, the maximum height (5 ft. 1 in. above summer level) being attained on October 30th; the height above summer level was still 4 ft. 9 in. on November 3rd, after which date the flood somewhat rapidly abated. From the water examiner's reports it appears that "for the first ten days of the month [of November] the Southwark, Grand Junction and Lambeth Companies' supplies were of bad quality, but after that time they steadily improved in quality until the end of the month." The cases, constituting the groups above referred to, sickened for the most part in the days between the 20th and 24th November, so that they must be thought of as having been infected about the period November 6th to 10th. It will be seen, therefore, that the flood attained its maximum a week or ten days before the date at which infection in these superadded cases was probably contracted, though the contaminating effects of the flood were still apparent at this date. An hypothesis of water-borne infection is, of course, difficult of acceptance in view of the topographical distribution of the cases—the exceptional incidence being clearly manifested only in the area of one water company, while there is suggestion of grouping of the cases within that area. Such distribution would not, on the other hand, be inconsistent with the second hypothesis referred to above, and the behaviour of enteric fever in parts of London other than the south-western portion of the county, at about the time when the unusual prevalence in South-West London was manifested, raises question as to whether the same cause may not have been concerned in producing the several observed abnormalities of incidence of the disease. The following further points of interest may be noted in connection with this second hypothesis— One of the groups referred to under the head (v.) mentioned above was a striking one. It consisted of two boys and a young girl belonging to families living at some distance from and having no communication with each other, and each of these patients had, independently of other members of his or her own family, partaken of fried fish obtained from a particular shop about a fortnight before the commencement of illness. Attention was directed to the existence of these cases by a man whose son had obtained fried fish from the same shop, had shortly after eating it complained that it made him feel sick, and had then after a fortnight's interval developed enteric fever. The series of events in this last case antedated * by about three weeks the corresponding events in the later group of cases. In a second group of three cases referred to under heading (v.), the patients who sickened at about the same time had all shortly before that time eaten fried fish from one shop. In examining most of the other groups occurring in the 43rd-49th weeks, I had the help of Mr. Shapley, one of the Council's inspectors, and I am also indebted for assistance in particular instances to Inspectors Lewis, Perry, Williamson, Garner, Gibb and Wood. As regards the group in North Camberwell under the heading (i.), no article of food had been obtained, so far as could be ascertained, from one common source—fish had been frequently eaten by all the sufferers at the time when infection must have been contracted, but it had not been obtained so far as could be learnt from one and the same vendor. A shop near the centre of the group of houses attacked had been an ordinary source of supply of the inmates of three of these. Again, much fish was bought from hawkers, and in one instance the sufferer was the only member of her family who partook of a dish of "lemon soles" purchased from a hawker about a fortnight before the child began to be ill; the fish "tasted bad," and the mother said it must be thrown away, but this particular child had then eaten her piece. The habit of buying from hawkers was common amongst persons in this locality, but it did not transpire that any one particular hawker had supplied all the sufferers. * A further case was found to have occurred in this locality—the patient, a girl, had sickened a few days before the first of the four cases referred to above; she aleo had shortly before her attack from time to time bought fish at the particular shop. 7 As regards the Lambeth cases under the heading (ii.), it was found that at a time corresponding with that of infection the majority of the cases grouped on either side of South Lambeth-road obtained wet fish from one of two shops close to one another, and most of the persons attacked bought indifferently at one or the other shop; no other article of food, so far as could be ascertained, was obtained from any common source by all the sufferers. Turning now to the remaining eight cases two sufferers proved to have been regular customers of a particular vendor of fried fish, and one or more of the others may also have obtained fish from the same shop. It was noted that the vendor carried on business under a name which was that of the man whose customers were attacked in one of the fried fish outbreaks in 1900. As regards group (iii.), one of the cases was a regular customer of a particular fried fish vendor, and one or more of the others may have obtained fish from this man. The vendor in question acted as manager of the shop which supplied fish to the sufferers in the fried fish outbreak of 1900 just referred to. Group (iv.) included three cases in one house, and these three patients, and at least one of the two remaining sufferers, were habitual fried fish eaters, and shortly before their illness obtained fish as a general rule from a particular shop. This shop is situated in an area to which further attention will be directed in the sequel. (See paragraph at bottom of page 8.) Reference has been made to the existence of localised groups of cases on the north side of the Thames. (See page 5.) Some inquiries were made by Mr. Wood as to cases in Stoke Newington, and here reasons for suspecting infected fish as a cause were forthcoming, particularly in the case of a group notified in the 42nd week. Interest specially centres, however, upon the two Stepney groups and the Poplar group previously mentioned which occurred contemporaneously with the Holborn cases. Mr. Shapley ascertained, in the case of the group of four cases in Stepney, that all the sufferers had shortly before attack bought wet fish from costers' stalls in a particular street (in area xx. See page 9.), and as regards the group of seven cases in Stepney he found that the sufferers had purchased fish from hawkers, but it was not possible to demonstrate that all had obtained fish from one particular hawker. In neither of these groups had there, so far as could be ascertained, been any other common source of food supply at a time corresponding with that of infection. The group of four cases in Poplar consisted of children from 4 to 10 years of age living in a house situated in an area (area xvii.) to be referred to later. (See page 8.) It will be seen, therefore, that an infected fish hypothesis is consistent with all the known facts as to the prevalences in Stepney and in South-West London in the 46th, 47th and 48th weeks of 1903, and in view of the facts of the occurrence of the Holborn outbreak in the 48th and 49th weeks, and of that of the Southwark outbreak a few weeks previously, there is strong ground for suspecting that infected fish was responsible for the increased prevalence of enteric fever in London manifested at this time. (d) The behaviour of enteric fever in certain areas in London during the years 1896-1903.— This behaviour can "Best be understood by reference to the diagram appended in which are shown the cases notified in each month of the period under review. Cases occurring among persons aged 3 to 25 inclusive are indicated by hatched squares, cases at other ages by black squares. In instances in which a second or third case was notified from a house within 10 days of a first notification, the later case is distinctively indicated by a cross. In instances in which a second or third case was notified, after more than 10 days and generally speaking within two months of the notification of a first case, the later case is indicated by a cross placed below the base line, distinction always being made in respect of age by employment of different types of cross. (See Diagram.) Charts i. and ii. relate to areas (in Southwark and Lambeth) in which outbreaks of enteric fever due to the consumption of fried fish occurred in September, 1900. In the area iii. (Kensal Town) an outbreak occurred at about the same time, and this was probably caused by infected fish purchased in an uncooked condition; iv. relates to the central portion of the area in which the Southwark outbreak of 1903 (see Appendix II.), due to fried fish, occurred at the end of October, the cases being notified in November, 1903; v. and vi. relate to areas in which outbreaks, probably due to the same cause, occurred about three weeks later, the cases being notified in December, 1903; it should be noted that in area v. (central portion of area referred to in Appendix I.) there was not, as in i., ii., iii., and iv., a single retail shop in question, but two retail sbops were implicated, and in area vi. (Kennington) there were in December, 1903, only three cases of illness; these two outbreaks v. and vi. stand, therefore, on a footing different from that of the other outbreaks. Limiting consideration in the first instance to outbreaks of considerable size, examination of charts i. and ii. shows that— (1) The special prevalence was accompanied by notable increase in the percentage of multiple attacks in houses. Additional eases occurring within 10 days of a first case are indicated on the chart by a cross occupying one square. The normal percentage of such cases may be taken, on the basis of the London notification figures, as about 5 per cent, of the total number; in the special prevalences i. and ii. it exceeded 20 per cent. (2) The special prevalence was accompanied by marked increase in the percentage of cases at the age9 3 to 25 inclusive. Cases at the ages 0 to 2 and 26 onwards are indicated on the chart by black squares or by distinctive crosses; the percentage of such cases to the remaining cases may be taken, on the basis of the London notification figures, as 50 per cent.; in the special prevalences in areas i. and ii. it fell to about 8 per cent, and 22 per cent, respectively. The special prevalence in area iii. exhibits features closely resembling those indicated as characterising i. and ii. The preponderance of hatched squares over black squares was, however, 8 slightly less marked in area iii., and the outbreak in this area also presented the peculiarity as compared with those in i. and ii., that it was apparently traceable not to fried fish, but to fish purchased in the wet condition and cooked at home. On turning now to the prevalences of November and December, 1903 (charts iv., v., and vi.), it will be found (allowance being made for the smaller number of cases) tbat chart v. (Holborn) yields distinct suggestion of relationship, so far as age-incidence and multiple cases are concerned, to charts i., ii. and iii.; in chart iv. (Southwark) the resemblance is less striking, the percentage of black squares being high, but the figures dealt with are still smaller than in v., and the area to which chart iv. relates is a small one—as a matter of fact the outbreak of November, 1903, extended somewhat beyond the area dealt with in the chart, and if the outlying cases be included, the percentage of cases at ages 0 to 2 and 26 onwards to other cases becomes appreciably lowered. In chart vi. there are, as already noted, only three cases in December, 1903, and no conspicuous resemblance to charts i., ii., and iii. can, under the circumstances, be looked for. The history of consumption of fish obtained from a particular shop, at about the time when infection must have been contracted in the case of the three patients in area vi., has already been referred to (See page 6), and it has been noted that a case infected some weeks previously to these three was held by the patient's friends to have been caused by eating fried fish obtained from the same shop one fortnight prior to attack by the disease.* In the fried fish enteric fever prevalences of 1900 (i., ii. and iii.) the districts involved were not attacked quite simultaneously ; and again in 1903, area iv. was attacked about three weeks before areas v. and vi. Having in view these instances of want of simultaneity of infection, the possibility presents itself that the same retail shop may have distributed infection at the close of 1903 on two distinct occasions separated by an interval (See chart for area vi. in October and December, 1903). There then arises the further possibility that persons living in the area vi. and in other areas surrounding implicated fried fish shops may have from time to time been infected during recent years from those shops. Examination of notifications (1896—1903) for the areas in which the six implicated shops lie shows— (a) That in each instance the area has during these eight years suffered unduly from enteric fever, London as a whole being taken as the standard of incidence. (b) That in each instance the percentage of cases at ages 3 to 25 inclusive to other cases is unduly high compared with London as a standard. (c) That in area ii.t there were, at the close of 1896 and 1899, two small outbreaks, the appearance of which on the chart suggests their possible affinity to that of 1900 ; in area iii. the small outbreak at the close of 1899 is also noteworthy ; in the case of area iv. attention may be directed to the appearance of the chart at the beginning of 1900 ; and charts v. and vi. yield indications of a somewhat similar kind, the former at the end of 1898, and the latter at the end of 1899. The suggestion now presented itself that the characteristics of the fried fish outbreaks occurring in certain areas in 1900 might perhaps in other areas be more nearly approached during 1899 and 1900 (years when enteric fever was unwontedly prevalent in London) than in other years, and this consideration, has led to examination of areas in which there was exceptional prevalence of enteric fever in those two years. Under this head reference may be made to charts vii., viii., xiv., xv., xvi., and xvii. In each of these areas (with an exception to be noted as regards viii.) it will be found that— (1) The proportion of cases at the ages 0 to 2 and 26 onwards to the remaining cases is below the normal 50 per cent. In area xvii. it is 46 per cent., in area xvi. 37 per cent., in area vii. 44 per cent., in area xv. 36 per cent., and in area xiv. it is only 22 per cent; in area vii., on the other hand, it is nearly 74 per cent. (2) That outbreaks presenting suggestion of affinity to those of 1900 in areas i. and ii. have from time to time occurred. In area vii. (Kentish Town) there were such outbreaks in 1896, 1899, 1900, and 1902. In area viii. (Starch Green) similar outbreaks occurred in 1899 and 1900. In area xiv. (Hackney Wick) there are several outbreaks presenting some suggestion of having similar affinity, the most notable of these being one in 1901 ; it will also be seen that an outbreak having somewhat similar features occurred in this area in September, 1903, shortly before the occurrence of the outbreaks of that year in areas iv., v. and vi. In area xv. (Hackney Wick) outbreaks also raising suspicion occurred at the close of 1899 and 1900, and in this area the occurrence of a group of cases at the close of 1903 is also noteworthy. In area xvi. (Millwall) the years 1896 and 1897 present a small percentage of black squares, and the outbreaks at the close of 1898, 1899 and 1900 are noteworthy. In area xvii. (Cubitt Town) the year 1896 is suggestive, less so the years 1899 and 1902, while the group of cases in the two last months of 1903 is again striking. (See pages 5 and 7.) Chart xiii. (Garratt-lane) relates to an area (See paragraph commencing " Group (iv.) included " on p. 7.) to which attention was directed owing to multiple house attacks occurring in * My attention was in the first instance directed to this case by Dr. Millson, and I found on visiting the house that the circumstances which have been already referred to had particularly impressed themselves upon the minds of the inmates, who attached importance to the facts that the sufferer alone had partaken of the fifh, and that he had complained at the time of eating it that it was not of good quality. As already noted, a fifth case was apparently associated with this shop. t The shop in area ii. was carried on in the same name as shops situated at the centre of two areas, ix. and x. Each of these last named areas presented cases of enteric fever at the time of the 1903 prevalences in areas iv.. v. and vi., and area x. presents a somewhat suggestive prevalence at the close of 1902, while the chart for area ix., at the close of 1899 and 1900, raises some suspicion of being affected by the cause operative in the case of area ii., certainly in the latter and possibly in the earlier of those two years. 9 it at the time of the prevalence of 1903 in areas iv., v. anil vi. It was found that this area showed excessive incidence of enteric fever during the period 1896—1903, and the behaviour of the disease in it in 1899 and at the close of 1900 and beginning of 1901 is noteworthy. Charts xviii. (an area in llotherhithe) and xix. (an area in Bermondsey) furnish two further examples of localities specially involved in 1899 and 1900. In both these instances the proportion of black squares is much below the normal 50 per cent. and, further, examination of the charts brings to light a very striking prevalence in area xviii. in the year 1901 and one in area xix. (small in extent but with no black squares) in the following year. Most of the areas examined are occupied in the main by poor people, the streets being, as a rule, coloured light blue or purple on Mr. Charles Booth's poverty maps.* For purposes of comparison two areas, altogether apart from any question as to enteric fever prevalence in them, numbers xi. and xii., Lisson-grove and Somers-town, have been taken as presenting instances of poverty-stricken localities. It will be seen that the charts for these areas exhibit from time to time throughout the period 1896-1903 some suggestion of affinity to the charts already given, the behaviour of the disease in Somers Town in 1900 being specially noteworthy in this connectiou. In these two areas it will, however, be found that the percentages of cases at the ages 0-2 and 26 onwards to the remaining cases are above the normal, viz., 67 and 54 respectively. All the areas hitherto examined, including xi. and xii., resemble one another not only in comprising, in the main, light blue and purple streets, but also in forming centres in which fried fish is largely consumed. It might at first sight be supposed that it would be possible to determine to vmat extent the one, as opposed to the other condition, was associated with phenomena such as those exhibited in the charts. The attempt has been made to find an area in London occupied by the particular classes of the population in question and in which fried fish is not largely eaten. This attempt has been quite unsuccessful. In Deptford some approximation to such an area had, it was thought, been discovered, but there were fried fish shops immediately outside and within easy reach of the locality, and the inhabitants were, no doubt, to some extent consumers of fried fish.t With a view to throwing light on the question how far poverty per se could be held accountable for abnormal age-incidence of enteric fever, study has been made of the figures furnished by five London boroughs, two rich and three poor, for the years 1898, 1900 and 1903. In Kensington and Wandsworth, on the one hand, the higher ages (over 25) manifest a greater tendency to be attacked than is, on the other hand, the case in Stepney, Southwark and Bethnal Green. The fact is in part explained by differences of age distribution of the several populations, but it is not thus wholly accounted for. The tendency for persons aged 3-25 to be affected in these boroughs is not equally marked throughout the whole period under examination; indeed —more particularly in the poorer boroughs—this tendency is evinced in notable degree at special times; in fact, the abnormality of age-incidence is generally observed coincidently with the occurrence of localised outbreaks of the disease. So far as the figures examined go, they do not suggest that the phenomenon in question has any definite relation to a particular season of the year. Inasmuch as Stepney and Bethnal Green yield the highest percentages among the boroughs examined of cases at the ages 3-25, further study has been made of particular areas in these two East-end boroughs, and charts xx-xxiv. have been prepared. These charts show that the abnormality of age-incidence (high percentage of hatched squares) generally presents itself at times when exceptional prevalence of the disease is manifested. In area xx. (in Stepney) the outbreak in 1899 is noteworthy, and the area is one in which four cases—account of which has been given in paragraph 4, p. 7—occurred at the close of 1903. Area xxi. (in Stepney) furnishes appearances at the close of 1899, 1901, 1902 and 1903 strongly suggestive of an infected food supply being at fault. Area xxii. (in Bethnal Green) presents features in 1899 which raise a similar suspicion. Area xxiii. (Bethnal Green) is less striking, though here the high percentage of hatched squares in the period 1896-1898 and in 1900 is noteworthy. Area xxiv. (in Bethnal Green) yields notable outbreaks in 1897 and 1899. In summary it may be stated, with regard to the areas i., ii., iii., iv., v. and vi., in which outbreaks of enteric fever, presumably due to consumption of infected fish, occurred at the close either of 1900 or 1903, that the disease has, throughout the period examined, been unduly prevalent in them and that there is reason for suspecting that the cause of the 1900 and 1903 outbreaks came into operation at other times during the years 1896-1903.‡ Turning now to the areas which have been examined on account of the excessive prevalence of enteric fever in tfiem—in the autumn of 1899 or of 1900, or at some other date within recent years—the distribution in time of the cases, and the abnormal age-incidence, in all save viii., of the disease, suggest that some food supply has been intermittently at fault throughout the period named. The close association of the phenomena to which attention is specially directed with poverty must, of course, be admitted, but it may be that an article of food consumed bv poor persons is one of the connecting links between poverty and these exceptional outbreaks of disease. Communication of the disease from person to person has no doubt to some extent been operative in these areas, but the manner of occurrence of multiple attacks in houses is not such as to suggest that this cause alone adequately explains the altogether abnormal incidences observed. * Mr. Booth's scheme of classification, beginning from below, included— black, lowest class, vicious, semi-criminal; dark blue. very poor, casual,chronic want; light blue, poor, 18. to 21s. a week for a moderate family; purple, mixed, some comfortable, others poor— and so upwards. Black and dark blue are comparatively little represented in the 24 areas on the diagram; light blue aud purple generally speaking dominate those areas. †In this are a there was comparatively little enteric fever during the years 1896-1903, and the proportion of hatched to black squares was. as a matter of fact nearly normal, London as a whole being taken as the standard. ‡ With regard to the two areas ix. and x., surrounding fried fish shops carried on under the same name as that of the owner of the shop implicated in outbr ak ii., there is some slight ground for suspecting that these shops may have acted as sources of infection at one time or another during the period reviewed. [2] 10 In view of tlie inquiries made by officers of the sanitary authorities, it may be assumed that milk cannot have played any considerable part in causing1 these outbreaks, and the localised distribution of the cases is not consistent with an hypothesis of water-borne infection. In a number of the areas inquiries have been made from which, it appears clear that infection by icecream, watercress or shellfish would not account for any considerable percentage of the cases; in each of them, however, fried fish is largely consumed, and while it has been found impracticable, owing to removals, death and absence from home, to make inquiry of individuals on any comprehensive scale, it is at least clear that an hypothesis of infection by fish is consistent with such facts as have been ascertained concerning the general habits of the populations in question. The inferences drawn in this report suggest that it by no means follows because outbreaks of the magnitude of those of 1900 in Southwark and Lambeth are of quite rare occurrence, that the infection of enteric fever is only exceptionally transmitted by fish. That such transmission is not more often recognised may be in part due to the very fact that the mischief is widespread and not localised. While the consumption of oysters, cockles, etc., a fortnight before attack by enteric fever is regarded as significant, no corresponding importance is attached to consumption of fried fish. This attitude of mind, it may be said, is justified by the consideration that fried fish eating is common, and the eating of oysters, cockles, etc., rare. If a food be frequently consumed this in itself tends to render it unlikely that notice will be directed to it, while on the other hand, oysters, etc., which are rarely purchased, are, partly on that account, more likely to be regarded as a possible source of mischief. In the case of fried fish, as in that of oysters, the sufferer is often the only member of the family who has consumed the food, and this renders inquiries at the home, after the removal of the patient to hospital, unlikely to be productive of positive result. Again, in the comparatively rare instances in which inquiries as to fish have been made by sanitary inspectors, they have been limited to the question as to fried fish ; there is, of course, no reason for supposing that frying enhances the infectivity of fish, though it may perhaps be a fact that the kind of fish which is apt to convey infection is, as a rule, fried. Plaice, haddock and skate are the species of fish ordinarily fried, but it is noteworthy that in all instances save one (in which question arose as to "lemon soles") suspicion has fallen upon "plaice"—under which term "flounders" and dabs" are apparently often included by fishmongers. Experience in Southwark in 1900 indicated that it was the "halfpenny bit" which was especially mischievous, and it was found that this consisted in some instances, at any rate, of an entire fish, and, therefore, of a very small one. "Dabs" and "small plaice" are sometimes bought in quantity at Billingsgate, more particularly in the summer, at times when large fish are scarce. In July, 1901, "dabs" were being sold at that market at !fs. to 2s. 6d. per trunk of about 84 lbs.—i.e. at approximately ½d. per lb. As it takes one man about 1½ hours to clean a trunk of small fish, the temptation during busy times to remove the heads only, the fish being fried with the gut in them, must be great; in the case of small fish there is, moreover, special difficulty in removing the gut. It is noteworthy in this connection that sufferers from enteric fever have in several instances complained that the fish eaten by them had a disagreeable flavour, and even that it made them sick, while insufficiently cleansed fish is, it appears, well known to have a characteristic bitter taste. Imperfect gutting is apparently far from uncommon, at any rate at busy seasons. I have seen small fish from which the heads and portions of the intestinal contents had been cut away by one stroke of a knife but from which the gut had not been completely removed, displayed for sale in a fried fish shop, and among some 30 or 40 penny and halfpenny pieces of fried fish purchased two samples were obtained—one from North London and one from South London—in which the intestines were in the fish. It may be surmised that frying under these conditions, having regard to the short time of exposure in the dripping or oil to a high temperature, would be unlikely to result in sterilisation of the intestinal contents. W. H. Hamer, Assistant Medical Officer of Health. II Appendix I. The Holborn Outbreak. No. Date of onset of illness. Date of notification. Sex and age. Milk supply. As to consumption of fish, fried fish, shell fish, etc. Celery Watercress. 1 Nov. 21 Dec. 2 M. 10 Condensed Fond of fried fish, generally obtained from C.'s, but he and his sister ate fried fish obtained from X.—he about a week, she about a fortnight before they sickened. Fond of winkles. Yes No 2 Nov. 28 or a few days earlier Dec. 2 F. 4½ Condensed Sister of above (q.v.). No shell fish. Yes No 3 Nov. 24 Dec. 2 F. 5 A Fried fish from Y. No shell fish. Mother at one time bought fried fish from X., and the child, who sometimes purchased on her own account, may have bought from X. No No 4 Nov. 24 Dec. 2 M. 16 No raw milk Fried fish from X. about a week before attack. No shell fish. Yes No 5 Nov. 26 Dec. 6 M. 15 Condensed Fried fish from X. No shell fish. No. No. 6 Nov. 23 Dec. 7 F. 33 ? Had eaten whelks about a fortnight before attack. Fond of fried fish. May have obtained it from X., more likely to have done so from Y. ? ? 7 Nov. 26 Dec. 8 F. 16 No raw milk. Fried fish from Y. No. No. 8 Nov. 25 Dec. 8 F. 4 A Fried fish from Y. as a rule. It is possible she may have bought from X., but not likely. Fond of winkles. No. No. 8 Dec. 2 Dec. 10 M. 11 ? Fried fish from both X. and Y. Yes. ? 10 Dec. 7 Dec. 11 F. 50 Condensed Never fried fish. Mother of case 5, probably secondary to that case. No shell fish. Yes. 11 Nov. 28 Dec. 11 F. 19 B Fried fish from X. No shell fish. 12 Dec. 7 Dec 14. F. 21 ? No fried fish at home, but may have eaten X.'s fried fish at her cousin's house, where she often spent the evening. No shell fish. No No 13 Doubtful. Ailing from Nov. 9. Dec. 14 M. 12 ? Fried fish from X. Yes Yes 14 Dec. 5 Dec. 14 M. 14 A Fried fish from X. one week or rather more before he began to be ill. No shell fish. No No 15 Nov. 23 or earlier Dec. 4 M. 22 Only in tea Fried fish from X. Occasionally eats winkles. Yes No 16 Nov. 25 about Dec. 4 F. 28 Only in tea Sister of above, but had not seen him for some weeks, and had, at time when illness was presumably contracted, been living in North London. Fond of fried fish. Never shell fish. Yes No 17 Nov. 29 Dec. 8 M. 7 ? Fried fish from X. Eats winkles occasionally on Sundays. Yes Yes Appendix II. The Southwark Outbreak. No. Date of onset of illness. Date of notification. Sex and Age. Milk supply. Icecream. As to consumption of fish, fried fish, shell fish, etc. As to use of swimming baths. Celery. Water- dress. 1 Oct. 17 Oct. 27 M. 11 A No raw milk consumed No Fond of fish and "taters," often bought "taters" without fish; obtained fried fish from X. or A. or B. No shell fish ? No No 2 Oct. 18 Oct. 30 M. 12 B No law milk consumed No Does not remember buying fried fish, but has bought "taters" from A. Has certainly not had fried fish or shell fish at home Yes Swallowed a mouthful of water about 14 days before illness began No No 3 Oct. 19 Oct. 31 F. 15 C No Fond of fried fish, obtained it from B. as a rule, possibly from X. She used to go to entertainments at a hall close by X.'s shop. Never shell fish No No No 4 Oct. 20 Nov. 9 M. 17 D No Often fried fish from X. Eats winkles sometimes on Sundays Yes No No 5 Oct. 20 Oct. 27 M. 12 Condensed No Fond of fried fish Obtained it at C.'s as a rule, may have bought it from X. as he often used to pass by X.'s shop, and went to the hall close by Yes No Yes 6 Oct. 21 Nov. 2 M. 15 D No Often fried fish from X. Eats winkles sometimes on Sundays No No No 7 Oct. 22 Nov. 5 F. 26 E No Oysters 14 days before illness began. Fond of fried fish usually obtained from C., but may have obtained it from X. Was seen outside X.'s shop a fortnight previous to illness No No No 8 Oct. 25 Nov. 13 M. 27 F No Fond of cockles, whelks and winkles, also of fried fish, obtained from X. and occasionally from another purveyor No Yes Yes 9 Oct. 27 Nov. 10 M. 9 F. No raw milk consumed No Fond of fried fish obtained from X. No shell fish No No No 10 Oct. 27 ? Oct. 20 Oct. 31 M. 41 Condensed No Fond of fried fish obtained from X. prior to his illness but since from other sources. Fond of whelks. No No No 11 Oct. 28 Nov. 4 M. 13 G Yes Fried fish frequently obtained from X. Occasionally eats winkles. Some mussels about 3 weeks before illness Yes, 8 days before illness began Yes No 12 Oct. 29 Nov. 6 F. 15 C No Fried fish from B, possibly from X. also. Mussels 7 or 8 weeks before illness began Yes No No 13 Oct. 31 Nov. 9 M. 36 Condensed No Fond of fried fish; probably obtained it from X. Mussels eaten 3 weeks before illness began No No No 14 Oct. 31 Nov. 4 M. 22 H No Fond of fried fish, purchased it as a rule from X. Oysters occasionally, but not for many weeks before illness ? No No 15 Nov. 9 Nov. 16 M. 28 I. No raw milk consumed No Fond of fried fish, obtained from various sources, but his wife does not like X.'s fish and does not buy it No No Yes 16 Nov. 9 or a few days earlier Nov. 17 M. 31 F No Fried fish frequently from X. Sometimes eats winkles No Yes Yes 17 Nov. 12 Nov. 27 M. 38 F No Fried fish frequently from X. No Yes Yes 12 ENTERIC FEVER 1896-1903. DIAGRAM shewing cases of Enteric Fever notified during each month of the years 1896—1903 in certain selected areas in London distinguishing (a) cases aged 3—25 inclusive from cases at other ages; (b) cases notified within 10 days of the notification of a first case in the same house, and (c) cases similarly notified after a longer interval than 10 days. N.B.—Each square represents one case. APPENDIX II. London country Council. HOUSES ADAPTED AS TENEMENT HOUSES. Report by the medical officer submitting Dr. Young's report on the question of securing proper sanitary accommodation in houses originally built for one family, but which are now being let off in separate tenements to several families. Printed by order of the Public Health Committee. In the latter part of last year Dr. Young inspected a number of tenements in London for which certificates had been given by medical officers of health for the purpose of exempting the landlords from inhabited house duty. In all these tenements antecedent to the granting of the certificate, some structural alterations of the building had been made with a view to adapting it for occupation by more than one family, and indeed, in some instances, the house had been re-built, but in such a way that it did not occupy larger area than the building which originally stood upon the site. During the present year Dr. Young has extended his inspection to tenement houses generally, irrespective of any question whether the houses had been regarded as proper for exemption from inhabited house duty, and has thus visited nearly 200 houses, each containing two or more tenements. It may be said generally that in the majority of the premises visited the houses remain much as they were originally constructed for one family, except in so far as the larger number of inhabitants of the house due to its sub-letting has led to increase of water-closet accommodation to comply with the provision of the Council's by-law made under the Public Health (London) Act, which requires that the landlord or owner of every lodging-house shall provide a watercloset for every 12 persons inhabiting the house. A lodging-house is defined in the by-law as " a house or part of a house which is let in lodgings or occupied by members of more than one family." This by-law, Dr. Young found, has been generally complied with. The additional water-closet has usually been provided in the back yard, but in some houses, where the conditions allow, it has been placed in the back addition building, and it is then approached from the staircase between the ground and first floors. Even in the matter of water supply, in the majority of houses no alteration has been made to adapt it to the requirements of the inmates of a sub-let house. The only tap from which water is drawn is usually situated in the back yard or in the washhouse on the ground or basement floors. In houses in which an additional water supply at a higher level has been provided, the higher tap is usually placed on the staircase landing over a sink which, if properly constructed and provided with a trapped waste pipe, can be used for the discharge of waste water, thus serving as a scullery sink. It is, however, not intended for the receptiou of bedroom slops, which must necessarily be taken to the water-closet wherever it may be situated, and there is, of course, always risk that any sink may be misused and become a source of nuisance within the house. The disadvantage from which the housewife suffers is obvious if, living on an upper floor of a three or four storey house, she has to journey to the ground floor or basement for every drop of water she requires, or to empty the waste water of her tenement. The result is, as pointed out bv Dr. Young, that water for potable purposes is often stored in receptacles in the tenement, and that waste water, which ought to be speedily removed from it, is retained, militating against the wholesomeness of the dwelling. In this connection the position of the water-closet deserves consideration, for where the only water-closet is situated on the ground floor or in the Tmsement there is encouragement to the retention of bedroom slops in the dwelling rooms, to the prejudice of their atmosphere. In tenement houses provision for washing clothes is generally, but not always, made. The ground floor room of a back addition, or a room in the basement, or an outhouse in the baok- prihted 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, A.grnti for the talc of the Publication* of the London County Council. No. 706 Price 4d., post free 5d. [8117 2 yard is frequently used for this purpose, and is provided with, a copper, a water tap and a sink. The washhouse is available for all the tenants, but Dr. Young did not lind that it was always used. This, in some instances, may be due to fault in its situation when a dark basement is used for the purpose, or to want of maintenance of the copper in condition fit for use. The facilities which exist in public washhouses for washing the linen of tiie occupants of a tenement no doubt also contribute to disuse of the washhouse in a dwelling house. The small sum of 2d. an hour paid at a public washhouse, where ample facilities are provided, is not more than would be expended for fuel in the tenement house. Inquiry has also been made as to the accommodation provided in the ordinary tenement house for the cooking of food. Of 739 tenements visited for this purpose by the Council's inspectors, including tenements of one, two, three and of four rooms, in a third of the tenements there was no oven in which food could be baked, the fire-grate being the same as that provided when the house was originally constructed, or of the same kind, and not more adapted for cooking purposes than an ordinary bedroom grate. This condition was found especially in tenements of one room, more than half of which were so circumstanced; in tenements of two rooms about a quarter were without coal fire or gas ovens for cooking purposes, but in tenements of three or four rooms an oven heated in one or other of these ways was always found to be provided. In tenements of one room in which an oven was found, this oven was almost always heated by a coal fire, in exceptional instances the oven was associated with a gas stove, and in one or two instances the tenement had both. In tenements of two rooms provided with an oven, in about 85 per cent, the oven was heated by the fire-grate, in about 2 per cent, there was a gas cooking stove, and in about 12 per cent, there were both. In tenements of three or four rooms an oven was found, with a single exception in association with the coal fire-grate, and in 16 per cent, of these tenements there was also a gas cooking stove. It was often found that no provision had been made for carrying off the products of combustion of such gas stoves. For hot water the tenant has to depend upon the use of a kettle. In a trifling number of instances it was found that a boiler existed in connection with the fire-grate, but almost invariably this was defective and out of use. In the tenements visited no special provision had been made by the landlord for the storage of food or coals. The conditions most needing improvement are the provision of more accessible water supply for each tenement, so as to enable the tenant to obtain water on the floor on which his tenement is situated, or on the hilf-landing adjoining, and the provision of a suitable place in connection with each tenement in which food can be properly stored. The question needs consideration whether each tenement should not be required to be provided with a cooking stove. No doubt, in many instances, cooked food is purchased at the cook-shops to be found in poor neighbourhoods, and the requirement cannot be urged with the same force as in the case of water supply and storage for food. These conditions fall far short of those which the Metropolitan Branch of the Society of Medical Officers of Health has recommended for the purpose of exemption of dwellings from inhabited house duty. A medical officer of health, in certifying for this purpose, has to be satisfied that the house is so constructed as to afford suitable accommodation for each of the families or persons inhabiting it, and that due provision is made for their sanitary requirements. The Metropolitan Branch of the Incorporated Society of Medical Officers of Health in 1897 recommended that the certificate should onlv be granted when the following requirements were complied with— (а) A definite height and superficial area for living and sleeping rooms, as defined by the London Building Act, 1894, section 70 ; (b) That there is a sufficient and available supply of water on each floor ; (c) That there is at least one water-closet, properly supplied with water, for eveTy 12 occupants (or less) on each floor ; (d) That the drainage of the premises is in accordance with the regulations recognised by the authoritv in whose jurisdiction the house is situated ; (e) That accommodation for clothes washing is provided sufficient for the number of persons inhabiting1 the house. Manv houses could no+ be adapted to meet the renuiremen+s of the med:cal officers of health, but there would be few, if any, which could not, at small expenditure, he made to comply with the lower standard which I have indicated. Shirley F. Mhupttt, Medical Officer of Health. Dr. Young's Report. In accordance with the instructions of the Committee inspection has been made in different parts of London of houses occupied by more than one tenant, with a view to reporting on the sanitarv accommodation existing in such premises. The term sanitary accommodation has been regarded as including— 1. The water supplv and the means of getting rid of waste water. 2. The water-closet accommodation and its position. 3. The washhouse accommodation. A large number of houses in different districts have been visited and details as to the accommodation existing in them is set out in the appendix to this report. These may be summarised as follows— The majority of the premises visited contain from six to ten rooms, usuallv on three and four floors and a basement.. Thev are let out in single rooms, in two or more rooms, or in floors, according to the size of the family of the occupants. In some cases it is found that the whole house is taken by one tenant, who sublets part of it unfurnished to one or more lodgers. 3 The sanitary accommodation which exists in these houses is usually as follows— (1) The water supply for the house is obtained from a water tap placed in the yard at the rear of the house, or in the washhouse, which is either situated in and approached from the yard or is a room on the basement floor. There may be two taps, one in the yard and one in the washhouse, or sometimes in the front area when the house possesses a basement. In some houses a supply tap is found at the end of the passage of the ground tloor, and occasionally the supply is carried up through the house and taps are provided on one or more of the upper floors. The most frequent condition met with, however, is the first-mentioned, namely, one where water can only be obtained at the basement or ground iioor level, so that the occupants of the upper floors must come down whenever they require water, or are compelled to stote water in utensils in their own rooms to meet the needs of the day. In those instances where the supply is carried up to the upper floors there is provided under the water tap on each floor a sink for waste water. Where the supply is limited to the ground floor level no provision is made for the discharge of refuse water except at the ground floor level. This may consist of the drain inlet in the yard only, but generally there is also a sink in the washhouse. It thus follows that all waste water must be carried downstairs from the upper floors. (2) Water-closet accommodation is nearly always provided outside the house, namely, in the yard at the rear, and frequently two water-closets exist in this situation, the second one having obviously been provided to comply with the by-law requiring one water-closet to every twelve inhabitants. In only a small number of houses was the proportion of persons to one water-closet found to be in excess of that allowed by the by-law; generally speaking, the requirement of the by-law is complied with. In some houses a water-closet is found inside the house on the ground floor level and approached from the passage. It is exceptional to find accommodation on the floors above. (3) The washhouse accommodation found to exist in this class of house is usually situated in one of two places. In some there is a back addition building or an outhouse in the yard fitted up with a copper, water supply tap and sink. In other houses, if there be a basement floor, the back basement room is fitted up in a similar manner, and is available for the use of all the tenants in the house. In some houses no adequate accommodation exists. The absence of water supply on the upper floors of tenement houses, where these consist of premises having three and four storeys, as well as the absence of means for getting rid of fouled water, must give rise to inconvenience, and must tend to the storage of water for domestic use, and the retention of waste water in utensils in the living rooms for longer periods than is desirable. There appears to be no power by which improvement in this respect can be effected. At the present time the powers relating to the means of water supply of inhabited houses are contained in sections 2 and 48 of the Public Health (London) Act, 1891. These are as follows— Section 2.—" Any such absence from premises of water fittings as is a nuisance by virtue of section 33 of the Metropolis Water Act, 1871," shall be a nuisance liable to be dealt with summarily under the Act. Section 48 (1).—" An occupied house without a proper and sufficient supply of water shall be a nuisance liable to be dealt with summarily under this Act, and if it is a dwelling house, shall be deemed unfit for human habitation." The requirements of both these sections are no doubt met by the provision of one water tap with suitable fittings and so placed as to be available to all tenants living in the house. As regards water-closet accommodation there is evidence that the by-law requiring one water-closet to every twelve persons has been enforced, and it is only occasionally that noncompliance with this requirement is met with. The additional accommodation is, however, usually provided in the yard, this being the most readily available position, as to erect it at a higher ievel would involve considerable structural alterations in the house. In some cases, where the conditions allow it, the second water-closet has been placed on the roof of the back addition building and is then approached off the staircase between the ground floor and first floor levels. This is a more convenient position for tenants on the upper floors. The requirement of the bylaw, however, relates only to the proportion of water-closet accommodation to number of residents, and does not refer to position. In connection with the washhouse accommodation which exists, it is not always obvious that full use is made of it in all cases. This, in some cases, may be due to the fact that it is inconveniently placed, or is dark, and not well suited for the purpose, as well as to the habits of the residents, but in this connection it is to be remembered that the provision of public baths and washhouses mav to some extent lessen the extent to which washhouses attached to houses are used bv the resident. The conditions existing in ordinary tenement houses, as regards water supply, means for getting rid of foul water, and washhouse accommodation, do not compare favourably with the sanitary accommodation which is provided in houses which have been built with the special object of accommodating more than one family, or in recently erected blocks of dwellings for persons of the working class. In the case of houses which have been sneciallv built with a view to occupation bv more than one familv, the accommodation usually consists of living and sleeping rooms, together with a small scullerv-washhouse, separate water supply tap and separate watercloset all on one floor, and each floor of the house is a repetition of the other. Sometimes, especially where the premises contain only two floors, each has a separate entrance door from the street. Examples of this class of premises, and an account of the accommodation provided in each, has been eiven in a previous report. The Customs and Inland Revenue Act, 1890, as amended by the same Act of 1891, offers inducement, by way of exemption or abatement from inhabited house duty, to owners to build, 4 or to adapt existing premises for the use of more than one family. In the previous report already referred to it was shown that the number of existing houses for which certificates under the Act had been granted, owing to their having undergone structural alteration with a view to their being inhabited by more than one family, was very small. In other words, the provisions of the Act have not had the effect of bringing about structural adaptation of houses for a different method of usage, although it would appear that a considerable number of certificates under the Act have been granted since 1890. These certificates, however, relate to newly erected blocks of dwellings, to houses specially built for the purpose of housing more than one family, or to houses which, originally built for one family, already possess such sanitary accommodation, that a medical officer of health could not reasonably refuse to grant certificates of exemption to the owner if he effected in the premises certain small improvements which are not of the nature of extensive structural alterations. In addition to the opportunity for improving the conditions existing in tenement houses afforded by the Customs and Inland Revenue Acts, the Housing of the Working Classes Act, 1890, contains provisions by which it is possible that improvement might also be effected. Thus, under section 58 in Part iii. of this Act local authorities are empowered to purchase existing lodginghouses, and if this were done they have power under section 59 to alter, enlarge, repair and improve them for the use of the working classes. These sections are as follows— Section 58.—The trustees of any lodging-houses for the working classes for the time being provided in any district by private subscriptions or otherwise, may, with the consent of a majority of a committee or other persons by whom they were appointed trustees, sell or lease the lodging-houses to the local authority of the district, or make over to them the management thereof. Section 59.—The local authority may, on any land acquired or appropriated by them, erect any buildings suitable for lodging-houses for the working classes, and convert any buildings into lodging-houses for the working classes, and may alter, enlarge, repair, and improve the same respectively, and fit up, furnish, and supply the same respectively with all requisite furniture, fittings and conveniences. C. W. F. Young, Assistant Medical Officer of Health. Public Health Department, 8, St. Martin's-place, December, 1903. APPENDIX. Details as to the sanitary accommodation found to exist in houses now occupied by several tenants, which were apparently originally built for the use of one family. In order to obtain information as to the sanitary accommodation now existing in houses which when erected were intended for the use of single families, but which, owing to change in the conditions of the district, are now occupied by more than one family, a considerable number of streets in several sanitary districts both north and south of the river have been visited, and one or more houses in these have been inspected with a view to seeing the nature of the accommodation existing. The streets visited are those in which it was thought likely that houses of the class referred to exist. With few exceptions inspection was made of houses having not less than three floors, as it is in these that the absence of sanitary accommodation on other floors than the ground floor is most likely to give rise to inconvenience. In the following account details are given as to the number and position of the water-closets provided, as to the position of the water supply tap or taps, and of the sinks for the reception of fouled water, and as to the washhouse accommodation which exists. The details as regard houses in any street are typical of the conditions generally existing throughout the street or of a large number of the houses in it, and the streets visited consist of houses, practically all of which are now occupied by more than one family. In the case of some of the houses information as to rent was obtained. This is set out in tlhe account. *Hollinqton-street, Cambcrwell.—This is a long street with three-storey houses on either side There are between sixty and seventy in all. They are all of the same class, containing two rooms, a front and back, on each floor, and in addition, on ground floor, a back addition room through which the yard is approached. The houses are let out in tenements, each tenant paying directly to the landlord, with but few exceptions, in which it is found that one tenant is responsible for the rent of the whole house, but sublets rooms. No. (a). Occupied by three tenants, one on each floor. Rents, 4s. and 4s. 6d. a week. No. (b). Occupied by two tenants, three Toonis each. Rents, 6s. a week each. No. (e). Occupied by two tenants, three rooms each Rents, 6s. a week each. No. (d). One tenant takes the whole house and sublets three rooms to one other tenant. * Hollington, Crown and Sultan streets form part of a group of streets of tenement houses in which the Camberwell Borough Council are at present acquiring homes under Part III. of the Housing of the Working Classes Act with a view to the improvement of the accommodation and condition of the premises. 5 follows each °f the above the washhouse and water-closet accommodation and water supply are ai There is one water-closet in the yard. The ground-floor back addition room has a copper, and serves as washhouse for all tenant* Here also is placed a water-tap and sink for the use of all. *Crown-street, Camberwell.— A short street of three-storey houses with back addition buildings. All tenemented. No. (a). There are five separate tenants in this house occupying single rooms and two rooms. W ater-closet accommodation.— One in the yard. Scullery and wa,ter supply.— There are three taps and sinks, one in the ground-floor, one in first-floor, and one in second-floor back addition rooms respectively. The first and second floor back addition rooms are only available for the two tenants occupying them. The others make us» of the water supply and scullery sink in the ground-floor room, which is common to all tenants. Washhouse.— In the ground-floor back addition room a copper is provided, and is available to all tenants. No. (b). There are three tenants, here, making nine persons in all. The water-closet and washhouse accommodation and the water supply are the same as in No. (a). No. (c). Occupied by two tenants, one having four rooms, one having two. Eleven persons in all Water-closet accommodation.-— One in yard. Water supply, sink, and washhouse.— The ground-floor, back addition room has water-tap and sink, and is fitted with a copper. This room is for common use. Rents, first floor, two rooms, 4s. 6d. a week ; ground and top floors, four rooms, 9s. a week *Sultan-street, Camberwell.— A street containing some seventy houses of three storeys each. It is a typical street of tenement houses. The houses are all of the same class and have the same accommodation. The following are examples— No. (a). Contains six rooms, two on a floor, and a back addition room at end of passage on ground floor, throngh which the yard at rear is approached. There are two tenants, one of these takes the whole house and sublets three rooms to the other tenant. Water-closet accommodation.— There is one in yard. Water supply.— One tap in yard. Washhouse.— The back addition room on ground floor is fitted up with a copper, and here also is a sink. No. (b). This is similar to above house, but in this case there are three tenants, but one occupies four rooms (first and seoond floors) and the others each one room. No. (c). Similar house and accommodation. Two tenants, each three rooms. Peckjiam-park-road, Camberwell.— This is a long road with a varying class of house, mostly two storeys. No. (a). This is a three-storey house with basement. It is occupicd by one tenant, who sublets first floor to a lodger. The washhouse is situated in the basement, and in it is placed the water-tap. The water-closet is in the yard. No. (b). This is a similar house, and with the same accommodation. It is occupied by one tenant, who sublets part to one other. Gye-street, Lambeth.—There are three-storey houses on one side of this street. They all have three-storey back addition buildings. No. (a). Let in floors and occupied by three tenants. Each floor has a separate water-closet, water-supply tap, and sink. There is a washhouse, available for the use of all, in the yard. All these houses are similar, as well as houses on one side of Italian-walk at the back of this row. Auckland-street, Lambeth.—Contains houses three storeys high with two-storey back addition buildings. No. (a). Let in floors, except one room, which is a single room tenement. Occupied by four tenants. The sanitary accommodation consists of— One water-closet in the yard. A washhouse in the yard. A water-tap and sink in the washhouse. No. (b). Occupied by one tenant, who sublets the first floor and the top floor to two tenants. There is a washhouse and water-closet in the yard. The water-tap and a sink are provided in the washhouse. Jonathan-street, Lambeth.— There is a row of three-storey houses here. No. (a). Is occupied by one tenant who sublets part to one other lodger. The water-closet and washhouse are both placed in the yard. There is a water-tap and sink in the washhouse. No- (b). One tenant occupies the house and sublets the three front rooms to three other tenants. The house has been provided with water supply and washhouse accommodation on each floor. There is one water-closet in the yard. V auxhall-walk, Lambeth.— No. (a). A three-storey house, occupied by one tenant who sublets the top and first floors to two other tenants respectively. The water-closet and washhouse are both situated in the yard. There is a water-tap and sink in the washhouse. No. (b). A similar house to above. It is occupied by three tenants. Boyson-road, Southwark.— This contains houses with three storeys and half-basement doors. Two rooms on a floor, but at basement level there is a third back addition room which is the washhouse. Water supply and sinks are found usually at the basement and ground floor levels and on stairs between first and second floors. No. (a). Four tenants, one on each floor. Water-closet accommodation.— One is provided at end of passage on ground floor, and one in the yard. 6 Water supply.— There are three taps and sinks, one in basement and one on ground floor and second floor respectively. Washhouse.—There is one for the use of all tenants. No. (b). Four tenants, one on each floor. Rents, 6s. 6d., 7s., and 9s. a week. Water-closet accommodation.— One in the yard and one at end of passage on ground floor. Water supply.—There is a tap and sink in washhouse in basement, one in passage of ground floor, and one between first and second floors. Washhouse.— At basement level for use of all tenants. No. (c). Five tenants, one each on basement, ground and first floors, and two on top floor. The accommodation is the same as in above houses, except that there is no water-tap higher than ground-floor level. Rents, 3s., 6s., 6s. 6d., and 7s. a week. Merrow-street, Southwark.— There are some twelve three-storey houses in this street. Two rooms oil a floor with a back addition washhouse at rear on ground floor. No. (a). In this house one tenant holds the house and sublets ; in all there are five separate occupiers. One washhouse, one water-closet, and one water-tap, all in the yard, for common use. Darwin-street, Southwark.— A street of three-storey houses with back addition buildings. Each contains eight rooms and a washhouse. No. (a). One tenant occupies the house and sublets three rooms to two separate lodgers, viz., the— (а) The top floor. (b) The first-floor front room. Water-closet accommodation.— Two ; one in yard and one on first floor. Water supply and washhouse accommodation.— There is one water-tap and a sink under it on first floor, and another on ground floor. One washhouse. No. (b). Similar accommodation as above. Occupants consist of four tenants. Marcia-road, Southwark.— This road contains houses three storeys high and having back additions two storeys in height. About eighty houses in all. They have each eight rooms. No. (a). This house is occupied by one tenant, who sublets part to two other families. The sanitary accommodation consists of— One water-closet situated in the yard. A washhouse in the back addition on the ground-floor level. One water-supply tap placed in the washhouse. Nos. (b), (c) and (d) are each of them similar houses to the above, and are provided with the same sanitary accommodation. No. (e). A similar house, except that the washhoifse also serves as the kitchen of the tenant who occupies the house, end who sublets the top floor and the first floor to two other tenants. Northampton-street, Southwark.— The houses here are three storeys high and have back addition buildings on the ground and first floors. No. (a). One tenant takes the house and sublets to two others the top and first floors respectively. There is one water-closet situated in the yard. The washhouse is on ground floor and is approached from the back addition kitchen. There are two water-taps, one in the washhouse and one in the yard. No. (b). This house is occupied by five tenants, or a total of seventeen persons, five of whom are children under five years of age. There are eight rooms in the house. Some are single-room tenements. There is only one water-closet, which is situated in the yard. The water-tap is in the yard. There is no proper washhouse. Flinton-street, Southwark.— In this road is a single row of houses three storeys in height with back addition buildings two storeys high, and containing eight rooms. No. (a). Let in floors, three occupants, at rents of 7s., 8s. 6d., and 8s. a week. The washhouse is in the back addition building off the kitchen. There are two water-closets, one on first floor and one in the yard. There are two taps, one in the washhouse and one on the first floor. Aldlridqe-street, Southwark.— A long street containing houses of three storeys and two storey back addition buildings. Some eighty to one hundred houses. No. (a). This house is occupied by one tenant, who sublets the top and first floor to two other tenants. There are two water-closets, one on the first floor and one in the yard. The washhouse is in the yard. There are two water-taps, one in the washhouse and one on the first floor. No. (b). Occupied by one tenant, who sublets to two others, each occupying a floor. The sanitary accommodation is as in above house. Giffen-street, Deptford.— This is a street off the High-street, having houses three storeys high on either side. These are all of the tenement class and they are let in floors or in single rooms. In some cases the rooms are let furnished by the night. No. (a). Occupied by four tenants, one each on the top and first floors and two on the ground floor. There is no washhouse, nor a copper. One water-closet and one water-tap are provided in the yard. The rents paid are 2s. 3d., 2s. 9d., 3s. 6d. and 3s. a week. No. (b). Occupied by one tenant, who retains the two ground floor rooms and sublets to three lodgers three single rooms. The washhouse is a wooden building in the yard. There are one water-closet and one water-tap, both situated in the yard. No. (c). Occupied by three tenants, one on each floor of two rooms each. There is no washhouse provision. The water-closet and the water-tap are both situated in the yard. The rents are 3s. 9d., 4s. and 4s. 6d. a week each. No. (d). Let in furnished rooms by the week. All single-room, tenants. Rents, 4s., 4s. 6d. and 6s. a week. There are a water-closet and a watr ta p in the yard. The washhouse is a basement room. 7 No. (e). Furnished rooms, six tenants. Rents, 5s. a week for front rooms and 4s. a week back rooms. There are a water-closet and a water-supply tap in the yard. There is no washhouse provision. Lady well-park, Lewisham.— This road contains some houses of three storeys with basements. Some of them are semi-detached, others form part of a row. They have two rooms on each floor and back addition buildings at basement, ground floor and first floor levels. No. (a). Let to four tenants, one on each floor, and the rents paid are 5s. 6d., 7s. 6d. and 6s. 6d. There are two water-closets, one in the basement and approached from the washhouse, and one on the first floor. The washhouse is in the basement. There are two water-supply taps, one in the washhouse and one on the first floor. No. (b). Occupied by six tenants, some in single rooms and some in two rooms. There are two water-closets, one in basement and one on first floor. The washhouse is in the back addition building at basement level. There are two water-supply taps, one in basement washhouse and one in the disused bathroom on first floor. No. (c). Occupied by one tenant, who retains four rooms but sublets the top floor (two rooms) to one lodger. There is one water-closet on the ground floor. The water-tap is in a combined bath-room and water-closet on the ground floor. Malham-road, Lewisham.— Contains two and three storey houses. No. (a). House contains two rooms on each floor and a back addition kitchen. Occupied by one tenant, who retains first floor and the kitchen, and sublets the ground floor and top floor to two tenants, each paying 3s. 6d. a week. The washhouse is an outbuilding in the yard The water-tap and a sink are placed in the washhouse. There is one water-closet in the yard. No. (b). Contains six rooms and a back addition kitchen and washhouse. Only one family. No. (r). Occupied by two families. Each has separate washhouse, water-tap, and water-closet provision. Dalmain-road, Lewisham.— A road with houses two and three storeys in height. No. (a). Contains six rooms. Occupied by two separate families. There is one washhouse which is situated in the yard ; one water-closet also in the yard. The water-lap is placed in the washhouse, in which is also a sink. No. (b). This is a similar house. It is occupied by one tenant, who sublets part to one other. Amberley-road, Paddinqton.— This road contains on each side houses three storeys high with basement floors, and they are all of the tenement class. Each floor has two rooms except basement and ground floor, each of which has a back addition room. All the houses have back addition buildings at level of basement and ground floor. No. (a). Let in single, two, or more rooms to each tenant. There are seven tenants, and the rents paid are 2s. 6d., 3s. 9d., 3s., 4s. 3d. and 5s. a week. The washhouse is in the back addition building on the basement floor. There are two water-closets, one on the ground floor and one in the yard at the basement level. There is one water-tap placed in the washhouse. No. (b). Let in floors, each tenement consisting of two rooms, except on the ground floor, which has a third room in the back addition building. There are four tenants, and the sanitary accommodation which exists consists of—- Two water-closets, one in yard at basement level, and one on roof of back addition building, at level of first floor. A washhouse in the back addition room at basement level. A water-supply tap in washhouse. Brindley-street, Paddinqton.—Contains three-storey houses. No. (a). This house is occupied by one tenant, who retains three rooms and sublets the remaining three to two other tenants, one occupying one and one occupying two rooms. The sanitary accommodation consists of— A washhouse, which is an outbuilding in the yard. One water-closet. One water-supply tap placed in the washhouse. No. (b). This house is let in floors, and is occupied by three tenants. There are a water-closet and a water-supply tap, both in the yard. The washhouse is a back addition building in the yard. No. (e). Three tenants, each occupying a floor. Each floor contains two rooms. Twelve persons in all. j.i The washhouse is an outbuilding in yard. In the washhouse are two water-taps and a sink. There is one water-closet. Clarendon-street, Paddinqton.— This is a long street containing houses three storeys high with basements and back addition buildings. They are all of the tenement class. No. (a). This is occupied by five tenants, there being two on the first flxor. The house contains nine rooms and a washhouse. The rents are 2s. 9d. and 4s. a week for single rooms, and 6s. and 7s. a week for two rooms. The sanitary accommodation provided is as follows— Two water-closets, one in the yard at basement level and one on the roof of back addition building, about first-floor level. A washhouse in basement. One water-tap placed in the washhouse. No. (b). Let in floors, four tenants, one on each floor. The rents are 5s. 6d., 6s. and 7s. a week. The sanitary accommodation is as above. No. (c). A similar house, but let partly in floors, partly in single rooms. There are five tenants. There are two water-closets. A washhouse approached from yard. Two water-taps, one in front area and one in washhouse. 8 Woodchester-street, Paddinqton.— These are houses of three storeys with basement floors. They are all of the tenement class. No. (a). Let in floors. There are four tenants, one on each floor. The sanitary accommodation provided consists of— Two water-closets, one on the roof of back addition building, about level with first floor, and one in the yard. A washhouse in the back addition at basement level, and approached from the yard. A waier-supply tap in the washhouse. No. (b). Occupied by four tenants. The sanitary accommodation is similar to that in No. (a). Cirencester-street, Paddinqton.— The houses in this street have three storeys and basements, and they are all occupied by more than one tenant. No. (a). Let in floors. There are four tenants, each having two rooms, and the rents paid by them are 5s. 9d., 6s. 6d., 6s. 6d., and 5s. a week each. There are two water-closets, one on ground floor, approached from the passage, and one in the yard. The washhouse is a back addition room approached from the basement passage. The water-tap is in the washhouse, in which is also a sink. Bessborouqh-street, Paddinqton.— This road contains houses three storeys high with back addition buildings of one storey. No. (a). Let in floors, and at present occupied by three tenants, each having two rooms. There are one water-closet, one water-supply tap, and a washhouse in the yard. No. (b). Occupied by three tenants, each a floor containing two rooms. There are one water-clo§et, one water-tap, and a washhouse, all on the ground-floor level. Hall-place, Paddinqton.— Contains houses some two storeys and some three storeys high. No. (a). A three-storey house, containing six rooms. It is occupied by one tenant, who retains the first floor and sublets the ground floor and top floor respectively to two other tenants. There is one water-closet in yard. The washhouse is an outbuilding in the yard, and in it is placed the water-supply tap. No. (b). A three-storey house occupied by three tenants, one on each floor, who pay 7s. 6d., 8s., and 8s. a week each. There is one water-supply tap in the washhouse. The washhouse is an outbuilding in the yard. There is one water-closet in the yard. Cuthbert-street, Paddinqton.— A street of three-storey houses. No. (a). Occupied by three tenants, one on each floor. The sanitary accommodation consists of— A water-closet and a washhouse out in the yard, and a water-supply tap with sink in the washhouse. No. (b). This house is occupied by one tenant, who reserves three rooms and sublets rooms to three others, each single-room tenants. There is a water-closet and washhouse in the yard, and a water-supply tap in the washhouse. Hethpool-street, Paddinqton.— Three-storey houses containing six rooms. No. (a). Occupied by four tenants, one each on the ground and first floors and two on the top floor. There are a water-closet, water-tap and washhouse out in the back yard. Crompton-street, Paddinqton.— This street contains three-storey houses. No. (a). One tenant occupies the house and retains three rooms, but sublets to four lodgers four rooms, one of these being a furnished room. A water-closet and a washhouse are provided in the yard. The water-supply tap is in the washhouse. Netley-street, Paddinqton.— A short street containing three-storey houses with basements, all tenemented. Small amount of rear yard space. No. (a). This house contains nine rooms and a washhouse, and is occupied by five tenants. The sanitary accommodation provided consists of— Two water-closets, one in the yard and one approached from the staircase landing between the first and second floor. A washhouse in the back addition building, at the basement level. A water-supply tap in the washhouse. No. (b). Occupied by four tenants, one on each floor. There are two water-closets, one on the ground floor and one in the yard. The washhouse is an unsuitable and neglected structure. There are two water-taps, one on the roof of the back addition building at first-floor level, and one in the washhouse. Hastinqs-street, St. Pancras.— This street contains many houses haying three storeys and basements. They have, at some previous date, been occupied by single families. No. (a). Occupied by eight tenants. House contains basement, ground floor, and first, second and third floors. Two rooms on each floor. There are two water-closets, one in the yard and one on the ground floor. There is one water-tap placed in the back-yard for the use of all tenants. There is a small washhouse, an outbuilding in yard, fitted up with a copper and a disused sink. Nos. (b), (c) and (d) are similar houses, occupied in the same way and provided with the same accommodation. No. (c). Occupied by four tenants. One m ground-floor rooms and front basement, one in first- floor front, one in first-floor back, and one in top-floor rooms. There is one water-closet on the ground floor. One water-tap in the back basement room, also a copper. No. (f). Is a similar class house. Mabledon-place, St. Pancras.— Houses here consist of four storeys and basement. No. (a). There are two rooms on each floor, or nine rooms and a washhouse. There are seven tenants. Water-closet accommodation.— Two. Water supply and washhouse accommodation.— The back room in basement is the washhouse, 9 and here is placed the one water-tap for the supply of the whole house. There is also a sink here. Nos. (b) and (c) are similar houses, and are let to several tenants. No. (c) is provided with two water-closets and has two water-taps, one in the yard and one in the washhouse. The back basement room is the washhouse. Lancing-street, St. Pancras.— Here are houses three storeys high with basements. No. (a). Three tenants. There is one water-closet, and the washhouse is an outbuilding in yard. Here is placed the water-tap for the supply of the whole house. No. (b). In this case one tenant occupies the house, but sublets the top floor to one lodger. There are one washhouse, one water-closet, and one water-tap in the yard. Tottenham-street, St. Pancras.— This street contains houses three and four storeys high. Some of them are used as shops and obviously the mode of occupation of the houses varies. Some are tenemented. No. (a). Contains three separate tenements. There is one water-closet. The washhouse is provided in the back basement room. The water-tap is placed in the washhouse. Little Goodge-street, St. Pancras.— A short street, with houses having four floors and basements. No. (a). Occupied by eight tenants, two on each floor, except the top floor and basement, each of which is occupied by one tenant. In the yard are two water-closets and a washhouse. The water-supply tap is placed in the washhouse. No. (b). Eight tenants, two on each floor, except the top floor and basement, each of which ia occupied by one tenant. There are two water-closets in the yard. The back basement room is fitted up as a washhouse, and has a sink and water-tap. There is a water-tap in the front area and another in the backyard. Euston-street, St. Pancras.—This street contains houses the mode of occupation of which varies considerably, but some, containing three storeys with basements, are let in tenements. No. (a). Four tenants, one on each floor, paying 7s. 6d. and 8s. a week. There are one water-closet, one water-tap, and a washhouse. All situated m the yard. There is no scullery or sink. No. (b). Four tenants, one on each floor. The washhouse is a dilapidated building in the yard, and in it are to be found a water-tap and sink. There are two water-closets in the yard. George-street, St. Pancras.— This is a long road containing houses having four storeys and basements. Mode of occupation variable, some few probably tenemented. No. (a). Four tenants. A washhouse is provided in yard, and in this is the water-tap for supply of the whole house. There is no sink. There is one water-closet in the yard. Warren-street, St. Pancras.— This is a long street turning off Tottenham-court-road. It contains houses having four storeys and basement floors. The houses vary in character and some are shops. No. (a). Four tenants in this house. There are two water-closets, one water-supply tap, and one washhouse, all on basement level, for the use of all the tenants. (No. (b). Occupied by eight separate tenants. There are two water-supply taps, one in the front area and one in the backyard, at basement level. There are two water-closets. There is no proper washhouse, but a copper is provided in backyard under a projecting portion of an adjoining mission hall. No. (c). Occupied by ten tenants. There are two water-closets, one in backyard and another under the pavement in front of the house, approached from front area. One water-supply tap is placed in the washhouse and one in the front area. There is a small washhouse in the yard. Cleveland-street (partly in St. Pancras and in Marylebone).— Contains three-storey premises of a. mixed class, many being utilised as shops, and some of much better class than others. No. (a). Four storeys and basement. There are live tenants, one on each floor, paying from 5s. 6d. to 9s. 6d. a week. There are two water-closets in yard. Two water-supply taps, one in front area and one in yard. There is a washhouse in yard. No. (b). In this house there are eight tenants, viz., one on top floor, two on second floor, two on first floor, one on ground floor, two in basement. Water-supply taps are placed in the back room on each floor as well as in the washhouse in the backyard and in the front area of tenement. There is a good washhouse in the yard. No. (c) has a similar accommodation to above. Upper Cliarlton-street, Marylebone.— A long street containing houses having four storeys and basement floors. Some of the houses are used as shops. They are obviously intended to be let in floors as there are separate bells, one for each floor, at the door. No. (a) contains five tenants, one on each floor. Water-supply taps and sinks are provided in each back room. A washhouse and two water-closets are provided in the yard. No. (b). Seven tenants occupy the house, viz., one on the top floor, two each on the second and first floors, and one each in the ground and basement floors. [ 2 ] 10 There are two water-closets and a washhouse situated in the yard. The water-tap is placed in the yard. No. (c). Nine tenants, two on each floor and one in the basement. There are one water-closet, one washhouse, and one water-supply tap, all placed in the yard. The water-closet accommodation is insufficient in proportion to the number of persons in the house, namely, seventeen. No. (d). Seven tenants, two on the top and ground floors respectively, and one on each of the t.hree other floors. There are one water-closet, one washhouse, and one water-tap, all placed in the yard. Charlton-street, Marylebone.— No. (a). One tenant occupies the house and sublets rooms. There are eight tenants, each in single rooms. In the yard are a water-closet and a washhouse. There are two water-taps, one in the front area and another in the yard at rear. Foley-street, Marylebone.—This street contains houses having four storeys and basement floors. No. (a). This house is occupied by eight tenants. The sanitary accommodation consists of two water-closets, both situated in the yard. One washhouse in the yard. Two water-taps, one in the washhouse and the other in the front area. Union-street, Marylebone.— No. (a). Occupied by seven tenants, all in single rooms except on the top floor. There is a water-closet in the front area, and the water-supply tap is also in this area. The washhouse is in the backyard. Upper Rathbone-place, St. Pancras and Marylebone.— This street contains four-storey houses with basements. Many of them are used as shops, but others are obviously tenemented houses. No. (a). There are seven tenants living here, and the sanitary accommodation consists of two water-closets, one in the backyard and one in the front area. Two water-supply taps, one on the basement floor and one on the second floor. The washhouse is provided in the back basement room. No. (b). Several tenants. There are two water-closets, one in yard and one in front area. There is one water-tap in the washhouse. The washhouse is situated in the yard. Earl-street, Marylebone.— Contains three-storey houses. No. (a). There are six rooms in this house, which is occupied by four tenants, there being two on the top floor. There is one washhouse, which is an outbuilding in the yard. The water-closet and water supply tap are both in the yard. There is no sink. No. (b). This house contains six rooms, and is occupied by one tenant, who sublets four rooms to four separate lodgers. There is one water-closet. The washhouse is an outbuilding in the yard, and the water-supply tap is in the washhouse. Carlisle-street, Marylebone.— A street of three-storey houses, usually with two rooms on each floor. No. (a). Contains six rooms, and is occupied by four tenants, two having single rooms each. There is one water-closet. The water-tap is placed in the yard. The washhouse is an outbuilding in the yard. No. (b). Occupied by three tenants, one on each floor, containing two rooms each. The one water-closet, washhouse and water-tap are all placed in the yard. Sydney-street, Finsbury.— No. (a). A three-storey house with basement containing four tenants. One takes the house and occupies the two ground floor rooms and the basement kitchen. Lets two single rooms on first fleer to two lodgers and the two top floor rooms to a third. The back basement room is the washhouse. There is one water-closet in the yard. There are two water-taps, one in the yard, one in the washhouse. Rents top floor two rooms 6s. 6d., single rooms 3s. 6d. each. White Conduit-street, Finsbury.— Contains three-storey houses with two rooms on each floor. No. (a). Six-roomed house. One tenant occupies house and sublets one room unfurnished. There are a washhouse, water-closet and one water-tap in the yard. Warren-street, Finsbury.— A road of three-storey houses. No. (a). Contains three storeys and basement. There are five tenants occupying single and two rooms. There are two water-closets, a washhouse and a water-tap all placed in yard. Rents, 3s., 5s. 6d., and 7s. a week. No. (b). Three tenants, one in two rooms and two in three rooms each. Two water-closets, a water-tap and a washhouse in yard. Rents, 6s. 6d., 9s. 6d., and 8s. a week. No. (e). One tenant takes the house and occupies the ground floor and basement kitchen. There are four lodgers. The back basement room is fitted up as washhouse, with copper, water-tap and sink. There is also a water-tap in yard, and the water-closet is situated here. Richard-street, Finsbury and Islington.— Contains houses of three storeys and basements. No. (a). One tenant occupies the house, and sublets the top and first floors to two tenants. There is one water-closet in yard. There are a water-tap and sink in the washhouse, which is the back basement room. Albert-street, Islington and Finsbury.— Contains houses of three storeys with basements, two rooms on a floor. No. (a). One tenant occupies the house, and sublets to two lodgers the top floor and the ground floor, each two room tenements. The washhouse is a back addition building at the basement level. 11 There is one water-closet situated at the end of the ground floor passage, and one water-tap in the yard. No. (b). Occupied by three tenants, two in two rooms each and one in four rooms. There are two water-closets, one at the end of ground floor passage, and one in yard. There is one water-tap with a sink in the back basement room, which is the washhouse. Macclesfield-street, Finsbury.— Contains three-storey houses. No. (a). Six rooms. One tenant holds the house and lets one room each to two lodgers. There is no washhouse, but a copper is provided in the backyard. There are one water-closet and a water-tap in the yard ; no sink No. (b). This house is occupied by four tenants, two in two-roomed tenements, and two in oneroomed tenements. The sanitary accommodation is as in No. (a). Rents, 2s. 9d., 4s. 9d., 5s. 6d. and 6s. 6d. a week. There are nine houses all of the same class in this street. Southampton-street, Finsbury.—Contains houses having three storeys and basement floors. No. (a). Occupied by four tenants, one on each floor, two rooms each, except in basement, one room only. The rents paid are 3s., 7s., 6s. 6d. and 6s. a week. The back basement room is fitted up with a copper and water-tap, and serves as the washhouse. There is also a water-tap in the yard. One water-closet in yard. No. (b). One tenant occupies the whole house, and utilises the ground floor and basement and sublets the first and second floors to two tenants. There are two water-taps, one in the yard and one in the back basement room. The water-closet is placed in the yard. The washhouse is a wooden building in the yard. Coldbath-square, Finsbury.— A short street, with houses having three storeys, attic storey and basements. No. (a). Two rooms on each floor. There are five tenants, each in single rooms, except one (landlord), who occupies the ground floor rooms and the front basement kitchen. Water-closet accommodation. One in the yard. Scullery and water supply. The back basement room has a water-tap and sink, and there is also a water-tap in yard. These serve for the whole house. No water supply or sinks on upper floors. Washhouse. The back basement room is fitted with a copper, and is available as a washhouse to all the tenants. Rents, 2s. 6d., 4s., 5s. 6d., and 6s. a week. No. (b). This house is similar to above, except that all the tenements are single rooms, and that there are two water-closets in the yard. No. (r). Similar house. Eight tenants. Two water-closets, both in yard. One water-tap in yard. One water-tap and a sink in the back basement, which is also a washhouse. All are single-room tenements except one, which is a two-roomed tenement, consisting of froi\t basement room and ground floor back room. Rents, 2s. 9d., 3s. 9d., 5s., and 5s. 6d. a week. Tufton-street, Westminster.— This street contains old houses mostly three storeys high. Some have basements and attics. No. (a). Contains three storeys, attic and basement. It is let in floors, one tenant on each floor. There are three rooms on each floor except the ground floor. The rents are 8s. 6d. and 7s. 6d. There is only one water-closet, situated in the yard. The washhouse is an outbuilding in the yard. There is one water-supply tap in the yard. No. (b). This house is let in single and two-room tenements. There are seven tenants. There are two water-closets, one on the first floor and one on the ground floor. The washhouse is situated in the basement, but is obviously not made use of. The water-supply tap is placed in the washhouse, in which is also a sink. No. (c). Occupied by four tenants, one on each floor. There are one water-closet and a water-supply tap, both in the yard- There is also a tap in the basement kitchen, but this is not available for all tenants. The washhouse is in the basement. Arneway-street, Westminster.— Contains two-storey houses, but one large house, apparently of fairly recent construction, has three storeys. No. (a). This is a three-storey house with a basement. It is let in Aoots, except one, which has two tenants. There are five in all. The rents are 5s. 6d., 9s., 10s. and 6s. 6d. a week. There are two water-closets, both in the yard. A washhouse with two coppers is situated in the basement. The water-supply tap is in the washhouse. Hanover-street, Westminster.— Contains houses three storeys high with basements. No. (a). Occupied by one tenant, who retains the ground floor, basement, and two back addition rooms. The top floor and first floor are sub-let to two other tenants. Water-supply and a sink, also a water-closet, are provided both on the upper floor and in the basement. No. (b). Let in floors, and occupied by four tenants. There is water-closet and water-supply accommodation with a sink, both on the first floor and in the basement. Westmoreland-road, Westminster.— No. (a). Occupied by one tenant, who sublets part to two other tenants. The sanitary accommodation which exists is as follows— There are two water-closets, one in the basement and one on the ground floor. Two water-supply taps, one in basement and one on first floor. A washhouse in the basement. 12 Porten-road, West Kensington-park, Hammersmith.— This is a road containing houses three storeys high with basements. Some of them are well kept and looked after, whilst others are obviously let in separate tenements to more than one occupant. The former are mostly houses occupied by one person, who sublets furnished or unfurnished lodgings. No. (a). Contains eight rooms. One tenant occupies the house, but sublets three rooms on the top and first floor to three lodgers. The sanitary accommodation consists of— Two water-closets, one on the ground floor approached from the passage, and one in the yard. A washhouse in the yard. A water-supply tap and sink in a scullery in the basement. No. (b). This house is let to four tenants, one on each floor, two rooms each, and the rents are 6s. 6d., 7s. 6d., 7s. 6d. and 6s. 6d. a week each. The sanitary accommodation consists of— Two water-closets, one on the ground floor and one in the yard. One water-supply tap in the basement scullery. A washhouse scullery in the basement. No. (c). This is occupied by one tenant, who also owns the house, and retains three rooms. Sublets to three lodgers, one of whom occupies a furnished room. The sanitary accommodation is as above. Nos. (d and e). Both these houses are let in separate tenements, and the sanitary accommodation is the same in each. At No. (e) there are six tenants, four in single rooms and two in two-room tenements. There are two water-closets, one on ground floor and one in yard. The water-supply tap is placed in the basement scullery. The washhouse is in the yard, but is not a proper place, consisting merely of a copper with a temporary roof over it. Overstone-road, Hammersmith.— The houses in this street are mostly three-storey premises with basements. Some are two storeys high. No. (a). Occupied by one tenant who retains two rooms, and sublets to three lodgers, each having two rooms. There are two water-closets, one in the yard and one on first floor. There is a scullery-washhouse in the basement. There are three water-taps, one on the top floor, one on the stairs, and the other in the washhouse. No. (b). Occupied by four tenants, one on each floor. Each has two rooms, except on top floor, which contains three. Rents, 7s. and 7s. 6d. a week each. There are a scullery and water-supply tap on first floor, and another in the basement washhouse. There are two water-closets, one on the ground floor, approached from passage, and one in the yard. The washhouse is in the basement. No. (c). Let to three tenants ; one occupies the top, one the first floor, and the third the ground floor and basement. There are two water-closets, one in yard, one on first floor. The washhouse is in basement, and is approached from the passage. There are two water-taps, one on the staircase with a sink, and one in the washhouse. Southerton-street, Hammersmith.— This street contains three-storey houses. Some have bwements, others have not. No. (a). A three-storey house containing six rooms. Occupied by one tenant, who sublets part to one other tenant. There is one water-closet in the yard. The washhouse is a back addition building approached from the ground floor passage. In the washhouse is the water-tap, with a sink. No. (b). Three families, one on each floor, two rooms each. Rents, 5s. 6d., 6s. 6d. and 6s. a week. There is one water-closet. There are two water-taps, one in the washhouse, and one on the top floor with a sink. The washhouse is a back addition building. No. (c). This house contains three storeys and a basement. It is occupied by four tenants, one on each floor, and the rents paid are 5s., 6s., 6s. 6d.. and 5s. 6d. a week. Each floor has two rooms, except the ground floor, which has three. There are two water-closets, one in the yard and one in front area ; two water-taps, one on the staircase and one in the washhouse. The washhouse is at basement level, and is provided with a sink. Fleet-road, Hampstead.— This road contains three-storey houses, and some of them have basement floors. Some of the houses are used for shop purposes. No. (a). No basement floor. One tenant occupies the house and sublets to two lodgers, but one of these is seldom there. There is one water-closet, situated inside the house off the staircase. At the end of passage on ground floor there is a scullery-washhouse, ?n which is the watersupply tap and a sink. No. (b). Here there are two tenants. The sanitary accommodation is as in No. (a). No. (c). This house has a basement floor. There are four tenants, one on each floor, each having two rooms. The rents are 6s., 7s. and 7s. 6d. a week. The sanitary accommodation consists of one water-closet on the ground floor ; one water-tap in the passage on ground floor, with a sink under it, and another in the washhouse; and a washhouse in basement at end of passage. No. (d). There are four tenants, one on each floor, and the rents are 5s., 7s. 6d., 6s. and 6s. a week. The sanitary accommodation consists of— Two water-closets, one situated in the yard and one on the ground floor. One water-tap in the washhouse. One washhouse in the basement. No. (e). This house is one of a long row of newly built premises (within eight years). They have been built with the object of housing a separate tenant on each floor. Each floor contains two rooms and a kitchen, off which is a small scullery provided with a copper and water-tap. Each tenement has its own water-closet, which is approached from the scullery. The rent of each floor is 10s. 6d. a week, and not less than a floor is let, but the tenant can take a man lodger, who lives as part of the family, if desirous of doing so. 13 Lowfield-road, II amp stead.— The houses in this street are at the present time in process of change in the mode of occupation from single families to several families. It contains houses of three storeys high with basements. Some are tenemented, others not so. No. (a). This house is let to four tenants, one on each floor, at rents of 5s. 6d., 6s. 6d. and 5s. 6d. a week each. There are two water-closets, one in the yard and one at end of ground floor passage. The washhouse is the basement back addition room, and here is placed the water-supply tap. No. (b). This house is occupied by one tenant, who sublets the top floor to one other tenant. There are two water-closets situated as in number (a) and a washhouse in basement with a water-supply tap. There is also a water-tap on the staircase near first floor. Paimerston-road, Ilampstead.— This road contains houses two and three storeys high with basements. No. (a). A three-storey house with basement. Occupied by four tenants, in two and three-room tenements. Rents, 5s. 6d., 8s., 7s., and 6s. a week. There are two water-closets, one inside, and approached of! staircase landing, and one in the yard. There are two water-supply taps ; one is indoors, and placed in the water-closet apartment, in which is also provided a sink. The other is in the washhouse. The washhouse is a back addition room in the basement. No. (b). This house is occupied by one tenant, who uses ground floor and basement and sublets upper part to two other tenants. There are two water-closets, one inside on first floor landing, and one out in front area. The washhouse is a back addition building in yard at basement level. There are two water-supply taps, one in water-closet on first floor landing with a sink, and one in the washhouse. No. (c). This house is Jet out in floors. There are four tenints, one on each floor, the rents for which are 6s. and 7s. a week. There are two water-closets, one in yard and one at end of passage of ground floor. There is one water-tap in the washhouse, with a sink. The washhouse is at basement level. Charlton-crescent, Islington.— No. (a). Contains three floors and a basement, and is occupied by three tenants, one on each floor. Two rooms on each floor, or seven rooms and a washhouse. There are two water-taps, one in the yard and one in the washhouse. The back basement room is fitted up as the washhouse. One water-closet situated in the yard. No. (b). Is a similar house to last. Nos. (c), (d), (e). These are all let in separate tenements, and have similar accommodation to the above. The landlady lives in No. (e). St. Peter's-street, Islington.— Contains houses of two and three storeys and some have basements. No. (a). One tenant occupies the house, and sublets unfurnished the first and second floors to two other tenants respectively. Six persons in all. The water-closet is on the ground floor, approached off the passage. The washhouse is in the yard. The water-tap is placed in the washhouse, and there is also a sink here. No. (b). Is a similar house. No. (c). Occupied by three tenants. There are two water-closets, a water-tap in the washhouse, and a small washhouse in the yard. Copenhagen-street, Islington.— This is a long street containing varying classes of houses two and three storeys high, some of them occupied by shopkeepers. No. (a). A three-storey house, with a basement. Two rooms on each floor, and one back addition room on the ground floor. Occupied by three tenants, two occupying three rooms each and one a single room. Rooms in basement not occupied. The washhouse is situated in the basement back addition room, and in it is provided the watersupply tap. The water-closet is in the basement. Rents 8s. and 8s. 6d. No. (b). Contains six rooms and one attic- Occupied by one tenant, who sublets one room unfurnished. There are two water-taps, one in yard and one in washhouse. The washhouse is in the back basement room. There is one water-closet situated in the yard. Bemerton-street, Islington.— Contains three-storey houses having two rooms on each floor. No. (a). Not tenemented. No. (b). Occupied by three tenants, one on each floor. Fifteen persons. There are two water-closets, both situated in the yard. One water-supply tap is placed in the yard. There is no proper washhouse, but part of the yard is covered in, and a copper is provided here. Rents. Ground floor 7s., first floor 6s. 6d., top 6s. No. (c). Contains six rooms and two back addition rooms. One tenant occupies the house, retaining four rooms and subletting four rooms to two lodgers. There are one water-tap, one water-closet and a washhouse, all situated in the yard. No. (d). Occupied by three tenants, two occupying three rooms each, one occupying two rooms. The washhouse is situated in the yard, and in it is placed the water-tap. The water-closet is provided in the yard. Nos. (e, f and g) are similar tenemented houses. Stanmore-street, Islington.— Contains houses having three storeys and containing six rooms and two back addition rooms. No. (a). One tenant occupies the house, and sublets part unfurnished to two others, viz., the first and top floors, each containing two rooms . There is a small washhouse at rear of the back addition in the yard. 14 The water-tap is placed in the washhouse. The water-closet is situated in the yard. No. (b). Is a similar house, having the same sanitary accommodation. No. (c). Similar kind of house. The two rooms on top floor are sublet. Sanitary accommodation as in above houses. No. (d). Occupied by three tenants, each two rooms, except one who takes the house and reserves , four rooms. Sanitary accommodation as above. Caledonian-road, Islington.— This is a main road with a varying class of house. No. (a). Contains three storeys and a basement. One tenant occupies the house, and sublets part unfurnished to two other tenants, each occupying single rooms. There is one water-closet, situated in the passage on ground floor. The back basement room is fitted up as. washhouse with a copper, and here is placed the watersupply tap with a sink under it. No. (b). Three-storey house with basement. One tenant occupies the house and sublets the top floor two rooms to one lodger, and the two rooms on the first floor to two other lodgers. There are a water-closet and water-tap in the yard. The back basement room is the washhouse. and is supplied with a water-tap and scullery sink. Wharf dale-street, Islington.— This road contains houses three storeys high and having basements. There are two rooms on each floor. No. (a). Four tenants, one on each floor, occupving two rooms each. The washhouse is a wooden building in the yard. There are two water-taps, one in the washhouse and one with a sink underneath it on the ground floor. There is one water-closet in yard. No. (b). This house is let in single-room tenements ; six tenants at presentThere is one water-closet. The back basement room serves as the washhouse, and here is placed the water-tap for supply ing the whole house. There is also a sink here. No. (c). One tenant occupies the house and sublets rooms to three lodgers. There are one water-closet, one water-tap, and a washhouse, all situated in the yard. Danvers-street, Chelsea.—- This road contains houses having three storeys and basement floors. No. (a). This house is occupied by one tenant, who sublets the basement, first floor and second floor to three others. The sanitary accommodation consists of— Two water-closets, one in the yard and one on the ground floor. Two water-supply taps and sinks, one in the washhouse and one on the first floor. A washhouse in the basement. Mil man-street, Chelsea.— This street contains houses having three storeys and basement floors. No. (a). This is an old three-storey house. It is let in single and two-room tenements, and contains two rooms on each floor. There are at present four tenants, consisting of ten persons and three children. There are one water-closet and one water-sunnly tap in the yard. The washhouse is a back addition building in the yard. No. (b). Contains three storeys and a basement floor. It is occupied by three tenants, one occupying two floors. There are two water-closets, one in the yard and one on the ground floor. There are two water-supply taps, one on the staircase, but no sink is provided, and the other in the yard. The washhouse is a small building in the yard. No. (c). This is a similar house. It is let in floors, and is occupied by four tenants. The rent of the ground floor is 6s. 6d. a week. There are two water-closets, one in yard and one on ground floor. The water-supply tap is placed in the yard. The washhouse is in yard. Gilray-square, Chelsea.— A considerable number of houses all of practically the same class, and with similar accommodation. They contain three storeys and basements. The back yards are at the basement level. No. (a). Let in floors and occupied by four tenants. The sanitary accommodation provided consists of two water-closets, one situated in the yard, the other on the ground floor. A water-tap in the front area. , A washhouse in the yard. Herbert-street, Shoreditch.— Contains houses of three storeys with basement and attic floors. No. (a). This house is occupied by one tenant, who sublets part to three lodgers. The water-closet is on the ground floor, and is approached from the passage. There is one water-tap in the yard, and the washhouse is a wooden structure in the yard. No. (b). Occupied by four tenants. One each on the basement, first and second floors, and one on ground and attic floors. There are fifteen persons living here, including children. There is one water-closet, one water-tap, and a washhouse, all situated in the yard. Rents, 7s., 9s. 6d., 8s. and 7s. 6d. a week. No. (c). One tenant occupies the house and sublets the first and second floors to two lodgers respectively. There are sixteen persons in the house, including children. There is one water-closet in the yard. Two water-taps, one in the back basement room, one in the yard. There is no proper washhouse, the back basement room serves for the purpose. Crondall-street, Shoreditch.— No. (a). Consists of ground, first and second floors, containing seven roomB. One tenant takes the house and sublets three rooms to one lodger. There is one water-closet in the yard and a washhouse. The water-supply tap is provided in the washhouse, in which is also placed a sink. 15 No. (b). Has three storeys and a basement and contains eight rooms. There are two tenants, one of them subletting three rooms to the other. There is one water-closet and one water-tap both in the yard. The washhouse is the back basement room, and in it is a water-tap and sink. No. (c). A three-storey house with basement. Let in single-room tenements. About twenty persons. There is a washhouse and water-tap both in the yard. There is only one water-closet. Essex-street, Shoreditch.— This is a long street with houses of a similar kind on either side. They consist of three storeys with basements and having back addition buildings on basement and ground floor levels. No. (a). There are nine tenants, each occupying single rooms. For their use are provided two water-closets in the yard. A washhouse in the back addition room at basement level. The water-tap is placed in the washhouse. No. (b). There are three tenants at present, one occupying three rooms on ground floor, one occupying two rooms on first floor, and one occupying two rooms on top floor. For their use is provided one water-closet in the yard. A washhouse in the basement back addition room. A water-supply tap in the washhouse. Gifford-street, Shoreditch.— In this street are some two-storey houses, and one row of threestorey houses, thirteen in number, and all of same character. No. (a). One tenant occupies the house, who sublets to four lodgers, one occupying two rooms and two occupying one room each. There are nineteen persons in all. There is only one water-closet situated in the yard. In the washhouse is placed the water-supply tap. Huntingdon-street, Shoreditch.— This is a long street containing houses three storeys higli with basements. No. (a). Contains nine rooms, and is occupied by four tenants, three in single rooms and one in five rooms. There is one water-closet in the yard. The washhouse is in the basement, and here is placed the water-supply tap. Weymouth-terrace, Shoreditch.— A long street, with some houses having three storeys and basements. No. (a). Contains seven rooms, and is occupied by four tenants, three in two rooms each, and one in a single room. There is one water-closet in yard. The water-tap is placed in the yard and the washhouse in the back basement room. No. (b). Similar house occupied by three tenants, two in two rooms each and one in three rooms, for which 7s. 9d. a week is paid. There are one water-closet, one water-tap and one washhouse (dilapidated), all placed in yard. Brunswick-street, Shoreditch.— This street contains three-storey houses. No. (a). Contains six rooms. It is occupied by one tenant, the two rooms on top floor to two lodgers. The water-closet, washhouse and water-tap are placed in the yard. APPENDIX III. Londom County Council. THE MANUFACTURE OF AERATED WATERS IN LONDON. Report by the medical officer presenting a report by Dr. Hamer on the results of inspection of a number of premises upon which aerated waters are manufactured. (Printed by order of the Public Health Committee, 26th February, 1903.) Public Health Department, 8, St. Martin's-place, W.C. 26th February, 1903. On the 3rd October, 1902, a letter was addressed to the Clerk of the Council by the Secretary of the Mineral Water Bottle Exchange and Trade Protection Society, Limited, stating that in populous districts, aerated and mineral waters are, in many instances, manufactured under insanitary conditions, pointing out that in New York this manufacture has been placed entirely under the control of the Board of Health, from whom a licence or permit has to be obtained before aerated or mineral waters can be manufactured, and suggesting the desirability of the Council taking action in the matter. This letter was referred to me for report, and on November 20th the Public Health Committee directed that a number of premises upon which aerated waters are manufactured should be inspected, and this duty has been undertaken by Dr. Hamer, whose report I present. Dr. Hamer is led to the conclusion that it is desirable the manufacture of aerated water in London should be regulated in the interests of the health of the consumer, mainly for the following reasons. In the first place he points out that the quantity of aerated water sold in London at the present time is very large. The trade has only attained considerable importance within comparatively recent years, but so rapid has been its growth that there is reason for assuming the amount of aerated water now consumed is at least a third, and it may be nearly half, as large as that of water used for drinking purposes in the form of cold water by the London population. While aerated water is thus largely employed as a beverage, inspection of numerous premises shows that there are many possible sources of pollution of the water during the process of manufacture, and that in particular instances risk of contamination is not adequately guarded against. On the other hand it may be pointed out that, in London, at any rate, the water used in making aerated water is derived either from a public supply or from deep wells, and assuming that its quality is not deteriorated during the process of manufacture, the resulting aerated water may be presumed to comply with the standard generally accepted in London as applicable to potable water. It has further been urged that when water is charged with carbonic acid gas under pressure the number of its contained micro-organisms is reduced and that pathogenic germs are destroyed. Dr. Hamer refers to investigations which have been made by various observers, but the results obtained are, he finds, somewhat contradictory and further knowledge appears to be needed with regard to the matter. In one or two instances in this country and abroad it has been suggested that enteric fever has been disseminated by consumption of ginger beer or aerated water. Evidence of the relationship in question would obviously be inconspicuous unless the outbreaks were of some magnitude. It appears, as the result of Dr. Hamer's inquiry, that there would be advantage in regulating, in the interest of the consumer, the conditions under which aerated waters are manufactured, although having regard to the want of precise knowledge as to the influence exerted upon germs by carbonic acid gas under pressure, it is difficult to estimate how far the possibilities of contamination referred to by Dr. Hamer can be regarded as constituting a serious menace to the health of aerated water drinkers. Shirley F. Murphy, Medical Officer of Health. Dr. Hamer's Report. Attempts to produce artificial aeration of water were made from time to time in the eighteenth century, but it was not until the close of that century that the manufacture began to assume anything like commercial importance. One of the earliest experimenters was M. Venel, and two memoirs on his work were read before the Royal Academy of Sciences in 1750. Dr. Joseph Priestley, in 1767, devised a method of charging liquids with what he termed " fixed air " by exposing shallow pans feinted 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. 631. Price 3d., or post free 3½d. [6328 2 containing water near fermenting vessels in a brewery. In 1772 he employed gases obtained from decomposition of chalk, etc., which he confined in an air-tight vessel, and, according to Professor Huxley, to Priestley really belongs the credit of inventing soda water. Between 1807 and 1852 thirty-one English patents for apparatus for preparing aerated water, for methods of bottling, etc., were taken out; the applications under the title " aerated liquids, mineral waters, aerating," during the years 1882-1886 inclusive, numbered 95. Since the year last-named there has been a very great development of the industry, and it is stated in " Thorpe's Dictionary of Applied Chemistry " that there are now manufactories of these beverages in nearly every town in the kingdom. The number of accidents caused by bursting of bottles raised question as to the need for regulation by " special rules," and such rules (dealing with provision of wire gauze faceguards, masks, etc., the use of gauntlets and the fencing of machinery), were issued by the Factory Department in 1897. The desirability of exercising control in the interest of the consumer of aerated water has from time to time been suggested, both in this country and on the Continent, but it was reserved for New York to make a first attempt in this direction; under section 202 of the Sanitary Code of the Department of Health of that city, no person may manufacture or bottle mineral, carbonated or table water without a permit. The example of New York is said to have been followed by other cities in the United States. In the following report an attempt will first be made to estimate the extent to which aerated waters are consumed in London, then the risks of contamination to which water is exposed in process of manufacture will be considered, the nature of the bacterial flora of aerated waters and the possibility of spread of disease by this means will be referred to, and finally the question as to the steps which may advantageously be taken to protect the health of the public will be discussed. The amount of aerated water consumed in London. The census returns show the number of males and females returned under the heading " Ginger beer, soda water, etc., manufacturer," and these, so far as London is concerned, are given in the annexed statement, which also contains, for purposes of comparison, the number of persons returned under the heading " Brewer." Ginger beer, soda water, etc., manufacturer. Brewer. M. F. 1861 401 – 3,006 1871 599 – 3,693 1881 924 79 2,907 1891 829 240 3,191 1901 1,153 603 3,406 These figures show marked increase in the number of ginger beer, soda water, etc., manufacturers in recent, as compared with earlier census years; they also indicate that female labour is being employed in this industry more and more as time goes on. Mr. Idris, J.P., L.C.C., has very kindly given me particulars which enable an idea to be formed of the extent to which aerated waters are now being consumed in this country. It appears that 22,000 horses are employed in the industry in the United Kingdom, and from this it may be estimated, on the usual basis, that there are 70,000 persons employed, and capital invested from 30 to 40 millions. It is important to realise what these figures represent in quantity of aerated water consumed, and thanks to Mr. Idris I am able to translate them in this sense. It transpires that the total consumption per annum in the United Kingdom is upwards of 300,000,000 dozen half-pints. The larger portion of this amount is sold in the north of England and London. It" the total quantity consumed be divided by the number of persons in the United Kingdom, the average consumption, per head of population, will obviously be far understated for London and the north of England. A fairly close approximation to the average consumption per head of population in the localities named may, perhaps, best be made by dividing say ¾, i.e. 75 per cent., of the total amount consumed, by 15,000,000. On this basis some 15 doz. half pints would be the average consumption in London per head per annum, i.e., ¼ pint per head* per diem. Of course in summer time this average would be exceeded, in cold weather it would not be attained. From inquiries which I have made of a number of persons living under various conditions in several parts of London, and from an independent calculation based upon observations I have made in the East-end of London, I am led to the conclusion that the figure given under-estimates rather than over-estimates the amount for London as a whole, while there can be no dcubt that it falls far short of the consumption per head in certain neighbourhoods. It is interesting to compare the amount of liquid of various kinds consumed in London. The "Alcoholic Beverages" returns, made by the Board of Trade, give particulars relating to beer, spirits and wine ; there are also available records concerning tea, coffee, etc. These figures relate, of course, to the United Kingdom. In an article in the "Quarterly Review" (1900), entitled " The Food of London" the amount of various beverages consumed in London is discussed; particulars of interest in connection * Ginger-beer, and some other beverages of an allied character, in which aeration is effected by fermentation processes, have been, in making this calculation, included under the designation " aerated waters." it is important to bear in mind that there is a difference between such forms of gmger-beer, etc., and soda water, etc., in that, in the case of the former, there is a preliminary boiling process which does not, as a rule, find any place in the manufacture of the beverages last referred to. The distinction is one which may prove to possess importance from a health point of view. 3 with beer are given in Mr. Charles Booth's "Life and Labour of the People," and the statistics of the London milk supply are examined in a paper contained in the "Journal of the Statistical Society, 1892." There remain, however, two difficulties with regard to making a complete statement concerning beverages consumed by Londoners. In the first place the quantity of tea, coffee, etc. needs to be converted into terms of amount of the liquid infusions in question actually consumed. This must necessarily be, to some extent, a matter of conjecture. Secondly there remains the question as to cold water. To attack this problem directly would involve very extended inquiry, so dissimilar are the habits of individuals as regards use of cold water. I have endeavoured to arrive indirectly at a solution, by fixing the average amount of liquid of all kinds consumed, deducting from this everything except cold water, and finding what remains. Judging by experience of institution dietaries and by figures given in treatises on physiology, etc., some 3 pints may be regarded as the average amount of liquid of all kinds consumed per diem by the unit of population. According to Parkes "an adult requires daily about 70-100 ounces (3½-5 pints) of water for nutrition, but about 20 to 30 ounces of this are contained in the bread, meat, etc., of his food. . . . women drink rather less than men, children drink of course absolutely less, but more in proportion to their bulk than adults." Sidney Martin estimates the total amount of water, including that taken in food, at 70-80 ounces daily. Observations made concerning selected individuals, and calculations based upon physiological needs, do not take account of hard drinkers, of whom there are many in London, and for the present purpose some allowance must be made for them. Instead of the physiological 3 pints I prefer therefore to fix the average at 3¼ pints.* The following amounts may then be taken as being approximately correct— Beer 16 ounces. Aerated waters 5 ounces. Wine, spirits, etc., 2/3 ounce. Milk 51/3 ounces. Hot drinks (tea, coffee, cocoa, broths and soups) 23 ounces. This leaves a balance of about f pint which may be assigned to cold water. Had the physiological 3 pints been taken as the average of total liquids, only ½ pint would have been left to be assigned to cold water. If the additional allowance made, in consideration of the hard drinking done in London, had been more than ¼ pint, then the balance left to be assigned to cold water would have exceeded ¾ pint. The quantity of beer given above is, at first sight, surprisingly large,† the figure is even more significant when regard is paid to the fact that many persons drink no beer at all, and that the average is therefore necessarily maintained by the consumption of large amounts by a section of the population. Londoners may be divided into three practically equal groups, men, women, and young people (under about 17 years), and the following approximate statement may be made concerning the average consumption per unit of the population belonging to each of these three groups— Young persons. Women. Men. Beer - About 12 oz. 1 pint 16 oz. Wine, spirits, etc - ⅓ oz. 1⅔oz. Aerated waters ¼ pint ¼ pint¼ pint Milk 11 oz. 3 oz. 2 oz. Hot drinks 1 pint 1 pint 8 oz. 1 pint Cold water 1 pint 15 oz. 10 oz. Total 2 pints 16 oz. 3 pints 4 oz. 3 pints 15 oz. These amounts are of course only approximate, and the allotment of quantities of beer, wine and spirits to men and women, respectively, is more or less a matter of guesswork. The large average consumption of alcohol per unit of population is, it may safely be assumed, in great part attributable to the excessive quantities taken by a section of the population; the man who habitually drinks 6-10 pints of beer or ¼-½ pint of spirits daily, naturally raises the average for men generally. The most interesting result of the above analysis, from the point of view of this report, is the fact that the quantity of aerated water is at least a third, and it may be it is as much as half, as large as the total amount of cold water consumed. Cold water is for one reason or another steadily falling out of favour; the Londoner of to-day drinks rather more alcohol (wine, spirits and beer), and five or six times as much tea as did the Londoner of fifty years ago. Had the habits of persons who lived in the years of great cholera prevalence, between 1830 and 1866, been those of the modern Londoner, the * Inquiry made among common lodging-house inmates by Mr. Shapley, one of the Council's inspectors, indicates that on an average about 4 pints of beer are consumed daily, in addition to some spirits and a considerable quantity of tea ; lodgers appear to eat comparatively little solid food, but many of them spend all that is left, after paying for this and for their bed, upon beer. Among 30 lodgers taken at random, 3 said they never drank beer, the remaining 27 specified the following amounts as having been consumed by them on the preceding day (an ordinary week day in February); in one instance ½ pint; three said 2 pints; ten 3 pints; five, 4 pints; two, 5 pints; one, 6 pints; one, 8 pints; two, 10 pints; and the two remaining had drunk far more but could not remember how much. A fish-porter, questioned by Mr. Jury, the Council's chief inspector, fixed his previous day's expenditure upon beer at "five and a penny." He had received 5s. 8d., had spent 6d. on his bed and 1d. on food, for the rest he had passed a particular public-house 60 times, in going and coming on 30 separate journeys, and each time had looked in, and further, had had a final half-pint at the end of the day. †It may be noted that Messrs. Rowntree and Sherwell computed that in the United Kingdom the expenditure per week by each working class family upon alcoholic drink was at least 6 shillings. 4 ravages of the disease would doubtless have been less considerable than they were. Coincidently with increased recognition of the need of safeguarding the purity of potable water, there has apparently been diminution in the use of cold water as a beverage, for there has been steady increase in the consumption of liquids other than cold water. The palatability of water is well known to depend largely upon its contained gases, and it may be that the growing popularity of aerated waters is in part attributable to the fact that modern methods of water supply have in some instances led to loss by the water of its sparkling quality, and thus to a sense of need of this quality being again imparted to it by artificial means. Many women and children and some men frequently drink London water, but I have been surprised, on making inquiry, to find that a large number of persons only do so quite exceptionally, and not a few men appear only to take water when admixed with spirits. In places resorted to by the public for meals, very little water is as a rule consumed ; the greatly increased consumption of tea and coffee must imply greatly diminished consumption of other forms of beverage, and probably cold water has suffered more than anything else. The common practice of providing water-bottles in offices, board-rooms, etc., must be regarded rather as throwing light upon the habits of a past generation of Londoners than as indicating that cold water is largely consumed by business men during office hours at the present day, for I am told that these bottles are not as a rule used. Among common lodging-house inmates cold water is looked upon as a medicine, and in only exceptional instances is it resorted to as a means of quenching thirst. The steady growth in popularity during recent years of aerated waters is, in so far as they replace alcoholic beverages, fraught with most important influence for good, and it is especially desirable therefore that there should be reason for assuming that due care is taken in the processes of manufacture, and that all avoidable risks are adequately guarded against. Inspection of premises upon which aerated water is manufactured. I have visited a few large and medium sized factories, and a considerable number of the smaller establishments upon which aerated water is made. The premises of the large makers present a general similarity so far as the processes of manufacture are concerned, though the class of goods produced is not in all instances identical. Some makers carry on what is known as "a grocer's business," others deal in the main with hotels and public-houses, others supply chemists' shops more particularly, and again a very large trade is carried on in "highly sweetened, fancy, cheap goods," which are retailed at general shops, especially in the poorer parts of London. Numbers of small makers are to be found in the Bast-end; they are as a rule foreign immigrants, and their prices rule much lower than those of the English makers. One of the latter told me that " the foreigners " were selling "two-dozen boxes" for 9d. (retailed at 1s.), the goods being, so far as appearance of bottles, etc., was concerned, such as he had been for years supplying at 1s. 6d. (retailed at 2s.). In Stepney I have found, in the same little general shop, both "halfpenny foreign lemonade" (purchased by the retailer at 4½d. *a dozen, and sold at 6d.), and lemonade made by one of the London manufacturers (purchased by the retailer at 1s. per dozen and sold at 1s. 6d.) The foreign makers may be divided into three classes. In class I. the operations resemble those of the large makers, but are conducted on a less extensive scale. In class II. bottling is carried on in quite a small way, the carbonic acid is not as a rule made on the premises, but cylinders containing liquid carbonic acid are employed; "a cylinder" for mixing water with the gas, "a filler" and a pump are ordinarily used—these can be purchased, I was told, for from ,£35-£40 ready money; in many instances, they are, however, paid for on the instalment system, and this arrangement leads sometimes to far larger sums being ultimately expended. The appliances for cleansing bottles in places of the kind under consideration are more or less similar to those seen in larger establishments but frequently they are of a much more primitive character. In class 111. no bottling is done but a cylinder of liquid carbonic acid is kept, in or near to a shop, often in a cellar beneath it; the gas is mixed with water in a mixer and conveyed to a tap situated over the shop counter, so that it can be drawn off, added to one or other kind of syrup and sold, usually at ½d. a glass, as Hollands, raspberry, aniseed, lovage, shrub, pineapple, etc., according to the taste of the consumer. These ½d. glassfuls are purchased largely by foreign tailors, shoemakers, etc., and I was repeatedly told that the trade in cheap aerated waters was producing an appreciable effect upon the sale of beer. With the foreign immigrants beer has never, it seems, been a popular drink, and I was assured by a foreign aerated water manufacturer in Whitechapel that "four-ale" was losing ground with the native population resident in his neighbourhood. This man pointed out that whereas two glasses of "four-ale" for a man and his friend cost 2d., two glasses of aerated water could be obtained for 1d. It is impossible to consider in detail in this report the mechanism of the many forms of apparatus in use at premises upon which bottling is carried on. I propose therefore merely to refer to some of the obvious risks of addition of impurity to aerated water which have come under my observation. (i.) Source of supply—First and foremost there is the question of the source of the water employed. In London it is generally derived from a public supply; a few of the large firms have private wells, and the water from these wells is, in most instances, from time to time analysed. (A number of such analyses are given in the Medical Press of Jan., 1899, p. 49.) It is clearly desirable that systematic examination of the water from these wells should be made by a public authority. Again, the water used for washing bottles, etc., should be of equally good quality with that actually charged with gas. In the Medical Press (loc. cit.) mention is made of an instance in which a manufacturer, who found his water supply was unsatisfactory, changed it, but contemplated, until dissuaded from doing so, using the old supply for the purpose of washing bottles. * I am told that "cutting the price " is sometimes carried to the extent of supplying a dozen half-bottles of "soda water" for 3½d. 5 (ii.) Filtration.—In some cases the water is filtered before use, and in a few instances the most approved forms of filter are employed; in others, reliance is placed upon charcoal, etc.; in one case, in which this latter condition of things obtained, I was told that the filter was only cleansed at intervals of some months. The filtration, designed as a safeguard, must in this case have been a source of added risk. In special instances distilled water is charged with gas and sold as aerated water, some customers insisting upon distillation as a sine qua non. (iii.) Storage tanks.—A frequent source of impurity in small bottling establishments was found to be the interposition of a receptacle between the water main and the cylinder in which the gas and water are mixed. In some of the forms of apparatus, in common use in East London, the water from the main is conveyed directly into the mixing cylinder; under such circumstances the question whether the said cylinder is placed in a position in which it is remote from any source of aerial contamination, is clearly less important than is the case when the water is first passed into a jar or cistern and then pumped into the cylinder. As a rule, when this latter condition of things was found to exist, the jar or cistern was kept covered and was fairly clean, but in a few instances particles of dust, soot, etc., were seen floating on the water, the state of cleanliness of the receptacle itself was not beyond criticism, and the atmosphere in which the water stored was being kept was a polluted one; thus in one case, bottling operations were being carried on in one part of a shed, another part of which was being used as a stable, and the water, before passing into the mixing cylinder, was exposed in a receptacle and was immediately in contact with the stable air, highly charged with ammonia and presumably with other impurity, inasmuch as there was an accumulation of dung in the shed, not far away from the bottling apparatus. In numerous instances the apparatus used was placed in the back yard in near proximity to the water-closet; in some cases the cylinder and the receptacle for storing water were found in an ill-ventilated cellar, or in a dark partitioned-off space behind the shop ; twice I found the apparatus within a bedroom, in one instance a storage receptacle was used, in the other the cylinder was supplied directly from the main. (iv.) Cylinders, etc.—The question of the cleanliness of cylinders and mixers and of their liability to contribute metallic impurity to the water, is an important one. Inasmuch as water is almost continuously circulating through the tubes, pipes and various parts of the apparatus, it might be thought that there was little opportunity for collection of sediment. As a matter of fact, it has been found in some instances that the water from a cylinder has become so turbid that it has been necessary to have the cylinder washed out, and. from time to time, cylinders are sent back to the maker to be retinned, or to have defects in their tin lining repaired. One manufacturer held it was necessary this should be done only every four years, others found it desirable to have the cylinder examined at much shorter intervals in order to prevent leakage. I was told by a manufacturer, who had never found it necessary to have his apparatus overhauled, that the water must be quite free from impurity, as if this were not the case it would block the pump, and no difficulty had ever arisen on this score. The trade appears to be particularly alive to the need of taking precautions to prevent lead poisoning; the use of copper cylinders lined with tin is said to be found satisfactory, provided the lining remains intact; all piping, etc., liable to be acted upon by the water needs also to be protected. The use of glass tubing has in some cases been tried, and the substitution of wooden for metal receptacles has been advocated. It may be noted that the liquid carbonic acid which is supplied in cylinders seems to be, in all instances, taken upon trust by those who use it; in the absence of proper precautions it is, however, conceivable that impurity might be communicated to the aerated water by this means, though the contingency is probably a remote one. (v.) Cleansing of bottles.—This is an all-important question. The ordinary practice is to first soak the bottles in a tank of warm water; in the large establishments steam is laid on to these tanks. In many instances an apparatus, containing a number of trays disposed radially around a horizontal central axis which revolves, is used, and as a tray comes to the surface the bottles in it are removed and cleansed; the tray is then filled once again with bottles and caused to descend into the warm water, the tray next in order being dealt with. The water in which bottles are soaked becomes "very gummy" and labels and flies may be found floating upon the surface; in some cases fresh water is continually running into the tank, in others the water is only changed once a day, or less frequently. I was informed, in one instance, that the water of the soaking tank was changed once every two days in winter, but had to be changed once a day in summer, on account of the flies. When the bottle is removed, after the preliminary soaking, its interior is brushed with a revolving brush and the bottle is then placed on one of the columns of a rack. Each of these columns has, as a rule, an aperture at its extremity through which a forcible jet of pure water is discharged, for a few seconds, into the bottle, which is then allowed to stand in order to drain. The revolving brushes which are used are renewed once every two or three days, sometimes more frequently. Many of the bottles brought to the works are in a very dirty condition, some come from dust depots, some have been used for holding dirty liquids. Special difficulty is experienced in dealing with those which have contained paraffin or other oily material. In not a few instances the bottle is destroyed; it is not worth while to attempt to cleanse it. A good deal of care is exercised as a rule in eliminating bottles of doubtful character. In large factories each bottle before being consigned to the tank for washing, must be "passed" by a girl, who, taking up bottle after bottle in rapid succession, holds them momentarily to her nose, and passes them on. The rapidity with which this process of "passing" bottles is conductod, makes it doubtful whether a very slight degree of offensiveness would be detected. It is especially desirable, it appears, to discard the bottles which have held paraffin, as the admission of one such bottle to a tank is a serious matter. The manufacturer already referred to, who changed the tank water every two days in winter, regretfully stated that he was sometimes compelled to change the whole of the water, by reason of the fact that such a bottle had obtained access to it. Again, if a dirty bottle is placed over the revolving brush, it may be deemed necessary to renew the brush forthwith, and this is therefore a contingency against 6 which the workers are expected to be on their guard. In no respect are there more striking differences in individual establishments than in the matter of precautions as to the cleanliness of bottles. In the large factories careful attention is given to the question. The preliminary cleansing is effectually carried out and, after the final rinse with clean water, the condition of the bottle leaves little to be desired. It may be that still better results might be obtained if the process of cleansing were supplemented by a further soaking in clean water and a second final rinse with a water jet; this second cleansing being carried out quite independently of the first. There would be advantage in conducting the preliminary cleansing upon some other part of the premises than that in which the bottling is done. In the case of the final cleansing, it is desirable that some attention should be given to the personal cleanliness of the workers engaged. The same principle should hold good, too, as regards bottlers, etc. This would, of course, necessitate provision of lavatory accommodation for the use of workers. In some instances, while the general arrangements are well designed, there appears to be a tendency to err on the side of economy in the use of fresh water and clean brushes. In many of the smaller places the water in the tanks was found to be very dirty, and was only renewed at intervals of many hours, the racks on which the bottles were placed to drain were not kept clean, the brushes were in need of being renewed, having obviously done their work and not infrequently there was no special provision made for a final rinsing of the bottle with clean water. Dr. Chas. Slater, Lecturer on Bacteriology. St. George's Hospital, in a paper to be presently more particularly referred to, has drawn attention to the fact that bottles intended to contain water which has been boiled, distilled, or otherwise purified, are sometimes finally "bottled with an admixture of ordinary tap water," inasmuch as "the spray with which the final rinsing is done is usually obtained from the mains of the company in whose district the factory lies, this supply being the most convenient on account of the available pressure." He says, "the use of main water for rinsing by the manufacturer whose aerated water is made from the same supply, is logical enough, but those makers who work on the assumption that purification processes are necessary, to secure the safety of the waters, should avoid stultifying their efforts. An examination of bottles has shown, as was to be expected, that they are far from sterile. They are used almost directly as they come from the spray, that is while still very wet, or after standing inverted for a day or two to drain. It was found by experiment, however, that in the great majority of inverted bottles, 48 hours after rinsing, there was a considerable quantity of unevaporated water, which gave rise to copious growths in nutrient bouillon." In the large majority of cases, it may be pointed out, the water has not been boiled, distilled, or otherwise purified, and here all that can be reasonably claimed, is that after the final rinsing with tap water, the bottle shall contain no impurity other than foreign matter derived from the tap water itself. This standard of cleanliness is certainly not in many instances attained in London at the present time. (vi.) Corks—In the case of corked bottles the question of cleansing the corks has to be considered. No attempt is made, as a rule, to effectually disinfect the corks after the manner usually recommended, for example, in the case of infants' feeding-bottles. The rubber rings are generally speaking not removed (and the same remark holds good with regard to the rubber rings of the ballstoppered or "Codd's bottles") unless they are defective, and I was informed by one maker of aerated water that his stoppers would not stand immersion in hot water. The water used in several instances which came under my notice was merely lukewarm. Hence, as a rule, reliance is merely placed on a prolonged soaking of the stoppers in warm water, and on the final administration of a rinse with clean tap water. Syphons are not it appears systematically cleansed at each refilling, but from time to time it is necessary to take them to pieces, and then the opportunity is taken of cleansing them. The final test to which bottles are subjected is that of passing the "sighter." To this functionary, usually a girl, the bottles are passed after "filling" (and subsequent "wiring" in cases in which ordinary corks are used); she holds up two at a time, one in each hand, glances momentarily at them, and rejects any which are found to contain particles of glass, straw or specks of dirt. The "sighter" is subjected to some risk in the not infrequent event of the bottles exploding while she is handling them, and under the special rules of the Home Office must be protected with gloves and a mask. The mask is more effective if thin-meshed, and it may be (opinions seem to differ a good deal on this point), that the meshes are apt to interfere with precise definition of small objects held close to the mask. Whether this be the case or not, the rapidity with which the sighter handles the bottles obviously precludes the possibility of her accomplishing more than the discovery of foreign particles of some size, and anything like a very critical examination for suspended matter cannot be expected. I have held up numbers of bottles to the light and examined them, more particularly during the past few weeks, and as a rule found them free from obvious visible impurity. It is by no means rare, however, to find suspended particles in bottles of aerated water. I have repeatedly found this to be the case since my attention was first directed to this question two years ago. During my recent inspection I only found one distinctly dirty collection of bottles; they belonged to a foreign immigrant, in Stepney, who carried on the business of bottling in quite a small yard, about 11 feet by 12 feet, in which was situated a water-closet; tho yard was not tidily kept and the water used was exposed to contamination by sooty particles and dust. Several of the bottles, filled three days previously, were turbid and two of the worst of them contained many fine filaments, specks and masses which looked like colonies of mould. One of the workers here informed me that much difficulty was experienced with bottles, more particularly in summer and whenthey had been kept a few days. Several times last summer bottlesfilled at these premises had been returned by customers who had complained that they were dirty. I examined many other bottles of aerated water, manufactured by foreign immigrants in Stepney, but did not detect suspended impurity in them. In one instance after careful examination of a number of bottles the occupier of the premises observed "you won't find those bad for ha'penny stuff," 7 a remark which might be taken to imply the speaker's belief that the condition of his goods was exceptional, and that the cheap aerated waters made in Stepney were not as a rule above criticism. Dr. Thomas, the medical officer of health of Stepney, has kindly analysed a couple of samples of these cheap waters for me, but the results obtained do not indicate the presence of impurity. I was told by an English maker, in Stepney, that there is a special tendency for "sweet goods" to become "piecey," as he expressed it, and he added that he had had much trouble at one time, but had overcome his difficulties by making use of a different sort of sugar. I examined a number of bottles bearing the names of well-known firms but did not find any "piecey" bottles, or indeed any to which exception could reasonably be taken on the ground of there being visible turbidity. I have, however, noticed that the sweet lemonade of an English maker is apt at times to present considerable numbers of visible particles. Microbes in aerated waters. The opinion appears to be widely entertained that the process of submitting water to aeration is destructive of germs; that in fact water after being charged for some time with carbonic acid is practically free from micro-organisms. This view has, no doubt, contributed largely towards popularising the use of aerated waters, and it is not a little surprising—having regard to the results obtained by investigators—to find that it is so generally accepted. A comprehensive inquiry into the matter was made some years ago by Dr. Slater, and a brief summary of a paper contributed by him to the "Journal of Pathology and Bacteriology," vol. i., 1893, p. 469, may here be given. It appears Sohnke showed in 1886 that the number of organisms in aerated water underwent diminution when the bottles had been kept for a long period (1-9 months), and that such waters, when examined 3-4 years after bottling, were practically sterile. Leone concluded that the diminution in question was not due to displacement of oxygen, but rather to the presence of carbonic acid. Hochstetter was inclined to question the germicidal action of carbonic acid; in ten of the 24 fresh samples which he examined he found from 10,000 to 70,000 or more micro-organisms per c.c. Reinl found great variations in the number of organisms in different samples. Dr. Slater's own observations showed that eleven samples, examined within 24 hours of aeration, presented from 354 to 2,919 micro-organisms per c.c.; that nine samples, examined from 48 hours to 7 days after aeration, presented from 51 to 2,615 micro-organisms per c.c., and that ten samples, examined three weeks or more after aeration, presented from 3 to 2,000 micro-organisms per c.c. The microbes found were for the most part bacilli, micrococci being less common, yeasts rare, moulds very variable in number, but on the whole more common in small bottles than in syphons; the proportion of liquefying organisms was never large. Dr. Slater selected samples prepared from waters of different kinds, the ordinary London river and deep well supplies—artesian well waters—distilled water and boiled water. He found that "the differences in the source of water supply or the purifying treatment it undergoes can scarcely be traced in the finished water" and hence he concludes that "bacterial examination gives no information as to the original purity of the sources of supply." He tested the behaviour of various pathogenic organisms when kept in bottles of aerated water and found the spirillum choleras of Koch and the spirillum described by Finkler and Prior as occurring in cholera nostras, very little resistant; staphylococcus pyogenes aureus was rather more hardy; bacillus typhosus and bacillus coli communis remained viable about a fortnight, and bacillus liquefaciens fluorescens was recoverable from the water after five weeks. The action of the pressure factor he regarded as unimportant, the organisms dying as quickly in water thoroughly saturated with gas as they did in water in which the gas was under pressure. The observations of Scala and Sanfelice are, Dr. Slater notes, in agreement, with this conclusion, though these observers pointed out that water thoroughly saturated with gas was more destructive to micro-organisms than water not saturated. Slater lays stress on the fact that the decrease referred to was most noticeable after three weeks, and he points out that although of general, it is not of constant, occurrence. It is due, he says, to the presence of carbonic acid, loss of the gas being followed by increase in the number of micro-organisms. "The bacteria therefore are not in all cases killed, but have their development arrested." Slater concludes that" aeration undoubtedly increases the safety of water," and that it "offers a practically absolute safeguard against cholera," though it affords less complete security against enteric fever ; he remarks that if obtained" from a good source and kept for more than fourteen days"* the water would "appear to offer complete safety from the usual water-carried diseases." In long-kept waters Slater says it is usual to find a few moulds, occasionally a colony of bacillus fluorescens liquefaciens, and variable and sometimes large numbers of colonies of baoillus luteus, an organism specially resistant to aerated water. In the case of the observations just referred to, the water employed in the process of manufacture was derived from a public supply or from a deep well, and in some instances the original water had undergone treatment with a view to its further purification. It is interesting to turn, therefore, to the results obtained in India, inasmuch as in some instances the water used was apparently of a far less satisfactory character than London water. In a paper "On Microbes in Soda Water" in the Indian Medical Gazette of December, 1893, p. 401, Hankin gives the results of investigations made in Agra. In several samples of aerated water examined, in which there was question as to the purity of the original source of water supply, the numbers of bacteria found were much larger than in London. Thus, in the case of one maker, 1,400 organisms per c.c. were found in the soda water, and a bottle of "tonic water" contained 4,900 microbes per c.c. Another maker's soda water contained 16,400 microbes per c.c. The soda water of a third manufacturer contained 4,100 organisms per c.c.; this maker stated that he used the municipal supply exclusively, but on examination the water was found to contain " various crustacea and mosquito larvae, whose presence threw some doubt on the accuracy of his statement." The original water used by a fourth manufacturer yielded 60,600 micro-organisms per c.c.; * E. Pfuhl has recently stated (Zeitschrift fiir Hygiene und Infectionskrank/ieiten, 1902) that he finds living typhoid bacilli in seltzer water after at least 27 days exposure. 8 his soda water contained 15,700 per c.c. A fifth maker's soda water contained 12,400 organisms per c.c. and that of a sixth maker, who used an inefficient filter and admitted that he washed his bottles in well water, contained 25,600 per c.c. An examination which was made of the aerated water manufactured at the East Surrey regimental soda water factory brought to light a fact of some interest. It was found that the original water contained only 11 organisms per c.c., and that this water was actually boiled before use, a procedure which Hankin, after examining the water, looked upon as being quite on a par with endeavouring "to paint the lily." Nevertheless the soda water made at this factory contained 4,800 microbes per c.c. Hankin found explanation of this apparent anomaly in the fact that the water employed for washing the bottles contained after use 26,400 organisms per c.c.; it was derived from a suspected well, but the high degree of impurity was no doubt mainly due to "dirt, perspiration, etc., from the hands and clothes of the coolies" who conducted the washing operations. Hankin's conclusions differ in some important respects from those already quoted; thus, he states that" the gas in the soda water acts as a poison to the microbe, so that a bottle which was teeming with bacteria when first used is generally perfectly free from them at the end of a week." He finds, as did Slater, that "the cholera microbe appears to be the easiest to kill," and adds "the typhoid microbe is unfortunately among the most resistant to the action of carbonic acid." Again, he states that " soda water in India, owing to the high temperature, has to be bottled at a much higher pressure than in England (180 lbs. as against 30 or 40 lbs per square inch), and it is probable that in the Indian soda water the gas acts on the microbe at this higher temperature, and pressure greatly aids its action." He goes on to contrast the results obtained by him in the case of a particular organism (bacillus liquefaciens fluorescens)with those obtained in England by Slater. In India the organism, even after 36 hours' stay in aerated water, was enfeebled and lost the power of producing green colouring matter, whereas Slater found it living and uninjured more than 5 weeks after bottling. Hankin says "I venture to conclude that the gas at relatively low pressure in English soda water is a less powerful germicide than that present in Indian soda water. However this may be, it is clear that any risk of infection from bad soda water can be avoided if it is kept a week or more before use." It will be seen that Hankin seems to have found the samples examined, more than a week after bottling, sterile, and that he attributes important germicidal influence to the pressure factor. These facts are not in agreement with the results referred to as having been obtained in temperate climates. G. Malfitano (Giornale della Reale Societa Italiana d'Igiene, Milano, 1897, xix, 545-551) found, as the result of experiments which he made, that some germs were killed by exposure for 60 hours to a pressure of 50-60 atmospheres, but that, even under these conditions, complete sterilisation was not produced. Illness attributed to the consumption of aerated water. The two diseases which must be regarded as water-borne par excellence are cholera and enteric fever. No instance of communication of cholera by aerated water appears to have been noted, although in India, where cholera is specially prevalent, aerated waters are largely consumed. The speedy destruction of Koch's spirillum in water charged with carbonic acid gas may possibly account for this. Ginger-beer* has, in one or two instances, been suspected of causing spread of enteric fever, and Hochstetter refers to an outbreak of the same disease at Mainz in 1894, which was attributed to contaminated aerated water. Having regard to the large quantities of aerated water consumed in this country, it might perhaps have been anticipated that if enteric fever were ever actually spread by this means, the fact would have been by this time rendered sufficiently apparent. It needs to be borne in mind, however, even assuming it possible for aerated water to be potent for mischief, that the fact of a number of sufferers from the disease having all consumed the same aerated water is less likely to be established, than would be the fact, say, of there being a common drinking water or milk supply in the case of those attacked. Again, the bacteriological finding is to the effect that the bacillus typhosus cannot live long in water charged with carbonic acid. Hankin appears to consider the water safe 7 days after bottling. Slater is only satisfied with an interval of 14 days, and even then stipulates that the water must originally have been obtained from a good source. The observations of the latter observer regarding the increase in the number of organisms when the water is kept, after escape of the gas, and his conclusion that the bacteria "are not in all cases killed, but have their development arrested," need also to be borne in mind. The possibility of other forms of disease (gastro-intestinal disturbance, diarrhoea, etc.) being caused by the consumption of aerated water, prepared from impure water or to which impurity has obtained access in the process of manufacture, is not an altogether remote one. In the existing state of knowledge no great reliance can be placed upon the disinfecting action of carbonic acid, and even if the water has been bottled a considerable time, there is no certainty that among the more resistant forms of organisms which survive, there may not be pathogenic germs. A special source of risk in the case of aerated water is that, at some stage in the process of manufacture, the water may have taken up metallic impurity. This question seems to have engaged a good deal of the attention of manufacturers. It is stated in an article "On mineral water machinery and metallic contamination" (Lancet, January 7,1893), that ordinary water containing excess of carbonic acid is capable of taking up into solution distinct quantities of lead, copper and zinc, but not tin. Dr. Slater, in referring to risk of lead-poisoning, says this source of danger has "been practically eliminated by the use of block-tin pipes, thickly-tinned cylinders, and syphon heads consisting of almost pure tin, or protected by porcelain linings or electro-plating." In occasional instances metallic impurity has been detected in aerated waters, and though apparently, at the present time, most of * See the Milroy Lectures, 1902. Dr. Corfield refers to an inquiry made by Dr. Parsons concerning a special incidence of the disease upon young adult males employed at an ironworks. "The beverage commonly in use by such persons was gingerbeer, made often at home from the water of polluted wells, and not wholly boiled." 9 the apparatus in use is probably constructed in such a way as to prevent such addition under ordinary conditions of working, it may be that, unless due care is taken from time to time to see that the protective lining of cylinders, pipes, etc., is intact, the water becomes exposed to risk of contamination. The need for systematic inspection of premises upon which aerated water is manufactured. In the light of present day knowledge, as to the bacteriology of aerated waters, the question as to the amount of risk associated with their consumption must, it appears to me, be left unanswered. At the same time, there would be great advantage in placing premises upon which aerated waters are manufactured under systematic inspection; on many of these premises conditions exist which are open to grave sentimental objection even if they be not regarded as menacing the health of the consumers of the water. In many instances these conditions admit of easy remedy, and some of them could, no doubt, be dealt with under the existing law. In reporting upon the preparation and sale of food in London, in 1899, I drew attention to the need for the more thorough inspection of places in which food is prepared and stored, and my present inquiries lead me to conclude that it is at least as necessary that premises upon which aerated waters are manufactured should be periodically inspected, that steps should be taken to remedy defects at these premises which can be remedied under the Public Health Act, and that all obvious sources of contamination should be as far as is reasonably practicable guarded against. The further question arises as to the need of additional powers. In New York, section 202 of the Sanitary Code of the Department of Health, which came into force last year, specifies that" It shall be the duty of every manufacturer, importer, or other person who manufactures or imports in the City of New York, any artificial or natural mineral, spring or other water for drinking purposes, to file under oath with the Department of Health the name of such water and the exact location from which it is obtained, together with the chemical and bacteriological examination thereof, and when manufactured, the exact formula used in its composition. No person shall manufacture or bottle mineral, carbonated or table waters in the city of New York without a permit from the Department of Health." Orders relating to mineral water factories in New York are customarily issued under the following rules— Rules. (1.) Carbonated waters shall not be manufactured in any tenement house or stable excepting it be in a room or rooms entirely separated by a solid partition from the rest of building above cellar floor. (2.) Carbonated waters shall not be manufactured in any cellar or basement unless provision is provided to properly ventilate the same. (3.) All tanks and receptacles for water or syrup must be kept clean and be provided with suitable covers. (4.) Where filters are used they must be frequently cleaned, and must at all times be kept tightly covered. (5.) Bottles must be thoroughly cleaned before filling; prior to final washing they should be soaked in a solution of washing soda, or other alkaline substance. (6.) Floors of premises to be perfectly water-tight and sewer-connected. (7.) Ceilings, floors and walls to be kept clean, and in good condition sanitarily. (8.) Water employed in manufacturing to be city water, or, if otherwise, it must on analysis show an equal standard of purity. (9.) Water used in washing bottles must be same standard as above. (10.) Agents, representatives or proprietors of carbonated or other spring or mineral waters bottled outside this city shall furnish this Department with full particulars as to the sanitary condition of their bottling or manufacturing premises, and the same shall be duly sworn to. (11.) It shall be the duty of every manufacturer, importer or other person who manufactures or imports into the City of New York any natural or artificial mineral or other spring water for drinking purposes, to file with the Department of Health a sworn statement giving name of water, exact location from which it is obtained, and chemical and bacteriological analysis thereof. There would clearly be advantage in requiring registration of makers of aerated waters, and in insisting that, in the premises upon which these waters are manufactured, a proper standard as regards sanitary conditions shall be complied with. In London, water is generally derived from a public supply, and such a rule as No. 11, in the New York code, requiring a statement as to chemical and bacteriological analysis is scarcely applicable under such conditions. Some of the London firms use private supplies of water, and in these instances some such statement would be useful. In any case more frequent examinations of aerated waters than are now undertaken by public analysts in London are needed. Some of the requirements in section 202 of the New York code are hardly necessary from a health point of view, and would no doubt be objected to by the trade, but several of the rules framed under this section are aimed at preventing particular conditions which undoubtedly exist in London at the present time as well as in New York, and the enforcement of some such rules in London is clearly much needed. In conclusion, I should like to acknowledge my indebtedness for information and assistance to Dr. Thomas and several of the inspectors of the Stepney Borough Council, to Dr. Legge and Mr. C. C. W. Hoare of the Factory Department of the Home Office, and to Mr. Davenport, the secretary of the Mineral Water Bottle Exchange and Trade Protection Society. W. H. Hamer, Assistant Medical Officer of Health. Appendix IV. Lonium 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, June, 1904. I present a return based upon information supplied by the medical officers of health of the City and the metropolitan boroughs. During the last eleven years returns have been presented to the Public 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— Number of sanitary inspectors year in the whole of Loudon. 1893 188a. 1894 219a 1895 228a 1898 256a 1901 275 1903 301 1904 313 Thus it will be seen that since 1893 the number of inspectors has increased by some 66 per cent. In 1903, the number of sanitary inspectors employed in each of the metropolitan boroughs was ascertained and comparison between these numbers and those obtaining in 1904 may thus be made— Metropolitan boroughs. Number of sanitary inspectors. Increase ( + ) or decrease (-) in 1904 compared with 1903. Metropolitan boroughs. Number of sanitary inspectors. Increase (+) or decrease (-) in 1904 compared with 1903. 1903. 1904. 1903. 1904. Battersea 11 13 + 2 Lewisham 8 10 + 2 Bermondsey 9 9 - Paddington 12 12 - Bethnal-green 9 10 + 1 Poplar 8 8 - Camberwell 14 14 - St. Marylebone † 8 † 8 - Chelsea 4 4 - St. Pancras 16 16 - Deptford 7 8 + 1 Shoreditch 6 6 - Finsbury 9 10 + 1 Southwark 17 16 - 1 Fulham 6 7 + 1 Stepney 18 18 - Greenwich ††7 † 6 - 1 Stoke Newington 3 3 - Hackney 14 ††l7 + 3 Wandsworth §§11 11 - Hammersmith 9 9 - Westminster, City of 11 12 + 1 Hampstead 7 7 Woolwich 9 10 + 1 Holborn 5 4 - 1 City of London ||17 || 19 + 2 Islington 20 20 - Kensington 13 13 - London 301 313 + 12 Lambeth 13 13 - n Excluding inspectors employed in districts mentioned in Schedule C of the Me'ropilis Management Act. || Including eight meat inspectors in 1904 and seven in 1903. f Including one temporary inspector. ft Including two temporary inspectors. §§ There are also five inspectors concerned with drains and sanitary fittings in old and new houses ; these officers are under the direction and control of the surveyors. Of the 313 inspectors now employed in London 28 are women. At the date of the last return 20 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 21 districts, for the most part in the inspection of factories and workshops employing female labour. Shirley F. Murphy, Medical Officer of Health. printed foe THE LONDON COUNTY COUNCIL by jas. tbuscott and son, ltd. And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, 2 akd 4, Cheat Smith-street, Victoria-street, Westminster, S.W, Agentt for the tale of the Publications of the London County Council. No. 735. Price 3d., post free, 3½d. [11458 SANITARY Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Battersea 11 2 23,462 38,987 24,089 3,032 168,907 88,999 18,381 1,805 2,999 1,853 233 12,993 6,846 1,414 mondsey 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 Bethnalgreen 10 - 14,005 28,209 23,732 6,384 129,680 98,853 38,410 1,400 2,821 2,373 638 12,968 9,885 3,841 well 13 1 36,671 56,985 31,926 4,073 259,339 117,648 25,012 2,619 4,070 2,820 291 18,524 8,403 1,787 Chelsea 3 1 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 Deptford 8 - 15,823 24,615 13,956 1,667 110.398 51,861 9,999 1,978 3,077 1,744 208 13,800 6,483 1,250 * For the purposes of this report the term "overcrowded tenements" is applied to those tenements of less than 5 rooms which at the date of the 1901 Census were occupied to the extent of more than two persons per room. 2 3 OFFICER 3. Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings in the register. No of times a year these houses are inspected. 121 Frequently. The chief inspector supervises generally, inspects in all cases of importance and where statutory proceedings are about to be taken, and is specially concerned with combined drainage. 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. One takes samples under the Food and Drugs Acts, and inspects slaughterhouses, butchers' shops, sausage factories, ham and beef shops, etc. One inspects factories, workshops and workplaces. One (female) inspects places employing female labour, and investigates cases of puerperal fever. She also visits the houses of children who are about to be discharged from isolation hospitals after scarlet fever and diphtheria, and inspects houses let in lodgings. One (female) investigates deaths of infants under one year, visits cases of non-notifiable infectious disease, visits children fed from the council's milk depot, and gives instruction to mothers in the feeding and care of infants. In addition to her salary as sanitary inspector she receives £30 per annum from the borough council. (a) 9 disinfecting assistants. 5 (b) 5 drain-testing assistants. (c) 1 mortuary keeper and 1 temporary assistant. 217 Four. 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 lodging-houses, offensive trades, factories and workshops, etc. 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 reconstruction. (a) 4 disinfecting assistants. 5 (b) 2 mortuary keepers. (c) 3 shelter caretakers (females) 400 (about) At least once a month. Special cases more often as may be found necessary. One superintends, and in conjunction with medical officer of health is responsible for the operations of the entire sanitary staff. Six have each an allotted district, in which they are concerned with duties arising under the Public Health Act including the inspection of registered tenement houses. One is concerned with duties under the Factory and Workshop Act, outworkers, etc., the inspection of cowsheds and milkshops, etc. One is concerned with the inspection of food, slaughterhouse and offensive trade premises. One supervises the drainage and enforcement of by-laws during construction of new buildings. (The whole of the salary of this officer is paid by the borough council.) (a) 1 general assistant. 5 (b) 4 disinfectors (c) mortuary keeper (d) 9 dust - pail men. 300 Once, and at irregular periods. One is concerned with smoke nuisances and Food and Drugs Act, and is emergency inspector under all Acts of Parliament relating to public health. Eleven have each an allotted district in which they carry out duties (a) 1 superintendent and 7 disinfecting assistants. 5 arising under the Public Health and Factory and Workshop Acts and exceptionally under the Food and Drugs Act. One acts as chief clerk and inspects in emergency cases. One (female) is chiefly concerned with laundries, factories and workshops employing female labour. (b) 1 mortuary keeper. † - 257 inspections made in 1903. Two have an allotted district, in which each is concerned with houseto-house inspection, and inspection under the Factory and Workshop Act, and (with assistants) disinfects clothing and bedding, One carries out duties connected with infectious disease and complaints, and obtains samples under the Food and Drugs Act. One (female) is concerned with inspection of workshops and outworkers' homes where female labour is employed. Also special investigations. (a) mortuary keeper. None. (b) 2 disinfecting and drain-testing assistants. 122 Twice. Five have each an assigned district in which they perform generally the duties of a sanitary inspector. 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. One is engaged with house-to-house inspection. (a) 2 disinfecting assistants. None. † The borough council are in possession of a register containing a list of 602 houses let in lodgings prepared some 20 years ago by the Vestry of Chelsea The borough council have not registered any houses since their constitution in 1899. 4 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Finsbury 9 l 9,280 24,097 20,515 6,373 101,463 78,346 35,723 928 2,410 2,051 637 10,146 7,835 3,572 Fulham 6 l 18,534 32,137 21,681 2,341 137,289 81,364 14,892 2,648 4,591 3,097 334 19,613 11,623 2,127 Greenwich 6* - 14,240 19,702 10,877 1,199 95,770 41,260 7,947 2,373 3,284 1,813 200 15,962 6,877 1,324 Hackney 15† 2 30,634 48,794 29,089 3,684 219,272 104,876 22,332 1,802 2,870 1,711 217 12,898 0,169 1,314 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 * Includes one temporary inspector. †Includes two temporary inspectors. 5 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 1,109 Once thorough ly Some of the houses owing to their position are very frequently visited; others probably less so; but those which require the greatest attention receive it. 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. One is concerned with Factory and Workshop inspection. One is a meat and market inspector. One supervises generally. One (female) is concerned with the inspection of factories and workshops where females are employed, out-workers' homes, etc., and makes special enquiries into infantile deaths and cases of measles. (a) 1 disinfector. 2 and 1 office youth. (b) 2 mortuary keepers one of whom also disinfects rooms, and the other also works steam disinfector. (c) 1 shelter keeper (who also disinfects rooms). (d) 1 van driver who also assists with disinfection. 329 Twice. Five have each an assigned district, in which they perform all duties arising under the Public Health Act and Factory and Workshop Act. One is employed on duties arising under the Food and Drugs Act and in the inspection of places where food is sold or stored. One (female) is chiefly engaged in the inspection of workshops, etc., where women are employed. (a) 2 drainage inspectors. 2 (b) 4 disinfectors and 3 assistants. (c) 1 mortuary keeper. - The work is in abeyance on account of shortness of staff. The question of increasing the staff is now under consideration. One is concerned with infectious disease. Four have each an allotted district in which they are concerned with duties under the Public Health and Factory and Workshops Act. One (temporary) is engaged upon house to house inspection. (a) 3 disinfecting assistants. 2 500 An endeavour is made to have these houses in spected once a year at least. (155 were inspected during 1903.) 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 County Council). 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. One (female) inspects the houses of outworkers. Two (temporary) are engaged upon house-to-house inspection. The inspectors supervise reconstruction and alteration of drains but not in new premises. (a) 1 dust inspector. 4 and 1 messenger. (b) 9 assistants for disinfecting. (c) 1 mortuary keeper, 1 temporary shelter caretaker (and wife). (d) 1 drain-testing assistant, 1 smoke nuisancp assistant. (e) varying number of dustmen. 1,748 Generally once a year. Four have each an assigned district, in which they are concerned with all duties arising under Public Health (London) Act. One makes a systematic house-to-house inspection of the district. One is employed on houses let in lodgings. One is employed on duties arising under the Food and Drugs Act and supervision of dustbins. One is concerned with duties transferred from the L.C.C., and also smoke nuisances. One is concerned with factories and workshops. (a) 2 assistants for disinfection. 3 (b) 1 mortuary keeper. (c) 2 drainage inspectors. (d) 1 or 2 labourers for cleansing and disinfection 6 Metropolitan borough. Number of .sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. H ampstead 6 1 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 Holborn 3 l 4,703 13,790 10,772 2,783 59,405 35,724 14,875 1,176 3,447 2,693 696 14,851 8,931 3,719 Islington 19 l 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 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 5,648 2,016 Lambeth 12 1 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 Lewisham 9 1 22,750 27,701 8,561 535 127,495 28,928 3,416 2,275 2,770 856 53 12,749 2,893 342 7 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. Wo. of houses let in lodgings on the register. No of times a year these houses are inspected. 908 Owing to decision of town clerk, that a change of landlords necessitated re - registration, nothing has been done beyond reregistering houses where such a change has occurred. One supervises work of other inspectors, visits premises with medical officer of health, investigates cases of infectious diseases and is responsible for work of disinfecting assistants. 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. (a) 2 disinfecting assistants. 3 and [1 clerk draughtsman. (b) 2 drain-testing assistants, one of whom acts as mortuary keeper. 801 Varies in accordance with the sanitary condition of the houses. Some weekly,others once or twice a year. Three 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. One (female) is engaged on special inspections under the directions of the medical officer, such as factories and workshops, restaurants where females are employed, the houses of outworkers, measles cases, etc. (a) 2 disinfecting assistants. 3 (b) 1 mortuary keeper. 670 On an average four times a year. One supervises and visits premises when it is necessary to serve a statutory notice. 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 visit ice-cream factories, and on Sundays in rotation take samples of milk under the Food and Drugs Act. One inspects workshops, workplaces and bakehouses. One inspects houses let in lodgings. One assists previous inspector and also takes samples of food and drugs. One inspects meat, food, cowsheds and offensive trade premises. One (female) inspects workshops and outworkers' homes where females are employed. (а) 5 disinfecting assistants. (b) mortuary keeper, (c) caretaker of shelter. (d) engineer at disinfecting station. 7 and 1 messenger, who assists in clerical work. 2,050 about No fixednumber of times. Frequency of inspection i s governed by character of houses,locality and inhabitants. One is chief inspector without a district and exercises supervision. Ten have each an allotted district, in which they are concerned with all duties arising under the Public Health (London) Act. They also obtain samples under the Food and Drugs Act. Two act at one time for three months and then are exempt from this duty for 12 months. No inspector collects samples for analysis in his own district except samples of water. Two (female) are engaged mainly in the inspection of workshops, workplaces, laundries, etc., where females are employed. (a) assistant for disinfection. 5 (b) mortuary keeper. (c) sanitary labourer for assisting in testing drains. 372 Several times Eleven have each an allotted district, in which they are concerned with all duties arising under the Public Health and Factory and Workshop Acts. One inspector deals only with smoke nuisances, and carries out duties under the Food and Drugs Act, assisted by a deputy. The district inspectors supervise the execution of drainage works in both new and old houses. One (female) carries out duties under the Factory and Workshop Act, inspects underground conveniences, and performs duties of a general character. The Council is considering the advisability of appointing an extra female inspector. (a) 11 disinfecting assistants. 4 (b) 2 mortuary keepers and a deputy. (c) 1 temporary caretaker of shelter (female) 16 Constantly Five have each an assigned district in which they carry out general sanitary duties. One is engaged on duties arising under the Factory and Workshop Act. Three are engaged in house-to-house inspection. One (female) visits laundries, workplaces, etc., where females are employed, and makes special investigations into cases of infantile diarrhoea, phthisis, etc. (a) 6 disinfecting assistants. 3 (b)2 drain-testing assistants. 8 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. males. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. 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 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 St. Marylebone *7 1 13,535 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 St. cras 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 Shore- ditch 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 * Includes one temporary inspector. 9 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 851 Frequently (5,493 visits during 1903.) 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.B.—Drainage works in new buildings under direction of surveyor.) One has supervision of workshops and work places, and has generally the enforcement of the Factory and Workshop Act. Two attend to houses let in lodgings, and the enforcement of by-laws under section 94, Public Health (London) Act, 1891. 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 enquiries into infectious disease not scheduled for notification. (a) inspector under the Food and Drugs Act. 4 (b) mortuary keeper. (c) caretaker and wife at shelter. (d) 6 navvies (employed for opening defective drains, etc.). (e) 1 disinfecting assistant. 600 The betterclass once every year, and the poorer class eight and nine times. 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 October, 1901) for measuring up rooms of houses let in lodgings, making night visits, etc. One (female) inspects all places where female labour is employed. (a) 4 disinfecting assistants. 4 and 1 temporary. (b) 5 labourers (who assist inspectors). (c) 1 female attendant at the Glaucus - street shelter. 784 As often as possible. 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 reconstruction. One is concerned with duties arising under the Factory and Workshop Act and deals with smoke nuisances. One (female) is concerned with duties arising under the Factory and Workshop Act. One (temporary) acts as dust inspector. (а) 3 disinfecting assistants. (b) mortuary keeper. (c) caretaker of shelter (female) 2 and 1 messenger. 1,838 2,307 inspections, and 5,535 re-inspections after notices served Eight inspectors have each an assigned district in which they deal with infectious diseases, complaints, drainage and nuisances generally. Two are inspectors of food and food-places, carry out the Food and Drugs Act, and the by-laws regulating slaughterhouses and dairies. Two perform duties under the Factory and Workshop Act. Of these inspectors, 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 of underground dwellings. One special inspector supervises the disinfectors and attendants at the contact-shelter and at the personal cleansing station, inquiries into contact notifications, makes smoke observations, inspects effluvia businesses and offensive trade premises, and instructs workmen, temporarily employed by the department, to open and examine drains, etc. (a) 3 disinfecting assistants and 1 general assistant 1 chief clerk, 6 assistant clerks, 1 temporary clerk and 1 messenger. (b) caretaker of mortuaries and coroner's court and 1 contact shelter attendant. 233 If found on inspection to be kept in a satisfactory sanitary condition once a year only. If not, the houses are inspected as often as may be necessary to secure improvement. Some houses have required frequent visits at short intervals. 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. Each of the five other inspectors has an allotted district in which he performs the various duties arising under the Public Health and Factory and Workshop Acts, including the abatement of smoke nuisances, the supervision of drainage work, both in new and existing houses, and the testing of drains. Each inspector is required to take four samples per fortnight under the Food and Drugs Act, and also to take turns of duty in the street markets on Saturdays and Sundays with a view to taking samples and watching the qualities of the food stuff exposed for sale. The inspectors are not restricted to their own districts for taking samples under the Food and Drugs Act. (a) 1 general assistant. 3 (b) 1 disinfector and 2 assistants. (c) 1 mortuary keeper. (d) caretaker (female) of shelter 10 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. males. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. wark 13 3 20,878 47,808 39,612 8,133 206,180 147,928 46,073 1,305 2,988 2,476 508 12,886 9,245 2,880 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 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 Wandsworth 10* l 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 Westminster (City of) 10 2 18,366 41,244 26,668 4,346 183,011 83,624 23,856 1,530 3,437 2,222 362 15,251 6,969 1,988 W oolwich 9 1 18,086 24,585 14,017 1,243 117,178 50,985 7,727 1,809 2,458 1,402 124 11,718 5,098 773 City of London 18† 1 3,865 5,339 3,307 504 26,923 10,625 2,921 203 281 174 27 1,417 559 154 County London ) 285 28 571,768 1,019,546 672,030 124,773 4,536,541 2,449,789 726,096 1,827 3,257 2,147 399 14,494 7,827 2,320 * There are also five inspectors concerned with drains and sanitary fittings in old and new houses under control of the surveyors. †Includes 8 meat inspectors. 11 Houses let in lodgings. Duties of sanitary inspections. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 1,100 Four. One chief male inspector supervises generally the work of the other male inspectors. One carries out the Adulteration Acts, inspection of bakehouses, slaughterhouses, dairies, milkshops and noxious trade premises. Ten have each 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. One has the wharves and warehouses on the river bank and is engaged with the inspection of food stuffs. Two (female) visit houses let in lodgings. One (chief female) visits factories and workshops employing females and supervises generally the other female inspectors. (a) 10 disinfecting assistants. 6 (b) 2 mortuary keepers, and a superintendent and his wife at reception house. The superintendent is concerned with infectious diseases. (c) 1 assistant drain tester. 2,649 Some of the best are only visited once or twice a year. Others are visited practically every month. 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. Two are concerned with houses let in lodgings. One inspects wharves and food landed at such premises. (a) 15 disinfecting and general assistants. 7 180 Twice. The three inspectors have each an assigned district in which they carry out general sanitary duties. (a) 1 disinfecting assistant. 1 200 Twice and more frequently if any special reason. 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 if required. 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. (a) 10 disinfecting assistants. 4 (b) 3 mortuary keepers. *2,004 Some weekly, others monthly, twice a year or once a year Eight district 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. Two (female) are engaged in the inspection of workshops, workplaces, etc., where female labour is employed. (a) 9 disinfecting assistants. 4 and 1 messenger and clerical assistant. (b) 2 mortuary keepers. 164 Mostly four times. 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. One (female) visits workshops and workplaces, etc. where females are employed. Eight have each an assigned district in which they perform duties arising under the Public Health Act. 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. (a) 3 disinfecting assistants. 3 (b) 3 drain-testing assistants. (c) 1 mortuary keeper. 366 Frequently. Two are concerned with notified infectious diseases. One is specially engaged in carrying out the provisions of the Food (a) 2 disinfecting assistants. 3 and Drugs Act. Eight are concerned with duties arising under the Public Health Act. One of these (female) also visits workplaces where females are employed. (b) 1 mortuary keeper. 20,632 Eight inspectors are engaged in meat inspection. * This number was shown in a return published by the Council in January, 1903. and is the most recent information on this point received from the medical officer of health of Westminster. Loutran County Council. ICE AND COLD STORAGE. Report of the Medical Officer presenting Report by Dr. Hamer on the use of Ice and on Cold Storage in London. (.Printed by order of the Public Health Committee, October 20th, 1904.) On the 16th July, 1903, the Committee had under consideration a letter from the Town Clerk of Bermondaey forwarding a report on ice prepared by the medical officer of health and asking on behalf of the Borough Council that the London County Council would cause inquiry to be made into the ice trade in London. The Committee referred the matter to me for report, and the investigation was forthwith undertaken by Dr. Hamer. The question raised by Dr. Brown, the medical officer of health of Bermondsey, was as to the fitness of natural ice imported into this country from lakes, rivers, and fiords in Norway and Canada for use for human consumption. Dr. Hauler's inquiries were, therefore, directed at the outset to the ascertainment of particulars concerning natural ice and its manipulation in London; and further, to study of the methods adopted in the manufacture of artificial ice. As a result of visiting various ice factories, he was led to conclude that the question of use of artificial ice was, to a large extent, bound up with that of cold storage, and on January 28th of this year the Committee decided that the inquiry should be accordingly extended. In the report which I now present, Dr. Hamer, after giving in the first place an account of the development of the ice industry, discusses the records of ice-borne disease which, it may be noted, are by no means extensive or precise, and the bacteriology of ice, which is obviously a subject of considerable importance in connection with the present inquiry. In particular, I may allude to recent results obtained by Professor Abba, to which Dr. Hamer refers, as throwing quite a new light upon the bacteriology of ice. Professor Abba concludes that water bacteria are not so much destroyed as extruded from ice in the process of freezing, and this fact has important applications, more especially in connection with the use of artificial ice. It may, moreover, be noted that Professor Abba's conclusions are consistent with previously ascertained facts as to extrusion from ice of foreign matter in the course of freezing. As regards the conditions under which the ice industry is carried on, there are undoubtedly certain sources of risk of contamination incidental to the manipulation of ice in London, but the main question to be decided is, as to the advisability of employing natural ice under circumstances in which it comes into actual contact with beverages and with food. Dr. Hamer points out that the use for the purposes named of ice made from distilled water was recommended on the best authority in Germany twenty years ago, and the employment of artificial ice has steadily gained ground in the United States and is being slowly but surely extended in this country. Having in view the facilities which now exist for obtaining artificial ice it appears not unreasonable to suggest that for all purposes in which there is actual contact with food, such ice made from absolutely pure and preferably from distilled water should be used, inasmuch a3 the source of natural ice can never be known with certainty by the consumer. With extension of the manufacture of artificial ice there will doubtless be in the near future steadily increasing provision of cold storage, and the question has already been raised in America as to the need of supervising cold stores in the interests of the public health. Apart altogether from the desirability of the inspection of such premises with a view to seizure of unsound food, there has to be considered the need of securing that questions of structure and arrangement which are of importance for ensuring freedom of foodstuffs from contamination should be duly considered in designing cold stores. If this is to be successfully accomplished, it would necessitate the compulsory registration of all premises of this sort with the requirement that before being used the plans Bhould be approved by a health authority. Finally Dr. Hamer notes that there is need of extension of knowledge with regard to the effect of cold storage on perishable foodstuffs. Shirley F. Murphy, Medical Officer of Health. Ds. Hamer's Report. The use of ice is steadily growing, while as regards cold storage there has in recent years been quite a remarkable development in London. But little importance, however, has hitherto been attached to the question of the quality of the ice used, and knowledge concerning the effect of refrigeration upon food is almost entirely wanting. I have endeavoured to learn how much is 740] [S.S./18010 2 known as to possible risks to health associated with ice and refrigerated foods, and have included some notes on these points in this report. It appeared, moreover, desirable to give a short account of the growth of the use of ice and cold storage, and this subject may with advantage be considered in the first instance, as a study of it will serve to show that the other questions to be later referred to are beginning to assume no little importance from a health point of view. The Development of the Ice Industry. Snow and ice were used by the Greeks and Romans for cooling purposes, and Nero is said to have caused extensive storage vaults to be constructed for the reception of the refrigerating material brought from the mountains to Rome. In England, until quite recent times, employment of ice has been almost entirely confined to the wealthy; in many country houses it has been the practice to store it in winter for use throughout the year, and the "ice-house" has even come to be regarded by some authorities as one of the first necessaries in a well-ordered mansion, a fairly capacious ice-well being, in some instances, constructed for storage purposes. In London there is at a particular ice merchant's premises a well 40 ft. in diameter and 104 ft. deep, and practically the whole available space is utilised at times. When the well is full it is, I was told, no uncommon occurrence for a pickaxe, or other implement, to be lost in some crevice between the blocks of ice; should this occur the missing article is not, as a rule, recovered until the contents of the well are completely removed, and an interval of months or even years may thus elapse. The exploration of the well when nearly empty is not a matter to be lightly undertaken, as may be imagined; indeed, after examining it, I was not surprised to learn that writers of fiction have had recourse to the "ice-well" as a means of providing an unanticipated denouement. I was shown some of the books of the firm owning this particular "ice-well," and they yielded evidence that ice has long been deemed indispensable in the town houses of the aristocracy; that the trade in ice during "the season" is an extensive one may be judged by the fact that this one firm of London ice merchants had supplied during 1903, four hundred "ice pyramids," consisting of columnar masses of clear natural ice weighing from 20 to 400 lbs., to say nothing of the ordinary daily routine supply for ice-safes, etc. Before imported ice was available, suburban ponds and canals were relied upon, and some of the ice-hammers, "snakes" and punts which were used, even up to twenty-years ago for collecting the ice are still to be seen in London. Although as recently as 1895, when the winter was very severe, the question was raised by more than one medical officer of health, as to the employment of canal-ice, an increasingly large percentage of the total supply from "the seventies" onwards has come from Norway, for as soon as it was found that ice 18 in. or more in thickness could be brought here from abroad, it was no longer worth while, as a general practice, to attempt to store the thin ice occasionally to hand in this country. In Germany, ice has been used more largely than in England, and the employment of refrigeration in connection with the numerous public slaughter houses in that country has no doubt helped to increase the demand. According to Schmidt-Miilheim, scarcely any greater service has been rendered to hygiene in connection with food supplies in that country, that has been afforded by the construction of cooling rooms. In Italy ice has been greatly in request, and during recent years rumours have reached this country concerning the disastrous effect of the ice famines which have occurred in the middle of summer in such cities as Rome, Florence and Turin. "The ice habit" has, however, been especially developed in the United States. Writing as long ago as 1882, Herbert Spencer1 commented upon the " passion of the Americans for iced water." He says, "not only does it come up at every meal, but even in the middle of the night it must be made accessible, the habit being to place in the mouth of the jug a wedge-shaped piece of ice, too large to go in and with its narrow end downwards, so that, thawing all night and dripping into the jug, it ensures an ever-ready supply of water just above freezing point." He attributes the custom to "the need for a sensation which in one form or another is universal,"and says," drinks that have flavours sweet or bitter are preferred to tasteless drinks; and if a liquid not otherwise attractive is taken, then it must be not tepid, but decidedly hot or decidedly cold." He further notes a "prevalent disuse of alcoholic drinks" in America, and explains that "the sensation of taste being ungratified, the sensation of temperature is as far as possible substituted for it." The extremely wet summer of 1903 was somewhat inauspiciously chosen to inaugurate a new departure by introducing American methods in London, and among other advantages offered by the "quick lunch counter," it was stated that there a glass of iced water would be always available. The large hotels patronised by Americans in London are, it appears, large consumers of ice, indeed, so much a matter of course has the employment of ice become in the States that Americans are quite unable to understand the want of appreciation of its usefulness here. The only comment made by an American exploring "old London," who was taken to an inn famous on account of its having been commonly frequented by Dr. Johnson, was that it was strange manufactured ice was not obtainable there. In order to supply the cities of America lakes, ponds and rivers have been freely drawn upon. Boston obtained ice from Wenham Lake; New York in part from the Hudson river, which consisted of about "1,100 parts of rather dirty river water from Troy and one part of Albany sewage," in part from lakes and ponds adjacent thereto, and in part also from Maine. Large ice-houses were constructed and already in 1887 there was storage capacity for three million tons of ice on the banks of the Hudson from Troy to Poughkeepsie (Prudden, Medical Record, 1887). In 1903 it was estimated that approximately forty million tons of ice were provided for use during the year in the States, the aggregate amount of natural ice stored being about thirty million tons, while the ice-factories provided some ten million tons in addition. Many of the ponds originally resorted to were subject to serious risk of pollution. 1Autobiography. Vol. II., p. 399. 3 Thug the report of the State Board of Health of Michigan, 1880, refers to emanations from decaying wood in contact with ice as a possible cause of disease—specimens of lake ice when melted were found to yield a deposit of fine, dark particles, which proved to be decaying sawdust, and the water from the melted ice speedily became very offensive. Again, ice which wa3 believed to have caused an outbreak of illness in 1875, at Eye Beach, to be referred to later, was found to have been contaminated with sawdust. That the danger of pollution was already recognised twenty years ago may be seen from the fact that in New Jersey an Act was passed in 1885, giving power to Boards of Health in the State to regulate and control the cutting and sale of ice. (State Board of Health, New Jersey, 25th Report, 1901). In Massachusetts a penalty might be imposed for driving a horse on the ice of a pond supplying ice for consumption (Eighteenth Annual Report, 1887). In the same State a statute provides that any twenty-five consumers may ask the State Board of Health to investigate an ice supply, but it appears (Boston Medical and Surgical Journal, 1894) that only one complaint had been brought before the Board, and this by an ice-dealer in order to enable him to break a contract. Nearly a century ago, when the usefulness of ice was first appreciated in the States, a merchant named Tudor conceived the idea of exporting it to distant lands. In 1805, he is said to have transmitted it successfully to Martinique, and later he shipped it to India, where it was sold in 1833 in Calcutta at 3d. a pound. The idea of conveying ice 15,000 miles during a four months' voyage, is said to have been suggested by the fact that an ice ship bound for Cuba was wrecked, and that months after, when she was discovered and salvage operations were commenced, it was found that very little of the ice forming her cargo had melted. Some of the ice first brought to this country is said to have come from the States, and was known as Wenham Lake ice.1 A lake near Drobak in Norway, from which ice was shipped in large quantities to England, was later known by the same name, and "Wenham Lake ice" became a familiar term in this country. The importation of natural ice from Norway gradually developed in the closing third of the last century, and at the present time some 200,000 tons of Norwegian ice are brought over to London every year—the amount sent into the whole country already exceeded 200,000 tons in the early eighties, and was more than 300,000 tons in the early nineties; in 1899 it was more than 500,000 tons, but this figure has not since been attained. Appreciation of the need for safeguarding the purity of ice intended for human consumption grew as time went on, and coincidently the available sources of supply of natural ice tended, generally speaking, to become more and more polluted. It is not surprising, therefore, to find that in this connection ice-machines began to excite an increasing amount of attention. Attempts were at one time made to employ freezing mixtures on a commercial scale, but these chemical methods were destined to be supplanted by mechanical devices. The original airmachine invented by Dr. Gorrie, of Florida, dates from 1845, improvements were effected by Postle (1868), Windhausen (1869 and onwards), Giffard (1873), and the Bell-Coleman machine was patented in 1877. In 1860 James Harrison had made the experiment of sending meat preserved by artificial ice from Australia to London ; in 1879 the Stratldeven fitted with coldair machinery, arrived in London with 34 tons of frozen meat on board; in 1881 the Dunedin, with Bell-Coeman plant, brought some 5,000 frozen sheep to London. In recent years coldair machines have yielded place to appliances worked with ammonia, carbonic acid, or sulphurous acid. In the earliest form of the modern compression machine ether was employed, the idea being first suggested by Jacob Perkins in 1834. Carre invented the first ammonia absorption machine. James Harrison in the fifties succeeded in placing ice-making on a commercial basis, and in 1859, he had an ether machine at work in Sydney, producing artificial ice for sale. Mort and Nicolle greatly improved the ammonia machine during the sixties, and at length in 1873 the original Linde ammonia-compression machine was introduced. Thomas Sutcliffe Mort was one of the great pioneers in the ice industry; he was early impressed with the waste of food material in Australia, where it was said that surplus sheep were boiled down for tallow ; when forming the Fresh Food and Ice Company in 1861, in Sydney, he is reported to have prophesied "the half-starved nations of the earth shall now be fed." In 1868, Mort's name is associated with Nicolle's in application for patents "for obtaining reduction of temperature by expansion of air or other permanent gases in special connection with the preservation of articles of food, the manufacture of ice, and the cooling of rooms and liquids," but already in the previous year Mort had registered a patent for "an application of Faraday's discovery of the liquefaction of certain gases by pressure, and the capacity of such gases for the absorption of heat on their release from liquefaction." Drawings accompanied the specifications, which show that Mort had fully in mind the application of his methods on board ship, and he clearly foresaw that, in years to come, refrigeration was to play an important part in food distribution.2 The manufacture of artificial ice has made remarkable strides during the last twenty years in Germany and America. Companies were formed in the larger cities in the late eighties, and during the nineties manufacturing plants were laid down not only in Europe and America, but in India and the Colonies, and at length in English towns, and even in London itself. The "iceplant" has more recently penetrated to such places as Buluwayo, Honolulu, Khartoum, Perak, and Wei-hai-wei. The greater part of the ice used in London at the present time comes from small lakes and ponds in Norway, which, according to the "Lancet" (27th July, 1901), are situated in such solitary 1The blocks of ice were much thicker than the blocks of Norway ice now imported, and were viewed with great interest as they were drawn on float or lorry through the streets of Liverpool. (Ice and Cold Storage, April, 1903.) 2See paper by C. C. Lance, read 6th May, 1904, before the Cold Storage and Ice Association. 740] A 2 4 and secluded sites as to render any contamination with animal matters "highly improbable"; furthermore, samples of the ice were found by the "Lancet," pure, sparkling, and clean, and the conclusion was drawn that "no harm is likely to accrue even when the ice is consumed, as it is when placed in beverages for cooling purposes," though a word of caution is given incidentally with regard to the lead-dissolving powers of ice-water. In the last few years, however, exception has from time to time been taken to the use of natural ice. Thus the reader of a paper which appears in Cold Storage, July, 1904, expresses what is now coming to be a general feeling about ice of unknown origin, when he exclaims, "It may have had a past"; while nearly twenty years ago a first note of warning was sounded in Germany as to using only artificial ice made from pure water for purposes of consumption in beverages, or in cases in which the ice was brought into contact with food consumed in the raw state.1 In the large American cities the need for insisting upon the use of such ice for the purpose in question is now, it would appear, fairly well recognised, indeed, even in some small seaside resorts on the English coast, which chance to be near centres of the fishing industry,2 the use of pure ice is quite a matter of course. In London, however, though there are factories capable of producing some three or four hundred tons of artificial ice per diem, the quantity of natural ice consumed or brought in contact with articles of food still probably exceeds that of artificial ice. The rapid growth of cold storage as applied to food-stuffs dates from the early eighties. At the present time meat, dairy produce and fruit are refrigerated on a vast scale. Frozen meat has slowly but surely grown in popularity, and during the first six months of 1904, upwards of 2,000,000 cwts. of fresh beef from the United States, Argentina, Australia, and New Zealand, and some 1,700,000 cwts. of fresh mutton from Argentina, New Zealand, and Australia were imported into this country. In 1903 the ships engaged in the frozen meat trade were possessed of capacity for nearly 10,000,000 carcases, and the cold stores of London were capable of accommodating some 2,500,000 carcases of sheep alone. Pork, bacon, and game are, of course, also largely stored, and the annual export of rabbits from Australia now amounts to about 12,000,000. During the first half of the present year, some 800,000 cwts. of refrigerated butter, some 700,000 cwts. of cheese, some £600,000 worth of bananas, and some £600,000 worth of eggs were imported into this country. The trade in preserved eggs has grown very rapidly of late; at the beginning of the present year Dr. Brown made inquiries in Bermondsey which showed that in that borough there were in store 559 cases, each containing twelve "great hundreds," i.e., twelve times one hundred and twenty eggs; but these figures are dwarfed by those from American cities. At the end of June, 1904, there were reputed to be 700,000 cases (containing thirty dozen eggs each) in cold storage in Chicago, and in New York there were over 500,000 such cases, the total "egg storage capacity under refrigeration" in the United States exceeding 2,500,000 cases of thirty dozen each. During the early part of the year 1904 there was great demand for eggs in New York, and several car loads of " California eggs" were brought into the city. "These California eggs were really Kansas eggs, which had been shipped to California in April last, placed there in cold storage to be shipped across the continent in February of next year, and then sold at high prices, the owners realising a handsome profit although they had to pay 424 dollars freightage per car." 3 The trade in refrigerated milk now bids fair to become important, and that in fruit is, of course, a well-established one, not only apples, pears, and bananas, but refrigerated nectarines, peaches, grapes, plums, tomatoes, green peas, French beans, etc., being now brought into this country from overseas. Again, in the preservation of flowers, and particularly of lilies, cold is being employed, and it has even been suggested that it would be of use in connection with the cultivation of dwarf trees. Considerable quantities of frozen fish are exported from this country, more particularly to South America, and 320,000 lbs. of salmon were sent to England from Canada in 1903. Furs, furniture, timber1 and hops are, now cold stored, while freezing apparatus is extensively employed in the manufacture of ice-creams, confectionery, cocoa, chocolate, wine, beer, and dairy produce. Cold is used in hospitals, mortuaries, and skating rinks, in tunnel making5 and mining and in pit sinking; and it has, it is said, been employed for drying clothes in laundries, for cooling gelatine for photographic plates, for preserving mulberry leaves, and for other purposes in connection with silkworm culture, and quite recently it is reported to have been used by beekeepers, who have placed bees in cold storage to prevent loss by winter swarming. In America it is laid on like water or gas in houses, it is used for supplying ice-water in public fountains, as at Pittsburg, and for "town cooling," as at Baltimore. In Germany attention has been especially directed it is said to the question of cold storage in connection with fortresses. 1 By Fraenkel in his paper in the Zeitschrift fur Hygiene, 1885. A specimen form of notice issued to warn the public against the use of impure ice in beverages, and for cooling butter, etc., is given in Schlacht-und-Yiehhofe by Dr. Oscar Schwartz, p. 183. A writer in Ice and Cold Storage, April, 1903, observes: "The surprising thing is that the ratio of natural ice sold year by year in the metropolis remains so high, while in every outport it falls away toward vanishing point. . . . Of course," he adds, "trawling and artificial ice making go so much together that the expansion of the one may account for the swelling of the other in seaside places; but even in inland towns artificial ice has made it* way in a much greater degree than in London." 3 Cold Storage, loth March, 1904. 4 With a view to preventing the ravages of insects. 5 Artificial refrigeration was found invaluable in boring the Simpion tunnel; hot water flowing into the tnnnel at a temperature from 112" to 140° F., rendered work impossible until the flowing water was made to supply power for a freezing plant, which made the conditions endurable. 5 The Records of Ice-borne Disease. The literature of " impure ice" is a fairly extensive one, and numerous references are given in the Index Catalogue of the Washington Library; the number of instances in which there has been evidence that actual disease has been caused by the consumption of ice is, however, small.1 Heyroth2 refers to five papers in American journals giving account of outbreaks of illness traced to eating impure ice. I have been unable to follow up two of these references ; two others which I have traced merely refer to the occurrence of ice-borne-disease in a general way, one of them quotes one of the two reports just mentioned which I have been unable to obtain (Second Annual Report of the State Board of Health of Connecticut, 1879, p. 90). There remains the fifth paper, a " Report on an Outbreak of Intestinal Disorder Attributal to the Contamination of Drinking Water by Means of Impure Ice," by A. H. Nichols, M.D., of Boston (State Board of Health,of Massachusetts, January, 1876, p, 467), which gives an account of an outbreak of illness in July, 1875, among the guests in one of the large hotels at Rye Beach, a popular seaside resort upon the coast of New Hampshire. The chief symptoms manifested by the sufferers were giddiness, nausea, vomiting, diarrhoea, abdominal pain, fever, loss of appetite, and mental depression ; in most instances the illness was not sufficiently severe to necessitate the aid of a physician, but twenty-six adults presented "grave symptoms" the attacks were limited to the inmates of a single hotel accommodating about three hundred guests. Examination of the water-supply, drainage, cooking-utensils, and milk-supply yielded negative results, but the ice used was found to be "rather impure and opaque" and it "contained numerous foreign substances varying in size and apparently of vegetable origin." Further inquiry elicited the fact that a resident of the place who had consumed ice from the pond whence the ice-supply of the hotel was obtained, had experienced nausea and distress for the remainder of the day, and two gentlemen who had taken a quantity of the ice with them on an excursion had also been attacked. Moreover, there was a distinct odour given off by the melted ice, and the atmosphere of the ice-house was offensive. The ice was found to be derived from the practically stagnant water of a flooded marsh, which contained a putrescent mass of marsh mud and decomposing sawdust; it is noted, too, that there were several large houses at no great distance. Finally, coincidently with the disuse of the ice there was amelioration of the symptoms of those hitherto ill, and no fresh cases occurred during the season. In a somewhat similar outbreak, affecting persons who dined at the table-d'hote of a London hotel, in 1898, some suspicion fell upon the ice, but in London, as at Rye Beach, no precise statement was obtained from each sufferer as to the various foods, etc., consumed, and in the absence of an exact analysis of this kind no inference could be drawn. In neither of these cases can the connection of the gastro-intestinal disturbance with ice be regarded, therefore, as conclusively demonstrated, though having in view the occasional spread of illness of the kind in question by contaminated water, it is possible that dirty ice may have been the source of trouble in these and similar instances, since, as will be seen, freezing affords no guarantee of freedom from disease germs. Interest, however, especially attaches to a class of cases which remains to be considered— instances in which enteric fever is believed to have been spread by contaminated ice. Reference is made to such a case by Dunbar (Boston Medical and Surgical Journal, 1894, p. 261). " Careful search of the records," he says, resulted in the discovery of " but one presumably authentic case of transmission of typhoid fever through ice " ; he adds " this occurred in France, and resulted from the use in wine of ice taken from a river below the sewage outlet of a town."3 An outbreak of enteric fever referred to by Osier (" The Principles and Practice of Medicine ") may be here mentioned, though the medium of infection in this case was not, strictly speaking, ice. Plymouth, Pennsylvania, a town of 8,000 inhabitants, in part supplied by reservoirs fed by a mountain stream, suffered severely in 1885 from enteric fever. In January, February and March, a man living in a cottage by the side of, and some 60 to 80 ft. distant from, the mountain stream suffered from that disease. The ground was then frozen and covered with snow, and the patient's evacuations were thrown upon it on the side of the cottage next to the stream. Late in March and in early April, there was considerable rainfall and a thaw, during which " a large part of the three weeks' accumulation of discharges was washed into the brook." About the 10th April, cases of typhoid fever broke out in the town, appearing for a time at the rate of fifty in a day until some' 1,200 persons in all had been attacked, and " an immense majority of all the cases were in a part of the town which received water from the infected reservoirs." In the American Journal of the Medical Sciences (October, 1903), there appeared a paper by R. H. Hutchings, M.D., and A. W. Wheeler, M.D., on " An Epidemic of Typhoid Fever due to Impure Ice." The outbreak occurred in the St. Lawrence State Hospital, situated on the St. Lawrence River three miles below the city of Ogdensburg. Between 2nd and 5th October, 1908, eight attacks of illness, which proved to be enteric fever, occurred. The ordinary sources of infection, water, milk, vegetables, oysters, could be excluded, and "there remained only the ice to be considered." This ice, which had been taken from the river and had been stored more than seven months, had, it appeared, come into use about six days before the cases of illness developed ; furthermore, during January and February, 1902, when the ice was forming, there were three or four attacks of typhoid in the city of Ogdensburg, the sewers of which discharged into the river, 1 Excluding from consideration, of course, outbreaks of ice-cream poisoning—i.e., cases in which the source of infeotion was presumably the cream or custard rather than the ice. Some instances of this kind have been referred to in my report on food, published as an Appendix to the Annual Eeport of the Medical Officer of Health of the County of London, 1898. 2 Axbelten aus dem Kaiserlichen Gesundheitsamte, 1888, p. 23. I have not been able to trace this case. 6 apparently some three miles above the place from which the ice was taken. Opposite the hospital the river, it may be noted, is a mile and a quarter wide and has an average depth of from 12 to 20 ft., while the current flows at the rate of three miles an hour. On examination of the ice it was found that " some of the cakes contained foreign substance in the form of black or dark brown granular matter frozen in the ice." The number of bacteria per c.c. was " on agar plates, 30,400 ; on gelatin plates, 50,400." The report continues: "Five colonies were selected, which presented characteristics resembling the typhoid bacillus, and fresh cultures were made from them. Of these cultures three proved to be the colon bacillus, one was a bacillus not identified, while the fifth was a pure culture of the typhoid bacillus as shown by the following tests. On nutrient agar it grows readily; in broth no pellicle is formed; in lactose media no fermentation occurs; on potato the growth is invisible; in litmus milk the reaction is faintly alkaline, and no coagulation occurs; with the serum of typhoid patients characteristic clumping is produced ; it is an actively motile bacillus having the appearance of the bacillus typhosus." The reporters add: " the disease was identified clinically by autopsies in three of the cases, in all of which the intestinal and abdominal lesions were demonstrated." Finally they state: "with the discontinuance of the use of the infected ice the epidemic gradually subsided. There were in all thirty-nine cases, the last of which developed in November." The evidence in this case, it will be seen, is based exclusively on the bacteriological finding, and while it might have been regarded as fairly satisfactory three or four years ago, recent growth of knowledge would appear to render it by no means conclusive. Nothing, for example, is said as to the degree of dilution in the clumping experiments, nor are particulars given as to the serum used; nowadays importance would be attached to the employment of serum from an immunised animal. Thus, that the ice was the cause of the outbreak cannot, in this instance, be regarded as being definitely proven. It remains to add, in connection with the supposed spread of enteric fever by ice, that charges have been made in New York journals to the effect that much of the enteric fever of the city is attributable to the impure Hudson River ice, and in support of this view it has been alleged that the very poor who use no ice suffer comparatively little from the disease. There may be something in the suggestion, though it must be noted that several other considerations might equally well account for the escape of the very poor, supposing always the statement to be well founded that immunity from the disease is enjoyed by them. Refrigerated Produce in Relation to Disease.—As regards the risk of the spread of infectious disease by refrigerated produce, it may be stated at once that there is really no evidence at the present time bearing upon it. Many persons, including, it may probably be assumed, some of those interested in the trade in home-grown meat, have from time to time been inclined to entertain gloomy forebodings as to the evils which might result from use of frozen meat, and public attention has been repeatedly drawn to the subject. Thus a writer, " Medicus," addressing a London evening paper, considers that appendicitis is caused by frozen meat; again, in a paper in the " British Medical Journal" of 12th December, 1903, reference is made to the increase of cancer in Ireland, and there follows the statement that " cancerous diseases . . . are caused by the longcontinued consumption of unwholesome animal food, and that this unwholesomeness is produced by modern economic conditions." "Physical deterioration of certain classes of the population," also occupies the attention of the same writer in a similar connection. Quite recently a question was asked in the House of Commons as to the relation between frozen meat and cancer, and the President of the Local Government Board, after communicating with the Executive Committee of the Cancer Research Fund, replied that that Committee believed the consumption of frozen and chilled meat was " not in any degree accountable for the increase in the recorded number of cases of cancer in this country." I have not been able to trace any allegation of a more precise kind as to injury to health caused by meat or other refrigerated food. A complaint, however, was made to the London County Council in November, 1903, to the effect that thousands of cases of bad eggs were sent into cold storage by traders who wished to prevent seizures being made by inspectors ; the medical officer was thereupon instructed to confer with the medical officers of Bermondsey, Southwark, and Stepney, with regard to this subject, and at his request I made inspections, and saw numbers of eggs examined for " spots." 1 I found that a number of bad eggs had been destroyed in the boroughs named from time to time, but for the most part these had been voluntarily surrendered and their destruction had been paid for by the egg merchants. The Bacteriology of Lce. In England comparatively little attention has been directed to the bacteriology of ice, but in America, Germany, and Italy, countries in which ice is much more largely used than it is here, the subject lias not been altogether neglected. The popular opinion has no doubt been that freezing tends to purify water, and three lines of reasoning seem in the main to have been responsible for fostering this notion. In the first place, reference must be made to the old observation that water in freezing rejects impurity. The Rejection of Impurity by Ice.—Dr. Prudden, in reporting on the ice supply of New York some eighteen years ago, had drawn special attention to the " filthy condition of the Hudson (from which much ice was derived) just below Albany," and he thereupon remarked " a certain proportion of New Yorkers have gone on amiably consuming their distant neighbours' 1 " Spot eggs " are the eggs which present evidence of growth of mould, &c. An explanation, given of the cause of the appearances in question is to the effect that if the egg is allowed to rest on its side, the yolk is apt to shift and attach itself to the shell, producing a "spot." Eggs should, it is maintained, be packed resting ou the small ends, a? in that position the yolk is least likely to be displaced. 7 filth under the impression, when it was thought of at all, that water purified itself from its contaminations in freezing." In Ure's Dictionary it is stated that " water in freezing really rejects everything it may contain, even air, and hence solid ice is actually pure water further, reference is made (loc. cit.) to Byron's knowledge of this fact (" Don Juan," 13th canto), and it is stated that the old nobles of Russia, when they desired a more intoxicating drink than usual, placed their wines or spirits in the ice of their frozen rivers, until all the aqueous portion was frozen, when they drank the ardent fluid accumulated in the centre. Several modern observers have experimented upon this property of water on assuming the solid condition. Tyndall describee in "The floating-matter of the air" how in 1871 he " sought anxiously and assiduously for water free from suspended particles," and how the thought occurred to him of examining the liquid derived from the fusion of the most transparent ice. He melted accordingly a block of ice, under conditions in which it was surrounded by moteless air, and he subjected water from the very heart of the ice " to the scrutiny of the concentrated beam." It proved to be probably the purest liquid " human eye had ever seen," but still it contained " myriads of ultra-microscopic particles," and was as infectious as the water from any ordinary tap." Abba1 refers to the experience of Arctic explorers—Nansen2 and the Duke of Abruzzi—who describe the mineral salts of sea-water as being separated out like hoar frost upon the surface when temperatures of from 30° to—40° C. are recorded, and who note the almost complete freedom from saline taste of the water obtained from projecting ice-shafts " which have been exposed to the rays of the sun during a summer, and are thus freed from the greater part of their salt."3 Again, Abba describes the entire want of success attending an effort made in Turin to distinguish between pure artificial ice and ordinary ice by the employment of pigments. Laboratory experiments suggested the use of aniline dyes as a means of differentiating pure from impure ice, but on applying this method on a large scale, the ice frozen from coloured water proved to be colourless. Heyroth4 gives a full account of the various experiments made prior to the date of his paper by way of historical introduction to his own work on the subject. Robinet, in Paris, found the hardness of samples of ice-water materially less than that of the original water; Bolley, in Zurich, and Bordoni-Uffreduzzi, in Turin, obtained somewhat similar results. Dufour concluded that solid substances in solution were completely extruded by the ice-crystals themselves, but remained'to a greater or less extent entangled between individual crystals in the block of ice. Rudorff held that the existence of finely divided foreign solid particles between the ice-crystals was impossible, and that the ice-block therefore contained within it collections of saline solution. This observer adduced the results of experiments with solution of magnesium-platinum-cyanide (a salt which in the solid condition is coloured, but which yields a colourless solution) in support of his views. Guthrie held that ice entered into combination with various solid matters, forming "kryohydrates," having definite crystalline forms. Offer instanced as an objection to this hypothesis the fact that on melting sea-water ice the first samples showed a considerable quantity of salt, while later specimens, derived therefore from what was once the interior of the block, proved to be almost pure water. Buchanan is cited as having obtained results confirmatory of those of Offer. Heyroth refers further to the work Riidiger, Warren, Orlando Brown, Hills and Nichols, Schelenz, and Prudden. The experiments of Pengra5 are also quoted by Heyroth, as indeed they are by most writers on this subject. Pengra concluded that in freezing, ice casts out about 50 per cent, of the crystalloids, and only some 20 per cent, of the colloids contained in the original solution frozen. This observer also experimented with bacteria (of these he found 90 per cent, removed); with coleps hirtus of stagnant pools (91.6 per cent, removed); with paramoecium aurelia (98.3 per cent, removed); and with glaucoma scintillans from infusion of hay (89 per cent, removed). He states that freezing does not kill these organisms, which multiply rapidly. Further work on the chemical analysis of ice quoted by Heyroth relates to observations by Fritzsche on coloured solutions, and to experiments on the freezing of milk by various observers: this last-mentioned subject has received a good deal of attention of late years. Finally, Heyroth refers to the application of freezing processes in the manufacture of pharmaceutical preparations and in connection with wine and beer-making. The Self-Purification of Ice from the Biological Standpoint.—A second reason for entertainment of the opinion that freezing purifies water, and one which dates, of course, from growth of knowledge concerning the germ theory of disease, is based upon belief in the destruction of living organisms by prolonged exposure to cold. The earliest work of a precise character in this connection was done by Fraenkel6. A company had been formed in Berlin—" Ivrystalleis-Actien-Gesellschaft"—with the object of manufacturing ice from distilled water, and this company had examinations made of the natural ice sold in that city. The results were of a somewhat alarming character, and Dr. Karl Fraenkel was directed to investigate the subject by Koch. Dr. Fraenkel indicated certain sources of error which require to be guarded against in making bacteriological examinations of samples of ice, and as a matter of fact, his results (which ranged from 21 to 8,400 organisms per c.c.) fell considerably short of those obtained by the bacteriologist who had been employed by the artificial ice company. 1 Zeitschrift fur Hygiene und Infectionskrankheiten. Band 45, Heft 2. 2 Nansen says (" Farthest North," Vol. I., p. 220): " As soon as ice is formed in this temperature the frost forces it to throw out its salinity on the surface, and this itself freezes into pretty salt flowers resembling hoar-frost.'' 3 "At our last camping place," Eays Nansen, "it was impossible to find any ice which had been exposed to the summer sun, and consequently freed from 6alt.—Ibid, "Vol. II., p. 137. 4 Arbeiten aus d'm Kaiserlichen Gesundheitsmte, 1888. Annual Reports of the State Board of Health of Michigan, 1882 and 1884. Zeitschrift fur Hygiene, 1886. 8 He points out, however, that the presence of some thousands of germs per c.c. would be held to condemn water, and, inasmuch as ice generally contains a smaller number of germs than the water from which it is made, it may be safely assumed, if the ice contains many organisms, that the original water was quite unfit for use. Fraenkel found the number of living bacteria in a sample was sometimes reduced as much at 90 per cent, by freezing for three or four days, but that the ice might still contain large numbers if the water had been greatly contaminated with them. Crystal-ice prepared from distilled water was ascertained by Fraenkel to be almost free from germs, and he conclndes that if ice were always eaten, this last sort of ice alone should be allowed to be sold. Ice, however, as he notes, is largely used as a cooling agent and preservative, and provided it does not come into contact with food, he sees no reason for insisting on its purity. As he says, examination by the eyes and nose of an ordinary ice-chest1, which has been a fortnight in use, suffices to demonstrate how much dirt ice contains. He then proceeds to point out that fish, vegetables, etc., are laid upon ice, and that raw ice is actually added to beverages, and he says, if it be deemed desirable to avoid Spree water or bad spring water in wine, all ice save that made from distilled water must be avoided. Of course, the use of pure ice is to be recommended for medicinal purposes. Hence Fraenkel finally concludes that natural ice is unfit for consumption in beverages, or for use medicinally, or for application to wounded surfaces. If it be a question merely of contact with foods which are afterwards cooked, raw ice may be permitted, though pure ice is even then to be preferred. Raw ice may be used when the cooling agent does not come into actual contact with the food. Dr. T. Mitchell Prudden's report " On Bacteria in Ice and their relation to Disease, with special reference to the Ice supply of New York City," appeared in the Medical Record, Vol. 81, 1887. Dr. Prudden experimented with six different species of micro-organisms, and found the effect of freezing on the numbers recoverable on cultivation was in the direction of marked diminution, but the germs did not always disappear altogether. He tried alternate freezing and thawing, and the results were more striking, the organisms being completely destroyed in a short time. He further experimented with low temperatures, under conditions in which the water was not allowed to crystallise into ice; by coating the inside of test tubes with sterilised sweet oil, he found it was possible to cool small quantities of water placed in the tubes considerably below freezing point without occurrence of solidification, provided the water was kept perfectly still; it is, of course, well known that fluids crystallise more readily when in contact with rough than with smooth surfaces. Dr. Prudden compares the effects produced under these conditions with those of ordinary freezing, and remarks that the " different destructive capabilities of what may be called dry and moist cold are interesting in view of the similar differences which exist at the other end of the scale between dry and moist heat." He concludes that water which contains bacterial contaminatian "by freezing and remaining frozen for a few days may purify itself by the destruction of as much as 90 per cent, of the bacteria "; further, that the " number of living bacteria is gradually reduced in ice," but " this reduction does not go on to extinction." By way of practical illustration, he refers to the New York water supply, and says: " He, who, impressed with the importance of a pure drinking water, should perfectly filter half a glass of average Croton water, and then add to it an equal quantity of the average ice, would have the satisfaction of replacing the bacteria removed, with more than eight times as many from much more uncertain an questionable sources. The reduction in numbers of typhoid bacilli in ice was made the subject of experiments by Sedgwick, "Winslow and Park (Boston Medical and Surgical Journal, CXLV., p. 556;. They found that beginning with a certain number of typhoid bacilli in the ice, after three weeks the percentage dead was 99"5 : this being also the percentage purification achieved in an ordinary water filtering plant. Hence they argue that ice known to be definitely infected with typhoid bacilli might, after standing three weeks from the date of freezing, be consumed with no more danger than that involved in drinking infected water after efficient filtration. It is noted, moreover, loc. cit. the " mere act of freezing itself results in the diminution by 90 per cent, at least, by physical throwing out of the bacteria." The reporters of the outbreak of enteric fever due to ice referred to on page 5, point out that but little regard can be paid to considerations Buch as those which have just been adduced. An important light upon the bacteriology of ice was thrown by Professor Abba2, who sought to reconcile the alleged absence of interference with the life processes of bacteria upon exposure to low temperatures, with the observed diminution in the number of organisms in ice. He quotes the results of Belli3, who, using liquid air, exposed anthrax and fowl-cholera bacilli to temperatures of from—180° to—190° C., without causing perceptible impairment of their pathogenic property, and in the light of these experiments Abba is driven to conclude that the diminution of organisms associated with freezing is brought about not so much by their destruction as by their being extruded from the ice. In order to put the matter to the test he caused 25 litres of water containing 3 per cent, of chloride of sodium to be frozen into a parallelepiped of ice, the outer part of which consisted of clean ice, the inner axial portion, that last frozen and therefore containing the solid matters expelled from the ice as freezing proceeded, being quite opaque. Examination of specimens of the clear and opaque ice showed the former to bo free from chloride of sodium, while the latter on being melted gave a rich 1 " Any sort of ice is good enough for the home ice-box. It melts there, and the same heat which melts it lets loose its tenors into the meats, butter, and other food substances which form the contents of the refrigerator. Half the time the ice-box is never scalded or sterilised."—Cold Storage, 15th August, 1904. 2 Ueber dem Mechanismus der biologischen Selbstreinigung des Eises."—Zeitschrift fur Hygiene und Infectionskrankheiten. Band 45, Heft II. 3 Riforma Medica, 1901. 9 white precipitate with a soluble salt of silver and possessed, moreover, a decidedly saline taste. On examining the clear and opaque ice bacteriologically, Abba found that while the germs in the opaque core of the ice ranged between 100 and 1,000 per c.c. in the large majority of instances, the number in the clear ice very rarely exceeded 100 per c.c., and was often less than 10 per c.c. In four instances out of sixty examinations, the specimen from the clear ice was found to be sterile. Abba concludes, therefore, that the biological self-purification of ice is effected in the same way as its chemical purification, and that it is necessary in making artificial ice to have regard to the fact that the central core contains the impurities of the water. Hence, if distilled water be not used, the liquid remaining within the block of ice when solidification is nearly completed should be removed and replaced by clean water.1 The Clearness and Sparkle of Crystal Ice.—" The beautiful clearness and sparkle of wellformed ice," says Dr. Prudden, " tend to confirm the belief that the act of freezing is a very perfect purifying agency." He goes on to explain, however, that bacteria may exist in water in enormous numbers without in the slightest degree impairing its clearness and transparency. Thus he examined water containing one and a half million organisms per " tablespoonful" in a thin walled glass tube half an inch in diameter, and on passing a beam of light from a lens through the tube only the faintest opalescence could be detected. " Snow ice " and " bubbly ice" were found on examination to compare unfavourably with crystal ice, and the results of precise bacteriological experiment strikingly confirmed the " popular prejudice against bubbly ice." It must be borne in mind that ice made from the purest water may be quite opaque, for, as Dr. Prudden says, " ordinary opaque ice . . . with comparatively few bubbles is . . . as free from bacteria" as the most transparent ice. Further, with regard to the source of the bacteria in snow and ice, he says " a part of the excess may be due to the washing down upon the surface of the ice, from the shores, of bacterial impurities, or their collection from the air; a not insignicant share is probably due, at least in the bubbly streaks, to the tendency which some forms of bacteria exhibit to collect in the vicinity of air bubbles, and perhaps also to unknown physical conditions in the irregularly crystallised ice about these bubbles." He points out, moreover, that freezing must not be regarded as necessarily giving protection against impurity similar in kind to that afforded by filtration; for, he says, freezing is a selective filtration, germs may not all be eliminated with equal efficiency, and the dangerous disease-producing species may possess special capacity for resisting low temperatures. In a report presented to the State Board of Health of Massachusetts for the year 1899, distinction is made between " snow ice," "bubbly ice," and " clear ice," and again between " top ice," and " bottom ice." It is stated that " when ice first forms on the surface of a pond or river, a considerable part of the impurity in the water near the surface is entangled in the first inch or less in depth, and that the ice which forms below this first inch contains but a very small percentage of the impurities of the water." Again : " If snow falls upon the thin ice, causing it to sink, so that water from below saturates the snow, it will freeze without purification ; or if rain falls upon the snow and freezes, the ice thus formed contains the impurities of the snow and of the rain water and whatever else may have settled out of the air. The method often pursued of flooding the ice of a pond or a river by cutting holes through it gives a layer of ice as impure as the water from which it is formed." The earlier notions concerning clear, bubbly, and opaque ice, require to be considerably modified in the light of knowledge gained concerning artificial ice. As has already been seen, ice made from distilled water may be quite opaque, owing to the entanglement within its substance of minute air-bubbles. Hence such " tombstone ice," as it was called in America when it was first placed on the market, was at a great disadvantage as compared with the relatively transparent ice from ponds and rivers, although bacteriologically the former is far superior to the latter. Makers of artificial ice gradually perfected devices for securing clearness as well as purity—notably the water in the freezing well was kept in a state of agitation by the movement of a plunger, and when this system was adopted the outer layers of the ice-block, those which froze first, were quite clear, and it was only the internal core, containing the water which froze last of all, which was opaque. Professor Abba suggests that this core should be removed, the impure water being replaced by pure water.2 In American cities, in which ice is largely used, it is a well-recognised fact that the opaque core has a pronounced salt taste, and servants are instructed to detach this opaque ice, and to destroy it. If by an oversight a piece of this ice were inadvertently brought to table, it would be removed, and the glass in which it was found would be carefully cleansed, the fact that this ice contains the bulk of the foreign matter in the original water being fully appreciated. The London Ice Trade. Some 200,000 to 300,000 tons of Norway ice are brought to London each year, and in addition some 30,000 to 40,000 tons (approximately) of artificial ice are manufactured in London. The amount of artificial ice made has rapidly increased in the last few years. The ships which bring ice from Norway are old sailing vessels. I am indebted to Dr. Williams, medical officer of the Port of London, and to Dr. R. K. Brown, medical officer of 1 This device has also been recommended with a view to avoidance of the " cloud and colour which occur frequently near the centre of ice-blocks." It has been suggested that this water, " which would otherwise form the opaque core of a block of ice," should be replaced by clean water and freezing be then allowed to proceed, the water being agitated during the early stage of coagulation."—Ice and Cold Storage, May, 1904. 2 In " Mechanical Refrigeration " (Hal Williams, Whittaker & Co., 1903) an account is given under the heading " Defects in Ice due to the Use of Distilled Water," of " red core," which is due to rust, and " white core," due to the presence of air and sometimes of carbonate of lime and magnesia. Ice made from London water, soon after heavy rainfall had caused the river Thames to be in flood has been found to exhibit " red core." (See p. 10). 740] B 10 health of Bermondsey, for the facilities afforded me by them for visiting some of these ships. In one of them, visited with Dr. Williams, I found that the hold had a superficial capacity on section of some 280 square feet, and its length was about 80 feet; it was capable, therefore, of containing some 640 tons of ice, and was fairly clean, there being no likelihood, so far as I could ascertain, of the ice being contaminated by bilge-water, or, indeed, in any ordinary way on board the vessel. Most of the ice, we were told, came from lakes near Christiana (Brevik, Pornung, and Laurvik were especially mentioned as being seats of the ice-industry). The ice is brought from Norway between April and October; it is reckoned that if fortune favours about twenty-four days are taken up from leaving London to returning to London again, but contrary winds, rough weather, and fog cause uncertainty, indeed, a boat may be delayed as long as fourteen days at Gravesend. The vessel inspected had loaded 640 tons in Norway, and the skipper expected to weigh off at about 540 tons. We are told that the freight charge made was about 6s. 6d. a ton, and that the ice fetched about 2s. a cwt. in London. The charges which had to be met included £1 for towing out of the fiord, £10 for towing across, and .£3 for the Thames pilot. The vessel carried a crew of nine men, who were all housed on deck and not in the hold; wind pumps were used to remove water from the hold, it being all important to keep the ice dry. We were further informed that various cargoes might be taken back to Norway on the return voyage ; coke, for instance, might be carried, but, in that case, the hold would be washed out before being again filled with ice. The lakes in Norway are farmed out for ice harvesting. They are situated in a sparsely populated country and I was shown photographs of several of them which certainly suggested that few, if any, sources of pollution of lake water could exist. In the removal of ice from the ships to the lighters in the Thames or the Regent's Canal Dock there is some opportunity for contamination of the blocks, and no special precautions are taken to prevent pollution during conveyance to the ice-stores. There are a number of premises of the kind just referred to in London—sometimes a railway arch is thus used, in a few instances brick structures above ground, provided with more or less complete means of insulation, have been erected for the purpose, and lastly there are a number of icewells. In many of the stores there is great waste of ice. This was notably the case, for example, in a comparatively old store enclosed by brick walls, lined internally with wood, the space between being packed with sawdust; the capacity of the structure was such that when full some 800 tons of ice could be stored, but the "suction of the bricks" was, according to the manager, so great that after four or five weeks "you could walk round the ice" in the store, the blocks immediately adjoining the walls having completely melted away. The question arises as to what becomes of the waste-water in ice-stores and ice-wells. Some of the stores or wells rest upon gravel or other pervious material, and the water soaks away: in other instances there is a drain inlet at the bottom of the store or well and the water runs into the sewer. Under the circumstances last named it cannot be denied that there is the possibility of back flow from the sewer. The trapping of the inlet to the drain might be held to assume importance; I was assured in most of the instances to which my attention was directed that the inlet in question was trapped. Some of the ice-wells are in the near neighbourhood of the river or of a canal, and here again is a possible source of pollution of the ice. Yet another cause of contamination arises from the ice being trodden over again and again by dirty boots ; in only one instance did I find that any precaution was taken as regards this matter. In this single case, however, the use of boots was prohibited in the well, the men being required to wear clean clogs. At this depot, moreover, the well was said to be washed down with a hose once a year, and the " cesspool" beneath the well was cleaned out at the same time ; further the ice was dragged over a special hauling-way, and was not allowed to lie on the wharf, or to be exposed to the contamination of ordinary yard surfaces, &c. The remark generally made when attention is directed to the desirability of adopting precautions as regards cleanliness, is to the effect that ice by melting continually purifies itself, and I was even told that all that need be done is to swill the ice over with water when it is packed in the carts for delivery, so as to make it look clean. The carts and barges in which the ice is conveyed are not very carefully looked after in all instances. A barge may " ship " canal or Thames water, for example, and the ice-carts are not always limited in their use to carrying ice ; there is nothing to prevent a cart in which refuse has been conveyed from being pressed into service as an icecart at times of stress, and during a period when little business was being done in ice, I have been told of a contractor sending a number of ice-carts for use as platforms at a public meeting. Observations made in the London streets outside fishmongers' premises, restaurants, etc., abundantly demonstrate that there are many possibilities of contamination even after the block leaves the ice-cart. It is, for example, usually dragged along the roadway and over the pavement on its way to the shop or to the storage vault. Reliance, of course, should not be placed upon self-purification by melting of the outside layers as a safeguard against risk of pollution, and clearly, in the case, at any rate, of ice intended for human consumption, proper precautions should be taken which would preclude fouling by dirt from boots, from horsemanure, road-sweepings, material expectorated upon pavements, and so on. There are now a few factories in which artificial ice is made in London. The water used in them is in some instances distilled water; in others it is obtained from the ordinary London water service. At a factory supplied with Southwark and Vauxhall water, some 200 tons of ice had to be destroyed in 1903 owing to the fact that the water, after a period when the Thames was in flood, was much discoloured, and at the edges of the ice and down the middle of the blocks, the brown material thrown out during freezing had collected, causing the ice to be quite unsightly. In some cases exhaust steam from steam-engines is condensed and filtered to get rid of the engine-oil, and this filtered distilled water is then converted into ice. Such ice, and, of course, also ice made from water specially distilled for the purpose, must be free from microbial impurity ; the blocks are quite clear, and command an enhanced price when sold 11 as crystal-ice. I have seen ice of this sort exposed for sale in a seaside town, and recommended to the attention of the public as being germ free. Further, I have been informed that oysters have been served with a piece of distilled-water-ice upon each oyster; the accompanying menu contained an assurance that the ice was made from sterlised water; reference to the purity of the oyster was apparently regarded as a work of supererogation. A stimulus to the use of distilled water has been furnished by the fact that the crystal clearness of the resulting ice renders it especially attractive. If tap water is frozen in the ordinary way the ice is full of minute air bubbles and is quite opaque and as unsightly as, though probably far purer than, ordinary natural " snow ice." In order to overcome this difficulty the water may be agitated during the process of freezing, and the ice free from bubbles can be thus produced. The opacity of ordinary artificial ice has militated greatly against its popularity in the past. The idea has been entertained that the lack of transparency was due to chemicals, and the use of the expression " ammonia process " appears to have led to the suggestion that ammonia was actually introduced into the ice itself. Fishmongers have, for instance, complained that artificial ice turned their fish black, and much misapprehension on the subject has undoubtedly existed. Artificial ice, of course, contains no chemicals. The principle underlying the use of ammonia or carbonic acid is simply that the gas, when allowed to expand, absorbs heat, and this power of taking away heat is utilised to cool brine1, which circulates in pipes around the cells or receptacles in which the water to be frozen is placed. There is, of course, a possibility that the brine may escape from the pipes and contaminate the freezing water, but if this happens the resulting ice is, I was assured, of necessity, so discoloured and unsightly as to make it impossible for it to be sold. Another alleged disadvantage is that artificial does not possess the lasting power of natural ice. In a note in " Cold Storage" for August, 1903, attention is called to the argument advanced by the " Chicago Chronicle " to this effect. " Hygeia ice " (i.e., manufactured ice) never steams or gives off, according to the American journal, that "live frigidity which is the essence of coolth." " Lake ice," on the other hand, " smokes and radiates, lives, and dies," while manufactured ice "cannot die because it is dead in the beginning." The "Chicago Chronicle" continues, "Air is life; hygeia ice has no air in it: lake ice is full of air." It will be recollected that, according to Dr. Prudden and other bacteriologists, "bubbly ice" is particularly impure. Moreover, one of the great difficulties with regard to manufactured ice has been seen to be the fact that it is opaque, owing to contained air bubbles. Indeed, there appear to be more things deserving study in connection with the " essence of coolth" than are dreamt of in the philosophy of the " Chicago Chronicle." One very important consideration which muBt not be lost sight of is the size of the blocks compared. Ordinary Norway ice averages from twenty to twenty-four inches in thickness, and a block cut from such ice presents less surface in proportion to its bulk than does the average block of artificial ice which, as a rule, is only about half that thickness. The reason lies, of course, in the fact that increase in thickness means increased time in freezing. I was informed at an ice factory that the first four inches frozen became congealed in twenty-four hours, but after that the average time occupied in freezing the rest of the slab was twenty-four hours per inch, and with further increase in thickness of the slab increasing intervals of time would, of course, be required. That the staying power of ice depends upon the size of the ice-blocks will be appreciated by considering that if a block of ice one foot cube be divided into pieces of one inch cube, the total superficial area exposed in the small cubes taken altogether is twelve times as great as in the case of the large cube. Such a consideration makes it clear that it is not worth the while of the ice merchant to store ice which is only a few inches thick, and indeed, since 1881, canal and river ice have not, I am informed, been stored in London on any considerable scale. Hence, again, blocks of artificial ice, twelve inches or less in the smallest dimension, and Norway ice when the winter has been mild and the ice is, only it may be, fourteen inches thick, do not keep as well as blocks which are, say, two feet at least in the smallest dimension. There are three different systems of making artificial ice which are practised at the present time.2 In the "can system" tapered blocks from six to eight inches thick are frozen in cans suspended in a tank containing refrigerated brine kept at a temperature of about 14° F. In the " plate system " large plates of ice, ten or eleven inches thick are produced. A tank is divided by vertical partitions within which cold brine circulates, the interspaces left between these partitions are some 8 to 12 ft. long, 6ft. deep, and from 29 to 27 in. wide. The ice forms on each side of the partitions in which the brine circulates, and freezing is allowed to go on until the ice is from 6 to 10 in. thick. Sometimes the partitions are 10 or 12 in. apart, and freezing is continued until the ice, forming on one side of a partition, meets the ice advancing from the next partition and makes with it a coherent mass. In this case, however, air bubbles and impurities are apt to be frozen in ; in other words, the ice has a "core." In the " cell system" blocks of approximately cubical shape are produced. Artificial ice may be of three kinds—ordinary opaque ice, agitated ice (the water being deprived of most of its air by agitation), and distilled water ice (the water frozen being distilled water, and the ice formed consequently free from air bubbles, and clear as crystal.) It remains to say a few words with regard to cold storage as carried on in London at the present time, and of course the hygienic aspect of this subject alone will be here referred to, and it may be premised that very little appears to be known with regard to the question, the ground being at the present time practically unbroken. 1 The circulating brine is capable of carrying a lower temperature than 32 deg. F. Chloride of calcium is the salt usually employed in the brine of refrigerating works ; it produces a greater refrigerating effect, and is less apt to clog the pipes than sodium-chloride brine. 2 Further details with regard to these systems will be found in " Mechanical Refrigeration," by Hal Williams, Whittaker & Co., 1903. 12 There are three principal methods of refrigerating. (1). Direct expansion. In this method gas is expanded directly into coils of pipes placed on the walls or ceilings of the cold rooms; the pipes become very cold, and the moisture of the air is deposited upon them in the form of snow. This method is simple and economical, but does noi readily lend itself to providing considerable variations of temperature, and it is therefore best suited for stores designed for one class of goods only, in which, therefore, a uniform temperature can be maintained throughout. (2.) Brine circulation. Here the gas expanded is used to cool brine which is circulated in pipes through the cold rooms. This system readily adapts itself to the production of varying temperatures. (3.) Cold air blast. Here air is cooled by being blown over a battery of pipes, in which cold brine circulates or in which gas is being expanded, and the cooled air is drawn through the storage rooms. This system is cheap and has come largely into use of late years. Inasmuch as the moisture is removed from the air by cooling it, there is risk of the very dry atmosphere causing damage to certain kinds of goods. Moreover, the air is apt to take up odours, and being distributed throughout a cold store may give the flavour of hops to apples, or of onions to butter. Hence it has been found necessary to purify the air, and this may be accomplished1 either by removing the frost adhering to the pipes, when the closed system is used, or by renewing or purifying the brine in cases in which there is immediate contact with the cold solution. On the withdrawal of an old supply of brine abundant evidence of the extent to which it has been contaminated is afforded. Steaming was at one time practised for strengthening purposes, but it was found that the impurities and smells of the cold air rooms were so concentrated in the brine that nuisance was caused, and this practice has had to be abandoned. There are two points of practical importance to which further attention might with advantage be directed in connection with cold storage from the public health point of view : first, the question as to cleanliness of surfaces, and, secondly, that of purity of air. While it may be admitted that "dirt" is less likely to be productive of harm at 14° F. than at 64° F. or 74° F., it would a priori appear essentially necessary that a room in which it is intended that food shall be stored should be kept clean. " Cleanliness," says the Managing Engineer of the Cologne slaughterhouse,2 " is a main desideratum in the cold store. The best air-cooling apparatus and the most careful attention are worthless if the store is dirty, or if pieces of flesh and fat hang about the compartments or lie on the floor. These soon become decomposed, and spoil the whole cold-air store." This writer goes on to prescribe that " some time every day whilst the cold store is shut the passages on the floor should be cleaned. If the floor is properly laid it is best to swill it out. Then the water can be removed with squeegees, as is done with asphalte pavement, to the gutters. No damage can be done by the swilling and the consequent increased moisture in the air, since there is no raising of the temperature, in which case the moisture might settle on the already cooled meat." The second question—that of purity of air—has already received a good deal of attention, for some foods continually give off gases and odours (meat is said to be the only food which " does not gas "), and certain of the articles commonly cold-stored are specially apt to take up odours. In a few instances, moreover, difficulty has arisen on account of use having been made, for insulation of the cold store walls, of a preparation containing tar, inasmuch as during warm weather a tarry smell has resulted, andgreat difficulty has been experienced in dealingwith the same; indeed, at Frankfort-onMaine and at Cologne it was found necessary to " change the insulation" on this account. Therelative air-purifying effect in the case of apparatus in which there is direct contact with brine, as contrasted with apparatus in which air-cooling is accomplished by direct expansion, has been referred to. The respective merits of the two systems are referred to in a paper by E. Stetefeld,3 from which it may be incidentally inferred that a good deal of difficulty has been experienced in some cold air stores in keeping down smell resulting, among other things, from a dirty condition of the storage chambers. More attention will doubtless be directed to this question of purity of air in cold stores in the near future. Conclusions. The main issue raised by the Bermondsey Borough Council in sending the report of their medical officer to the London County Council is as to the fitness for consumption of the natural ice brought chiefly from Norway into London. Dr. Brown in his report says it is obvious that only a very small proportion of the ice is destined for food, and yet " any particular consignment may be used either for drinking or for cold storage purposes." He adds that, while he does not doubt most of the natural water from which the ice comes is perfectly pure, there is no guarantee that villages and towns do not drain into the places whence the ice is derived. As regards the artificial ice, Dr. Brown remarks that the water supplied in London " is presumably suitable for manufacturing ice from as long as it it considered fit for drinking purposes." " Distilled water," he adds, " is, of course, the best for the purpose, though however pure the water used may be, it will avail little as regards the purity of the ice made from it unless it is strictly guarded from contamination during the freezing process and the subsequent handling." These conclusions appear to me to be well-founded, and I quite agree with Dr. Brown in thinking it undesirable to continue to repose absolute confidence in natural ice in ignorance of the conditions which exist at the harvesting grounds. The employment of distilled-water ice was recommended on the best authority in Germany twenty years ago and the use of artificial ice has steadily gained ground in the United States, and is being slowly but surely extended in this country. Having in view the nature of the risks involved in consuming natural ice, and the 1 Lessons gathered from the Working of Cold Air Stores, Joseph Musmacher.—Ice and Cold Storage, 2 Ice and Cold Storage, April, 1903. 3 Ice and Cold Storage, February, 1903. 13 demonstrated insufficiency of the supposed safeguarding circumstances, the reasonable course would appear to be to abandon the use of such ice for actual consumption or for purposes in which it is brought into direct contact with foodstuffs. Under such conditions ice made from absolutely pure and preferably from distilled water should be used,1 and strict precaution should be taken to ensure that such pure ice does not become contaminated subsequent to its manufacture. That ice is not more largely used for domestic purposes in this country is regrettable. The " Lancet " (June, 1904) imagines that " nobody will deny the very great advantages derived from keeping certain foods in the summer, and preserving them in a state fit for consumption and attractive to the eye and palate." But the only shop where ice can be obtained is that kept by the fishmonger, and the " Lancet" is not satisfied that this always represents an "environment " that is, sanitarily speaking, satisfactory, and indeed adds, " It seems ridiculous that in the English summer the demand for ice should not be sufficient to warrant the establishment of a special agency for its supply." A further question to which it is necessary to call attention is the need of supervision of cold stores. The New York Legislature, last year, had under consideration a Bill for the inspection of storage warehouses "located in cities of the first class, to ensure sanitary conditions in these stores and to give the inspectors authority to condemn any foods stored therein, which are considered as unfit for use or deleterious to health ; also to provide a licence fee of 500 dollars per annum for such inspection." The attempt has been made in Chicago to provide for the inspection of cold storage plants, and to limit the time of storage of perishable goods. Further, in the Salmon and Fresh Water Fisheries Bill introduced into the House of Commons last year it was proposed to make compulsory the registration of refrigerating premises in which salmon may be stored. The question appears to have been raised in some parts of the country as to the right of entry of sanitary inspectors into cold stores. Owners in London, so far as I am aware, have not raised any question of this sort, and, indeed, far from doing this, their attitude appears to have been one of welcoming inspection and inquiry. It is obvious, however, that what is needed in the interests of public health is not merely that any unsound food in a cold store should be seized and destroyed, but that consideration should be given, in originally designing refrigerating premises, to questions of structure and arrangement having importance in relation to health, and in order to attain this object it will probably be found necessary in the near future to require registration of all such places. The possibilities of mischief in the case of a cold store are possibly greater than they are in that of a dairy, yet the latter is subject to control by the health authority, while the former is not. It may be added that an amendment was recently inserted in the Agriculture Appropriation Bill in the United States Congress " providing for a fund to defray the cost of investigation into the effect of cold storage on perishable foodstuffs, as to the effect on their nutritive qualities, or their liability to cause disease," and it is stated (Cold Storage, May, 1904) that at the present time the American Government is spending money upon investigations in refrigeration at Chicago. W. H. Hamer, Assistant Medical Officer of Health. 1 In the course of a lecture on the technical applications of liquid air, delivered last year by Dr. Carl von Lindo before the Cold Storage and Ice Association, small cylindrical glass vessels with double walls, each capable of receiving four to five cubic inches of liquid air, wore shown, and it was suggested that such vessels might be placed before guests with a view to their using the liquified air at discretion as a refrigerant for drinks, possibly also for viands. The cost of each charge, it was stated, would be less than a penny. 740] c MAP SHEWING PRIMARY CASES OF ENTERIC FEVER NOTIFIED, During the period November 21st to December 5th, 1903, in the Area supplied wholly or in part by the Southwark and Vauxhall Water Company. N B.—The RED DOTTED LINE indicates the boundary of the area supplied by the Southwark and Vauxhall Water Company. The BLACK CROSS-HA TCHtNQ indicates the area supplied jointly by the Southwark and Vauxhall and Lambeth Water Companies. The RED DOTS indicate cases of enteric fever occurring in houses supplied by the Southwark and Vauxhall Water Company. The RED CROSSES indicate cases of enteric fever occurring in houses supplied by the Lambeth Water Company. Martjn,Hoo4&Larkin.Photo Iitbo.C't,"Newport SrjWC London County Council. Public Health Department, 8, St. Martin's-place, W.C. April, 1904. Report by the Medical Officer presenting report by Dr. Hamer on prevalences of Enteric Fever in London at the close of 1903. (Ordered to be printed by the Public Health Committee.) Since the occurrence of the outbreaks of enteric fever in Southwark, Lambeth, and Kensal Town,* which were investigated by Dr. Hamer, whose report I presented to the Committee in January, 1901, the question has from time to time risen as to whether fish has again played a part in spreading the disease in London. In 1902 Dr. Allan, the medical officer of health of Westminster, called attention to a small group of cases in which there was some ground for supposing fish had been at fault.t Another case Dr. Allan reported was " believed to nave been contracted from eating fried fish while staying at Old Ford." Dr. Newman, the medical officer of health of Finsbury, states that in that borough in 1902 there were eight cases of enteric fever, concerning which there was some evidence that they were caused by the consumption of fried fish. Dr. Bulstrode, medical inspector of the Local Government Board, has called my attention to references to the possible transmission of the infection of enteric fever by consumption of fried fish contained in reports by Dr. Annis, formerly medical officer of health of Huddersfield, now medical officer of health of Greenwich, and by Dr. A. S. Williamson, medical officer of health of the Urban District of Sandal Magna. The report of the third quarter of 1898 of the medical officer of health of Huddersfield contains the statement that out of a total of 29 cases of enteric fever several " appear to have had a common origin from a case occurring in the person of a fried fish shopkeeper, who, whilst suffering from the earlier stages of the illness, still attended to his business without apparently having a sufficient regard to cleanliness in all its details whilst conducting the same." Dr. Williamson's annual report for 1899 describes how the occurrence of a case of enteric fever in Heath-road, on June 17th, was followed from July 12th-14th by that of five other cases, three in separate houses (one of the three being that of the keeper of a fried fish shop), and two in the Heath-road house. Dr. Williamson writes: "At the house in Heath-road, of four children who had been customers (the parents never ate fried fish) three contracted the disease; in another house the patient was a lodger, and the only one in the house who had had fried fish; and in the other case the patient was also the only one in the house who had." The circumstances which led to Dr. Hamer's present inquiry were as follows—In the week ending December 5th, 1903, Dr. Bond, the medical officer of health of Holborn, raised question as to fish sold at two fried fish shops having caused enteric fever in his district, and he later prepared a special report on the outbreak which he forwarded to the Council. I was from the outset in communication with Dr. Bond and Dr. Allan (one of the shops held to be at fault was situated in Westminster), and Dr. Hamer, at my request, conferred with them on December 14th and succeeding days, and made inquiries as to the source of the fish sold at the implicated shops. Examination of the notification figures directed attention to undue prevalences of enteric fever in 1903 in other parts of London, and Dr. Hamer was afforded help by Dr. Millson, the medical officer of health of Southwark, in making inquiries in that borough, and later extended his investigations to other districts. It speedily became clear that a localised prevalence of enteric fever in Southwark, occurring a few weeks before the Holborn and Westminster cases, was in all probability due to consumption of fried fish, and it became necessary therefore to inquire as to the possibility of mischief being thus caused in other parts of London during the closing weeks of 1903. The localised outbreaks in Holborn and Southwark were on a smaller scale than the prevalences in 1900 had been, but it was by no means clear that they represented the whole of the cases due to distribution of infected fish in October, November and December, 1903. There were, in fact, three periods subsequent to attainment of the autumnal maximum, when the number of cases in some parts of London showed increase, one towards the end of October, another in the 51st and 52nd weeks, and an intermediate period. The tendency to grouping of cases in the * In the Southwark and Lambeth outbreaks fried fish was incriminated. In Kensal Town fish sold in the uncooked condition (wet fish) fell under suspicion. † " One patient was a fishmonger and three others were regular customers buying fried 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 * * * to attribute his illness to oysters eaten off a barrow in the East-end."—Annual Report, Medical Officer of Health of "Westminster, 1902. 2 intermediate period was marked—it was in this period that the Holborn and Southwark groups occurred—and partly on account of this tendency to grouping these cases have been more particularly studied by Dr. Hamer. The first period presented groups of cases, but inquiry was not made as to these when they occurred, and difficulty was experienced in following the matter up after an interval of time. The third period, in which the increase (as, indeed, was the increase in the first period) was quite small, did not present marked grouping of cases. The abnormal incidence of enteric fever in the intermediate period examined was in part accounted for by the Holborn and Southwark groups already mentioned, and by groups in Stepney and Poplar, but an important contribution to the increase was furnished by South-West London as a whole, though more particularly by the portion of that area supplied by the Southwark and Vauxhall Water Company. In the absence of other explanation it has, therefore, been necessary to consider alternative hypotheses—one of water-borne infection, the other of infection by fish, as accounting for the exceptional incidence of the disease. Dr. Hamer discusses the topographical distribution of the cases and the time relations between the occurrence of flood in the river Thames and the exceptional prevalence of enteric fever in South-West London, and he points out that there are difficulties in the way of accepting the first hypothesis. An infected fish hypothesis, on the other hand, he finds, is consistent with the known facts as to exceptional prevalence of enteric fever in various parts of London in the intermediate period (43rd-49th weeks) of 1903, and no other adequate explanation of this prevalence is forthcoming. If this hypothesis be well founded it becomes a matter of interest to ascertain whether there is reason for suspecting infected fish has produced mischief in the past, for it is clear that if this cause were widely operative at the close of 1903, when indications of its existence were so little apparent save in two localities (Holborn and Southwark), it may readily have been a source of infection on numerous previous occasions without exciting notice. The three outbreaks attributed to consumption of fish in 1900 and in less degree those of 1903, were characterised by two features, both frequently met with in outbreaks due to food, to which Dr. Hamer directs special attention—the occurrence of multiple attacks in houses, and abnormality of age-incidence of the disease, persons at the ages 3-25 inclusive being attacked with special frequency. Examination of the notifications of enteric fever in the areas involved in these outbreaks showed that there were not wanting indications suggestive of the existence of the characteristic features in question at other times during the years 1896-1903 in these areas. This has led Dr. Hamer to examine spot-maps showing the distribution of cases of enteric fever in 1899 and 1900, a period in which there was excess of enteric fever in London beyond the average of recent years, and more particularly to study the notification records of further areas which enteric fever especially affected in those years, and he finds that the cases in these areas also present in greater or less degree the features above referred to, not only in 1899 and 1900, but also in other years. A number of charts have thus been examined, and it transpired in each instance in which these appearances were manifested that the further areas in question were occupied by poor persons by whom fried fish was largely consumed. The secondary cases occurring in these areas were in each instance distinguished (so far as it was possible to do this on the notification data which were for this purpose alone available), and the evidence pointed less to communication of the disease from person to person than to a common source' of origin. The simultaneity of occurrence of an abnormal number of cases in widely separated areas also suggests some food supply as being at fault; while the abnormality of age-incidence, although possibly explicable on the ground of character of the populations invaded, was specially marked, in particular instances examined, at the times of the exceptional prevalences—a fact which is consistent with the food hypothesis. It should be noted, moreover, that so far as there is information on the subject, the cases now in question were not attributed at the time of their occurrence to any of the foods ordinarily credited with ability to produce enteric fever. The phenomena commonly met with in food outbreaks (occurrence of multiple cases and abnormal age-incidence) were found by Dr. Hamer, in his inquiry, always associated with the two conditions—poverty and fried fish eating, and it was impracticable, in the absence of precise inquiry at the time, to demonstrate in the case of these further areas that this article of food as apart from poverty stood in causal relationship with excessive fever prevalence; it was indeed found impossible to discover an area in London in which the one set of circumstances existed apart from the other. The appearances exhibited on the charts are sufficiently striking, however, to make it desirable that the future behaviour of enteric fever in the particular areas should be studied, and that henceforth attention should be directed to the possibility of fish acting from time to time as an infecting agent. Shirley F. Murphy, Medical Officer of Health. 3 Dr. Hamer's Report. During the first two weeks of December, 1903, Dr. Bond, the medical officer of health of Holborn, made inquiry concerning a group of cases of enteric fever in that borough, and found "the only article of food that had been eaten in common was fried fish obtained from two shops." One of these shops was in Westminster, and Dr. Bond communicated the facts observed by him to Dr. Allan, the medical officer of health of that city, who ascertained there was reason for concluding that fish purchased at the shop in question had been consumed by one or more persons recently attacked by enteric fever in Westminster, and he subsequently mentioned the suspicion entertained to the Council's medical officer. At Mr. Shirley Murphy's request I conferred witu Dr. Bond on December 14th, and was then informed by him that in most of the cases notified during the preceding fortnight he had elicited the history that shortly prior to attack the patient had consumed fried fish from one of two shops.* I conferred with Dr. Allan later in the day, and we visited the fried fish shop in Westminster. On succeeding days further inquiries were prosecuted, and with a view to learning whether the two shops received fish from a common source, I called upon Dr. Collingridge, the medical officer of health of the City of London, who gave me facilities for ascertaining the facts as to those portions of the two fish vendors' supplies which were obtained from Billingsgate. Meantime, it was found that in other parts of London there had recently been small exacerbations of prevalence of enteric fever, and these were made the subject of further investigation. Special attention was devoted to areas in Southwark, Camberwell, Battersea, Lambeth and Stepney, in which during the closing weeks of the year the behaviour of the disease presented unusual features. In Camberwell Dr. Stevens, the medical officer of health, had noted that almost all the invaded houses were supplied by the Southwark and Vauxhall Water Company. For the most part the houses involved in Camberwell were situated in portions of the borough in which water was supplied exclusively by that company, hence the incidence of enteric fever upon houses so supplied was possibly explicable as resulting from the fact that the disease happened to affect a Southwark and Vauxhall supplied area. In Southwark, just over the borders of Camberwell, both the Southwark and Vauxhall and the Lambeth companies were supplying water; there were still, in fact, in parts of this district, as was the case nearly half a century ago, in the time of cholera prevalence in 1854, two " mutually interfused" populations living in the same streets having other circumstances in common, but one obtaining water from the Lambeth and the other from the Southwark and Vauxhall Company. The investigation of the Southwark cases was therefore undertaken in the first instance with a view to throwing light upon the question of water supply. I accordingly called upon Dr. Millson, the medical officer of health of Southwark, who placed the services of one of the officers of his department at my disposal, and we commenced a visitation of infected houses. It then soon became clear that there had recently been a well-defined localised prevalence of enteric fever in an area immediately to the east of Walworth-road. Detailed inquiries as to the water supply of this area were at once instituted, and this duty was undertaken by two of the Council's inspectors, Messrs. Perry and Swinson. As my own inquiry progressed it became clear the evidence to hand strongly pointed to the conclusion that the localised prevalence referred to above was attributable to the consumption of fried fish obtained from a particular shop. It was therefore a matter of much interest to find that the houses in the near neighbourhood of this shop constituted as it were an island of buildings exclusively supplied with Southwark and Vauxhall water, while surrounding houses were supplied some by the Southwark and Vauxhall Company and some by the Lambeth Company. Thus, on the assumption that an infected article of food had been distributed from this shop and had caused the localised prevalence, the involvement of the water of one company to the almost complete exclusion of that of another was at once explained ; the area in question being a Southwark and Vauxhall supplied area, the fact that houses deriving water from this company were especially attacked, may be regarded as a mere coincidence. It will, however, be seen in the sequel that, the Southwark outbreak apart, there was reason for concluding that the behaviour of enteric fever in other parts of the Southwark and Vauxhall Company's area of supply had been exceptional, and that some special cause of enteric fever had operated in South-West London during November and December. In point of fact, further inquiry led to the entertainment of a strong suspicion that infected fish had been somewhat widely distributed in London during this period, but that a considerable proportion of the whole amount had been sold in South-West London. Again, on reviewing the facts ascertained, the further suggestion presented itself that enteric fever might have been intermittently caused at various times during recent years in numerous widely separated parts of London by the agency in question. The reasons for entertaining this suspicion are briefly set out in section (d) of this report. In sections (a) and (I) the Holborn and Southwark outbreaks, respectively, are dealt with, and in section (c) the behaviour of enteric fever in South-West London during November and December, 1903, is referred to. * Reference may here be made to the question as to the extent to which fried fish is consumed in certain localities in London. Inquiry in Southwark in 1900 showed, taking an area bounded by a circle with a radius of a quarter of a mile, having as its centre a fried fish thop, that 42 per cent, of the population had, shortly prior to the time of inquiry, eaten fried fish from the particular shop, 16 per cent, had eaten fried fish obtained from other sources and 42 per cent, had not eaten fried fish at all. The area chosen in Southwark was one in which fried fish was consumed to a quite exceptional extent, and it may be assumed that the percentage of persons eating fried fish from a particular shop, viz., 42 per cent., would be very unlikely to be exceeded in any area of the same size and configuration elsewhere. 4 (a) The Holborn outbreak.—This outbreak has been made the subject of special report by Dr. Bond, and is referred to by Dr. Allan in his monthly report for December, dealing with statistics relating to the fourth quarter of the year 1903. A statement of particulars of the cases is appended (See Appendix I.) ; briefly the facts may be analysed as follows. Between November 21st and December 7th, 17 persons commenced to sicken with enteric fever within an area, partly in Holborn and partly in Westminster, bounded by a circle of a quarter mile radius and having at its centre a fried fish shop in the latter district. One of the patients denied having partaken of fried fish, the date of attack in this person was consistent with the case being regarded as secondary to a previous case in the same house ; in another instance no history of having eaten fried fish was obtained, but this case was apparently imported into the area, and infection was presumably contracted in North London. Of the remaining 15 cases, 10 had, at about the time when infection presumably occurred, eaten fried fish obtained from the shop taken as the centre of the area ; another probably did so also, and three more ate fried fish which was possibly obtained from this shop. The remaining patient had at about the time when infection must have occurred eaten fried fish purchased at a shop situated north-east of the centre of the area, and four other patients (included in the 15) had been supplied with fish from this second shop (these four included the three whose having been supplied from the first shop was not a matter of certainty). In view of these occurrences the suggestion presented itself that there had been community of origin of the fish sold at the two shops ; inquiry was made as to this, but while the possibility was not negatived the information obtained did not demonstrate a common source of supply. Both fishmongers, at the time when infective material must be assumed to have been introduced into Holborn and Westminster, had bought plaice at Billingsgate, and both had in the main been supplied with this fish from a particular port, but nothing beyond this was ascertainable so far as community of original source was concerned. It was definitely stated by both the vendors that there had been no intercommunication between their retail establishments, and though both on occasion had been supplied with fish from Grimsby sent direct to King's-cross, the middlemen concerned in supplying the fish did not, so far as could be learned, belong to the same firm, nor were their businesses in any ascertainable way related to one another. (b) The Southwark outbreak.—Particulars as to individual cases constituting this localised prevalence of the disease are appended (See Appendix II.). These cases occurred in an area surrounding a small fried fish shop, and for the most part the invaded houses were within a few hundred yards of the shop. In an area bounded by a circle of a quarter mile radius with this shop as centre, there occurred between October 17th and 31st 14 cases, in nine of which there was a history that the patient had in all probability eaten fried fish obtained at this shop, at about the date when he or she must have been infected, while four others are quite likely to have done so.* The incidence upon consumers of fried fish from a particular shop in this small outbreak was thus very striking, and further, the age-incidence of the disease was noteworthy, young persons being specially affected. It has been mentioned that most of the sufferers (12 out of 14, in fact) lived in houses supplied by the Southwark and Vauxhall Water Company. It has also been pointed out that the central portion of the area, in which the majority of the cases occurred, was found to be supplied exclusively by that company. The possibility of pollution of a local main presents itself, but no reasons for supposing such pollution had occurred were forthcoming. The circumstances as regards water supply generally, however, will be further considered in connection with the behaviour of enteric fever in surrounding parts of London at the close of the year 1903. Inquiries made as to milk, shellfish, ice-cream and watercress yielded negative results. The question of use of a swimming bath was also considered, but in only five of the 14 cases was there a history of having visited this bath, and this proportion was not larger than might a priori have been anticipated, having in view the ages of those attacked; again, if pollution of the water of the bath had been responsible for the outbreak, it may be assumed that the disease would have extended over the entire area inhabited by persons who used the swimming bath referred to, and would not have been limited, as was actually the case, to a particular portion of that area. Having regard to all these facts, and considered in the light of the history of enteric fever prevalences in London in 1900, the case against fish in this Southwark outbreak must be regarded as a very strong one. (c) The behaviour of enteric fever in London at the close of the year 1903.—When it was ascertained that localised outbreaks of enteric fever occurring in November in Holborn and Southwark were in all probability attributable to the consumption of fried fish, attention was naturally directed to the behaviour of the disease in London as a whole at this time. It was found that the number of weekly notifications of enteric fever, having attained a maximum in the 40th week of the year (the week ending 10th October), had fallen sharply in the 41st week, and again slightly in the 42nd week ; in the 43rd and 44th weeks there was a small rise, the notifications in the 45th and 46th weeks were, however, somewhat smaller in number, and then in the 47th and 48tb weeks a notably increased prevalence declared itself ; after this the notifications fell off again, as the end of the year approached. The small rise referred to above in the 43rd and 44th weeks coincided in point of time with the Southwark outbreak, and may thus be thought of as being accounted for by that outbreak ; the considerable rise in the 47th and 48th weeks corresponded * In one instance only was the information to the effect that fried fish from this shop had not been consumed ; the sufferer, a lad of 12, stated that some days before his illness commenced he bought fried potatoes at a fried fish shop (not the shop in question), but he denied ever having eaten fried fish. It may be noted that the fried fish shop in this instance supplied far fewer persons with fish than did the shop in Southwark, referred to in footnote on p. 3. The percentage of persons obtaining fried fish from the latter shop being 42 (See footnote on preceding page), it maybe taken for granted that the corresponding figure for the shop now in question would not exceed 15 or at most 20 per cent. DIAGRAM Shewing cases of Enteric Fever notified In the several Water Companies' Areas during the 34th to 52nd weeks of the year 1903 (N.B.—The hatched portions of the diagram indicate the number of cases in each area, probably attributable to a special cause, the effects of which were manifested during the 43rd to 49th weeks). No. of Week. GRAND JUNCTION WEST MIDDLESEX CHELSEA NEW RIVER Martin HooA8tLork;n,Lith.London,W.C. 5 roughly speaking in time with the Holborn outbreak, but as this latter outbreak was only a small one it could in no case explain the increase in the figures for London as a whole in those weeks. In view of the possibility entertained in the first instance that Southwark and Vauxhall water had been at fault, it was deemed desirable to study the distribution of enteric fever throughout London during the closing weeks of the year in relation to water supply. The results obtained may be quoted, as they give a general idea of the topographical distribution of the disease. Each, case, it should be stated, is referred to the week in which the day on which it was notified falls. It was found that north of the Thames some small but noteworthy irregularities had presented themselves. The extent of these variations will be seen on reference to the diagram facing this page, which shows that— (i.) In those parts of North-West London supplied by the Grand Junction, West Middlesex and Chelsea Companies, following the fall after the attainment of maximum prevalence in the 38th-40th weeks, there was a slight rise, culminating in the 44th week, and another slight rise in the 50th week. (ii.) In those parts of North and Central London supplied by the New River Company, following upon a maximum prevalence attained in the 39th and 40th weeks, there was a rise in the 42nd-44th weeks, and further a short sharp rise in the 48th and 49th weeks. This last-mentioned rise was due to the Holborn outbreak already referred to. (iii.) In East London there were some marked irregularities, particularly there may be noted the rise in the 43rd week, partially accounted for by a group of cases in NorthEast London, and the rise culminating in the 46th week, due in the main to three groups of cases, one in Poplar and two in Stepney. A further rise in the closing weeks of the year will also be observed. Turning now to the south side of the river it transpires that— (i.) In those parts of South-East London supplied by the Kent Company there was no specially noteworthy irregularity of incidence of enteric fever ; the maximum was attained in the 40th week and this corresponds fairly well with the time of occurrence of the ordinary seasonal maximum of the disease. (ii.) In those parts of South and South-West London supplied by the Lambeth Company a maximum was attained in the 40th week, and there was then a slight rise of prevalence in the 42nd and 43rd and again in the 47th and 48th weeks of the year. (iii.) In those parts of South-West London supplied by the Southwark and Vauxhall Company a remarkable increase in prevalence was manifested between the 43rd and the 49th weeks. On comparing the curves for the areas supplied by the several water companies it will be seen that three periods of exceptional prevalence may be roughly marked out in the closing weeks of the year. One toward the end of October is marked in East London, but is also traceable in the charts of the New River and Lambeth areas. Another occurring in the 51st and 52nd weeks is marked in the New River and East London areas. A third (intermediate) prevalence was that developed during the 43rd-49th weeks of the year, when the Southwark and Holborn outbreaks occurred which have already been discussed. It is this intermediate prevalence to which attention will now be more particularly directed and interest specially centres upon the areas supplied by the Southwark and Vauxhall and East London Companies, the rise in the New River Company's area being already sufficiently accounted for by the Holborn outbreak. Taking first the East London area, there were in Stepney two definitely localised prevalences, the one comprising four cases in Whitechapel, the other a group of seven cases in the east of Stepney, confined to a circumscribed area surrounding the point where the Regent's Canal passes from Mile End Old Town into Limehouse. To these cases, and to a group of four cases in one house in Poplar, further reference will be made later (See area xvii. referred to on pages 7 and 8). On examination of the area supplied by the Southwark and Vauxhall Company (which includes an area in part supplied by the Lambeth Company) the cases well be found to have a much more generalised distribution. The accompanying map shows the cases notified during a portion of the period included in the 46th-48th weeks when the prevalence was at its height. Between 21st November and 5th December inclusive 74 cases were notified from houses within the area bounded by a red line. One of these cases was returned from hospital owing to error in diagnosis, and three more occurred in a block of dwellings from which a number of cases of enteric fever had already been notified during preceding weeks. Omitting these four cases there remain 70 cases, 62, indicated by red dots, removed from houses supplied with Southwark and Vauxhall water, 8, indicated by red crosses, from houses supplied with Lambeth water. Having in view the ordinary behaviour of enteric fever in London at this time of year, it may be assumed that rather more than half these cases must be looked upon as due to some superadded cause over and above the causes normally operative. But if some 25 or 30 cases, due to such ordinary causes, be more or less uniformly distributed over the area, and then, in addition, 40 or 45 further cases due to special causes be distributed, the question as to whether or no the total cases will show evidence of a tendency to grouping will be necessarily complicated by the 25 or 30 cases scattered more or less uniformly over the area. Having this consideration in view it is necessary to examine the distribution of the cases shown on the map somewhat more closely. It will be noted, then, that Bermondsev and portions of Southwark, Lambeth, Battersea and Wandsworth near the river, all thickly populated areas, are almost free from cases; on the other hand, there is suggestion of grouping of cases— (i.) In North Camberwell, in the neighbourhood of the Grand Surrey Canal, and more particularly of its southern extension into Peckham (8 cases). 6 (ii.) In Lambeth (6 cases) on either side of South Lambeth-road, and again, in this borough and in the adjoining parish of Clapham (8 cases), near the southern end of Clapham-road. (iii.) In Battersea (6 cases) in the neighbourhood of Battersea-park-road. (iv.) In Wandsworth (5 cases) near the point where Garratt-lane approaches the county boundary. (v.) In Newington there is suggestion of grouping in two or three localities, but it must be borne in mind that in the Borough of Southwark, of which that parish forms part, there had been increased prevalence of the disease in weeks preceding the time now under consideration, and some of the cases notified in the latter periods (over and above the three cases excluded as already mentioned) may have been secondary cases. Two groups of three cases are particularly noteworthy, one to the south-east of Kennington-park, on the borders of Newington and Lambeth, and one near the southern end of Walworth-road, and to these attention will be further directed later. (See 3rd and 4th paragraphs from bottom of this page.) The question of age and sex distribution, as well as that of the topographical distribution of cases at this period, may be thought of as possessing importance in connection with inquiry as to the nature of the superadded cause of enteric fever operating in South-West London during the period in question. Examination of the returns shows that of the 70 cases on the map 40 were males and 30 females, and that 45 were under and 25 were over 25 years of age. These results do not deviate widely from the normal; there is, however, some slight tendency for younger ages, and more particularly for persons aged 15-20, to suffer unduly. Two hypotheses naturally present themselves as possible explanations of the superadded cases—(i.) That in the 40 or 45 cases in question infection was water borne ; (ii.) that the cause (infected fish), to which the Southwark and Holborn prevalences have been ascribed, had been operative just prior to the 47th and 48th weeks in two or three areas in South-West London. In connection with the first hypothesis, it may be noted that during late October and early November the River Thames was in flood, the maximum height (5 ft. 1 in. above summer level) being attained on October 30th; the height above summer level was still 4 ft. 9 in. on November 3rd, after which date the flood somewhat rapidly abated. From the water examiner's reports it appears that " for the first ten days of the month [of November] the Southwark, Grand Junction and Lambeth Companies' supplies were of bad quality, but after that time they steadily improved in quality until the end of the month." The cases, constituting the groups above referred to, sickened for the most part in the days between the 20th and 24th November, so that they must be thought of as having been infected about the period November 6th to 10th. It will be seen, therefore, that the flood attained its maximum a week or ten days before the date at which infection in these superadded cases was probably contracted, though the contaminating effects of the flood were still apparent at this date. An hypothesis of water-borne infection is, of course, difficult of acceptance in view of the topographical distribution of the cases—the exceptional incidence being clearly manifested only in the area of one water company, while there is suggestion of grouping of the cases within that area. Such distribution would not, on the other hand, be inconsistent with the second hypothesis referred to above, and the behaviour of enteric fever in parts of London other than the south-western portion of the county, at about the time when the unusual prevalence in South-West London was manifested, raises question as to whether the same cause may not have been concerned in producing the several observed abnormalities of incidence of the disease. The following further points of interest may be noted in connection with this second hypothesis— One of the groups referred to under the head (v.) mentioned above was a striking one. It consisted of two boys and a young girl belonging to families living at some distance from and having no communication with each other, and each of these patients had, independently of other members of his or her own family, partaken of fried fish obtained from a particular shop about a fortnight before the commencement of illness. Attention was directed to the existence of these cases by a man whose son had obtained fried fish from the same shop, had shortly after eating it complained that it made him feel sick, and had then after a fortnight's interval developed enteric fever. The series of events in this last case antedated * by about three weeks the corresponding events in the later group of cases. In a second group of three cases referred to under heading (v.), the patients who sickened at about the same time had all shortly before that time eaten fried fish from one shop. In examining most of the other groups occurring in the 43rd-49th weeks, I had the help of Mr. Shapley, one of the Council's inspectors, and I am also indebted for assistance in particular instances to Inspectors Lewis, Perry, Williamson, Garner, Gibb and Wood. As regards the group in North Camberwell under the heading (L), no article of food had been obtained, so far as could be ascertained, from one common source—fish had been frequently eaten by all the sufferers at the time when infection must have been contracted, but it had not been obtained so far as could be learnt from one and the same vendor. A shop near the centre of the group of houses attacked had been an ordinary source of supply of the inmates of three of these. Again, much fish was bought from hawkers, and in one instance the sufferer was the only member of her family who partook of a dish of " lemon soles " purchased from a hawker about a fortnight before the child began to be ill; the fish " tasted bad," and the mother said it must be thrown away, but this particular child had then eaten her piece. The habit of buying from hawkers was common amongst persons in this locality, but it did not transpire that any one particular hawker had supplied all the sufferers. * A further case was found to have occurred in this locality—the patient, a girl, had sickened a few days before the first of the four cages referred to above ; she also had shortly before her attack from time to time bought fish at the particular shop. 7 As regards the Lambeth cases under the heading (ii.), it was found that at a time corresponding with that of infection the majority of the cases grouped on either side of South Lambeth-road obtained wet fish from one of two shops close to one another, and most of the persons attacked bought indifferently at one or the other shop ; no other article of food, so far as could be ascertained, was obtained from any common source by all the sufferers. Turning now to the remaining eight cases two sufferers proved to have been regular customers of a particular vendor of fried fish, and one or more of the others may also have obtained fish from the same shop. It was noted that the vendor carried on business under a name which was that of the man whose customers were attacked in one of the fried fish outbreaks in 1900. As regards group (iii.), one of the cases was a regular customer of a particular fried fish vendor, and one or more of the others may have obtained fish from this man. The vendor in question acted as manager of the shop which supplied fish to the sufferers in the fried fish outbreak of 1900 just referred to. Group (iv.) included three cases in one house, and these three patients, and at least one of the two remaining sufferers, were habitual fried fish eaters, and shortly before their illness obtained tish as a general rule from a particular shop. This shop is situated in an area to which further attention will be directed in the sequel. (See paragraph at bottom of page 8.) Reference has been made to the existence of localised groups of cases on the north side of the Thames. (See page 5.) Some inquiries were made by Mr. Wood as to cases in Stoke Newington, and here reasons for suspecting infected fish as a cause were forthcoming, particularly in the case of a group notified in the 42nd week. Interest specially centres, however, upon the two Stepney groups and the Poplar group previously mentioned which occurred contemporaneously with the Holborn cases. Mr. Shapley ascertained, in the case of the group of four cases in Stepney, that all the sufferers had shortly before attack bought wet fish from costers' stalls in a particular street (in area xx. See page 9.), and as regards the group of seven cases in Stepney he found that the sufferers had purchased fish from hawkers, but it was not possible to demonstrate that all had obtained fish from one particular hawker. In neither of these groups had there, so far as could be ascertained, been any other common source of food supply at a time corresponding with that of infection. The group of four cases in Poplar consisted of children from 4 to 10 years of age living in a house situated in an area (area xvii.) to be referred to later. (See page 8.) It will be seen, therefore, that an infected fish hypothesis is consistent with all the known facts as to the prevalences in Stepney and in South-West London in the 46th, 47th and 48th weeks of 1903, and in view of the facts of the occurrence of the Holborn outbreak in the 48th and 49th weeks, and of that of the Southwark outbreak a few weeks previously, there is strong ground for suspecting that infected fish was responsible for the increased prevalence of enteric fever in London manifested at this time. (d) The behaviour of enteric fever in certain areas in London during the years 1896-1903.— This behaviour can "Best be understood by reference to the diagram appended in which are shown the cases notified in each month of the period under review. Cases occurring among persons aged 3 to 25 inclusive are indicated by hatched squares, cases at other ages by black squares. In instances in which a second or third case was notified from a house within 10 days of a first notification, the later case is distinctively indicated by a cross. In instances in which a second or third case was notified, after more than 10 days and generally speaking within two months of the notification of a first case, the later case is indicated by a cross placed below the base line, distinction always being made in respect of age by employment of different types of cross. (See Diagram.) Charts i. and ii. relate to areas (in Southwark and Lambeth) in which outbreaks of enteric fever due to the consumption of fried fish occurred in September, 1900. In the area iii. (Kensal Town) an outbreak occurred at about the same time, and this was probably caused by infected fish purchased in an uncooked condition; iv. relates to the central portion of the area in which the Southwark outbreak of 1903 (see Appendix II.), due to fried fish, occurred at the end of October, the cases being notified in November, 1903 ; v. and vi. relate to areas in which outbreaks, probably due to the same cause, occurred about three weeks later, the cases being notified in December, 1903 ; it should be noted that in area v. (central portion of area referred to in Appendix I.) there was not, as in i., ii., iii., and iv., a single retail shop in question, but two retail shops were implicated, and in area vi. (Kennington) there were in December, 1903, only three cases of illness; these two outbreaks v. and vi. stand, therefore, on a footing different from that of the other outbreaks. Limiting consideration in the first instance to outbreaks of considerable size, examination of charts i. and ii. shows that— (1) The special prevalence was accompanied by notable increase in the percentage of multiple attacks in houses. Additional eases occurring within 10 days of a first case are indicated on the chart by a cross occupying one square. The normal percentage of such cases may be taken, on the basis of the London notification figures, as about 5 per cent, of the total number ; in the special prevalences i. and ii. it exceeded 20 per cent. (2) The special prevalence was accompanied by marked increase in the percentage of cases at the ages 3 to 25 inclusive. Cases at the ages 0 to 2 and 26 onwards are indicated on the chart by black squares or by distinctive crosses; the percentage of such cases to the remaining cases may be taken, on the basis of the London notification figures, as 50 per cent.; in the special prevalences in areas i. and ii. it fell to about 8 per cent, and 22 per cent, respectively. The special prevalence in area iii. exhibits features closely resembling those indicated as characterising i. and ii. The preponderance of hatched squares over black squares was, however, 8 slightly less marked in area iii., and the outbreak in this area also presented the peculiarity as compared with those in i. and ii., that it was apparently traceable not to fried fish, but to fish purchased in the wet condition and cooked at home. On turning now to the prevalences of November and December, 1903 (charts iv., v., and vi.), it will be found (allowance being made for the smaller number of cases) that chart v. (Holborn) yields distinct suggestion of relationship, so far as age-incidence and multiple cases are concerned, to charts i., ii. and iii.; in chart iv. (Southwark) the resemblance is less striking, the percentage of black squares being high, but the figures dealt with are still smaller than in v., and the area to which chart iv. relates is a small one—as a matter of fact the outbreak of November, 1903, extended somewhat beyond the area dealt with in the chart, and if the outlying cases be included, the percentage of cases at ages 0 to 2 and 26 onwards to other cases becomes appreciably lowered. In chart vi. there are, as already noted, only three cases in December, 1903, and no conspicuous resemblance to charts i., ii., and iii. can, under the circumstances, be looked for. The history of consumption of fish obtained from a particular shop, at about the time when infection must have been contracted in the case of the three patients in area vi., has already been referred to (See page 6), and it has been noted that a case infected some weeks previously to these three was held by the patient's friends to have been caused by eating fried fish obtained from the same shop one fortnight prior to attack by the disease.* In the fried fish enteric fever prevalences of 1900 (i., ii. and iii.) the districts involved were not attacked quite simultaneously ; and again in 1903, area iv. was attacked about three weeks before areas v. and vi. Having in view these instances of want of simultaneity of infection, the possibility presents itself that the same retail shop may have distributed infection at the close of 1903 on two distinct occasions separated by an interval (See chart for area vi. in October and December, 1903). There then arises the further possibility that persons living in the area vi. and in other areas surrounding implicated fried fish shops may have from time to time been infected during recent years from those shops. Examination of notifications (1896—1903) for the areas in which the six implicated shops lie shows—• (a) That in each instance the area has during these eight years suffered unduly from enteric fever, London as a whole being taken as the standard of incidence. (b) That in each instance the percentage of cases at ages 3 to 25 inclusive to other cases is unduly high compared with London as a standard. (c) That in area ii.t there were, at the close of 1896 and 1899, two small outbreaks, the appearance of which on the chart suggests their possible affinity to that of 1900 ; in area iii. the small outbreak at the close of 1899 is also noteworthy ; in the case of area iv. attention may be directed to the appearance of the chart at the beginning of 1900 ; and charts v. and vi. yield indications of a somewhat similar kind, the former at the end of 1898, and the latter at the end of 1899. The suggestion now presented itself that the characteristics of the fried fish outbreaks occurring in certain areas in 1900 might perhaps in other areas be more nearly approached during 1899 and 1900 (years when enteric fever was unwontedly prevalent in London) than in other years, and this consideration has led to examination of areas in which there was exceptional prevalence of enteric fever in those two years. Under this head reference may be made to charts vii., viii., xiv., xv., xvi., and xvii. In each of these areas (with an exception to be noted as regards viii.) it will be found that— (1) The proportion of cases at the ages 0 to 2 and 26 onwards to the remaining cases is below the normal 50 per cent. In area xvii. it is 46 per cent., in area xvi. 37 per cent., in area vii. 44 per cent., in area xv. 36 per cent., and in area xiv. it is only 22 per cent; in area vii., on the other hand, it is nearly 74 per cent. (2) That outbreaks presenting suggestion of affinity to those of 1900 in areas i. and ii. have from time to time occurred. In area vii. (Kentish Town) there were such outbreaks in 1896, 1899, 1900, and 1902. In area viii. (Starch Green) similar outbreaks occurred in 1899 and 1900. In area xiv. (Hackney Wick) there are several outbreaks presenting some suggestion of having similar affinity, the most notable of these being one in 1901 ; it will also be seen that an outbreak having somewhat similar features occurred in this area in September, 1903, shortly before the occurrence of the outbreaks of that year in areas iv., v. and vi. In area xv. (Hackney Wick) outbreaks also raising suspicion occurred at the close of 1899 and 1900, and in this area the occurrence of a group of cases at the close of 1903 is also noteworthy. In area xvi. (Millwall) the years 1896 and 1897 present a small percentage of black squares, and the outbreaks.at the close of 1898, 1899 and 1900 are noteworthy. In area xvii. (Cubitt Town) the year 1896 is suggestive, less so the years 1899 and 1902, while the group of cases in the two last months of 1903 is again striking. (See pages 5 and 7.) Chart xiii. (Garratt-lane) relates to an area (See paragraph commencing " Group (iv.) included " on p. 7.) to which attention was directed owing to multiple house attacks occurring in * My attention was in the first instance directed to this case by Dr. Millson, and I found on visiting the house that the circumstances which have been already referred to had particularly impressed themselves upon the minds of the inmates, who attached importance to the facts that the sufferer alone had partaken of the fish, and that he had complained at the time of eating it that it was not of good quality. As already noted, a fifth case was apparently associated with this shop. † The shop in area ii. was carried on in the same name as shops situated at the centre of two areas, ix. and x. Each of these last named areas presented cases of enteric fever at the time of the 1903 prevalences in areas iv., v. and vi., and area x. presents a somewhat suggestive prevalence at the close of 1902, while the chart for area ix., at the close of 1899 and 1900, raises some suspicion of being affected by the cause operative in the case of area ii., certainly in the latter and possibly in the earlier of those two years. 9 it at the time of the prevalence of 1903 in areas iv., v. and vi. It was found that this area showed excessive incidence of enteric fever during the period 1896—1903, and the behaviour of the disease in it in 1899 and at the close of 1900 and beginning of 1901 is noteworthy. Charts xviii. (an area in Rotherlithe) and xix. (an area in Bermondsey) furnish two further examples of localities specially involved in 1899 and 1900. In both these instances the proportion of black squares is much below the normal 50 per cent, and, further, examination of the charts brings to light a very striking prevalence in area xviii. in the year 1901 and one in area xix. (small in extent but with no black squares) in the following year. Most of the areas examined are occupied in the main by poor people, the streets being, as a rule, coloured light blue or purple on Mr. Charles Booth's poverty maps.* For purposes of comparison two areas, altogether apart from any question as to enteric fever prevalence in them, numbers xi. and xii., Lisson-grove and Somers-town, have been taken as presenting instances of poverty-stricken localities. It will be seen that the charts for these areas exhibit from time to time throughout the period 1896-1903 some suggestion of affinity to the charts already given, the behaviour of the disease in Soiners Town in 1900 being specially noteworthy in this connection. In these two areas it will, however, be found that the percentages of cases at the ages 0-2 and 26 onwards to the remaining cases are above the normal, viz., 67 and 54 respectively. All the areas hitherto examined, including xi. and xii., resemble one another not only in comprising, in the main, light blue and purple streets, but also in forming centres in which fried fish is largely consumed. It might at first sight be supposed that it would be possible to determine to what extent the one, as opposed to the other condition, was associated with phenomena such as those exhibited in the charts. The attempt has been made to find an area in London occupied by the particular classes of the population in question and in which fried fish is not largely eaten. This attempt has been quite unsuccessful. In Deptford some approximation to such an area had, it was thought, been discovered, but there were fried fish shops immediately outside and within easy reach of the locality, and the inhabitants were, no doubt, to some extent consumers of fried fish.† With a view to throwing light on the question how far poverty per se could be held accountable for abnormal age-incidence of enteric fever, study has been made of the figures furnished by five London boroughs, two rich and three poor, for the years 1898, 1900 and 1903. In Kensington and Wandsworth, on the one hand, the higher ages (over 25) manifest a greater tendency to be attacked than is, on the other hand, the case in Stepney, Southwark and Bethnal Green. The fact is in part explained by differences of age distribution of the several populations, but it is not thus wholly accounted for. The tendency for persons aged 3-25 to be affected in these boroughs is not equally marked throughout the whole period under examination; indeed —more particularly in the poorer boroughs—this tendency is evinced in notable degree at special times ; in fact, the abnormality of age-incidence is generally observed coincidently with the occurrence of localised outbreaks of the disease. So far as the figures examined go, they do not suggest that the phenomenon in question has any definite relation to a particular season of the year. Inasmuch as Stepney and Bethnal Green yield the highest percentages among the boroughs examined of cases at the ages 3-25, further study has been made of particular areas in these two East-end boroughs, and charts xx-xxiv. have been prepared. These charts show that the abnormality of age-incidence (high percentage of hatched squares) generally presents itself at times when exceptional prevalence of the disease is manifested. In area xx. (in Stepney) the outbreak in 1899 is noteworthy, and the area is one in which four cases—account of which has been given in paragraph 4, p. 7—occurred at the close of 1903. Area xxi. (in Stepney) furnishes appearances at the close of 1899, 1901, 1902 and 1903 strongly suggestive of an infected food supply being at fault. Area xxii. (in Bethnal Green) presents features in 1899 which raise a similar suspicion. Area xxiii. (Bethnal Green) is less striking, though here the high percentage of hatched squares in the period 1896-1898 and in 1900 is noteworthy. Area xxiv. (in Bethnal Green) yields notable outbreaks in 1897 and 1899. In summary it may be stated, with regard to the areas i., ii., iii., iv., v. and vi., in which outbreaks of enteric fever, presumably due to consumption of infected fish, occurred at the close either of 1900 or 1903, that the disease has, throughout the period examined, been unduly prevalent in them and that there is reason for suspecting that the cause of the 1900 and 1903 outbreaks came into operation at other times during the years 1896-1903.† Turning now to the areas which have been examined on account of the excessive prevalence of enteric fever in them—in the autumn of 1899 or of 1900, or at some other date within recent years—the distribution in time of the cases, and the abnormal age-incidence, in all save viii., of the disease, suggest that some food supply has been intermittently at fault throughout the period named. The close association of the phenomena to which attention is specially directed with poverty must, of course, be admitted, but it may be that an article of food consumed bv poor persons is one of the connecting links between poverty and these exceptional outbreaks of disease. Communication of the disease from person to person has no doubt to some extent been operative in these areas, but the manner of occurrence of multiple attacks in houses is not such as to suggest that this cause alone adequately explains the altogether abnormal incidences observed. * Mr. Booth's scheme of classification, beginning from below, included—black, lowent cla*s, vicious, semi-criminal; dark blue very poor, casual,chronic want; light blue, poor, 18*. to 21s. a week for a moderate family : purple,, mixed, some comfortable, others poor— and so upward*. Black and dark blue are comparatively little represented in the 24 areas on the diagram; light blue and purple generally speaking dominate those areas. † In this art a there was comparatively little enteric fever during the years 1896-1903, and the proportion of hatched to black squares wa«. as a matter of fact nearly normal, London as a a whole being takpn as the standard. ‡ With regard to the two areas ix. and x., surronnding frited fish shops carried on under the same name as that of the owner of the shop implicated in outbreak ii, there is some slight ground for suspectinig that these shops may have acted as sources of infection at one time or another during the period reviewed. [2] 10 Iii view of tlie inquiries made by officers of the sanitary authorities, it may be assumed that milk cannot have played any considerable part in causing these outbreaks, and the localised distribution of the cases is not consistent with an hypothesis of water-borne infection. In a number of the areas inquiries have been made from which it appears clear that infection by icecream, watercress or shellfish would not account for any considerable percentage of the cases ; in each of them, however, fried fish is largely consumed, and while it has been found impracticable, owing to removals, death and absence from home, to make inquiry of individuals on any comprehensive scale, it is at least clear that an hypothesis of infection by fish is consistent with such facts as have been ascertained concerning the general habits of the populations in question. The inferences drawn in this report suggest that it by no means follows because outbreaks of the magnitude of those of 1900 in Southwark and Lambeth are of quite rare occurrence, that the infection of enteric fever is only exceptionally transmitted by fish. That such transmission is not more often recognised may be in part due to the very fact that the mischief is widespread and not localised. While the consumption of oysters, cockles, etc., a fortnight before attack by enteric fever is regarded as significant, no corresponding importance is attached to consumption of fried fish. This attitude of mind, it may be said, is justified by the consideration that fried fish eating is common, and the eating of oysters, cockles, etc., rare. If a food be frequently consumed this in itself tends to render it unlikely that notice will be directed to it, while on the other hand, oysters, etc., which are rarely purchased, are, partly on that account, more likely to be regarded as a possible source of mischief. In the case of fried fish, as in that of oysters, the sufferer is often the only member of the family who has consumed the food, and this renders inquiries at the home, after the removal of the patient to hospital, unlikely to be productive of positive result. Again, in the comparatively rare instances in which inquiries as to fish have been made by sanitary inspectors, they have been limited to the question as to fried fish ; there is, of course, no reason for supposing that frying enhances the infectivity of fish, though it may perhaps be a fact that the kind of fish which is apt to convey infection is, as a rule, fried. Plaice, haddock und skate are the species of fish ordinarily fried, but it is noteworthy that in all instances save one (in which question arose as to " lemon soles ") suspicion has fallen upon " plaice "—under which term " flounders " and " dabs " are apparently often included by fishmongers. Experience in Southwark in 1900 indicated that it was the " halfpenny bit" which was especially mischievous, and it was found that this consisted in some instances, at any rate, of an entire fish, and, therefore, of a very small one. " Dabs " and " small plaice" are sometimes bought in quantity at Billingsgate, more particularly in the summer, at times when large fish are scarce. In July, 1901, " dabs " were being sold at that market at 3s. to 2s. 6d. per trunk of about 84 lbs.—i.e. at approximately ½d. per lb. As it takes one man about 1½ hours to clean a trunk of small fish, the temptation during busy times to remove the heads only, the fish being fried with the gut in them, must be great; in the case of small fish there is, moreover, special difficulty in removing the gut. It is noteworthy in this connection that sufferers from enteric fever have in several instances complained that the fish eaten by them had a disagreeable flavour, and even that it made them sick, while insufficiently cleansed fish is, it appears, well known to have a characteristic bitter taste. Imperfect gutting is apparently far from uncommon, at any rate at busy seasons. I have seen small fish from which the heads and portions of the intestinal contents had been cut away by one stroke of a knife but from which the gut had not been completely removed, displayed for sale in a fried fish shop, and among some 30 or 40 penny and halfpenny pieces of fried fish purchased two samples were obtained—one from North London and one from South London—in which the intestines were in the fish. It may be surmised that frying under these conditions, having regard to the short time of exposure in the dripping or oil to a high temperature, would be unlikely to result in sterilisation of the intestinal contents. W. H. Hamer, Assistant Medical Officer of Health. 11 Appendix I. The Holborn Outbreak. No. Date of onset of illness. Date of notification. Sex and age. Milk supply. As to consumption of fish, fried fish, shell fish, etc. Celery Watercress. 1 Nov. 21 Dec. 2 M. 10 Condensed Fond of fried fish, generally obtained from C.'s, but he and his sister ate fried fish obtained from X.—he about a week, she about a fortnight before they sickened. Fond of winkles. Ye s No 2 Nov. 28 or a few days earlier Dec. 2 F. 4½ Condensed Sister of above (q.v.). No shell fish. Yes No 3 Nov. 24 Dec. 2 F. 5 A Fried fish from Y. No shell fish. Mother at one time bought fried fish from X., and the child, who sometimes purchased on her own account, may have bought from X. No No 4 Nov. 24 Dec. 2 M. 16 No raw milk Fried fish from X. about a week before attack. No shell fish. Yes No 5 Nov. 26 Dec. 6 M. 15 Condensed Fried fish from X. No shell fish. No. No. 6 Nov. 23 Dec. 7 F. 33 7 Had eaten whelks about a fortnight before attack. Fond of fried fish. May have obtained it from X., more likely to have done so from Y. ? ? 7 Nov. 26 Dec. 8 F. 16 No raw milk. Fried fish from Y. No. No. 8 Nov. 25 Dec. 8 F. 4 A Fried fish from Y. as a rule. It is possible she may have bought from X., but not likely. Fond of winkles. No. No. 9 Dec. 2 Dec. 10 M. 11 ? Fried fish from both X. and Y. Yes. ? 10 Dec. 7 Dec. 11 F. 50 Condensed Never fried fish. Mother of case 5, probably secondary to that case. No shell fish. Yes. 11 Nov. 28 Dec. 11 F. 19 B Fried fish from X. No shell fish. 12 Dec. 7 Dec 14. F. 21 ? No fried fish at home, but may have eaten X.'s fried fish at her cousin's house, where she often spent the evening. No shell fish. No No 13 Doubtful. Ailing from Nov. 9. Dec. 14 M. 12 ? Fried fish from X. Yes Yes 14 Dec. 5 Dec. 14 M. 14 A Fried fish from X. one week or rather more before he began to be ill. No shell fish. No No 15 Nov. 23 or earlier Dec. 4 M. 22 Only in tea Fried fish from X. Occasionally eats winkles. Yes No 16 Nov. 25 about Dec. 4 F. 28 Only in tea Sister of above, but had not seen him for some weeks, and had, at time when illness was presumably contracted, been living in North London. Fond of fried fish. Never shell fish. Yes No 17 Nov. 29 Dec. 8 M. 7 ? Fried fish from X. Eats winkles occasionally on Sundays. Yes Yes 12 Appendix II. The Southwark Outbreak. No. Date of onset of illness. Date of notification. Sex and Age. Milk supply. Icecream. As to consumption of fish, fried fish, shell fish, etc. As to use of swimming baths. Celery. Water- cress. 1 Oct. 17 Oct. 27 M. 11 A No raw milk consumed No Fond of fish and " taters," often bought " taters " without fish ; obtained fried fish from X. or A. or B. No shell fish No No No 2 Oct. 18 Oct. 30 M. 12 B No raw milk consumed No Does not remember buying fried fish, but has bought " taters " from A. Has certainly not had fried fish or shell fish at home Yes Swallowed a mouthful of water about 14 days before illness began No No 3 Oct. 19 Oct. 31 F. 15 C No Fond of fried fish, obtained it from B. as a rule, possibly from X. She used to go to entertainments at a hall close by X.'s shop. Never shell fish No No No 4 Oct. 20 Nov. 9 M. 17 D No Often fried fish from X. Eats winkles sometimes on Sundays Yes No No 5 Oct. 20 Oct. 27 M. 12 Condensed No Fond of fried fish Obtained it at C.'s as a rule, may have bought it from X. as he often used to pass by X.'s shop, and went to the hall close by Yes No Yes 6 Oct. 21 Nov. 2 M. 15 D No Often fried fish from X. Eats winkles sometimes on Sundays No No No 7 Oct. 22 Nov. 5 F. 26 E No Oysters 14 days before illness began. Fond of fried fish usually obtained from C., but may have obtained it from X. Was seen outside X.'s shop a fortnight previous to illness No No No 8 Oct. 25 Nov. 13 M. 27 F No Fond of cockles, whelks and winkles, also of fried fish, obtained from X. and occasionally from another purveyor No Yes Yea 9 Oct. 27 Nov. 10 M. 9 F. No raw milk consumed No Fond of fried fish obtained from X. No shell fish No No No 10 Oct. 27 ? Oct. 20 Oct. 31 M. 41 Condensed No Fond of fried fish obtained from X. prior to his illness but since from other sources. Fond of whelks. No No No 11 Oct. 28 Nov. 4 M. 13 G Yes Fried fish frequently obtained from X. Occasionally eats winkles. Some mussels about 3 weeks before illness Yes, 8 days before illness began Yes No 12 Oct. 29 Nov. 6 F. 15 C No Fried fish from B, possibly from X. also. Mussels 7 or 8 weeks before illness began Yes No No 13 Oct. 31 Nov. 9 M. 36 Condensed No Fond of fried fish; probably obtained it from X. Mussels eaten 3 weeks before illness began No No No 14 Oct. 31 Nov. 4 M. 22 H No Fond of fried fish, purchased it as a rule from X. Oysters occasionally, but not for many weeks before illness ? No No 15 Nov. 9 Nov. 16 M. 28 I. No raw milk consumed No Fond of fried fish, obtained from various sources, but his wife does not like X.'s fish and does not buy it No No Yes 16 Nov. 9 or a few days earlier Nov. 17 M. 31 F No Fried fish frequently from X. Sometimes eats winkles No Yes Yes 17 Nov. 12 Nov. 27 M. 38 F No Fried fish frequently from X. No Yes Yes ENTERIC FEVER 1896-1903. DIAGRAM shewing cases of Enteric Fever notified during each month of the years 1896—1903 in certain selected areas in London distinguishing (a) cases aged 3—25 inclusive from cases at other ages; (b) cases notified within 10 days of the notification of a first case in the same house, and (c) cases similarly notified after a longer interval than 10 days. N.B.—Each square represents one case. 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, June, 1904. I present a return based upon information supplied by the medical officers of health of the City and the metropolitan boroughs. During the last eleven years returns have been presented to the Public 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— Number of sanitary inspectors Year. in the whole of London. 1893 188a 1894 219a 1895 228a 1898 256a 1901 275 1903 301 1904 313 Thus it will be seen that since 1893 the number of inspectors has increased by some 66 per cent. In 1903, the number of sanitary inspectors employed in each of the metropolitan boroughs was ascertained and comparison between these numbers and those obtaining in 1904 may thus be made — Metropolitan boroughs. Number of sanitary inspectors. Increase ( + ) or decrease (-) in 1904 compared with 1903. Metropolitan boroughs. Number of sanitary inspectors. Increase (+) or decrease (-) in 1904 compared with 1903. 1903. 1904. 1903. 1904. Battersea 11 13 + 2 Lewisham 8 10 + 2 Bermondsey 9 9 — Paddington 12 12 — Bethnal-green 9 10 + 1 Poplar 8 8 — Camberwell 14 14 — St. Marylebone †8 †8 — Chelsea 4 4 — St. Pancras 16 16 — Deptford 7 8 + 1 Shoreditch 6 6 — Finsbury 9 10 + 1 South wark 17 16 - 1 Fulham 6 7 + 1 Stepney 18 18 — Greenwich ‡7 †6 - 1 Stoke Newington 3 3 — Hackney 14 ‡7 + 3 Wandsworth §§11 11 — Hammersmith 9 9 — Westminster, City of 11 12 + 1 Hampstead 7 7 — Woolwich 9 10 + 1 Holborn 5 4 - 1 City of London ||17 || 19 + 2 Islington 20 20 — Kensington 13 13 — London 301 313 + 12 Lambeth 13 13 — a Excluding inspectors employed in districts mentioned in Schedule C of the Metropolis Management Act. || Including eight meat inspectors in 1904 and seven in 1903. † Including one temporary inspector. ‡ Including two temporary inspectors. §§ There are also five inspectors concerned with drains and sanitary fittings in old and new houses ; these officers are under the direction and control of the surveyors. Of the 313 inspectors now employed in London 28 are women. At the date of the last return 20 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 21 districts, for the most part in the inspection of factories and workshops employing female labour. Shirley f. Murphy, Medical Officer of Health. printed FOR 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. 735. Price 3d., post free, 3½d. [11458 2 SANITARY Metropolitan borough. N umber of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. In- habited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Battersea 11 2 23,462 38,987 24,089 3,032 168,907 88,999 18,381 1,805 2,999 1,853 233 12,993 6,846 1,414 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 Bethnalgreen 10 — 14,005 28,209 23,732 6,384 129,680 98,853 38,410 1,400 2,821 2,373 638 12,968 9,885 3,841 Camberwell 13 1 36,671 56,985 31,926 4,073 259,339 117,648 25,012 2,619 4,070 2,820 291 18,524 8,403 1,787 Chelsea 3 1 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 Deptford 8 — 15,823 24,615 13,956 1,667 110,398 51,861 9,999 1,978 3,077 1,744 208 13,800 6,483 1,250 * For the purposes of this report the term "overcrowded tenements" is applied to those tenements of less than 5 rooms which at the date of the 1901 census were occupied to the extent of more than two persons per room. 3 OFFICERS. Houses let in lodgings. Duties of sanitary inspectors. Assistants. cal staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 121 Frequently. The chief inspector 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. (c) 1 mortuary keeper and 1 temporary assistant. One takes samples under the Food and Drugs Acts, and inspects slaughterhouses, butchers' shops, sausage factories, ham and beef shops, etc. One inspects factories, workshops and workplaces. One (female) inspects places employing female labour, and investigates cases of puerperal fever. She also visits the houses of children who are about to be discharged from isolation hospitals after scarlet fever and diphtheria, and inspects houses let in lodgings. One (female) investigates deaths of infants under one year, visits cases of non-notifiable infectious disease, visits children fed from the council's milk depot, and gives instruction to mothers in the feeding and care of infants. In addition to her salary as sanitary inspector she receives £30 per annum from the borough council. 217 Four. 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 lodging-houses, offensive trades, factories and workshops, etc. (a) 4 disinfecting assistants. 5 (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 reconstruction. (c) 3 shelter caretakers (females) 400 (about) At least once a month. One superintends, and in conjunction with medical officer of health is responsible for the operations of the entire sanitary staff. (a) 1 general assistant. 5 Special cases more often as may be found necessary. Six have each an allotted district, in which they are concerned with duties arising under the Public Health Act including the inspection of registered tenement houses. (b) 4 disinfectors (c) mortuary keeper One is concerned with duties under the Factory and Workshop Act, outworkers, etc., the inspection of cowsheds and milkshops, etc. (d) 9 dust-pail men. One is concerned with the inspection of food, slaughterhouse and offensive trade premises. One supervises the drainage and enforcement of by-laws during construction of new buildings. (The whole of the salary of this officer is paid by the borough council.) 300 Once, and at irregular periods. One is concerned with smoke nuisances and Food and Drugs Act, and is emergency inspector under all Acts of Parliament relating to public health. (a) 1 superintendent and 7 disinfecting assistants. 5 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. (b) 1 mortuary keeper. One acts as chief clerk and inspects in emergency cases. One (female) is chiefly concerned with laundries, factories and workshops employing female labour. † - 257 inspections made in 1903. Two have an allotted district, in which each is concerned with houseto-house inspection, and inspection under the Factory and Workshop (a) mortuary keeper. None. Act, and (with assistants) disinfects clothing and bedding, (b) 2 disinfecting and drain-testing assistants. One carries out duties connected with infectious disease and complaints, and obtains samples under the Food and Drugs Act. One (female) is concerned with inspection of workshops and outworkers' homes where female labour is employed. Also special investigations. 122 Twice. 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. One is engaged with house-to-house inspection. † The borough council are in possession of a register containing a list of 602 houses let in lodgings prepared some 20 years ago by the Vestry of Chelsea The borough council have not registered any houses since their constitution in 1899. 4 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Finsbury 9 l 9,280 24,097 20,515 6,373 101,463 78,346 35,723 928 2,410 2,051 637 10,146 7,835 3,572 Fulham 6 l 18,534 32,137 21,681 2,341 137,289 81,364 14,892 2,648 4,591 3,097 334 19,613 11,623 2,127 Greenwich 6* — 14,240 19,702 10,877 1,199 95,770 41,260 7,947 2,373 3,284 1,813 200 15,962 6,877 1,324 Hackney 15† 2 30,634 48,794 29,089 3,684 219,272 104,876 22,332 1,802 2,870 1,711 217 12,898 6,169 1,314 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 * Includes one temporary inspector. † Includes two temporary inspectors. 5 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 1,109 Once through. ly 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 disinfector. 2 and 1 office youth. Some of the houses owing to their tion are very frequently visited; others probably less so; but those which require the greatest n receive it. (b) 2 mortuary keepers one of whom also disinfects rooms, and the other also works steam disinfector. One is concerned with Factory and Workshop inspection. One is a meat and market inspector. One supervises generally. (c) 1 shelter keeper (who also disinfects rooms). One (female) is concerned with the inspection of factories and workshops where females are employed, out-workers' homes, etc., and makes special enquiries into infantile deaths and cases of measles. (d) 1 van driver who also assists with disinfection. 329 Twice. Five have each an assigned district, in which they perform all duties arising under the Public Health Act and Factory and Workshop Act. (a) 2 drainage inspectors. 2 (b) 4 disinfectors and 3 assistants. One is employed on duties arising under the Food and Drugs Act and in the inspection of places where food is sold or stored. (c) 1 mortuary keeper. One (female) is chiefly engaged in the inspection of workshops, etc., where women are employed. - The work is in abeyance on account of shortness of staff. The question of increasing the staff is now under consideration. One is concerned with infectious disease. Four have each an allotted district in which they are concerned with duties under the Public Health and Factory and Workshops Act. (a) 3 disinfecting assistants. 2 One (temporary) is engaged upon house to house inspection. 500 An endeavour is made to have these houses inspected once a year at least. (155 were inspected during 1903.) 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 County 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. One (female) inspects the houses of outworkers. Two (temporary) are engaged upon house-to-house inspection. 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. 1,748 Generally once a year. 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 keeper. One is employed on houses let in lodgings. One is employed on duties arising under the Food and Drugs Act and supervision 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. 6 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenemeats under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Hampstead 6 1 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 Holborn 3 l 4,703 13,790 10,772 2,783 59,405 35,724 14,875 1,176 3,447 2,693 696 14,851 8,931 3,719 Islington 19 l 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 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 5,648 2,016 Lambeth 12 1 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 Lewisham 9 1 22,750 27,701 8,561 535 127,495 28,928 3,416 2,275 2,770 856 53 12,749 2,893 342 7 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 908 Owing to decision of town clerk, that a change of landlords necessitated re-registration, nothing has been done beyond reregistering houses where such a change has occurred. One supervises work of other inspectors, visits premises with medical officer of health, investigates cases of infectious diseases and is responsible for work of disinfecting assistants. (a) 2 disinfecting assistants. 3 and 1 clerk draughtsman. (6) 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. 801 Varies in accordance with the sanitary condition of the houses. Some weekly, others once or twice a year. Three 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 (b) 1 mortuary keeper. One (female) is engaged on special inspections under the directions of the medical officer, such as factories and workshops, restaurants where females are employed, the houses of outworkers, measles cases, etc. 670 On an average four times a year. One supervises and visits premises when it is necessary to serve a statutory notice. (a) 5 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 visit ice-cream factories, and on Sundays in rotation take samples of milk under the Food and Drugs Act. (b) mortuary keeper. (c) caretaker of shelter. (d) engineer at disinfecting station. One inspects workshops, workplaces and bakehouses. One inspects houses let in lodgings. One assists previous inspector and also takes samples of food and drugs. One inspects meat, food, cowsheds and offensive trade premises. One (female) inspects workshops and outworkers' homes where females are employed. 2,050 about No fixed number of times. Frequency of inspection is governed by character of houses, locality and inhabitants. One is chief inspector without a district and exercises supervision. (a) assistant for disinfection. 5 Ten have each an allotted district, in which they are concerned with all duties arising under the Public Health (London) Act. They also obtain samples under the Food and Drugs Act. Two act at one time for three months and then are exempt from this duty for 12 months. No inspector collects samples for analysis in his own district except samples of water. (b) mortuary keeper. (c) sanitary labourer for assisting in testing drains. Two (female) are engaged mainly in the inspection of workshops, workplaces, laundries, etc., where females are employed. 372 Several times Eleven have each an allotted district, in which they are concerned with all duties arising under the Public Health and Factory and Workshop Acts. (a) 11 disinfecting assistants. 4 (b) 2 mortuary keepers and a deputy. One inspector deals only with smoke nuisances, and carries out duties under the Food and Drugs Act, assisted by a deputy. The district inspectors supervise the execution of drainage works in both new and old houses. (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. The Council is considering the advisability of appointing an extra female inspector. 16 Constantly Five have each an assigned district in which they carry out general sanitary duties. (a) 6 disinfecting assistants. 3 One is engaged on duties arising under the Factory and Workshop Act. (b)2 drain-testing assistants. Three are engaged in house-to-house inspection. One (female) visits laundries, workplaces, etc., where females are employed, and makes special investigations into cases of infantile diarrhoea, phthisis, etc. 8 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. males. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. 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 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 St. Marylebone *7 1 13,535 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 St. cras 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 ditch 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 * Includes one temporary inspector. 9 Houses let in lodgings. Duties of sanitary inspectors. Assistants. Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 851 Frequently (5,493 visits during 1903.) 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. (a) inspector under the Food and Drugs Act. 4 (N.B.—Drainage works in new buildings under direction of surveyor.) (b) mortuary keeper. One has supervision of workshops and work-places, and has generally the enforcement of the Factory and Workshop Act. (c) caretaker and 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 enquiries into infectious disease not scheduled for notification. (e) 1 disinfecting assistant. 600 The betterclass once every year, and the poorer class eight and nine times. 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 October, 1901) for measuring up rooms of houses let in lodgings, making night visits, etc. (a) 4 disinfecting assistants. 4 and 1 temporaly. (6) 5 labourers (who assist inspectors). One (female) inspects all places where female labour is employed. (c) 1 female attendant at the Glaucus-street shelter. 784 As often as possible. 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 reconstruction. (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. 1,838 2,307 inspections, and 5,535 re-inspections after notices served 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 1 chief clerk, 6 assistant clerks, 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 contact shelter attendant. Two perform duties under the Factory and Workshop Act. Of these inspectors, 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 of underground dwellings. One special inspector supervises the disinfectors and attendants at the contact-shelter and at the personal cleansing station, inquiries into contact notifications, makes smoke observations, inspects effluvia businesses and offensive trade premises, and instructs workmen, temporarily employed by the department, to open and examine drains, etc. 233 If found on inspection to be kept in a satisfactory sanitary condition once a year only. If not, the houses are inspected as often as may be necessary to secure improvement. Some houses have required frequent visits at short intervals. 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. Each of the five other inspectors has an allotted district in which he performs the various duties arising under the Public Health and Factory and Workshop Acts, including the abatement of smoke nuisances, the supervision of drainage work, both in new and existing houses, and the testing of drains. Each inspector is required to take four samples per fortnight under the Food and Drugs Act, and also to take turns of duty in the street markets on Saturdays and Sundays with a view to taking samples and watching the qualities of the food stuff exposed for sale. The inspectors are not restricted to their own districts for taking samples under the Food and Drugs Act. (c) 1 mortuary keeper. (d) caretaker (female) of shelter. 10 Metropolitan borough. Number of sanitary inspectors. Census, 1901. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. Males. Females. Inhabited Louses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded ments. wark 13 3 20,878 47,808 39,612 8,133 206,180 147,923 46,073 1,305 2,988 2,476 508 12,886 9,245 2,880 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 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 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 Westminster (City of) 10 2 18,366 41,244 26,668 4,346 183,011 83,624 23,856 1,530 3,437 2,222 362 15,251 6,969 1,988 Woolwich 9 1 18,086 24,585 14,017 1,243 117,178 50,985 7,727 1,809 2,458 1,402 124 11,718 5,098 773 City of London 18† 1 3,865 5,339 3,307 504 26,923 10,625 2,921 203 281 174 27 1,417 559 154 County of London 285 28 571,768 1,019,546 672,030 124,773 4,536,541 2,449,789 726,096 1,827 3,257 2,147 399 14,494 7,827 2,320 * There are also five inspectors concerned with drains and sanitary fittings in old and new houses under control of the surveyors. † Includes 8 meat inspectors. 11 Houses let in lodgings. Duties of sanitary inspections. Assistants Clerical staff. No. of houses let in lodgings on the register. No of times a year these houses are inspected. 1,100 Four. One chief male inspector supervises generally the work of the other male inspectors. (a) 10 disinfecting assistants. 6 One carries out the Adulteration Acts, inspection of bakehouses, slaughterhouses, dairies, milkshops and noxious trade premises. (6) 2 mortuary keepers, and a superintendent and his wife at reception house. The superintendent is concerned with infectious diseases. Ten have each 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. One has the wharves and warehouses on the river bank and is engaged with the inspection of food stuffs. Two (female) visit houses let in lodgings. (c) 1 assistant drain tester. One (chief female) visits factories and workshops employing females and supervises generally the other female inspectors. 2,649 Some of the best are only visited once or twice a year. Others are visited practically every month. 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) 15 disinfecting and general assistants. 7 Two are concerned with houses let in lodgings. One inspects wharves and food landed at such premises. 180 Twice. The three inspectors have each an assigned district in which they carry out general sanitary duties. (a) 1 disinfecting assistant. 1 200 Twice and more frequently if any special reason. 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 if required. (a) 10 disinfecting assistants. 4 (6) 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. * 2,004 Some weekly, others monthly, twice a year or once a year Eight district inspectors. (a) 9 disinfecting assistants. 4 and 1 messenger and clerical assistant 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. Two (female) are engaged in the inspection of workshops, workplaces, etc., where female labour is employed. 164 Mostly four times. 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. 3 (b) 3 drain-testing assistants. One (female) visits workshops and workplaces, etc. where females are employed. (c) 1 mortuary keeper. Eight have each an assigned district in which they perform duties arising under the Public Health Act. 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. 366 Frequently. Two are concerned with notified infectious diseases. (a) 2 disinfecting assistants. 3 One is specially engaged in carrying out the provisions of the Food and Drugs Act. (6) 1 mortuary keeper. Eight are concerned with duties arising under the Public Health Act. One of these (female) also visits workplaces where females are employed. 20,632 Eight inspectors are engaged in meat inspection. * This number was shown in a return published by the Council in January, 1903. and is the most recent information on this point received from the medical officer of health of Westminster.